Objective: We assessed the independent associations of lifetime child abuse and neglect indices with behavioural characteristics of children. Study design: A cross-sectional study was conducted in Albania in 2022. Methods: Participants consisted of a nationwide representative sample of 1877 schoolchildren aged 15 years (55 % girls; response: 96 %). Data on lifetime child abuse and neglect were collected, along with behavioural factors and sociodemographic characteristics. Binary logistic regression was used to assess the independent associations of child abuse and neglect with behavioural factors of schoolchildren. Results: Irrespective of sociodemographic characteristics, lifetime physical abuse was positively related to lifetime smoking (OR = 1.8, 95%CI = 1.4-2.3), lifetime alcohol consumption (OR = 2.4, 95%CI = 1.9-2.9), and breakfast skipping (OR = 1.3, 95%CI = 1.0-1.6). Furthermore, positive independent factors associated with emotional abuse included lifetime alcohol intake (OR = 1.7, 95%CI = 1.3-2.1) and breakfast skipping (OR = 1.4, 95%CI = 1.0-1.8). Additionally, positive factors associated with lifetime emotional neglect consisted of lifetime smoking (OR = 2.2, 95%CI = 1.6-3.0) and alcohol intake (OR = 2.0, 95%CI = 1.5-2.6), and a lower fruit consumption (OR = 1.7, 95%CI = 1.3-2.3). Positive factors associated with lifetime sexual abuse included lifetime alcohol consumption (OR = 2.4, 95%CI = 1.4-4.1) and especially smoking (OR = 4.3, 95%CI = 2.6-7.3). Also, lifetime witnessing of family violence was positively related to lifetime smoking (OR = 2.7, 95%CI = 1.8-4.1) and alcohol intake (OR = 1.7, 95%CI = 1.2-2.6). Conclusions: We evidenced strong and consistent links between child maltreatment indices and unhealthy behavioural practices among 15-year-old children in Albania. These findings underscore the potential impact of early trauma on developmental trajectories. The association between child abuse and the adoption of detrimental behaviours highlights the urgent need for comprehensive support and intervention strategies to break the cycle of harm.

Abstract Background Human health can be affected by climate in direct and indirect ways. Increasing temperatures may affect ecosystems, water safety, and exposure to waterborne diseases. This is the first work in Albania aiming to demonstrate the link between gastroenteritis rate and climate in the country. This research was supported by UNICEF Albania through the WASH Global Thematic Fund, but it doesn’t necessarily represent UNICEF’s position. Methods Epidemiological surveillance reports of the period 2006-2022 were used for the yearly incidence of gastroenteritis in children 0-14 years old. Years 2020 and 2021 were not included because of pandemic confounding potential. Historic data for calculating the average summer temperatures were retrieved from timeanddate.com repository. Pearson coefficient is calculated to quantify the associations and linear regression is applied to project the increased rate in the future. Results There was a statistical association between gastroenteritis rate and summer temperatures during the study period (Pearson coefficient=0.78, p = 0.001). There was a tendency that in years with hotter summers higher incidence of gastroenteritis was reported by the health system. For each degree (Celsius) increase in the average summer day temperatures, the risk of gastroenteritis in children is expected to increase by 644/100 000 (CI 95%: 317 - 972). An excess rate of 966/100 000 is expected in the case of Intergovernmental Panel on Climate Change medium scenario projection of 1.5o C average temperature increase. That implies more than 4830 additional new cases every year in children 0-14 years old, attributed to climate change in the future in Albania. Conclusions The analysis demonstrated excess gastroenteritis risk may be related to higher summer temperatures observed in Albania. The expected gastroenteritis risk increase in a warmer future should be addressed by improvements in sanitation, education of parents and epidemiological intelligence. Key messages • A warmer climate is expected to affect the health by increasing the risk for diarrheic diseases. • Children will be the most at-risk population category.

