Changes in human immunodeficiency virus and sexually transmitted infections-related sexual risk taking among young Croatian adults: 2005 and 2010 population-based surveys

Aim

To determine changes in sexual behaviors and other relevant characteristics related to human immunodeficiency virus (HIV) and sexually transmitted infection (STI) risks among young Croatian adults.

Method

We surveyed adults aged 18-24 in 2005 (n = 1092) and 18-25 in 2010 (n = 1005). Both samples were probabilistic and stratified by county, settlement size, age, and gender. The samples were non-matched. Trained interviewers conducted structured face-to-face interviews in participants’ households. The part of the questionnaire assessing sensitive information was self-administered.

Results

A majority of participants at both survey points (85.2%-86.2%) were sexually active. Median age at sexual debut (17 years) remained unchanged. Lifetime number of sexual partners was also stable. More women than men reported only one lifetime sexual partner. The prevalence of condom use at first intercourse increased (from 62.6 to 70%, P = 0.002), while the prevalence of condom use at most recent sexual intercourse remained stable (54% in 2005 and 54.7% in 2010). Consistent condom use also remained unchanged. About one fifth of participants (19.2% in 2005 and 20% in 2010) reported consistent condom use in the past year. At both survey points for both genders, consistent condom use was associated with age (odds ratio [OR] _Women2005 = 0.74, P = 0.004; OR_Women2010 = 0.72, P < 0.001; OR_Men2005 = 0.73, P < 0.001; OR_Men2010 = 0.80, P = 0.006), negative attitudes toward condom use (OR_Women2005 = 0.84, P = 0.001; OR_Women2010 = 0.90, P = 0.026; OR_Men2005 = 0.92, P = 0.032; OR_Men2010 = 0.90, P = 0.011)), and condom use at first intercourse (OR_Women2005 = 3.87, P < 0.001; OR_Women2010 = 4.64, P < 0.001; OR_Men2005 = 5.85, P < 0.001; OR_Men2010 = 4.03, P < 0.001). In the observed period, HIV/AIDS knowledge was stable.

Conclusion

Risky sexual practices remain common among young Croatian adults. Given the recently reported STI prevalence rates in this age cohort, introduction of school-based sex education that would focus on protective behavioral and communication skills seems to be of crucial epidemiological importance.Adolescents and young adults are more vulnerable to sexually transmitted infections (STI) than other segments of the general population. Inclined to intense exploration of their sexuality (1), young people are more likely to frequently change sexual partners, have multiple, often high-risk partners, and experiment with different sexual practices (2). In the same time, they often lack comprehensive knowledge of risks related to sexual health, as well as the communication and behavioral skills required for safer sex (3). It is therefore no surprise that most studies on youth sexuality focus on negative consequences of sexual activities (4-8).A recent acquired immunodeficiency syndrome (AIDS) epidemic update suggested that almost half of all new human immunodeficiency virus (HIV) infections worldwide occurred among people aged 15-24 years (9). One study of adolescents in the United States of America found that about 50% of all newly contracted STIs were reported among adolescents and young adults, with human papillomaviruses (HPV), trichomoniasis, and Chlamydia trachomatis being the most frequently acquired STIs (10). Although we lack biological data on STIs in Croatia, the existing data on HPV suggest that the prevalence of STIs in the country might be comparable. As recently observed, vulnerability to HPV infections seems to be highest among women in their late teens and early twenties (11,12). This is not surprising given the well-documented inconsistency of condom use in the population (3,13-17). The situation is not substantially better among well-educated young adults. In a cross-sectional study carried out in 1998, 2003, and 2008 among the University of Zagreb first-year students, fewer than a half of participants reported using condoms regularly (18).Unfortunately, there is no comprehensive sex education in Croatian public schools. The recent debates about its introduction proved highly controversial and politicized (19). As a result, the initiative was officially qualified as an unnecessary burden to the national curriculum and dropped (20). Under such circumstances, systematic monitoring of sexual risks among young people is an important public health task. The aim of this article is to provide evidence-based rationale for interventions and educational programs focusing on reproductive and sexual health issues. In this first repeated cross-sectional study based on national probability samples carried out in Croatia, we examine core indicators of sexual risk taking and other relevant characteristics of young adults in the period 2005-2010 to inform a national response to HIV and STI risks among young people.     

Socioeconomic inequalities, health damaging behavior, and self-perceived health in Serbia: a cross-sectional study

Aim

To analyze the association of socioeconomic factors with self-perceived health in Serbia and examine whether this association can be partly explained by health behavior variables.

Methods

We used data from the 2007 Living Standards Measurement Study for Serbia. A representative sample of 13 831 persons aged ≥20 years was interviewed. The associations between demographic factors (age, sex, marital status, and type of settlement), socioeconomic factors (education, employment status, and household consumption tertiles), and health behavior variables (smoking, alcohol consumption) and self-perceived health were examined using logistic regression analyses.

Results

A stepwise gradient was found between education and self-perceived health for the total sample, men, and women. Compared to people with high education, people with low education had a 4.5 times higher chance of assessing their health as poor. Unemployed (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.29-2.10), inactive (OR, 2.82; 95% CI, 2.49-3.19), and the most deprived respondents (OR, 1.17; 95% CI, 1.02-1.34) were more likely to report poor self-perceived health than employed persons and the most affluent group. After adjustment for demographic and health behavior variables, the magnitudes of all associations decreased but remained clearly and significantly graded.

Conclusions

This study revealed inequalities in self-perceived health by socioeconomic position, in particular educational and employment status. The reduction of such inequalities through wisely tailored interventions that benefit people’s health should be a target of a national health policy in Serbia.Socioeconomic inequalities in health between and within countries have received considerable attention in health research. There are many measures that are of potential importance to the study of inequalities in health, but self-perceived health has been a very good source of information on subjective health status, incorporating aspects of both physical and mental health (1). This measure, based on a single-item, has been recommended as a population health measure by the World Health Organization and European Union Commission (2,3). The shape of health inequalities typically follows an inverse gradient, ie, the lower the socioeconomic status, the higher the probability of reporting a poor self-perceived health (4,5). Individuals with lower educational attainment or income, unemployed individuals, and individuals employed in manual occupations, are more likely to have poor self-perceived health (6-8). However, despite this typical pattern, the magnitude of socioeconomic inequalities in health varies widely in different populations (9).A consistent association between socioeconomic determinants and health related variables has been found in many European countries (10-12). Carlson demonstrated that the so-called European health divide, documented for mortality, was also noticeable in self-perceived health (13). Mackenbach et al compared the magnitude of inequalities in self-assessed health among 22 countries in Europe and found that in almost all countries the rates of poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, while the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others (14). On average, people from Eastern European countries rated their health worse than those from Western European countries (13,14). Poor health status in Eastern Europe may be influenced by unhealthy lifestyles associated with lack of information about health and behavior (15). East-west difference in health status may be partly explained by differences in health behaviors (such as smoking and alcohol consumption) and psychosocial factors (16).Despite the growing literature on this issue in central and west Europe, few studies have examined the impact of socioeconomic inequalities in self-rated health in southeastern Europe. In Serbia, a country still in the process of transition, little is known about health inequalities (17,18). Several recently published studies have brought to light the significance of socioeconomic inequalities in Serbia: in the prevalence of chronic diseases (19), morbidity status (20), and smoking habits of the population (21).The aim of this study was to analyze the association of socioeconomic factors with self-perceived health in Serbia using the 2007 Living Standards Measurement Study data (LSMS). Additionally, we examined whether this association can be partly explained by health behavior variables.     

Frequency of tuberculosis at autopsies in a large hospital in Zagreb, Croatia: a 10-year retrospective study

Aim

To assess the frequency and forms of pulmonary tuberculosis at autopsy in a high-traffic hospital in the capital city of a country with a low tuberculosis incidence.

Methods

We performed a retrospective search of autopsy data from the period 2000 to 2009 at Sestre Milosrdnice University Hospital Center, Zagreb, Croatia. We also examined patients’ records and histological slides.

