Associations of burnout with job demands/resources during the pandemic in health workers from Southeast European countries

Introduction

Despite several studies assessing job demands and burnout in countries from the Southeast European (SEE) region, there is still a lack of data about the psychological impact of the pandemic on health workers (HWs).

Aims

The present study aimed to demonstrate and compare levels of burnout dimensions in HWs from SEE countries and to reveal the burnout-job demands/resources relationships in these workers during the pandemic.

Materials and methods

During the autumn of 2020, this online multicentric cross-sectional survey studied a large group (N = 4.621) of HWs working in SEE countries. The Maslach Burnout Inventory was used for the measurement of burnout dimensions. We analyzed the job demands by using the Hospital Experience Scale. Remuneration and relationships with superiors were measured using the Questionnaire sur les Ressources et Contraintes Professionnelles (English version).

Results

A series of ANOVA comparisons of means revealed the countries in which respondents showed higher mean values of emotional exhaustion (Bosnia and Herzegovina, Bulgaria, Croatia, Moldova, Montenegro, and North Macedonia) and the countries in which respondents showed lower mean values of this burnout dimension (Israel and Romania) (Welch F = 17.98, p < 0.001). We also found differences among HWs from different countries in job demands and job resources. The testing of hierarchical regression models, which have been controlled for certain confounding factors, clearly revealed that emotional exhaustion was predicted by job demands (R2 = 0.37) and job resources (R2 = 0.16).

Conclusion

Preventive measures for the improvement of mental health in HWs during the pandemic and beyond have to take into account the differences between countries regarding the country context and current scientific knowledge. A modified stress test should be implemented in hospitals regarding future shocks that might include new pandemics, terrorism, catastrophes, or border conflicts.

Culture of Blame-An Ongoing Burden for Doctors and Patient Safety

Introduction: Every procedure in healthcare carries a certain degree of inherent unsafety resulting from problems in practice, which might lead to a healthcare adverse event (HAE). It is very important, and even mandatory, to report HAE. The point of HAE reporting is not to blame the person, but to learn from the HAE in order to prevent future HAEs. Study question: Our aim was to examine the prevalence and the impact of culture of blame on health workers’ health. Methods: A cross-sectional study on healthcare workers at two Croatian hospitals was conducted using the Hospital Survey on Patient Safety Culture (PSC). Results: The majority of PSC dimensions in both hospitals were high. Among the dimensions, Hospital Handoffs and Transitions and Overall Perceptions of Safety had the highest values. The Nonpunitive Response to Error dimension had low values, indicating the ongoing culture of blame. The Staffing dimension had low values, indicating the ongoing shortage of doctors and nurses. Discussion: We found inconsistencies between a single-item measure and PSC dimensions. It was expected that Frequency of Events Reported (PSC dimension) relates to Number of Events Reported (single-item measure). However, in our study, the relations between these pairs of measures were different between hospitals. Our results indicate the ongoing culture of blame. Healthcare workers do not report HAE because they fear they will be punished by management or by law.

Antecedents and associations of sickness presenteeism and sickness absenteeism in nurses: A systematic review

AIMS

This study comprehensively analysed and systemized the elements associated with nursing sickness presenteeism (SP) and sickness absenteeism (SA).

BACKGROUND

Both behaviours represent a real challenge to nursing departments because they can increase costs, cause health care adverse events, and impact the quality of health care.

DESIGN

The systematic review of cohort studies was designed to be consistent with the PRISMA guidelines.

DATA SOURCES

PubMed, ProQuest, and Emerald were systematically searched for peer-reviewed articles published from the 1950s to December 2016.

REVIEW METHODS

Cohort studies were included (12 SA and 1 SP) in the review if they examined the association between one or more exposures and SP and/or SA in nurses. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

Twenty-three antecedents were associated with SA and grouped as work and organizational, mental and physical health, and demographic; 3 antecedents were associated with SP (job demands, burnout, and exhaustion). Exhaustion (fatigue) and job demands were associated with SA and SP. Depersonalization was an outcome of SP over time.

CONCLUSION

The ability to predict presenteeism and absenteeism in nursing is useful to constrain costs and ensure that quality care is delivered.

