Key lessons learnt from COVID-19 intra-action reviews in the Republic of Moldova, Montenegro, Kosovo and North Macedonia 2020-2021: a qualitative study.

OBJECTIVES: Our study described how the WHO intra-action review (IAR) methodology was operationalised and customised in three Western Balkan countries and territories and the Republic of Moldova and analysed the common key findings to inform analyses of the lessons learnt from the pandemic response. DESIGN: We extracted data from the respective IAR reports and performed a qualitative thematic content analysis to identify common (between countries and territories) and cross-cutting (across the response pillars) themes on best practices, challenges and priority actions. The analysis involved three stages, namely: extraction of data, initial identification of emerging themes and review and definition of the themes. SETTING: IARs were conducted in the Republic of Moldova, Montenegro, Kosovo and the Republic of North Macedonia between December 2020 and November 2021. The IARs were conducted at different time points relative to the respective pandemic trajectories (14-day incidence rate ranging from 23 to 495 per 100 000). RESULTS: Case management was reviewed in all the IARs, while the infection prevention and control, surveillance and country-level coordination pillars were reviewed in three countries. The thematic content analysis identified four common and cross-cutting best practices, seven challenges and six priority recommendations. Recommendations included investing in sustainable human resources and technical capacities developed during the pandemic, providing continuous capacity-building and training (with regular simulation exercises), updating legislation, improving communication between healthcare providers at all levels of healthcare and enhancing digitalisation of health information systems. CONCLUSIONS: The IARs provided an opportunity for continuous collective reflection and learning with multisectoral engagement. They also offered an opportunity to review public health emergency preparedness and response functions in general, thereby contributing to generic health systems strengthening and resilience beyond COVID-19. However, success in strengthening the response and preparedness requires leadership and resource allocation, prioritisation and commitment by the countries and territories themselves.

Health Service Management and Patient Safety in Primary Care during the COVID-19 Pandemic in Kosovo.

BACKGROUND: Several changes must be made to the services to ensure patient safety and enable delivering services in environments where the danger of infection of healthcare personnel and patients in primary care (PC) institutions is elevated, i.e., during the COVID-19 pandemic. OBJECTIVE: This study aimed to examine patient safety and healthcare service management in PHC practices in Kosovo during the COVID-19 pandemic. METHODS: In this cross-sectional study, data were collected using a self-reported questionnaire among 77 PHC practices. RESULTS: Our main finding reveals a safer organization of PC practices and services since the COVID-19 pandemic compared to the previous period before the pandemic. The study also shows a collaboration between PC practices in the close neighborhood and more proper human resource management due to COVID-19 suspicion or infection. Over 80% of the participating PC practices felt the need to introduce changes to the structure of their practice. Regarding infection protection measures (IPC), our study found that health professionals' practices of wearing a ring or bracelet and wearing nail polish improved during the COVID-19 pandemic compared to the pre-pandemic period. During the COVID-19 pandemic, PC practice health professionals had less time to routinely review guidelines or medical literature. Despite this, implementing triage protocols over the phone has yet to be applied at the intended level by PC practices in Kosovo. CONCLUSIONS: Primary care practices in Kosovo responded to the COVID-19 pandemic crisis by modifying how they organize their work, implementing procedures for infection control, and enhancing patient safety.

Prevalence of Perceived Stress, Anxiety, and Depression in HCW in Kosovo during the COVID-19 Pandemic: A Cross-Sectional Survey.

A pandemic may have a negative impact on healthcare workers' (HCW) mental health. In this cross-sectional study, we assess the self-reported prevalence of stress, anxiety, and depression and identify their predictive factors among HCW in Kosovo. The online questionnaire collected data on socio-demographics (sex, age, occupation, education, workplace) and the presence and severity of depression, anxiety, and stress through the 21-item Depression, Anxiety, and Stress Scale (DASS-21) questionnaire. Descriptive statistics, t-test, and linear logistic regression were used to analyze the data. Of the 545 respondents, the majority were male (53.0%), under 60 years of age (94.7%), and married (81.7%). Most of them were physicians (78.2%), while the remaining were nurses, midwives, and other health professionals (22%). Prevalence rates for moderate to extremely high stress, anxiety, and depressive symptoms were 21.9%, 13.0%, and 13.9%, respectively. The nurses reported significantly higher mean scores for depression and anxiety than the physicians (p < 0.05). Being married, having poor health, not exercising, and reporting "burnout" from work significantly predicted higher levels of depressive, anxiety, and stress symptoms among health workers (p < 0.05). Most HCWs (71.6%) reported a mild, moderate, or severe mental health burden, and certain factors predicted higher levels of such burden.

Migration Intent of Health Care Workers during the COVID-19 Pandemic in Kosovo.