Abstract Aim: The objective of this analysis was to assess the association of excess COVID-19 mortality with regulation enforcement and vaccination rate in selected countries. Methods: This analysis included 50 countries pertinent to the WHO European Region, in addition to USA and Canada. Excess mortality and vaccination data were retrieved from Our World In Data database, while regulation implementation was measured from a well-respected, standardized measure. Outpatient visits were also included in the analysis. Multiple linear regression was used to assess the independent association between excess mortality and each covariate. Results: Excess mortality increased by 4.1/100 000 for every percent decrease in vaccination rate and with 6/100 000 for every decreased unit in the regulatory implementation score a country achieved in the Rule of Law Index. Conclusion: Degree of regulation enforcement, likely including public health measure enforcement, may be an important factor in controlling COVID-19s deleterious health impacts.

Abstract Background Avoidable mortality is headline indicator of relative health system performance in European Union policy processes. However, the reliability of this indicator for cross-national comparisons of health system performance is limited by the lack of control for cross-country differences in population health status, and the challenges in selecting causes of death and age limits. This study examined the feasibility and impact of several refinements of avoidable mortality addressing these concerns. Methods Using a sample of 30 European countries, including EU Member States, United Kingdom, Norway, and Iceland, we examined the feasibility and impact of adjusting avoidable mortality for cross-country differences in disease prevalence and disease stage, using extended age thresholds, and calculating the avoidable burden of disease. We measured the impact of the feasible adjustments by calculating the average absolute change in country ranks compared to the 2014 country ranking based on the standard avoidable mortality. Results Given publicly available data, only the calculation of years of life lost due to avoidable causes of death and using different age thresholds to calculate avoidable mortality are currently feasible. The impact of the feasible adjustments varied between countries with no visible geographic pattern. Including deaths due to avoidable causes at all ages changed the country ranks by an average of 1.9 places in men and 2.8 in women. Using years of life lost due to avoidable causes of death changed the rank by an average of 8.1 places in men and 8.7 in women. Conclusions Country rankings are highly sensitive to the type of refinement. However, a full assessment of refinements was not possible due to missing data. To ease the implementation of morbidity-based refinements of avoidable mortality, we recommend that a shorter list of avoidable causes of death is developed. Key messages A continuous refinement of relative health system performance measures and improving the availability of internationally comparable health data are critical to effectively support policy making. Updating the age thresholds used to calculate avoidable mortality and using years of life lost due to avoidable causes of death are currently feasible and have a sizeable impact on country rankings.

Nonformal education methodology is promoted by the European Union as a priority. Western Balkan countries are supported in using this methodology via access Community funds (Erasmus +, previously Youth in Action). Nonformal education (proven as the most effective education method for youth) is expected to have the same impact if used in Public Health. We aimed to explore how nonformal education methodology contributes to health promotion through elaborating the example of transitional Albania. An Exploratory Sequential Mixed Methods design was used. We organized two focus groups: one with students of medical sciences and another with none medical students. We randomly selected eight participants per focus group from the Beyond Barriers association database (Contact point for Erasmus+ Programme in Albania). We used conventional content analysis to analyze qualitative data. Exploratory group interviews were conducted previously, using a questionnaire, which was piloted prior to administration. Of a population of 581 youth who participated in nonformal education activities during 2007-2013, 113 youths were interviewed. Ninety percent of interviewees declared that nonformal education activities have influenced improvement of their skills/competences or helped to acquire new ones; 53% declared that they reflected a change into personal behavior/actions/attitudes. Trainees learned through practice. They intended to retain the healthy behavior even when the activity was finished. Nonformal education activities offered equal opportunities to all youth despite their gender or field of study. Nonformal education methodology is recommended to be used in health promotion campaigns targeting young people as a very effective tool.