Results

Of 3479 autopsies, we identified 61 tuberculosis cases, corresponding to a frequency of 1.8%. Active tuberculosis was found in 33 cases (54%), 23 of which (70%) were male. Of the 33 active cases, 25 (76%) were clinically unrecognized and 19 (76%) of these were male.

Conclusion

Clinically undiagnosed tuberculosis accounted for a substantial proportion of active tuberculosis cases diagnosed at autopsy. Autopsy data may be an important complement to epidemiological data on tuberculosis frequency.Each year, there are nearly 9 million new tuberculosis cases globally and nearly 2 million tuberculosis-related deaths (1,2). Tuberculosis occurs throughout the world, but its incidence varies greatly (3). Preventing infection through contact between healthy individuals and patients is the best measure to fight tuberculosis. The new World Health Organization strategy to fight tuberculosis, Stop TB Strategy (2006-2015), deals with the human immunodeficiency virus epidemic that has increased the incidence of tuberculosis (4). The European Centre for Disease Prevention and Control in 2008 created a strategy against tuberculosis called the “Framework Action Plan to Fight Tuberculosis in the European Union” (5). The long-term goal of the Stop TB Strategy and TB Framework Action Plan is to control and ultimately eliminate tuberculosis in the world based on four basic principles: ensure prompt and quality care for all; strengthen the capacity of health systems; develop new tools; and build partnerships and collaboration with countries and stakeholders (4,5).Croatia has a low incidence of tuberculosis, which has been steadily decreasing for the last five decades (6). The peak of the epidemic was at the turn of the 19th and 20th century, when more than 400 deaths per 100 000 people occurred as a direct result of tuberculosis (6). In the mid-20th century, the incidence of new tuberculosis cases was 20 000 per 100 000 people (6). In 2009, the incidence of new tuberculosis cases was 20 per 100 000 people (7) and in 2006 nearly all reported cases showed low levels of multidrug resistance (2,6,7). In accordance with international and European efforts, Croatia has its own guidelines for the fight against tuberculosis, with the following goals: to cure at least 85% of cases; to detect at least 70% of tuberculosis patients, and to decrease the incidence of the disease to 10 per 100 000 people (6-8).Although tuberculosis can affect any organ, 70%-80% of cases suffer from pulmonary tuberculosis (2). Generally, it is possible to detect tuberculosis infection 8-10 weeks after exposure based on a positive tuberculin skin test or an interferon-gamma release assay (9). The rest of the cases have latent tuberculosis infection (LTBI), which is an asymptomatic condition, and cannot transmit the disease (1,2). However, transmission becomes possible under certain conditions such as stress or immune suppression (6,10,11). It is believed that individuals with LTBI account for most infections in low-incidence countries like Croatia, and that this problem is compounded by migration and increasing numbers of homeless persons, alcoholics, and drug addicts (6,10,12).Statistics about tuberculosis prevalence may underestimate the number of infected people, since as many as half of the cases of pulmonary tuberculosis seen at autopsy were previously undiagnosed (12,13). In fact, few studies have examined the relationship between tuberculosis diagnoses at autopsy and reported tuberculosis prevalence in the population (14). This information may help assess whether clinically unrecognized tuberculosis poses a significant public health threat. The present study examined 3479 autopsies performed from 2000 through 2009, to assess the frequency and forms of pulmonary tuberculosis in a country with a low tuberculosis incidence. The results were compared with the number of tuberculosis patients in Croatia recorded in the Croatian Health Service Yearbook for the same period (7,8).     

Patterns of internet use and mental health of high school students in Istria County,Croatia: cross-sectional study

Aim

To examine associations between different forms of internet use and a number of psychological variables related to mental health in adolescents.

Methods

A cross-sectional survey was carried out on a representative sample of students (N = 1539) from all high schools in the region of Istria in Croatia (14-19 years). The associations between four factors of internet use and nine mental health indicators were analyzed using canonical correlation analysis.

Results

The four canonical functions suggested a significant association between different types of internet use and specific indicators of mental health (P < 0.001). Problematic internet use, more typical among boys, was associated with general aggressive behavior and substance abuse (P < 0.001). Experiences of harassment, more typical among girls, were associated with health complaints, symptoms of depression, loneliness, and fear of negative evaluation (P < 0.001). Using the internet for communication and entertainment was associated with better relationships with peers (P < 0.001), while use of the internet for academic purposes was associated with conscientiousness (P < 0.001).

Conclusion

The results suggest that different patterns of internet use are significantly associated with specific sets of positive and negative mental health indicators. The data support the assumption that internet use can have both positive and adverse effects on the mental health of youth.New technologies, and especially the use of computers and the internet, are part of the everyday lives of young people and have a significant impact on their psychological development. Indeed, this mass use of new media technologies presents parents and society with a challenge to protect and support the positive development of children and youth. To date, a number of studies have examined the positive and negative aspects of using internet technologies.Literature points to several positive aspects of internet use (1,2): for information acquiring, communication, and social networking, entertainment, and online shopping. More specifically, adolescents use the internet as a useful source of information about school assignments, daily events, interests and hobbies, or health and sexuality concerns. In these instances, online activities aimed at connecting with peers have a significant place. Visiting social networking sites and using communication tools such as email, chat, forums, and discussion groups enables the creation of friendships and social groups and contributes to the development of personal identity (3). The use of computers and the internet (cyberspace) has also been argued to provide opportunities for new and faster learning, exercising one''s self-control, considering different opinions, expressing one''s attitudes and tolerance, and developing skills in critical thinking and decision-making (4). Best et al (5) found that use of online communication technologies contributed to increased self-confidence, better perception of social support, greater social capital, positive experimenting with one’s own identity, and greater opportunities for open self-disclosure. Conversely, adolescents who do not use the internet might trail behind in the development of such positive attitudes and traits and risk being rejected by their peers (6). Finally, Livingstone et al (7) found that a certain amount of risk exposure was useful in building resilience.In contrast to these positive influences of internet use, harmful effects of internet abuse range from exposure to inappropriate sexual content, pornography, and violence (2,7) to humiliation and cyber-bullying (6,8-10) and internet addiction (11,12). Research has confirmed the link between internet abuse and social isolation, depression and, anxiety (1,5,13,14), alcohol and drug abuse and gambling (15), and problems with physical health (16). Ybarra and Mitchell (17) found a connection between experiences of threats or humiliation in the virtual world and absences from school, lower school achievement, substance use disorders, delinquency and depression. Fekkes et al (18) point to the association between victimizing experiences and a number of physical, emotional, and behavioral problems, such as headaches, tension, fatigue, loss of appetite, enuresis, and sleeping problems. Slonje and Smith (19) define such experiences as a product of cyber-bullying and argue that this can be viewed as another form of aggressive behavior. Gender has emerged as a significant predictor of the manner in which the internet is used. Specifically, girls tend to experience victimizing experiences, while boys more frequently demonstrate antisocial behavior (20,21).Although many studies have identified both positive and negative correlates of internet use, there have been only a few studies using complex multivariate analyses to identify broader patterns of internet use and adolescent mental health (22,23). Less is known about how adolescents exhibiting different personalities and different emotional and behavioral patterns engage in internet use and what might be the consequences of this engagement. The aim of this study was to determine the specific patterns of internet use and mental health among adolescents. The following hypotheses were tested:H1: Problematic internet use is associated with externalized symptoms and other negative indicators of mental health. Exposure to victimizing and disturbing content on the internet is associated with internalized symptoms and negative indicators of mental health.H2: Prosocial internet use (aimed at connecting with peers and entertainment) and internet use for school purposes are associated with positive aspects of mental health.H3: Problematic internet use is present more often in young men, while exposure to disturbing content on the internet is more frequently experienced by young women.     

Prevalence of erectile and ejaculatory difficulties among men in Croatia

Aim

To determine the prevalence and risk factors of erectile difficulties and rapid ejaculation in men in Croatia.