Reasons for Using Schizophrenia Internet Forums in Croatia

Searching the Internet is one of the main sources for obtaining health and medical information. When searching the Internet, users can find information published by various organizations, companies, agencies or institutions and also information posted by users on the user-oriented Internet platforms, such as forums, blogs, and various social networks. There are no single, standardized mechanisms to ensure the truthfulness, objectivity, credibility and comprehensibility of health information available on the Internet. Moreover, a very small proportion of medical content on the Internet is revised or moderated by health experts. The aim of this study was to examine the motives for using schizophrenia Internet forums in Croatia. The study sample consists of user-generated posts on the largest Croatian schizophrenia Internet sub-forum over a period of one year, analyzed using qualitative methodology–grounded theory. The results showed that the majority of users use schizophrenia Internet forums to receive emotional support from others with the same diagnosis. Other important reasons were to exchange information about medications, symptoms and prognosis of the illness. It was noted that a large number of entries, with information about drugs and symptoms of the illness, contain inaccurate information. Posts about treatment and symptoms of schizophrenia provided by Internet forums often contain unverified information and can potentially harm users of such forums and also undermine doctor-patient relationship. Expert moderation of these forums and better education of patients by their physician, could help patients receive better medical care and to strengthen the confidence of patients in their physicians.

[Pharmacoeconomics - Challenges for Health Professionals]

Over the last 30 years, medical expenditure has increased throughout the world. The main reasons estimated to lay behind it include aging, ever more chronic diseases and new emerging diseases, new drugs, expanded indications of current drugs, and development of pharmaceutical industry. A challenge for healthcare professionals is to sustain current quality of care and enable medical innovations while attempting to contain costs. The overall goal is to demonstrate the pharmacoeconomic value, i.e. a balance of economic, humanistic and clinical outcomes.

Development of a Croatian version of the US Hospital Survey on Patient Safety Culture questionnaire: dimensionality and psychometric properties

BACKGROUND

The Hospital Survey on Patient Safety Culture (HSOPSC), originally developed in the USA, is used worldwide to assess patient safety culture in hospitals. A limited number of studies have provided data on psychometric properties outside of the US healthcare system. Our aim was to determine if all 12 dimensions of the US HSOPSC were applicable, valid and reliable to Croatian healthcare workers.

METHODS

The study was conducted from September 2010 to April 2011. Questions were translated into Croatian and then translated back into English. The questionnaires (ie, the Croatian translation of the US HSOPSC) were distributed in unmarked envelopes along with a consent form to all the doctors and nurses in four Croatian hospitals. The responses were analysed using explorative factor analyses, reliability testing, and confirmatory factor analyses.

RESULTS

The study included 561 healthcare workers in four Croatian hospitals--a response rate of 32.69%. Our results are similar to the original US sample, but with some differences: 11 dimensions with acceptable reliability scores were identified by exploratory factor analysis compared with the original 12 in the US sample; five of 12 dimensions had a Cronbach's α higher than 0.7, suggesting a reasonable fit to the original US HSOPSC; the dimensions 'Staffing' and 'Organisational learning--continuous improvement' were found to have a Cronbach's α <0.6. The use of confirmatory factor analysis confirmed a good fit to the original US model.

CONCLUSIONS

Results show that the Croatian translation of the US HSOPSC is compatible in 11 of the original 12 dimensions. Results suggest that for the purposes of research in Croatia, the dimensions 'Staffing', 'Communication openness', and 'Organisational learning-continuous improvement' should be revised. For example, the use of question A7 ('We use more agency/temporary staff than is best for patient care') in the context of European healthcare systems should be adapted or removed for the Croatian version of the US HSOPSC questionnaire.

Development of the PICMIN (picture of mental illness in newspapers): instrument to assess mental illness stigma in print media

PURPOSE

The aim of this paper is to report on the development and applicability of a standardised and objective measure of stigma of mental illness in print media. Picture of mental illness in newspapers (PICMIN) instrument consists of eleven descriptive and five analytical categories. It is intended to allow comparison among countries and different studies over time.

