Introduction Between 2021 and 2023, a project was funded in order to explore the mortality burden (YLL–Years of Life Lost, excess mortality) of COVID-19 in Southern and Eastern Europe, and Central Asia. Methods For each national or sub-national region, data on COVID-19 deaths and population data were collected for the period March 2020 to December 2021. Unstandardized and age-standardised YLL rates were calculated according to standard burden of disease methodology. In addition, all-cause mortality data for the period 2015–2019 were collected and used as a baseline to estimate excess mortality in each national or sub-national region in the years 2020 and 2021. Results On average, 15–30 years of life were lost per death in the various countries and regions. Generally, YLL rates per 100,000 were higher in countries and regions in Southern and Eastern Europe compared to Central Asia. However, there were differences in how countries and regions defined and counted COVID-19 deaths. In most countries and sub-national regions, YLL rates per 100,000 (both age-standardised and unstandardized) were higher in 2021 compared to 2020, and higher amongst men compared to women. Some countries showed high excess mortality rates, suggesting under-diagnosis or under-reporting of COVID-19 deaths, and/or relatively large numbers of deaths due to indirect effects of the pandemic. Conclusion Our results suggest that the COVID-19 mortality burden was greater in many countries and regions in Southern and Eastern Europe compared to Central Asia. However, heterogeneity in the data (differences in the definitions and counting of COVID-19 deaths) may have influenced our results. Understanding possible reasons for the differences was difficult, as many factors are likely to play a role (e.g., differences in the extent of public health and social measures to control the spread of COVID-19, differences in testing strategies and/or vaccination rates). Future cross-country analyses should try to develop structured approaches in an attempt to understand the relative importance of such factors. Furthermore, in order to improve the robustness and comparability of burden of disease indicators, efforts should be made to harmonise case definitions and reporting for COVID-19 deaths across countries.

Abstract Adoption of eating habits starts early in life, through interaction with family members and alongside preschool settings that offer context for developing healthy lifestyles among children. The aim of this study was to explore the perceptions and practices of teachers and parents related to the development of healthy eating habits among preschool children. Focus groups were conducted with a total sample of 48 parents and teachers (three focus groups among parents and three among teachers) from 15 kindergartens in the Republic of Srpska, Bosnia, and Herzegovina. All of the mentioned kindergartens are part of the “Nutrition friendly preschool/school initiative”, a program aimed at creating and developing settings that support and improve children's health. Focus groups were audiotaped, transcribed verbatim, and analyzed according to the Framework Method. Teachers emphasized that good communication and support from parents are important factors for the development of healthy eating habits. During COVID‐19, direct communication with parents was restricted, and mutual activities among teachers, children, and parents were reduced. Lack of knowledge, finance, and time are perceived by parents as main obstacles to the improvement of children's healthy eating habits. All participants in the focus groups agreed that more education and informative material are needed so their skills related to good nutrition can be improved and adopted in a culture‐sensitive way. Mutual support, education, and dissemination of informative materials are imposed as particularly important needs by all actors involved in the upbringing of children in order to support the development of children's healthy eating habits.

Introduction The COVID-19 pandemic has had an extensive impact on public health worldwide. However, in many countries burden of disease indicators for COVID-19 have not yet been calculated or used for monitoring. The present study protocol describes an approach developed in the project “The Burden of Disease due to COVID-19. Towards a harmonization of population health metrics for the surveillance of dynamic outbreaks” (BoCO-19). The process of data collection and aggregation across 14 different countries and sub-national regions in Southern and Eastern Europe and Central Asia is described, as well as the methodological approaches used. Materials and methods The study implemented in BoCO-19 is a secondary data analysis, using information from national surveillance systems as part of mandatory reporting on notifiable diseases. A customized data collection template is used to gather aggregated data on population size as well as COVID-19 cases and deaths. Years of life lost (YLL), as one component of the number of Disability Adjusted Life Years (DALY), are calculated as described in a recently proposed COVID-19 disease model (the ‘Burden-EU’ model) for the calculation of DALY. All-cause mortality data are collected for excess mortality sensitivity analyses. For the calculation of Years lived with disability (YLD), the Burden-EU model is adapted based on recent evidence. Because Covid-19 cases vary in terms of disease severity, the possibility and suitability of applying a uniform severity distribution of cases across all countries and sub-national regions will be explored. An approach recently developed for the Global Burden of Disease Study, that considers post-acute consequences of COVID-19, is likely to be adopted. Findings will be compared to explore the quality and usability of the existing data, to identify trends across age-groups and sexes and to formulate recommendations concerning potential improvements in data availability and quality. Discussion BoCO-19 serves as a collaborative platform in order to build international capacity for the calculation of burden of disease indicators, and to support national experts in the analysis and interpretation of country-specific data, including their strengths and weaknesses. Challenges include inherent differences in data collection and reporting systems between countries, as well as assumptions that have to be made during the calculation process.