Method

We surveyed 615 of 888 contacted men aged 35-84 years. The mean age of participants was 54 ± 12 years. College-educated respondents and the respondents from large cities were slightly overrepresented in the sample. Structured face-to-face interviews were conducted in June and July 2004 by 63 trained interviewers. The questionnaire used in interviews was created for commercial purposes and had not been validated before.

Results

Out of 615 men who were sexually active in the preceding month and gave the valid answers to the questions on erectile difficulties and rapid ejaculation, 130 suffered from erectile or ejaculatory difficulties. Men who had been sexually active the month before the interview and gave the valid answers to the questions on sexual difficulties reported having erectile difficulties more often (77 out of 615) than rapid ejaculation (57 out of 601). Additional 26.8% (165 out of 615) and 26.3% (158 out of 601) men were classified as being at risk for erectile difficulties and rapid ejaculation, respectively. The prevalence of erectile difficulties varied from 5.8% in the 35-39 age group to 30% in the 70-79 age group. The association between age and rapid ejaculation was curvilinear, ie, U-shaped. Rates of rapid ejaculation were highest in the youngest (15.7%) and the oldest (12.5%) age groups. Older age (odds ratios [OR], 6.2-10.3), overweight (OR, 3.3-4.2), alcohol (OR, 0.3-0.4), intense physical activity (OR, 0.3), traditional attitudes about sexuality (OR, 2.8), and discussing sex with one’s partner (OR, 0.1-0.3) were associated with erectile difficulties. Education (OR, 0.1-0.3), being overweight (OR, 22.0) or obese (OR, 20.1), alcohol consumption (OR, 0.2-0.3), stress and anxiety (OR, 10.8-12.5), holding traditional attitudes (OR, 2.8) and moderate physical activity (OR, 0.1) were factors associated with rapid ejaculation.

Conclusion

The prevalence of erectile difficulties was higher than the prevalence of rapid ejaculation in men in Croatia. The odds of having these sexual difficulties increased with older age, overweight, traditional attitudes toward sex, and higher level of stress and anxiety.A growing number of international studies on sexual health issues suggest that many women and men worldwide have sexual health problems (1-4). According to surveys based on community samples, the prevalence of male sex disturbances ranges between 10% and 50% (2,4). The most frequent male sexual disturbance seems to be premature or rapid ejaculation (5,6), reported to range from 4% to 29% (6). The Global Study of Sexual Attitudes and Behaviors estimated the prevalence of rapid ejaculation at approximately 30% across all age groups (7). Actually, it seems to be the most common of all male sexual disturbances (5-9). However, when objective definition of rapid ejaculation is attempted, problems arise (9,10). According to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), rapid ejaculation is a persistent or recurrent onset of orgasm and ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it (11). It results in pronounced distress or interpersonal difficulties and is not exclusively due to the direct effects of a substance used (11). Although useful for clinical practice, this definition does not offer precise guidelines for epidemiological research. As indicated by large discrepancies in the prevalence rates (6), epidemiological analyses of rapid ejaculation are characterized by definition and measurement inconsistencies (1,10,12).In spite of the lack of agreement as to what constitutes rapid ejaculation (12) and the fact that it is not a well-understood problem (5,13), the consequences are well known. Chronic rapid ejaculation is accompanied by an array of psychological problems, including a psychogenic erectile dysfunction (14). Rapid ejaculation can seriously burden interpersonal dynamics and decrease sexual satisfaction (15) and sometimes the overall quality of intimate relationship (16,17). In addition to frustrations, withdrawal (including the lack of desire and cessation of sexual contacts), and strained relationship, rapid ejaculation causes changes in self-image and one’s sense of masculinity. It has been shown that rapid ejaculation has similar psychological impact as erectile problems, especially in terms of self-confidence and worries over the relationship, both the present and the future ones (14).Psychologically and culturally, erectile difficulties are the most dreaded male sexual problem (16,18,19), which not only result in deep frustration, but often lead to a crisis of masculine identity (19). Recent pharmacological breakthrough has initiated a rapid growth of interest in the epidemiology of erectile difficulties. Current studies suggest that a sizeable proportion of adult men suffer from erectile difficulties and that the likelihood of erectile difficulties increases with age (1-4). According to a recently published systematic review, the prevalence of erectile difficulties ranges from 2% in men younger than 40 years to over 80% in men aged 80 years or more (4). Due to the aging of population, the number of men with erectile difficulties is expected to be rising (20,21). The projection based on the results of the Massachusetts Male Aging Study (MMAS) from 1995 is that the number of men with the condition will more than double by 2025 (22).How do we explain considerable variations in reported prevalence rates of erectile difficulties? Methodological and conceptual differences between the studies (1,3,4,23) seem to be the main reason, although the effect of culture-specific perception of sexual problems should not be underestimated (24). In spite of a large number of population or community sample studies (18,20,25-38), inconsistent definitions and operationalization seriously hamper the analysis of the role of culture in perception and reporting of erectile difficulties in men.In transitional countries, sexual health is a rather neglected research area. The main reason for that is the lack of education and research training of possible investigators in the field of sexology. In Croatia, sexual health issues have only recently gained attention as a topic worthy of clinical (39) and non-clinical research (40,41). Our aim was to determine the prevalence of and risk factors for erectile difficulties and rapid ejaculation in a national sample of Croatian men.     

Awareness,knowledge, use,and attitudes toward evidence based medicine in a developing country: survey of physicians in a canton in Bosnia and Herzegovina

Aim

To assess awareness, knowledge, use, and attitudes toward evidence-based medicine (EBM) and The Cochrane Library (CL) among physicians from Zenica-Doboj Canton (ZDC), Bosnia and Herzegovina.

Methods

In this cross-sectional study, a self-administered anonymous questionnaire was sent by post to all state owned health institutions (2 hospitals and 11 Primary Health Care Institutions) in ZDC. The main outcome measures were physicians’ awareness of the Cochrane, awareness and use of CL, access to EBM databases, and access to internet at work. 358 of 559 physicians responded (63.69%).

Results

23.18% of respondents stated they had access to EBM databases, but only 3.91% named the actual EBM databases they used. The question on the highest level of evidence in EBM was correctly answered by 35.7% respondents, 34.64% heard about Cochrane and 32.68% heard about CL. They obtained information about CL mostly on the internet and from colleagues, whereas the information about EBM was obtained mainly during continuous medical education.

Conclusion

Although the attitudes toward EBM are positive, there is a low awareness of EBM among physicians in ZDC. Open access to the CL should be used more. Educational interventions in popularizing EBM and Cochrane are needed to raise awareness both among students and practicing physicians, and finally among lay audience.Evidence based medicine (EBM) is described as an integration of individual clinical expertise, the best available external clinical evidence from systematic research, and individual patients’ predicaments, rights, and preferences, in making clinical decisions about their care (1,2). However in many settings there are still barriers to its implementation (3-6).Awareness, knowledge, use, and attitudes toward EBM have been assessed worldwide (6,7). Attitudes toward EBM were mostly positive and participants welcomed the promotion of EBM (6-11). Barriers to practicing EBM differed between developing and developed countries. For example, respondents from Iran (8) reported that a major barrier was the lack of EBM training courses, while those from the Netherlands and Belgium reported limited time, attitudes, knowledge, and skills (5,12-14).Systematic reviews with or without meta-analysis produced by The Cochrane Library (CL) are considered as the “gold standard” in EBM (15-18). Cochrane systematic reviews (CSRs) can raise the quality of health care, especially in developing countries with scarce resources. For example, CSRs have been shown to provide invaluable evidence in creating national reimbursement lists (19).A nation-wide study among physicians in Croatia concluded that there was low awareness about EBM and the CL (30%), and additional educational interventions were required (6). Unlike Croatia, Bosnia and Herzegovina (BH) has no organized Cochrane activity (20). Our study aimed to assess the awareness, knowledge, use, and attitudes toward EBM and the CL (as the only available EBM database in BH with unrestricted access) among physicians in Zenica-Doboj Canton (ZDC), to help in the implementation of educational activities that would improve the use of EBM and the CL.     