METHODS

The research team conducted a three-phase study to develop the instrument based on the principles of content analysis and test its inter-coder reliability (ICR). In the first phase, keyword search and ICR assessment was performed on articles from Croatia (75), Czech Republic (203), and Slovakia (172). The second phase consisted of instrument revision and training, along with ICR reassessment on 40 articles from USA and UK. In the third, main phase articles from Croatia (238), Czech Republic (226), and Slovakia (158) were analysed with the final version of the PICMIN instrument.

RESULTS

Across three countries, ICR was found acceptable to assess mental illness representations related to stigma in print media. Print media representations of the mental illness in Croatia, Czech Republic, and Slovakia significantly differed in the type of media distribution, whether headline of the article was positioned on the media cover, in the use of a sensationalistic style of writing, in the association of aggressive behaviour with persons with mental illness and in the distribution of the global impression of the headline.

CONCLUSIONS

PICMIN instrument allows comparison among countries and different studies over time.

Psychiatric disorders and aggression in the printed media: is there a link? A central European perspective

BACKGROUND

A content analysis was used to describe the association between psychiatric disorders and aggression in the printed media in the Czech Republic and Slovakia.

METHODS

Articles were chosen from the most widely read daily newspapers and magazines in both countries during five one-week periods in 2007. A coding manual was developed and a content analysis was performed. Aggressive behavior was assessed by two separate categories - the role of the mentally ill person in the violent act (perpetrator/victim) and the type of aggressive act (homicide, suicide).

RESULTS

A total of 375 articles were analyzed.

MAIN FINDINGS

1) The proportion of articles depicting psychiatric disorders together with either self- or other-directed aggressive behavior is 31.2%; 2) Homicide was most frequently mentioned in the context of psychotic disorders and schizophrenia, while affective disorders were most frequently associated with both completed suicides and homicides; 3) Eating disorders and anxiety disorders were seldom associated with any kind of aggressive behavior, including self-harm; 4) The vast majority of articles presented mentally ill people as perpetrators, and these articles were more often coded as stigmatizing. 5) Articles with aggressive behavior mentioned on the cover are roughly as frequent as those with aggressive behavior in the later sections of the media (36.7% vs. 30.7%).

CONCLUSIONS

The results are similar to the findings in countries with longer histories of consistent advocacy for improved depiction of mental illness in the media. However, we have shown that persons with mental illness are still over-portrayed as perpetrators of violent crimes, especially homicides.

Case oriented approach to co-occurrence of risk lifestyle behavior with overweight, excess abdominal fat and high blood pressure: the CroHort study

Objective of this paper is to estimate interim risk factors (INTF) proportions and changes within 5-years of groups with at least one risk health behavior (BEHF) in CroHort population. Results show that CroHort 2008 group has higher proportions of excess abdominal fat and overweight. Men older than 65 without any BEHF have smaller proportions of INTF in 2008 than in 2003. Proportion of people with high blood pressure is smaller in 2008 for all groups except for young women who show increase. Analysis of middle age group shows significant increase in all INTF in women smokers while men smokers have the highest increase in abdominal fat. Physical inactivity in women is associated with increase of all INTF, while men have decrease in overweight INTF. Alcohol intake has protective effect on middle aged men, except for increase in waist circumference. Women show constant increase in all INTF with heavy alcohol intake.

Characteristics of people with the perceived stress in croatia: the CroHort study

This study aimed to assess levels of stress in Croatian adult population using PSS, in a population study (Croatian Adult Cohort Health Study - CroHort). Our results show that the levels of stress were 17.46 (SD = 6.73) for men and 18.32 (SD = 6.46) for women in Croatia. The lowest levels of stress experienced men living in urban area while women living in rural area had the highest level. Men and women who had university degree had significantly lower level of stress. The lowest levels of stress experienced participants who had much better financial condition than average. In men, stress was associated to weak heart, lower back pain, poor financial condition of the household and high alcohol consumption. In women, stress was associated to poor mental health, poor social functioning, poorer financial condition of the household, higher age, lower education, low monthly income of the household and poor general health.