Background and Objectives: Patient satisfaction with health care can influence health care-seeking behavior in relation to both minor or major health problems or influence communication and compliance with medical advice, which is especially important in emergencies such as the COVID-19 pandemic. Thus, it is important to continually monitor patient satisfaction with provided care and their dynamics. The aim of this study was to assess patient satisfaction with health care during the COVID-19 pandemic in the adult population of the Federation of Bosnia and Herzegovina (FB&H) and compare it with levels of satisfaction in the same population before the COVID-19 pandemic. Materials and Methods: A representative, population-based survey was implemented in the adult population of the FB&H using the EUROPEP instrument, which measures satisfaction with health care using 23 items. The sample included 740 respondents who were 18 years or older residing in the FB&H and was implemented in December 2020. All data were collected using a system of online panels. The survey questions targeted the nine months from the beginning of the pandemic to the time of data collection, i.e., the period of March to December 2020. Results: The mean composite satisfaction score across all 23 items of the EUROPEP tool was 3.2 points in all age groups; the ceiling effect was 22% for the youngest respondents (18–34 years old), 23% for 35–54 years old, and 26% for the oldest group (55+), showing increasing satisfaction by age. The overall composite score for both females and males was 3.2. The ceiling effect was higher in those with chronic disease (29% vs. 23% in those without chronic disease). The composite mean score for respondents residing in rural vs. urban areas was 3.2 with a ceiling effect of 22% in rural and 24% in urban residents. When comparing mean composite scores surveyed at various points in time in the FB&H, it was found that the score increased from 3.3 to 3.5 between 2011 and 2017 and dropped again to 3.3 in this study. Despite these observations in the overall trends of satisfaction scores, we note that no statistically significant differences were observed between most of the single-item scores in the stratified analysis, pointing to the relative uniformity of satisfaction among the analyzed population subgroups. Conclusions: The rate of satisfaction with health care services in the FB&H was lower during the COVID-19 pandemic compared to 2011 and 2017. Furthermore, while an increasing trend in satisfaction with health care was observed in the FB&H during the years prior to 2020, the COVID-19 pandemic may have contributed to the reversal of this trend. It is important to further monitor the dynamics of patient satisfaction with health care, which could serve as a basis for planning, delivering, and maintaining quality services during the COVID-19 pandemic and other emergencies.

Abstract Background Analysis of years of life lost (YLL) due to premature deaths during the COVID-19 pandemic can direct decision-makers towards specific public health recommendations in order to improve health and lives of people. Our study aimed to examine the existence of age- and sex-specific patterns of the three most common causes of premature death in Belgrade during the first year of the COVID-19 epidemic. Methods Mortality data disaggregated by age, sex and cause of death, as well as the estimated number of inhabitants and remaining life-expectancy by age-groups for Belgrade was provided by the Statistical Office of the Republic of Serbia. YLLs were calculated using the methods of the Global Burden of Disease Study, without garbage code redistribution. Mortality rates were standardized according to the European Standard Population. We acknowledge the support from the COST Action 18218 - European Burden of Disease Network. Results In 2020 in Belgrade, according to the share in all-cause YLLs, cardiovascular diseases ranked first (36.2%), followed by neoplasms (25.7%) and COVID-19 (11.1%). However, on average, COVID-19 generated higher number of YLLs per death case (11.9) than cardiovascular diseases (9.2), but fewer than neoplasms (13.9). In total of 31,943 YLLs due to COVID-19, men had 1.7 times more YLLs than women. By age groups, the highest YLL share due to COVID-19 was among men aged 45-49 (16%) and 70-74 (16%) and among women aged 20-25 (33%) and 25-29. years (29%). In men, COVID-19 YLL rate was 2,488 per 100,000 and was higher after standardization (2,714). In women, COVID-19 YLL rate was 1346 per 100,000 and was lower after standardization (1,245). Conclusions In Belgrade, COVID-19 was the third cause of premature mortality in 2020. The difference between COVID-19 YLL rates in men and women were even more prominent after standardization. Future research is needed to determine the synergistic impact of COVID-19 and other causes of premature death. Key messages • In 2020, COVID-19 was among the top three causes of premature mortality among male and female contingents of the Belgrade population. • Assessing the causes of premature mortality is important for determining community health priorities.

Introduction Healthcare utilisation requires knowing one’s entitlements and how to access them (navigation) and having access to grievance redressal when entitlements are denied. To ensure citizen access to and use of health insurance entitlements, the Health Insurance Fund established an initiative called the Protector of Patients’ Health Insurance Entitlements (PPHIE). PPHIEs are supposed to provide patient navigation and grievance redressal services. This paper explores to what extent this initiative meets its objectives and is used by the elderly in rural areas. Methods This study employed a mixed methods approach. We conducted in-depth interviews with elderly patients in rural areas, PPHIEs, health providers and health insurance managers (N=39), as well as focus groups (N=5) and a household survey (N=715) with elderly rural patients. Qualitative data were analysed using content analysis, and the household survey results were analysed using descriptive statistics. Results The majority of elderly patients were not aware of the PPHIE initiative and instead received patient navigation support from their healthcare providers. The PPHIE programme was poorly publicised among the population. Although PPHIEs had a mandate to pursue grievance redressal they rarely did so, and their role in the system was more symbolic than functional. Conclusion While healthcare providers have (by default) filled the navigation role left by inactive PPHIEs, the grievance redressal role remains unfilled. Information about health insurance entitlements and access to grievance redressal must be provided through visible, accessible and efficient mechanisms that should be continuously monitored and improved.