Validation of Questionnaire Estimating Predictors of Behavior Intention to Engage in First Sexual Intercourse Among Eighth-grade Pupils

Aim

To use structural equation modeling in testing the construct validity of the questionnaire on the first sexual intercourse among young adolescents.

Methods

Previously created questionnaire for the estimation of different factors influencing the intention to engage in the first sexual intercourse was validated. The data were gathered anonymously from a nationally representative sample of 1217 elementary school pupils aged 14-15 in Slovenia. The construct validity was determined by the structural equation modeling, LISREL 8.7.

Results

The reliability of the questionnaire was satisfactory (Cronbach α = 0.73). Using the structural equation modeling analyses, the fit between empirical and theoretical models was confirmed, with 18 variables (17 independent and 1 dependent) for 6 latent indicators (5 external and 1 internal). The measures of goodness of fit were χ²₈₀ = 57.040; P = 0.976; the root mean square error of approximation was <0.001; the root mean square residual was 0.0249; the goodness of fit index was 0.994; the adjusted goodness of fit index was 0.988; the normed fit index was 0.993; and the relative fit index was 0.986. The instrument explained 34% of the variance in behavior intention.

Conclusion

The construct validity of the questionnaire on the intention to engage in the first sexual intercourse among young adolescents was satisfactory. This questionnaire could be a useful tool in health promotion programs.A person''s sexual behavior, including behavior related to sexual initiation, is influenced by physical and psychological characteristics of an individual, written and unwritten moral norms and rules, and social and cultural beliefs and behaviors (1,2). Therefore, it is important to identify the factors that influence such behavior and incorporate the obtained knowledge in preventive activities.A number of theories exist to explain behavior and influences on behavior. The Theory of Planned Behavior (TPB) is the most popular socio-cognitive model, developed by Ajzen in 1985 (3). It is based on the theory of reasoned action of Ajzen and Fishbein (3-5), which proposes that people are normally reasonable and use available information in a predictable way. According to TPB, behavior is directly determined by intention to engage in behavior and perception of control over performance of behavior (3-5). The behavioral intention can be mathematically predicted from a linear combination of 3 variables (Figure 1): 1) attitudes toward a given behavior, which are a function of salient beliefs about consequences of this behavior, weighted by evaluation of the consequences; 2) subjective norms, which refer to the persons'' willingness to accept beliefs of important others and to their motivation to comply with the expectations of important others; and 3) perceived behavioral control, which indicates how effective a person is in controlling his or her behavior (3-5).Open in a separate windowFigure 1Theory of planned behavior (1).Ajzen’s model proved to be suitable for evaluation of determinants of a healthy life-style and is widely used in studying different types of healthy behavior: condom use, use of contraceptives, legal and illegal drug use, physical activity, dietary behaviors, sun protective behaviors, screening attendances, breast/testicular self-examination, and adherence to medications (5).Studying the determinants of behavioral intention to engage in the first sexual intercourse is important for understanding sexual behavior of youth and can be used in the creation of healthy behavior promotion programs (6-9). In our previous study, we used TPB model to develop a questionnaire for this purpose (10). The aim of the present study is to perform validity analysis of the questionnaire – to determine whether the questionnaire assesses what it was designed to assess. For validation of the questionnaire, we used structural equation modeling (SEM) analysis (11-13), which is one of multivariate techniques for the evaluation of construct validity of a questionnaire (6,13-18). SEM directly incorporates measurement error in the estimation process and simultaneously estimates several interrelated dependence relationships (19).The aim of the study was to use SEM in testing the construct validity of the questionnaire on engaging into the first sexual intercourse among young adolescents.     

Care-seeking and quality of care for outpatient sick children in rural Hebei,China: a cross-sectional study

Aim

To assess the quality of outpatient pediatric care provided by township and village doctors, prevalence of common childhood diseases, care-seeking behavior, and coverage of key interventions in Zhao County in China.

Methods

We conducted two cross-sectional surveys: 1) maternal, newborn, and child health household survey including1601 caregivers of children younger than two years; 2) health facility survey on case management of 348 sick children younger than five years by local health workers and assessment of the availability of drugs and supplies in health facility.

Results

Our household survey showed that the prevalence of fever, cough, and diarrhea was 16.8%, 9.2%, and 15.6% respectively. Caregivers of children with fever, cough, and diarrhea sought care primarily in village clinics and township hospitals. Only 41.2% of children with suspected pneumonia received antibiotics, and very few children with diarrhea received oral rehydration solutions (1.2%) and zinc (4.4%). Our facility survey indicated that very few sick children were fully assessed, and only 43.8% were correctly classified by health workers when compared with the gold standard. Use of antibiotics for sick children was high and not according to guidelines.

Conclusion

We showed poor quality of services for outpatient sick children in Zhao County. Since Integrated Management of Childhood Illness strategy has shown positive effects on child health in some areas of China, it is advisable to implement it in other areas as well.Globally the number of deaths of children younger than five years decreased from 9.6 million to 7.6 million between 2000 and 2010, despite increases in the number of live births (1-3). During the past 20 years China made great achievements concerning child survival. Between 1990 and 2006, under-five mortality rate decreased from 64.6 to 20.6 per 1000 live births, and Millennium Development Goal 4 (MDG4) was achieved nine years ahead of the target set for 2015 (4-6). In 2011, under-five mortality rate was further reduced to 15.6 per 1000 live births (7). While this progress is remarkable, there remains the challenge of urban-rural mortality rate differences. Under-five mortality rate in rural areas was 2.7 times higher than in urban areas, 19.1 and 7.1 per 1000 live births, respectively (7).Under-five mortality decrease was achieved by focusing on social development and sustained economic growth and investments in health system, including expansion of health intervention coverage (8-10). However, these were much lower in rural areas. In 2010, rural residents’ net income per capita was 5919 Yuan, which was less than one third of urban residents’ income (19 109 Yuan) (11), and the health expenditure per capita in urban areas was 3.5 times lower than in rural areas, 2316 Yuan vs 666 Yuan (7). In 2009, the number of health professionals per 1000 population was 6.03 in urban and 2.46 in rural areas, respectively (12). These factors reduce overall rural health care quality as well as the quality of pediatric care, which in rural China is often less than desirable (13-15).To improve child survival, in the mid-1990s the World Health Organization (WHO) and United Nation’s Children Funds (UNICEF) jointly developed the Integrated Management of Childhood Illness (IMCI) strategy (16,17). The IMCI strategy has reduced the number of deaths due to diarrhea, pneumonia, malaria, measles, and malnutrition, which was estimated to 70% of all global deaths of children younger than 5 years at that time (18). IMCI has already been introduced into more than 100 countries (WHO 2005). In China it was introduced in 1998 and since 2003 has been expanded to 46 counties in 11 provinces, considerably improving health workers’ skills (19,20). Although IMCI has been in force in China for more than 10 years, training coverage remains very low for township and village doctors (21).In 2010, the Ministry of Health of China launched a research project aiming to explore the use of appropriate medical techniques in rural areas, and IMCI was selected as a key component of the project. We carried out a household survey and a health facility survey in Zhao County, Hebei Province before IMCI implementation. The household survey aimed to assess the prevalence of common childhood diseases, care-seeking behaviors, and population coverage of key interventions, and the health facility survey aimed to assess the quality of outpatient pediatric care by township and village doctors.     

Attitudes of Slovenian family practice patients toward changing unhealthy lifestyle and the role of family physicians: cross-sectional study

Aim

To assess patients’ attitudes toward changing unhealthy lifestyle, confidence in the success, and desired involvement of their family physicians in facilitating this change.

Methods

We conducted a cross-sectional study in 15 family physicians’ practices on a consecutive sample of 472 patients (44.9% men, mean age  [± standard deviation] 49.3 ± 10.9 years) from October 2007 to May 2008. Patients were given a self-administered questionnaire on attitudes toward changing unhealthy diet, increasing physical activity, and reducing body weight. It also included questions on confidence in the success, planning lifestyle changes, and advice from family physicians.