The migration of healthcare workers from developing countries to more economically developed countries is a long-standing and ongoing trend. Loss of qualified staff due to migration can negatively impact healthcare systems. Understanding factors that drive migration is essential to identifying and managing health system needs. Our study explored factors related to the migration intent of healthcare staff in Kosovo, particularly after the COVID-19 pandemic. We carried out a cross-sectional survey of healthcare workers from public and private institutions. The survey analysed the prevalence of willingness to migrate and whether willingness was affected by the pandemic, and calculated crude and adjusted odds ratios for variables which may influence migration willingness. 14.43% of healthcare workers reported aspiration to migrate, and 23.68% reported an increased chance of migrating after the pandemic. Dissatisfaction with wages and working conditions, higher education and private sector engagement were associated with increased odds of migration willingness. After the pandemic, factors related to interpersonal relationships and state response gave lower odds of migration intent. These findings point to potential factors associated with the migration of healthcare workers, which can help policymakers address gaps in national health system strategy.

Air Pollution in Kosovo: Short Term Effects on Hospital Visits of Children Due to Respiratory Health Diagnoses.

The Republic of Kosovo is a small country in the Balkans. The capital city of Pristina hosts most of its population and is situated in a mountain basin with poor air exchange, especially during winter. Domestic heating, road transport, industry and coal-fired power plants contribute to high levels of air pollution. We performed a time-series analysis on effects of particulate air pollution (PM2.5) on respiratory health of children and adolescents, using hospital admission and ambulatory visit numbers from the pediatric university clinic. From 2018 until 2020, daily mean concentrations of PM2.5 ranged between 2.41 and 161.03 µg/m³. On average, there were 6.7 ambulatory visits per day with lower numbers on weekends and during the first COVID-19 wave in 2020. An increase in PM2.5 led to an immediate increase in visit numbers that lasted over several days. Averaged over a full week, this amounted to about a 1% increase per 10 µg/m³. There were, on average, 1.7 hospital admissions per day. Two and three days after a rise in air pollution, there was also a rise in admission numbers, followed by a decline during the consecutive days. This might indicate that the wards were overstressed because of high admission numbers and restricted additional admissions.

Use of antibiotics in COVID-19 ICU patients.

INTRODUCTION: The role of antibiotics in the treatment in COVID-19 cases has not yet been adequately defined, and no criteria have been established for antibiotic treatment, type and duration. METHODOLOGY: This paper reports the results of an observational study on the extent of antibiotic use in 52 randomly selected patients in the intensive care unit (ICU) at the University Hospital in Pristina, Kosovo with severe forms of COVID-19. RESULTS: Antibiotics were prescribed in all the cases (52; 100%). Of the 52 patients, 1) 13 (25%) were given antibiotics before hospitalisation, 2) 49 (94.2%) during treatment in the ward and 3) 52 (100%) during treatment in the ICU. Most often, empirical antibiotics were administered in 32 cases (61.5%) to treat methicillin resistant Staphylococcus aureus (MRSA) infections, and in 23 patients (44.2%) to treat atypical pathogens. The most prescribed antibiotics were ceftriaxone/cefotaxime plus macrolide in (17 cases; 32.7%), ceftriaxone/cefotaxime in (15 cases; 28.8%), ampicillin/amoxicillin plus clavulanic acid or sulbactam (five cases; 9.6%), and quinolones (five cases; 9.6%). Imipenem was the most frequently used antibiotic in the ICU (30 cases; 57.7%), followed by ceftriaxone (28 cases; 53.8%), and piperacillin/tazobactam and fluoroquinolone (17 cases; 32.7%). In 18 cases (34.6%), three antibiotics were given simultaneously; two antibiotics in 29 cases (55.8%) and in five cases (9.6%) only one antibiotic was given. The mean duration of antibiotic treatment was 12.71 days (3-22 days; SD 4.026). CONCLUSIONS: The study showed unrestricted use of broad-spectrum antibiotics in the treatment of severe cases with COVID-19.

Depression Measured by PHQ-9 in Kosovo during the COVID-19 Outbreak: An Online Survey.

BACKGROUND: There are reports from countries and in the scientific literature that COVID-19 affect also mental health worldwide. The aim of this study was to understand the level of depression as a result of the COVID-19 situation and possible associations with sociodemographic variables. SUBJECTS AND METHODS: It's a cross-sectional study. The participants were 155 respondents recruited online in the period 27.04.2020 until 05.06.2020, who completed the Albanian version of PHQ-9. RESULTS: Mean score of depression resulted 10.94 (SD=9.22). 63% of participants agreed that the situation has worsened their psychological state; 35.6% had a mild to severe form of depression and 18.7% had minimal symptoms. 13.4% of participants saw iCBT as helpful, 16.8% a little while 65.8% wanted to try it. Significantly higher depression resulted for females and age-group 18 to 24 years. No significant differences by levels of education, marital status, employment, socio-economic status and by expectations regarding iCBT. Gender and perception of worsened psychological state showed predictive abilities for depression. CONCLUSION: The situation with Covid-19 has increased depression levels especially among females and 18 to 24 years old and thus expectations for e-psychotherapy. Online treatments seem feasible solutions for outbreak times. Studies in future are needed to better scientifically elaborate these findings.