Association of behavioral cardiovascular risk factors with mortality in Croatian adult population: the CroHort study

This study examined individual and combined influence of smoking, physical inactivity, alcohol drinking, and unhealthy diet on total mortality. Relationship between individual and combined poor health behaviours and total mortality were examined using Cox proportional hazards regression. Out of 7490 individuals included in the study, during 5 years follow up 808 died. Adjusted hazard ratios (HRs), and 95% confidence intervals (95% CIs) for men with health behaviour scores 1, 2, 3, and 4 compared with those with score 0 were 1.67 (1.24-2.24), 2.28 (1.64-3.18), 2.24 (1.32-3.84), and 2.86 (0.77-11.70), respectively (p value for trend < 0.001). Adjusted HRs (95% CIs) for women with health behaviour scores 1, 2, and 3 compared with those with score 0 were 1.17 (0.97-1.42), 1.37 (1.02-1.86), and 1.20 (0.37-3.61), respectively (p value for trend = 0.04). A unit of the health behaviour score increased mortality risk equivalent to being 5.9 and 2.9 years older, for man and woman respectively.

Predictors of the desire/decision to quit smoking in a cohort of Croatian adult smokers followed for five years: the crohort study

This study provides an overview of the incidence of smoking, the socio-demographic characteristics of Croatian smokers during a five-year period and an assessment of predictors of the desire/decision to quit smoking. Analyses were performed separately for 2003 and 2008. A total of 3,229 subjects were included in the survey. There is a significant trend of a decreasing number of smokers in all age groups in 2008, compared to 2003. Almost half of the smokers included in the study expressed desire to quit smoking. Factors contributing significantly to decision to quit smoking were different in 2003 and 2008, except one. Concern about the harmful effects of tobacco smoking on health was a significant predictor in both models. Very worried respondents were more likely to decide to quit smoking (OR 17.6, 95% CI 9.41 to 33.17 vs. OR 12.54; 95% CI 6.0 to 26.2) than those who were not worried at all.

Association of the psychological distress and cardiovascular risk behaviors, conditions and diseases: the CroHort study

Aim of this study was to explore and compare association of PD (psychological distress) and cardiovascular risk behaviors, conditions and diseases in Croatian adult population. The sample of this study consisted of 3,229 respondents. Psychological distress status was measured by the five-item Mental Health Scale (MHI-5) of the Short Form questionnaire (SF-36), hence one distinguished subgroup consisted of population with PD and other without PD. Prevalence of cardiovascular risk behaviors, cardiovascular risk conditions and self-reported cardiovascular diseases within each subgroup were calculated. During the follow up period physical inactivity remained the only risk behavior showing significant difference between PD status subgroups for both genders demonstrating higher prevalence in men and women with PD. During follow up period hypertension, myocardial infarction, angina pectoris and self-reported heart failure in women remained constant in showing statistically significant prevalence difference among population with and without PD. In men that type of constant association was shown only for heart failure.

The CroHort study: cardiovascular behavioral risk factors in adults, school children and adolescents, hospitalized coronary heart disease patients, and cardio rehabilitation groups in Croatia

Based on repeated measurement of health behaviors the CroHort Study showed that health behavior explains a great deal more of class inequalities in mortality than observed in previous studies. These include decreasing prevalence of smoking and increase in obesity, hypertension and diabetes mellitus. The lowest prevalence of health risks was recorded among children and adolescents, followed by general adult population from the CroHort Study. Hospitalized coronary heart disease patients had higher risks prevalence than general population, while the highest prevalence of risks was recorded among patients in cardiac rehabilitation program. The higher levels of stress were associated to lower financial conditions, poorer social functioning and poorer mental health for both men and women. Higher levels of stress were also associated with heart problems, higher alcohol consumption in men while in women stress was associated to poorer general health, higher age and lower levels of education.