About 85% of the overall burden of disease in Albania is attributable to non-communicable diseases (NCDs) including cardiovascular diseases, cancer, diabetes and chronic respiratory diseases. Furthermore, NCDs account for about 94% of proportional mortality in the Albanian population. The three main risk factors responsible for the disease burden in the Albanian population include arterial hypertension, nutritional-related risks, and smoking. High systolic blood pressure accounts for about one-third of the overall mortality rate in Albania. In turn, dietary risks account for about 30% of the total mortality rate and about 15% of the overall burden of disease in Albania. Conversely, the proportional mortality attributable to smoking is about 16%. Smoking epidemics affects predominantly Albanian males and this trend is likely to increase. The proportion of Albanian females who smoke is still quite small (less than 10%) compared with other countries in the region, but female smoking is considered be steadily increasing. Differences in smoking prevalence amongst males from different socio-economic strata are not significant, whereas among females significant socio-economic differences are noted. Smoking epidemics in the future are expected to demonstrate large socioeconomic differences with lower social classes in both sexes smoking the most. Similar to other countries, actions and measures for tackling NCDs in Albania should include promotion of healthy nutrition; promotion of physical activity; and antismoking policies starting with school age children and have a gender specific component targeting different settings, enhanced by the intensive use of social media.

Objective: It is well known that both pressure and volume overloads contribute to left ventricular hypertrophy (LVH) and left ventricular dilatation in patients with chronic kidney disease (CKD). The aim of this study was to evaluate the impact of pulse pressure as an indirect assessment of arterial stiffness on ventricular geometry and left ventricular filling pressure in patients with end stage renal disease on peritoneal and hemodialysis treatment. Design and method: A case control study was conducted, enrolling all patients on chronic dialysis (HD and PD) who had more than 3 months in therapy. Two-dimensional echocardiography was performed 2–24 h after the dialysis session according to AEE recommendation. The ratio of early transmitral flow velocity (E) to early diastolic mitral annular velocity (Em) (E/Em ratio) assessed using tissue Doppler imaging was used for estimating LV filling pressure. Results: Our dialysis population studied consisted in 122 pts, 78 pts (61%) on hemodialysis, mean age 53.4 ± 14.5 years and mean time on therapy was of 40.4 ± 14.4 months. We didn’t found difference in PP between 2 groups (PD vs HD). Concentric hypertrophy was found in 42.3% of the pts in HD and 61.4% of pts in PD (p = 0.058) and eccentric hypertrophy in 43% of HD pts and in 29.5% of PD pts (p > 0.07). When the patients with LVH were stratified into tertiles based on their LVM-i there were found significantly increasing pulse pressure, across the three groups with increasing LVM-i (p = 0.036). Pulse pressure was found the only independent risk factor associated with LVM-i [1.04 (0.99–1.09) p < 0.05. Six % of patients on PD vs 16.8% on HD had E/Em Ratio>14 (p = 0.101). Patients with E/Em Ratio>14 have significantly higher PP value p = 0.039. Conclusions: These results suggest that severity of arterial stiffness have impact not only to cardiac remodelling but also to higher left ventricular filling pressure. The recognition of pulse pressure underline once again that more in focus needs to be the risk of vascular calcifications in ESRD patients.

Our aim was to assess the association of a Mediterranean diet and gastroesophageal reflux disease among adult men and women in Albania, a former communist country in South Eastern Europe with a predominantly Muslim population. A cross-sectional study was conducted in 2012, which included a population-based sample of 817 individuals (≥18 years) residing in Tirana, the Albanian capital (333 men; overall mean age: 50.2 ± 18.7 years; overall response rate: 82%). Assessment of gastroesophageal reflux disease was based on Montreal definition. Participants were interviewed about their dietary patterns, which in the analysis was dichotomized into: predominantly Mediterranean (frequent consumption of composite/traditional dishes, fresh fruit and vegetables, olive oil, and fish) versus largely non-Mediterranean (frequent consumption of red meat, fried food, sweets, and junk/fast food). Logistic regression was used to assess the association of gastroesophageal reflux disease with the dietary patterns. Irrespective of demographic and socioeconomic characteristics and lifestyle factors including eating habits (meal regularity, eating rate, and meal-to-sleep interval), employment of a non-Mediterranean diet was positively related to gastroesophageal reflux disease risk (fully adjusted odds ratio = 2.3, 95% confidence interval = 1.2-4.5). Our findings point to a beneficial effect of a Mediterranean diet in the occurrence of gastroesophageal reflux disease in transitional Albania. Findings from this study should be confirmed and expanded further in prospective studies in Albania and in other Mediterranean countries.