Relationship in dietary habits variations during COVID-19 lockdown in Kosovo: The COVIDiet study.

Changes in dietary habits and association with lifestyle during the coronavirus disease 2019 (COVID-19) lockdown in the Kosovo population have not been studied yet. Therefore, the intent of the present study was to determine whether if COVID-19 lockdown had any impact in lifestyle, including dietary habits and physical activity (PA) patterns of people from different areas of Kosovo. Dietary habits, PA, body weight and sociodemographic variables were measured through validated online survey started one week after lockdown decision and lasted for next two month (May and June 2020). Six hundred eighty-nine participants (women 79% and men 21%) aged between 20 and 65 years from the Kosovo territory participated in the research. Multivariate models showed that participants in family home residence, participants from Gjilan, participants female and participants with professional educations reported a higher likelihood of turning into a higher adherence to the Mediterranean diet (MedDiet) (OR: 6.09, 5.25, 5.17, 4.19, respectively). The weight gained during the lockdown was positively associated with a higher cooking frequency (OR; 2.90, p < 0.01), lower meat and fish consumption (OR; 1.15, p = 0.02; OR; 1.04, p = 0.04, respectively), higher fast-food consumption (OR; 0.49, p = 0.02) and no physical activity performance (OR; 0.43, p = 0.02) during the COVID-19 lockdown. The dietary habits during COVID-19 lockdown could be related to the improvements in adherence to the MedDiet and physical activities that may minimize related health complications.

Surveillance Metrics of SARS-CoV-2 Transmission in Central Asia: Longitudinal Trend Analysis.

BACKGROUND: SARS-CoV-2, the virus that caused the global COVID-19 pandemic, has severely impacted Central Asia; in spring 2020, high numbers of cases and deaths were reported in this region. The second wave of the COVID-19 pandemic is currently breaching the borders of Central Asia. Public health surveillance is necessary to inform policy and guide leaders; however, existing surveillance explains past transmissions while obscuring shifts in the pandemic, increases in infection rates, and the persistence of the transmission of COVID-19. OBJECTIVE: The goal of this study is to provide enhanced surveillance metrics for SARS-CoV-2 transmission that account for weekly shifts in the pandemic, including speed, acceleration, jerk, and persistence, to better understand the risk of explosive growth in each country and which countries are managing the pandemic successfully. METHODS: Using a longitudinal trend analysis study design, we extracted 60 days of COVID-19-related data from public health registries. We used an empirical difference equation to measure the daily number of cases in the Central Asia region as a function of the prior number of cases, level of testing, and weekly shift variables based on a dynamic panel model that was estimated using the generalized method of moments approach by implementing the Arellano-Bond estimator in R. RESULTS: COVID-19 transmission rates were tracked for the weeks of September 30 to October 6 and October 7-13, 2020, in Central Asia. The region averaged 11,730 new cases per day for the first week and 14,514 for the second week. Infection rates increased across the region from 4.74 per 100,000 persons to 5.66. Russia and Turkey had the highest 7-day moving averages in the region, with 9836 and 1469, respectively, for the week of October 6 and 12,501 and 1603, respectively, for the week of October 13. Russia has the fourth highest speed in the region and continues to have positive acceleration, driving the negative trend for the entire region as the largest country by population. Armenia is experiencing explosive growth of COVID-19; its infection rate of 13.73 for the week of October 6 quickly jumped to 25.19, the highest in the region, the following week. The region overall is experiencing increases in its 7-day moving average of new cases, infection, rate, and speed, with continued positive acceleration and no sign of a reversal in sight. CONCLUSIONS: The rapidly evolving COVID-19 pandemic requires novel dynamic surveillance metrics in addition to static metrics to effectively analyze the pandemic trajectory and control spread. Policy makers need to know the magnitude of transmission rates, how quickly they are accelerating, and how previous cases are impacting current caseload due to a lag effect. These metrics applied to Central Asia suggest that the region is trending negatively, primarily due to minimal restrictions in Russia.

Building Online and Telephone Psychological First Aid Services in a Low Resource Setting During COVID-19: The Case of Kosovo.