Background and Objectives: Cigarette smoking among the youth population has increased significantly in developing countries, including Bosnia and Herzegovina. However, no extant literature assesses the prevalence of tobacco use, nor identifies factors associated with smoking. This study determined the prevalence of cigarette smoking among a specific cohort of students and assessed factors related to tobacco use in this population. Materials and Methods: This cross-sectional study included 1200 students at all faculties of Banja Luka University. Data were collected from questionnaires adapted from the Global Youth Tobacco Survey (GYTS) and the Global Health Professional Student Survey (GHPSS) standardized questionnaires and were analyzed using descriptive statistics, Pearson’s χ2 test, and logistic regression. Results: When the prevalence of cigarette smoking within the last thirty days was recorded, we found that 34.1% of students smoked within this period. Nearly three-quarters (74.9%) of the student population had smoked or experimented with cigarette smoking. However, medical students were 27.2% less likely to smoke than their counterparts from other faculties. Overall, 87% of all students were aware of the harmful effects of cigarette smoking, 79% were aware of the harmful effects of secondhand smoke, and 65% reported that it was difficult to quit. Increased spending of personal money was associated with a higher probability of smoking, while exposure to secondhand smoke increased the odds of smoking by 62%. Conclusion: Policies, strategies, and action plans should be introduced in order to reduce the prevalence of smoking among university students and to create a smoke-free environment at the various universities involved.

ABSTRACT Men who have Sex with Men (MSM) are often exposed to stigma and discrimination, especially in developing countries. Discrimination might have an impact on their sexual behavior. The proportion of MSM among HIV positive persons is rising in Bosnia and Herzegovina (B&H). The aim of this qualitative study was to understand the country context and HIV-related risk behaviors among MSM in B&H. We found that MSM in B&H have a dominant fear of expressing their sexual orientation in the homophobic societal environment, including their own family. Disclosures are often connected with escalated family violence, followed by the silence and ignorance. The fear of being connected to one particular partner and being labeled as a gay lead to the need of “masking” their sexual orientation, and having sexual intercourse with non-steady sexual partners. Although most MSM were aware of the risk of HIV and other STIs, the fear of rejection and remaining alone, shapes their decisions to agree to have sex without condoms.

Background: Reasons for unmet health needs vary from individual to contextual determinants but are defined as the difference between needed health service and services actually received. Roma experience elevated health issues and challenging social conditions. Objective: The aim of this study was to explore the unmet health needs and potential risk factors among Roma women living in the two biggest Roma communities in the Republic of Srpska. Method: We conducted a health assessment of 183 adult Roma women in the Republic of Srpska. Unmet health needs were observed as the absence of needed medical supervision, despite having chronic conditions. We used logistic regression to assess the degree to which unmet health needs were related to the social determinants and the health status of Roma women. Results: The majority of Roma women were married or were in an unofficial relationship (55.2%), were without schooling (62.8%), and were unemployed (88.5%). The results showed that 94.0% had health insurance, had a health card, and were registered with a family medicine doctor. Sixty percent reported having a chronic disease; however, 68.2% reported that their chronic disease was not medically supervised. Roma women that had less education, those who were unemployed, and those who were divorced or widowed women were more likely to have unmet health needs. Conclusion: Roma women in Bijeljina and Prijedor have unmet health needs due to the circumstances they live in despite the fact that majority of them have health insurance and universal health access is legally guaranteed.

Men who have sex with men (MSM) are often exposed to unequal treatment in societies worldwide as well as to various forms of stigma and discrimination in healthcare services. Bosnia and Herzegovina (B&H) is a postconflict developing country located in Southeast Europe and the Western Balkans, where little is known about the experiences of MSM regarding their communities and interactions with healthcare services. The aim of this study was to explore the types of experiences MSM face and to assess the level of stigma and discrimination they are exposed to in this setting. We conducted twelve in-depth face-to-face interviews with MSM who were 16 to 45 years old and residing in B&H. The main findings indicated that they all experienced various levels of stigma, discrimination, prejudice and inequities in treatment and attitudes from different segments of society, including the health care sector, that prevented them from fully developing their human and health potential. Additionally, these experiences were adversely related to opportunities to receive good quality health care services due to the insufficiently educated and old-fashioned health professionals who sometimes believed in black magic practices. The findings present numerous opportunities for educational trainings and structural reform to create a society that provides and guarantees equal opportunities for all.