Prevalence and five-year cumulative incidence of psychological distress: the CroHort study

The aims of this paper are to investigate the change in prevalence of psychological distress (PD), to investigate the cumulative incidence of the psychological distress and to indicate are there any differences between genders and various age groups in Croatian adult population. Psychological distress status was measured by the five-item Mental Health Scale (MHI-5) of the Short Form questionnaire (SF-36). Psychological distress was present in 28.5% (95% CI 25.7%-31.2%) of men and 32.1% (95% CI 30.1%-34.0%) of women in 2003. In 2008 PD was present in 33.0% (95% CI 30.1%-35.9%) of men and 34.1% (95% CI 32.1%-36.0%) of women. The highest incidence of PD, both for men and women, was in the oldest age group (> 65 years). Results of this study demonstrating the fact that every third adult men and woman in Croatia are in psychological distress, the fact that there is an increase in PD prevalence for men and women should be taken into account in the future mental health policy planning.

The picture of mental health/illness in the printed media in three Central European countries

Even in the era of the Internet, printed media are still among the most frequently identified sources of mental health information. Many studies have shown that this information is frequently negative and contributes to stigmatization of people with mental illness. This international comparative study describes the content of media messages about mental health/illness in terms of stigma in three Central European countries. The study sample comprised all articles pertaining to the topic of mental health/illness (N = 450) identified during five week-long periods in 2007 chosen from the six most widely read newspapers and magazines in each country. The authors used content analysis methods to achieve quantitative and qualitative objectives. More than half of all articles contained negative statements reflecting stigma toward persons with mental illness. Substance abuse disorders are the most frequent mental conditions covered in all three countries (22%), and psychotic disorders are the most stigmatized. Countries significantly differ in length of articles, in the association of aggressive behavior with persons with mental illness, and in the use of a sensationalized style of writing. Coverage of mental health/illness issues differs to some extent across countries but is generally of poor quality. On the basis of the authors' findings, practical recommendations for journalists can be tailored specifically for each country.

Co-occurrence of risky lifestyle behavior with overweight, excess abdominal fat and high blood pressure--case oriented approach

The objective was to estimate the proportion of cases developed interim risk factors (INTF: overweight, excess abdominal fat, high blood pressure) in relation with behavioral risk factors (BEHF: smoking, heavy alcohol intake, unhealthy diet, physical inactivity). NOBIR group was defined as cases with no BEHF and BIR as those with them. Both groups show higher proportions of INTF in older age. The increase by age varies of twofold (overweight: 13.2-29.2 for men, 18.1-42.6 for women) to six fold (high blood pressure: 4.6-26.5 for men, 6.6-40.8 for women) in proportions. Women show higher proportions of INTF than men in both groups, but BIR group shows higher proportions than NOBIR in all the age groups taking the both gender together. As a BEHF the physical inactivity has a markedly increase with age (from 4% to more than 25%). Smoking is the only BEHF decreasing in oldest for all the INTF.

Psychological distress within cardiovascular risks behaviors, conditions and diseases conceptual framework

Psychological distress (PD) is being increasingly recognized as a risk factor for cardiovascular diseases (CVD). Our aim was to recognize an association of PD and CVD in the Croatian adult population. We also explored association's strength obtainable as relative risk of PD on three levels; cardiovascular risk behaviors, conditions and diseases. This study used Croatian Adult Health Survey 2003 (CAHS 2003) data (N = 9,070). PD status was measured by the five-item Mental Health Scale of the Short Form questionnaire (SF-36) hence one distinguished subgroup consisted of population with PD and other without PD. Prevalence of cardiovascular risk behaviors, cardiovascular risk conditions and self-reported cardiovascular diseases within each subgroup were calculated using bootstrap method. Women had higher prevalence of PD in general population. Among distressed population women had higher prevalence of body mass index over 30, metabolic syndrome and angina pectoris. Men with PD had higher prevalence of high blood pressure and myocardial infarction with contradictory lower prevalence of angina pectoris then myocardial infarction. Physical inactivity was proven to be a risk behavior determinant with most impact on mental health. All CVD are consistently associated with higher prevalence and relative risks for PD both in men and women.

Association of social roles, health, and health behavior of elderly women in Croatia

AIM

To explore the association between the social role and objective and subjective health measures and use of health care services in the population of women older than 65 years in Croatia.

METHODS

We used the data from the 2003 Croatian Adult Health Survey (Short Form 36 Health Survey). Two sub-populations, retired women and housewives aged over 65 years, were analyzed and compared according to anthropometric measures, health self-assessment, utilization of health care services, and socioeconomic status.