Results

Nearly 20% of patients planned to change their eating habits, increase physical activity, and reach normal body weight. Approximately 30% of patients (more men than women) said that they wanted to receive advice on this issue from their family physicians. Younger patients and patients with higher education were more confident that they could improve their lifestyle. Patients who planned to change their lifestyle and were more confident in the success wanted to receive advice from their family physicians.

Conclusion

Family physicians should regularly ask the patients about the intention of changing their lifestyle and offer them help in carrying out this intention.Unhealthy lifestyle, including unhealthy diet and physical inactivity, is still a considerable health problem all over the world. Despite publicly available evidence about the health risks of unhealthy lifestyle, people still find it hard to improve their unhealthy diet and increase physical activity. Previous studies have shown that attitudes toward lifestyle change depended on previous health behavior, awareness of unhealthy lifestyle, demographic characteristics, personality traits, social support, family functioning, ongoing contact with health care providers, and an individual’s social ecology or network (1-4).As community-based health education approaches have had a limited effect on health risk factors reduction (3,5), the readiness-to-change approach, based on two-way communication, has become increasingly used with patients who lead an unhealthy lifestyle (3,6,7). Family physicians are in a unique position to adopt this approach, since almost every patient visits his/hers family physician at least once in five years (8). Previous studies showed that patients highly appreciated their family physicians’ advice on lifestyle changes (9,10). Moreover, patients who received such advice were also more willing to change their unhealthy habits (3,7,11). The reason for this is probably that behavioral changes are made according to the patient’s stage of the motivational circle at the moment of consultation (12), which can be determined only by individual approach.Although family physicians are convinced that it is their task to give advice on health promotion and disease prevention, in practice they are less likely to do so (13). The factors that prevent them from giving advice are time (14,15), cost, availability, practice capacity (14), lack of knowledge and guidelines, poor counseling skills (16), and personal attitudes (17). It also seems that physicians’ assessment varies considerably according to the risk factor in question. For example, information on diet and physical activity are often inferred from patients’ appearance rather than from clinical measurements (14). Also, health care professionals seldom give advice on recommended aspects of intervention that could facilitate behavioral change (18). As a large proportion of primary care patients are ready to lose weight, improve diet, and increase exercise (19), it is even more important that their family physicians provide timely advice.So far, several studies have addressed patients’ willingness to make lifestyle change (2-5,20) and the provision of professional advice (3,5,7,10,11). However, none of these studies have investigated the relation between these factors. So, the aim of our study was to assess the relation between patients’ attitudes toward changing unhealthy lifestyle, confidence in success, and the desired involvement of their family physicians in facilitating the change.     

Association between social capital,health-related quality of life,and mental health: a structural-equation modeling approach

AimTo explore the association(s) between demographic factors, socioeconomic status (SES), social capital, health-related quality of life (HRQoL), and mental health among residents of Tehran, Iran.MethodsThe pooled data (n = 31 519) were extracted from a population-based survey Urban Health Equity Assessment and Response Tool-2 (Urban HEART-2) conducted in Tehran in 2011. Mental health, social capital, and HRQoL were assessed using the 28-item General Health Questionnaire (GHQ-28), social capital questionnaire, and Short-Form Health Survey (SF-12), respectively. The study used a multistage sampling method. Social capital, HRQoL, and SES were considered as latent variables. The association between these latent variables, demographic factors, and mental health was determined by structural-equation modeling (SEM).ResultsThe mean age and mental health score were 44.48 ± 15.87 years and 23.33 ± 11.10 (range, 0-84), respectively. The prevalence of mental disorders was 41.76% (95% confidence interval 41.21-42.30). The SEM model showed that age was directly associated with social capital (P = 0.016) and mental health (P = 0.001). Sex was indirectly related to mental health through social capital (P = 0.018). SES, HRQoL, and social capital were associated both directly and indirectly with mental health status.ConclusionThis study suggests that changes in social capital and SES can lead to positive changes in mental health status and that individual and contextual determinants influence HRQoL and mental health.Mental health is defined by World Health Organization (WHO) as “a state of well-being in which every individual realizes his/her own potential, can cope with the normal pressures of life, can work productively, and is able to make a contribution to his/her community” (1,2). Mental health and associated disorders have received increasing attention worldwide, largely due to their impact on socio-economic and overall health status of patients (3). Mental health problems remain a global concern, and account for a large fraction of diseases (4,5).The overall prevalence of mental disorders in Iran between 2000 and 2008 ranged from 12.5% to 38.9% and was similar in urban (20.9%) and rural areas (21.3%) (6). Anxiety and depression were more prevalent than somatization and social dysfunction (7). The provinces with the highest prevalence of mental problems were Chaharmahal with 38.3% and Golestan with 37.3% (8).Mental health is usually determined by a complex interaction of sociocultural, psychological, environmental, and demographic factors (9). The prevalence of mental health disorders is significantly associated with age, marital status, educational level, employment, and health-related to quality of life (HRQoL) (10). HRQoL incorporates physical and socio-emotional functioning and is used to measure individual''s perception of health status, welfare, and well-being in a society (11). A frequently used psychometrical tool for the assessment of HRQoL is Short-Form Health Survey (SF-12). Its two main components are physical component summary (PCS) and mental component summary (MCS), both of which are associated with mental health (12). Previous studies have confirmed a bidirectional association between physical health and depression (as one of the main dimensions of mental health) (13). However, it is not clear whether there is a causal relationship between them (13,14).The suggested mechanisms by which depression could lead to physical disability and decreased HRQoL are poor health behaviors, increased risk of physical disease, and characteristics of depression (eg, decreased pain threshold) (15). On the other hand, physical disability can lead to depression and deterioration of mental health due to restriction of social activities and loss of social capital (15). Ultimately, this bilateral association between depression and poor physical health can lead to increasing health risks (14).Mental disorders such as depression and anxiety are also influenced by socioeconomic status (SES) (16). SES is commonly conceptualized as an individual or group’s relative social standing or class (16,17). The main predictors of SES are education level, income, and occupation (15,17,18). The correlations between SES and mental health have been explained by various mechanisms. It has been found that negative impact of low SES on mental health (19) can be reduced by the mediating effect of social capital and physical health (4,18).Social capital has been defined as individual’s social networks and social interactions, shared norms, values, and understandings that facilitate collective action within or among groups. It can act as a protective factor, promoting mental health status by reducing socioeconomic inequalities (4,20) and play an important role in reducing the prevalence of mental disorders (4). Previous studies have found that social ties and support significantly improve mental health (9). Nonetheless, the association between social capital, mental health, quality of life, and SES is not consistently reported (21,22). This population-based study aims to explore the association between demographic factors, SES, social capital, HRQoL, and mental health among Tehran residents using structural-equation modeling (SEM).     

Multi-type childhood abuse, strategies of coping, and psychological adaptations in young adults

Aim

To retrospectively analyze the rate of multi-type abuse in childhood and the effects of childhood abuse and type of coping strategies on the psychological adaptation of young adults in a sample form the student population of the University of Mostar.

Methods

The study was conducted on a convenience sample of 233 students from the University of Mostar (196 female and 37 male), with a median age of 20 (interquartile range, 2). Exposure to abuse was determined using the Child Maltreatment Scales for Adults, which assesses emotional, physical, and sexual abuse, neglect, and witnessing family violence. Psychological adaptation was explored by the Trauma Symptom Checklist, which assesses anxiety/depression, sexual problems, trauma symptoms, and somatic symptoms. Strategies of coping with stress were explored by the Coping Inventory for Stressful Situations.

Results

Multi-type abuse in childhood was experienced by 172 participants (74%) and all types of abuse by 11 (5%) participants. Emotional and physical maltreatment were the most frequent types of abuse and mostly occurred together with other types of abuse. Significant association was found between all types of abuse (r = 0.436-0.778, P < 0.050). Exposure to sexual abuse in childhood and coping strategies were significant predictors of anxiety/depression (R² = 0.3553), traumatic symptoms (R² = 0.2299), somatic symptoms (R² = 0.2173), and sexual problems (R² = 0.1550, P < 0.001).