The COVID-19 pandemic and the measures brought for prevention of infections are associated with considerable psychosocial and psychological morbidity in the general population. Providing continuous mental health services during the pandemics is a challenge worldwide, especially in low- and middle-income countries (LMICs). This paper reports on the strategies and activities taken to protect public mental health during the COVID-19 pandemic in Kosovo. This included establishing online and phone psychological first aid services and developing psychoeducational videos and webinars. The paper concludes with several lessons learned during the process of establishing and maintaining these interventions, such as: initial political endorsement is crucial to gain and maintain the momentum of services; continuous training of volunteers is crucial for both addressing the needs/problems, which arise during the process of work and maintain the motivation of volunteers; promotion of the services is crucial; academic curricula training mental health professionals should include digital mental health related courses and manualization on how to establish this kind of services in midst of crisis is crucial in order to ensure quick operationalization when needed again especially in LMIC settings. The interventions developed provide opportunity for further research especially by evaluating the impact of the services and exploring how online and provision of mental health and psychoeducation services online could help to cover services gap in times of isolation, limited movement and situations similar to pandemics in settings with limited mental health services and resources. The situation with pandemics with COVID 19 is still far from ending. Future waves of infections and restriction could again spike the mental health and psychosocial and psychological strain of the general population, therefore being prepared in provisions of psychological first aid and other mental health services online is crucial.

Effect of Covid-19 pandemic on mental health among Albanian people residing in the country and abroad - Implications for mental care.

BACKGROUND: Coronavirus disease caused by the novel coronavirus Covid-19 is a current worldwide outbreak. The use of quarantine and isolation proved effective in containing the spread of infection. OBJECTIVES: The purpose of this cross-sectional study was to assess the mental health of Albanian people residing in the country and abroad during the quarantine period for the Covid-19 pandemic. DESIGN: This study was carried out from 25th March - 20th April 2020 through a web survey shared on social networks. The goal was to reach at least the minimum sample size for cross-sectional studies. The Patient Health Questionnaire (PHQ-9) was used to assess mental health. Chi-square (χ2) and Fisher -Exact test were used to assess the statistical significance among variables. P values ≤0.05 were considered statistically significant. RESULTS: 715 participants were included in the final analyses (78.41% females and 21.53% males). Most were residents in Albania (80.41%) and the others resided mainly in Italy (6.89%), Greece (3.51%), Germany (2.43%), Kosovo (1.62%) and the UK (1.69%). Statistical association was found between gender, country of residency and measures taken. Summary score of PHQ-9 items was 6.4662. The total score of depression classification shows that 31.82% and 12.90% of participants have respectively mild and moderate depression. Female participants showed the highest score for some items of PHQ-9, p≤0.05. CONCLUSIONS: Findings suggest that health care professionals should recognize and address mental health problems associated with Covid-19 especially in vulnerable groups. Acting in a timely and proper manner is essential in preventing these problems from becoming chronic.

Provision of community pharmacy services during COVID-19 pandemic: a cross sectional study of community pharmacists' experiences with preventative measures and sources of information.

Background An infectious disease caused by a novel coronavirus (later called COVID-19) reached pandemic levels in 2020 and community pharmacists were involved in responding to this pandemic, also in Kosovo. Objectives To explore the experiences of community pharmacists in relation to provision of community pharmacy services during COVID-19 pandemic. Setting Community pharmacists in Kosovo. Methods This was a cross-sectional study where data was collected via a self-administered online questionnaire, from 264 pharmacists actively practicing in Kosovo during the pandemic. The questionnaire consisted of a combination of closed and open-ended questions, optional statements and statements on a five-point Likert scale, derived at least in part from the Transtheoretical Model. One-way analysis of variance was used to analyze differences in responses to Likert-type items whereas categorical variables were analyzed using Chi square testing. Main outcome measures Community pharmacists' perceptions on COVID-19 related preventative measures. Results A response rate of 40.6% was achieved. Sufficient and adequate COVID-19-related preventative measures were being implemented by a majority of pharmacies (n = 232; 87.9%), and over two-thirds of respondents agreed/strongly agreed that their pharmacies were sufficiently prepared with protective equipment for their personnel. Implementation of preventative measures was associated with respondents' perception that pharmacists and the pharmacy profession were valued more by patients during the pandemic and to a lesser degree, by other health professionals. Most commonly stated pros dealt with employee and patient safety, while key cons dealt with increased costs and running out of the necessary protective equipment. Key barriers to pharmacy activities were price increases by wholesalers, and patients' panic and excessive buying, whereas drivers dealt with professional obligation to assist and opportunity to prove inseparable to other health professionals. The most popular means of accessing COVID-19 related information by pharmacists was via mobile devices and information from professional organizations was considered most useful by pharmacists. Conclusions Community pharmacies actively implemented various measures as precautions to mitigate the spread of COVID-19. Our findings highlight the value of continuous provision of information by professional organizations and use of mobile devices as key means to access information by pharmacists.