Objective: It is well known that both pressure and volume overloads contribute to left ventricular hypertrophy (LVH) and left ventricular dilatation in patients with chronic kidney disease (CKD). The aim of this study was to evaluate the impact of pulse pressure as an indirect assessment of arterial stiffness on ventricular geometry and left ventricular filling pressure in patients with end stage renal disease on peritoneal and hemodialysis treatment. Design and method: A case control study was conducted, enrolling all patients on chronic dialysis (HD and PD) who had more than 3 months in therapy. Two-dimensional echocardiography was performed 2–24 h after the dialysis session according to AEE recommendation. The ratio of early transmitral flow velocity (E) to early diastolic mitral annular velocity (Em) (E/Em ratio) assessed using tissue Doppler imaging was used for estimating LV filling pressure. Results: Our dialysis population studied consisted in 122 pts, 78 pts (61%) on hemodialysis, mean age 53.4 ± 14.5 years and mean time on therapy was of 40.4 ± 14.4 months. We didn’t found difference in PP between 2 groups (PD vs HD). Concentric hypertrophy was found in 42.3% of the pts in HD and 61.4% of pts in PD (p = 0.058) and eccentric hypertrophy in 43% of HD pts and in 29.5% of PD pts (p > 0.07). When the patients with LVH were stratified into tertiles based on their LVM-i there were found significantly increasing pulse pressure, across the three groups with increasing LVM-i (p = 0.036). Pulse pressure was found the only independent risk factor associated with LVM-i [1.04 (0.99–1.09) p < 0.05. Six % of patients on PD vs 16.8% on HD had E/Em Ratio>14 (p = 0.101). Patients with E/Em Ratio>14 have significantly higher PP value p = 0.039. Conclusions: These results suggest that severity of arterial stiffness have impact not only to cardiac remodelling but also to higher left ventricular filling pressure. The recognition of pulse pressure underline once again that more in focus needs to be the risk of vascular calcifications in ESRD patients.

IntroductionThalassemia major is a common hemoglobinopathy in Albania. However, there are no data available on the frequency of RBC alloimmunization and autoimmunization in transfusion-dependent Albanian patients with thalassemia.MethodsA total of 118 patients with thalassemia receiving regular transfusions were studied during 5years with antibody screening. During this period, they were exclusively transfused with blood matched for ABO, Rhesus and Kell system. These patients were previously exposed to unmatched blood because of blood shortages.ResultsFourteen of 118 (11, 8%) patients developed alloantibodies. Twelve (10, 1%) were already present at the start of the study. Only 2 (1, 7%) were formed after the application of a strict Rh and Kell matching policy. The most common antibody was anti-K, followed by anti-D, anti-C, anti-E, anti-c, anti-e, anti-Jk(b), and anti-C-w. Three patients developed anti-D plus anti-C. Anti-K was combined with Rh antibodies in two of five cases. Anti-c was combined with anti-E in two of three cases. The majority of antibodies (10/14) belonged to the Rh blood group system. With the exception of the anti-Jk(b) and the anti-C-w, all antibodies were already present at the beginning of the follow-up period. During our follow-up, 27 patients (22.8%) developed autoantibodies. A strong coincidence was found between the presence of alloantibodies and autoantibodies. Eleven of 14 (78%) of the patients with alloantibodies had also autoantibodies, whereas autoantibodies were found in 16 of 104 (15%) of patients with thalassemia without autoantibodies. The rate of alloantibody formation dropped from 10.1% to 1.7% after application of a strict Rh and Kell matching policy.ConclusionA policy of Rhesus and Kell matching without occasional exceptions greatly reduced the development of new alloantibodies and autoantibodies. Self-sufficiency through regular blood donation is necessary for the full implementation of an extended match policy and the prevention of antibody formation in our patients.