Conclusion

Exposure to multi-type abuse in childhood is a traumatic experience with long-term negative effects. Problem-oriented coping strategies ensure a better psychosocial adaptation than emotion-oriented strategies.There is a high degree of overlap between adults’ reports of sexual abuse, physical abuse, psychological maltreatment, neglect, and witnessing family violence (1-4). These problems tend to occur together. Children who are ridiculed or subjected to verbal attacks are also likely to be physically punished or harmed, have their physical or emotional needs neglected, and witness violence toward other members of the family. Multi-type abuse can be defined as the concurrent exposure of a child or adult to more types of maltreatment, including sexual abuse, physical abuse, psychological (emotional) abuse, neglect, and witnessing family violence (5).Researchers who study the consequences of multi-type abuse believe that more types of stress experienced by children exposed to various types of abuse and neglect actually accumulate and interact in different ways, thus producing more serious and less reversible consequences than in cases of single-type abuse (2,6-9). Posttraumatic stress disorder is one of the most common immediate consequences of abuse and neglect of children (10). Arata et al (11) have found that persons exposed to multi-type abuse were more depressed and suicidal, and expressed more feelings of helplessness than non-abused persons. Experiencing physical and mental abuse in childhood is associated with low self-esteem (12,13), deviant sexual behavior, difficulties in coping with anger/aggression, and psychosocial malfunctioning in adult age (14). When they reach adult age, victims of childhood sexual or physical abuse have more pronounced psychosocial disorders, chronic somatic symptoms, respiratory and gastrointestinal illnesses, increased risk of developing anxiety and depressive disorder, dissociative and trauma symptoms, as well as antisocial and asocial behavior (1,15,16). Edwards et al (17) have found a relationship between the number of different types of abuse and the consequences on mental health, ie, the more types of abuse a victim had experienced, the more serious were the consequences.Although the concept of coping with stress has been variously defined by different authors, coping can generally be conceived as a response to a stressful situation with the goal of psychosocial adaptation (18). Coping can involve problem-oriented strategies and emotion-oriented strategies. The former refer to attempts by a person to change the stressor, and specific strategies to achieve this are confrontation and planned problem-solving. In contrast, emotion-oriented coping refers to attempts to regulate negative emotional responses to a stressor, with self-control and distancing as specific strategies (19).Stressful life events are the most extensively studied environmental risk factors for the development of psychopathology in children and adolescents. These events can be everyday situations that pose irritating and frustrating demands on the child, events that are expected and desired by the child but that never take place, and intense stressful events such as traumas that are horrifying and very disturbing for the child. Stressful life events can precede various disorders, increase the risk of their occurrence, as well as appear as consequences of such disorders (20).Research on mechanisms that play a mediating role between the stressful events and occurrence of symptoms has yielded equivocal results. A number of variables such as age, sex, type of stressful event, reactions of parents and family, and coping strategies should all be taken into account when trying to answer why some individuals in certain situations react by developing symptoms of psychopathology, while others do not. Despite the complexity of this problem, one thing seems certain: how a child interprets and judges a certain event, and what strategies he or she uses to cope with stressful events, plays a decisive role in predicting future psychopathology (20).Research has still not established a reliable method for differentiating effective and non-effective coping strategies. Some studies indicate that emotion-oriented coping is associated with emotional and behavioral difficulties in children (21,22). At the same time, other researchers have failed to show that problem-oriented and active strategies contribute to the success of psychological adaptation (23,24). Indeed, the effectiveness of coping strategies depends on the specifics of the stressful situation. Strategies effective for one type of stress are not necessarily effective for other types (25).It has been shown that exposure to multi-type abuse in childhood is associated with more serious difficulties in psychological adaptation than exposure to single-type abuse (10-16). The question remains whether various protective factors, such as strategies of coping with stress (26-29), can mediate the psychological adjustment of people who were abused in childhood.The aim of this study was to perform a retrospective study on a sample of students of the University of Mostar, Bosnia and Herzegovina, in order to explore the rate of multi-type abuse in childhood and the effects of the type of childhood abuse and choice of coping strategy on the students’ psychological adaptation.     

Posttraumatic stress disorder symptoms and coping with the lockdown among help-seeking veterans before and during the COVID-19 pandemic

AimsTo compare the severity of posttraumatic stress disorder (PTSD) symptoms and of particular PTSD clusters among help-seeking veterans before and during the COVID-19 lockdown. The second aim was to identify the main coping strategies used.MethodsMale war veterans (N = 176) receiving outpatient treatment at the Referral Center for PTSD were assessed at baseline (12-18 months before the pandemic declaration in March 2020) and during the COVID-19 pandemic lockdown (March-June 2020). The Life Events Checklist for DSM-5, PTSD Checklist for DSM-5, and The Brief COPE were used.ResultsDirect exposure to the virus in our sample was low, and the majority of participants followed the preventive measures. The severity of the overall PTSD symptoms and of clusters of symptoms significantly decreased compared with the first assessment. At the second assessment, all participants still fulfilled the PTSD diagnosis criteria. During the lockdown, the participants used emotion-focused and problem-focused coping rather than dysfunctional coping.ConclusionThe severity of PTSD symptoms decreased during the lockdown. Further research is needed to study the trajectories of long-term psychopathology.

The COVID-19 pandemic has severely threatened the physical and mental health of individuals around the world. Stressors have included isolation, self-isolation or quarantine, restricted movement and physical contact, infection fears, loss of loved ones, lack of supplies, inadequate information (“infodemic”), financial loss, and social stigma (1-3). During emergencies, mental health requires special consideration due to increased rates of stress-related mental health problems and limited availability of mental health services (2-5).Depending on the emergency context, particular groups of people are at an increased risk of experiencing social and psychological problems (6), and ex-combatants have been repeatedly shown to be one of them (7).Exposure to a new traumatic or stressful life event might affect posttraumatic stress disorder (PTSD) symptoms. A growing body of research shows that such exposure is a risk factor for worsening of the condition in various groups of PTSD patients (8,9). This mainly happens if the subsequent event is of the same type as the initial stressors, serving as a reminder and as an additional traumatic factor with a “wear and tear” effect on the exposed person (10-13).Regarding the coping strategies used among PTSD patients, combat veterans with PTSD report a more ineffective and dysfunctional coping style, with the avoidance coping style as a predictive factor of the overall PTSD symptom severity (14-16). PTSD patients try to avoid confrontation with trauma-reminders, intrusive memories, and trauma-related thoughts and emotions (17,18). Some authors emphasize the importance of differentiating between coping strategies with PTSD symptoms and coping strategies with actual traumatic or stressful events as they depend on various factors related to the specific traumatic exposure (19).Twenty-five years after the Homeland War in Croatia (1991–1995), veterans still suffer from numerous health problems and have been highly prevalent among the users of the health facilities for PTSD treatment (20-22). The same is true for PTSD patients treated in the Referral Center of the Ministry of Health of the Republic of Croatia (RCPTSD) at the Clinical Hospital Center (CHC) Rijeka. A recent study revealed high rates of overall symptoms and severe posttraumatic symptoms (ie, complex PTSD) in this population years after the war ended (23).The COVID-19 pandemic lockdown in Croatia started on March 19, 2020. According to Oxford University, Croatia introduced the world''s strictest restrictions in relation to the number of the infected (24,25). On March 21, 2020, mental health experts from RCPTSD recommended self-help strategies for staying in good mental health and advice for front-liners on how to deliver psychological first aid (26,27). On the same day, the Croatian Psychiatric Association Expert Group released recommendations for the organization of psychiatric care, psychiatric interventions, and psychopharmacological treatment of mental conditions during the COVID-19 pandemic, and for de-escalation and appropriate communication techniques with aggressive patients (28-30). In RCPTSD, mental health service was restructured to be delivered via the internet or hotlines during the pandemic, with a possibility for urgent outpatient and inpatient treatment. On April 27, 2020, the lifting of restrictions began.To our knowledge, no study worldwide has examined the psycho-social correlates of the COVID-19 pandemic lockdown in veterans with PTSD. Therefore, we aimed to compare the severity of PTSD symptoms and of particular PTSD symptom clusters before and during the COVID-19 pandemic lockdown. Second, we identified the main coping strategies that veterans used during the lockdown.     

Delinquency in incarcerated male adolescents is associated with single parenthood,exposure to more violence at home and in the community,and poorer self-image

Aim

To assess the relationships between delinquency and demographic and family variables, academic performance, war stressors, home/community, school, and media violence exposure, self-image, and psychopathology.

Methods

This cross-sectional study included 100 delinquent, incarcerated male adolescents and 100 matched schoolchildren from Croatia. It lasted from January 2008 to June 2009, and used socio-demographic questionnaire, questionnaire on children’s stressful and traumatic war experiences, exposure to violence scale, the Offer Self-Image Questionnaire, and Youth Self-Report Questionnaire.

Results

Logistic regression analysis showed that delinquency in incarcerated adolescents was more likely related to having parents who did not live together (odds ratio [OR] 2.40; confidence interval [CI] 1.18-4.90, P = 0.015), being more exposed to violence at home/community (OR 3.84; CI 1.58-9.34, P = 0.003), and having poorer self-image (OR 1.09; CI = 1.03-1.16, P < 0.002).

Conclusion

Preventive and therapeutic interventions in incarcerated delinquents should be specifically targeted toward single parenthood, family factors, trauma oriented interventions, and focused on multiple dimensions of self-concept of adolescents.Delinquency is associated with many risk factors, including demographic, genetic, and family characteristics (single parenthood) or academic performance. Many studies have focused on exposure to various forms of violence – in the family or home; community and neighborhood; in school and peer groups; and the media, but other risk factors have also found to be important, such as poorer self-image, various forms of psychopathology, and social characteristics (neighborhoods characterized by poverty) (1-15). Most of the studies dealing with delinquency aim to develop therapeutic interventions in relation to the obtained factors or mediators (9,11,16).There are relatively few studies on incarcerated adolescents. Many report on delinquents’ traumatic experiences, posttraumatic stress disorder, and importance of developmental tasks of adolescence and parental monitoring (14,17,18). Therapeutic interventions are specifically directed toward assessment and intervention of trauma and psychopathology, and family interventions are used very often.There are not many studies on delinquents in Croatia and most of them deal with a model that takes into account the interplay between protective and risk factors (19-21). Factors that are often mentioned are parental distrust and punishment, and family dysfunctionality (22-24). The prevalence of delinquency in the last few years has not been reducing (25), which suggests that the current preventive and therapeutic efforts have not been sufficient (25). Another important factor that has to be considered when studying delinquency in Croatia is the influence of Croatian War for Independence 1991-1995. The relationship between war experiences (direct or indirect) and the development of delinquency in adolescents has been relatively rarely described, with contradictory findings. Some studies found no association between the impact of war and bullying (26), whereas others found a relationship between aggressiveness in child refugees and their past war experiences (27) or experiences of their parents, war veterans (28). Besides war-related violence, we expected that delinquency was related to the exposure to other types of violence, eg, violence at home (29). Finally, we also expected an association with poorer self-image (8) and the presence of significant psychopathological syndromes (7).Our aim was therefore to examine the relationship between demographic, family factors, academic performance, exposure to violence in different contexts (home, community, school, media, war related stress), psychopathology, and delinquency.     

Adverse drug reactions caused by drug-drug interactions reported to Croatian Agency for Medicinal Products and Medical Devices: a retrospective observational study

Aim

To analyze potential and actual drug-drug interactions reported to the Spontaneous Reporting Database of the Croatian Agency for Medicinal Products and Medical Devices (HALMED) and determine their incidence.

Methods

In this retrospective observational study performed from March 2005 to December 2008, we detected potential and actual drug-drug interactions using interaction programs and analyzed them.

Results

HALMED received 1209 reports involving at least two drugs. There were 468 (38.7%) reports on potential drug-drug interactions, 94 of which (7.8% of total reports) were actual drug-drug interactions. Among actual drug-drug interaction reports, the proportion of serious adverse drug reactions (53 out of 94) and the number of drugs (n = 4) was significantly higher (P < 0.001) than among the remaining reports (580 out of 1982; n = 2, respectively). Actual drug-drug interactions most frequently involved nervous system agents (34.0%), and interactions caused by antiplatelet, anticoagulant, and non-steroidal anti-inflammatory drugs were in most cases serious. In only 12 out of 94 reports, actual drug-drug interactions were recognized by the reporter.

Conclusion

The study confirmed that the Spontaneous Reporting Database was a valuable resource for detecting actual drug-drug interactions. Also, it identified drugs leading to serious adverse drug reactions and deaths, thus indicating the areas which should be in the focus of health care education.Adverse drug reactions (ADR) are among the leading causes of mortality and morbidity responsible for causing additional complications (1,2) and longer hospital stays. Magnitude of ADRs and the burden they place on health care system are considerable (3-6) yet preventable public health problems (7) if we take into consideration that an important cause of ADRs are drug-drug interactions (8,9). Although there is a substantial body of literature on ADRs caused by drug-drug interactions, it is difficult to accurately estimate their incidence, mainly because of different study designs, populations, frequency measures, and classification systems (10-15).Many studies including different groups of patients found the percentage of potential drug-drug interactions resulting in ADRs to be from 0%-60% (10,11,16-25). System analysis of ADRs showed that drug-drug interactions represented 3%-5% of all in-hospital medication errors (3). The most endangered groups were elderly and polimedicated patients (22,26-28), and emergency department visits were a frequent result (29). Although the overall incidence of ADRs caused by drug-drug interactions is modest (11-13,15,29,30), they are severe and in most cases lead to hospitalization (31,32).Potential drug-drug interactions are defined on the basis of on retrospective chart reviews and actual drug-drug interactions are defined on the basis of clinical evidence, ie, they are confirmed by laboratory tests or symptoms (33). The frequency of potential interactions is higher than that of actual interactions, resulting in large discrepancies among study findings (24).A valuable resource for detecting drug-drug interactions is a spontaneous reporting database (15,34). It currently uses several methods to detect possible drug-drug interactions (15,29,35,36). However, drug-drug interactions in general are rarely reported and information about the ADRs due to drug-drug interactions is usually lacking.The aim of this study was to estimate the incidence of actual and potential drug-drug interactions in the national Spontaneous Reporting Database of ADRs in Croatia. Additionally, we assessed the clinical significance and seriousness of drug-drug interactions and their probable mechanism of action.     

Breast and gynecological cancers in Croatia, 1988-2008

Aim

To analyze and interpret incidence and mortality trends of breast and ovarian cancers and incidence trends of cervical and endometrial cancers in Croatia for the period 1988-2008.

Methods

Incidence data were obtained from the Croatian National Cancer Registry. The mortality data were obtained from the World Health Organization (WHO) mortality database. Trends of incidence and mortality were analyzed by joinpoint regression analysis.

Results

Joinpoint analysis showed an increase in the incidence of breast cancer with estimated annual percent of change (EAPC) of 2.6% (95% confidence interval [CI], 1.9 to 3.4). The mortality rate was stable, with the EAPC of 0.3% (95% CI, -0.6 to 0.0). Endometrial cancer showed an increasing incidence trend, with EAPC of 0.8% (95% CI, 0.2 to 1.4), while cervical cancer showed a decreasing incidence trend, with EAPC of -1.0 (95% CI, -1.6 to -0.4). Ovarian cancer incidence showed three trends, but the average annual percent change (AAPC) for the overall period was not significant, with a stable trend of 0.1%. Ovarian cancer mortality was increasing since 1992, with EAPC of 1.2% (95% CI, 0.4 to 1.9), while the trend for overall period was stable with AAPC 0.1%.