Objectives: Functional health literacy (FHL) has been related to individual characteristics, ill-health and disease knowledge. However, the information about FHL in Kosovo is very limited and thus the aim of this study was to assess the demographic and socio-economic correlates of FHL among users of primary health care in Kosovo, a postconflict country in the Western Balkans.Study design: Cross-sectional study.Methods: A cross-sectional study was conducted in Kosovo between November 2012-February 2013, including a representative sample of 1035 consecutive primary care users aged >= 18 years (60% females; overall mean age: 44.3 +/- 16.9 years; overall response rate: 86%). Test of Functional Health Literacy in Adults (TOFHLA) was used to assess FHL. General linear model and logistic regression were used to assess the association of TOFHLA score with demographic and socio-economic characteristics.Results: Overall, four out of five participants exhibited inadequate or marginal FHL in this Kosovo sample. FHL score was independently and inversely related to age, but positively associated with educational attainment and being in a situation other than unemployed.Conclusions: Limited or marginal FHL was very common among primary care users in Kosovo and considerably higher than in the neighbouring Serbia. The low health literacy levels in Kosovo may provide an additional barrier towards achievement of health care goals. There is a need to design and implement suitable and effective educational and health system interventions in the Kosovo context. (C) 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

BACKGROUND Patient satisfaction with the quality of primary health care (PHC) in Kosovo has not been previously reported. Our aim was to assess the level and socio-economic correlates of satisfaction of PHC users (also referred to as patients' evaluation) in Kosovo, a transitional country in the Western Balkans. METHODS A cross-sectional study was conducted in 2010 in Gjilan region, Kosovo, including a representative sample of 1039 PHC users (87% response). Patients' evaluation of PHC services was assessed through EUROPEP, a 23-item instrument tapping different aspects of medical encounter. RESULTS Mean age of survey participants (56% females) was 41 ± 16 years. About 50% of the participants were satisfied with the overall quality of medical services, doctor-patient relationship and organization of care. Younger (below median age), urban and employed PHC users reported a significantly higher satisfaction level with the overall health encounter quality. Conversely, there were no sex or educational differences. CONCLUSIONS Considerably fewer PHC users in Kosovo were satisfied with the overall medical encounter compared with their European counterparts. This new and useful evidence may support health professionals and policy makers for improving the quality of PHC in Kosovo, a country struggling and mainstreaming all energies in order to get international recognition.

Our aim was to assess the prevalence of gastro protection in the Albanian population using non-steroidal anti-inflammatory drugs (NSAIDs). A cross-sectional study, conducted in November-December 2011 in Albania, included 610 NSAIDs users (236 men and 374 women) who visited pharmacies to receive their NSAID medication. A structured questionnaire was administered to all participants including information on age, sex, educational status, pathology being treated with NSAID, presence of gastrointestinal ulcer or related complications, duration of NSAIDs therapy, type of drug used, and gastro protection therapy. Almost all participants (N=599) received NSAIDs to treat rheumatic and/or musculoskeletal disorders. Of these, 475 individuals were on chronic therapy with high daily doses of NSAIDs. Concomitant gastro protective therapy was found in 184 individuals (30 percent of the overall sample). Women and the more educated individuals received more gastro protection than men and the low educated counterparts, respectively (33.4 percent in women vs 25 percent in men; 47 percent in highly educated vs 18 percent in low educated). Appropriate use of gastro protective therapy for NSAID users needs to be promptly implemented in Albania, as its inappropriate use raises ethical and economic concerns. Prescriptions should follow clear guidelines for prevention of gastrointestinal damage following NSAIDs therapy among persons at high risk.