Conclusion

Incidence trends of breast, endometrial, and ovarian cancers in Croatia 1988-2008 are similar to the trends observed in most of the European countries, while the modest decline in cervical cancer incidence and lack of decline in breast cancer mortality suggest suboptimal cancer prevention and control.Breast and gynecological cancers are among the seven most common female cancers in Croatia: in 2008 breast cancer was the most common cancer with the proportion of 26% of all cancer sites, endometrial cancer ranked fourth (6%), ovarian cancer (with fallopian tubes cancer) sixth (5%), and cervical cancer seventh (4%) (1).Breast, endometrial, and ovarian cancers share some similar risk factors like early menarche, late menopause, obesity, and low parity (2-5). Also, breast cancer in personal history increases the risk of endometrial and ovarian cancer (6). Delayed childbearing increases the risk of breast cancer but seems to have no impact on the development of ovarian and endometrial cancer (3-5). Diabetes mellitus increases the risk of endometrial and breast cancer (7,8). Use of tamoxifen or other selective estrogen receptor modulators increases the risk of endometrial and ovarian cancer, while the use of combined oral contraceptives is a protective factor (2,9,10). Also, tobacco smoking and alcohol intake reduce the risk of endometrial cancer (2,11,12). Alcohol intake and both oral contraceptives and hormonal replacement therapy are risk factors for breast cancer (2,13,14). Multiparty and physical activity are protective factors for all three cancers (2,4,15,16). Low socioeconomic status, sexually transmitted diseases, promiscuity, unprotected sexual behavior, earlier age of first intercourse, and smoking are risk factors for cervical cancer (2,17-23). Infection with human papillomavirus is considered as a necessary cause of cervical cancer (24).The aim of this study was to report the incidence and mortality of breast and ovarian cancers and incidence of endometrial and cervical cancers, analyze the trends in the period 1988-2008, and compare them to other European countries.     

Serosurvey of human metapneumovirus infection in Croatia

Aim

To assess the seroprevalence of human metapneumovirus (hMPV) in Croatia.

Methods

During 2005, a total of 137 serum specimens from Croatian patients aged from 6 days to 51 years, without respiratory symptoms, were collected at the Croatian National Institute of Public Health. The sera were examined using the indirect immunofluorescent assay.

Results

The overall hMPV seropositivity rate in the samples tested was 77.4% (106/137). The seropositivity rate increased from 18.7% in children aged between 6 months and 1 year to 100% in people older than 20 years of age. The highest proportion of titers ≥1:512 was found in children aged from 1 to 2 years.

Conclusion

Our results suggest that hMPV infection is present in Croatia, with primary infection occurring in early childhood. This is the first study that indicates the circulation of hMPV in Croatia.Human metapneumovirus (hMPV) is a newly discovered respiratory virus assigned to the Paramyxoviridae family, Pneumovirinae subfamily, Metapneumovirus genus. It was first isolated in 2001 from nasopharyngeal aspirates obtained from young children in the Netherlands (1). Sequence analysis of several isolates identified two major genetic lineages (subtypes A and B) that can be further divided into subgroups A1, A2, B1, and B2 (2). HMPV causes acute respiratory tract infections in all age groups (3,4). In hospitalized young children, hMPV infection is commonly present as bronchiolitis with or without pneumonitis (5,6), whereas bronchitis, bronchospasm, and pneumonitis are most commonly seen in elderly patients (3). Since the initial report, hMPV has been studied all over the world and it has been reported on all continents (7). Seroprevalence surveys from the Netherlands (1), Japan (8), and Israel (9) indicated that virtually all children are infected by 5-10 years of age. The aim of this study was to demonstrate the presence of hMPV infection in Croatia, by examining sera from Croatian people for specific anti-hMPV antibodies by an indirect immunofluorescent assay (IFA).     

Emotion work and burnout: cross-sectional study of nurses and physicians in Hungary

Aim

To investigate predictors of occupational burnout, such as emotion work, among health care workers and compare the frequencies of burnout and emotion work in nurses and physicians.

Method

A cross-sectional survey was conducted in 2007 and 2008 among 80 physicians and 76 nurses working in a variety of health care settings in Hungary. The survey contained sociodemographic questions and work- and health-related questions from, respectively, the Maslach Burnout Inventory-Human Services Survey and the Hungarian version of the Frankfurt Emotion Work Scale. To identify the dimensions of emotion work associated with burnout, linear regression analyses were carried out. To analyze differences in burnout and emotion work between nurses and physicians, independent t tests were used.

Results

Nurses reported significantly higher emotional dissonance and fewer regulation possibilities, such as interaction and emotion control, than physicians. However, no differences were found in the level or frequency of burnout. Nurses had fewer regulation requirements regarding sensitivity and sympathy. Linear regression analyses showed that emotional dissonance for emotional exhaustion (β = 0.401) and display of negative emotions for depersonalization (β = 0.332) were the strongest predictors of burnout.

Conclusion

The factors that should be taken into account when developing prevention and intervention programs differ for nurses and physicians. In nurses, the focus should be on stressors and emotional dissonance, while in physicians it should be on work requirements and display and regulation of negative emotions.During the last decade, the topic of emotion work has gained a much greater significance in organizational and health psychology. As defined by Zapf et al, emotion work occurs when employees are required by the employer to regulate their emotions in order to display appropriate emotions to the client (1). Emotion work determines the quality of social interaction between the caregiver and client. Action theory distinguishes 3 aspects of emotion work requirements: regulation requirements, regulation possibilities, and regulation problems. Regulation requirements (display of emotions) are related to properties of the hierarchical-sequential organization of action and constitute the complexity of decision. Regulation possibilities refer to the concept of control. Regulation problems, also known as emotional dissonance, are the discord between felt and expressed emotions and occur when stressors disturb the regulation of action (1,2). Current burnout research is greatly facilitated by theories explaining work stress (3-6). Using Karasek’s job demands control model, the research group of LeBlanc and DeJonge investigated emotional job demands (3-5). It was also found that health care workers are at high risk for emotional exhaustion resulting from interaction with clients (6,7).Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment occurring in people-oriented and service work (8). Emotional exhaustion refers to feelings of being depleted of one’s emotional resources. Depersonalization is a negative and cynical attitude and behavior toward clients. Reduced personal accomplishment is the self-perception of a decline in one’s own competence and self-efficacy. Burnout has most often been studied in caregiving professionals, such as clinicians, psychologists, social workers, and nurses (9-17). Indeed, several studies have directly measured the emotional aspects of job demands dealing either with emotion work (18-20) or burnout (21-24). However, few studies investigating the relationship between burnout and emotion work have been conducted in the nursing and health care profession, particularly in Hungary and Eastern Europe (25). The differences in burnout and emotion work between nurses and physicians have been studied in the Netherlands, Germany, and Spain (3-5,14,26). Some studies have suggested that physicians experience more burnout than nurses (14,16), while others have suggested the opposite (17).Recently, burnout has been conceptualized as a psychological syndrome that takes place in response to chronic interpersonal stressors on the job (6). According to Zapf, burnout makes individuals no longer able to adequately manage their emotions while interacting with clients (27). According to the model of emotion work by Grandey (28), antecedents of emotion regulation are the situational variables, eg, interaction between the caregiver and client.A relationship between burnout and emotion work has recently been found in the health care setting in Western European countries (3,4,29-31). Health care professionals, especially nurses, are at high risk of burnout because their job requires a high level of emotion work (18-20,32,33). Most studies have found a positive relationship between emotion work and burnout, suggesting that emotional dissonance may predict emotional exhaustion and depersonalization (25,34). Demerouti (35) argues that contribution of job demands and resources to explaining burnout may vary across occupations because these features differ across occupations. Burnout literature usually focuses on general variables that predict burnout and does not distinguish between predictors across health professions (6,8). Thus, we hypothesized that differences in emotion work can be detected between nurses and physicians, although the predictors of the syndrome do not vary.This study assesses the relationships between burnout and emotion work in a sample of Hungarian health care professionals and investigates how emotional job demands relate to the frequency of burnout.