RESULTS

The final sample consisted of 791 housewives and 1151 retired women. Housewives had larger waist circumference (98.44+/-13.9 vs 96.49+/-13.5, P=0.002, t test) and higher systolic blood pressure (152.88+/-25.2 vs 147.79+/-22.8, P<0.001, t test). On self health assessment, housewives had lower index on Mental Component Summary (MCS) (40.28+/-12.5 vs 42.96+/-12.4, P<0.001, t test). They also had lower self-assessed quality of life (40.28+/-12.5 vs 42.96+/-12.4, P<0.001, t test). Housewives performed regular breast check-ups significantly less often in the 12 months before the survey (7.5% vs 13.6%, chi2=18.0350, P<0.001), but they performed other forms of medical examinations, including general physical check-ups as often as retired women.

CONCLUSION

Housewives differed from retired women of the same age in objective and subjective measures of health status, use of health care services, self perceived health, and self-assessed quality of life. These differences should be taken into account when planning public health measures for these age groups of women.

[Metabolic syndrome in the Croatian population--the multiple cardiovascular risks]

OBJECTIVES

To estimate the regional prevalence of metabolic syndrome, and potential implication of socioeconomic characteristics to it.

METHODS

Assessment was performed in a sample representative of the Croatian population (N=9070). The metabolic syndrome was defined as "waist circumference greater than 102 cm for male and 88 cm for female, and at least two of the following criteria: arterial blood pressure > or =140/90 mm Hg (regulated hypertonic was considered as normal blood pressure person), elevated blood lipids, and elevated blood sugar (self reported). Statistically, the prevalence and confidence intervals, and comparative figure for the prevalence of metabolic syndrome (according to Julious et al. 2001) were applied.

RESULTS AND DISCUSSION

The prevalence of metabolic syndrome in young adults (aged < or =34) was less than 1%. In older population groups the prevalence was greater. In the > or =65 age group, the prevalence (male 7.7, 95%CI 8.6-9.2; female 9.9, 95%CI 8.6. 11.1) was twofold that recorded in the 35-64 age group (male 15.2, 95%CI 12.4-17.9; female 22.5, 95%CI 20.1-24.8). The prevalence of metabolic syndrome was higher in female population in all age groups. There were no regional statistically significant differences. Socioeconomically, the metabolic syndrome population showed lower economic status, lower education level, and unfavorable health perception. As socioeconomic characteristics are not independent of age and sex, adjustment was made by calculating comparative figure for the prevalence of metabolic syndrome. Results showed no statistically significant differences between different socioeconomic groups, however, the groups with poor health perception showed a higher rate of metabolic syndrome than other groups. Comparative prevalence of the metabolic syndrome was 126.5, 95%CI 121.7-131.5 in the group with poor health perception, and 70.7, 95%CI 70.6-70.9 in well being groups.

CONCLUSION

The prevalence of metabolic syndrome in the Croatian population is not region dependent. Socioeconomic status does not cause significant differences in the prevalence of metabolic syndrome, whereas poor health perception is associated with a higher prevalence of the syndrome.

Importance of health care issues in 2005 presidential elections in Croatia

Health and health care provision are among the most important and politically sensitive public service areas. Politicians carefully incorporate health care program changes in their political agendas to gain votes. However, knowing health care priorities of the electoral body is not useful only to politicians, but also to health policy makers, as it enables them to target the most problematic areas in health care. We conducted a telephone survey of representative sample of voters (n=643) immediately before the presidential elections in Croatia in 2005, to determine the possible differences in health care priorities between left-wing and right-wing voters, and found a high level of homogeneity in their opinions. Health care organization, corruption, and financing issues were identified as the top priorities by both left- and right-wing voters. This agreement in voters' expectations, probably caused by a similar frame of mind of Croatian citizens inherited from pre-democratic times of self-government, could be used by health policy makers to rationally invest the means and efforts in dealing with the most problematic health care issues.

Counties selecting public health priorities--a "bottom-up" approach (Croatian experience)

The subject of this paper is how to incorporate a multi-disciplinary and inter-sectored approach into development of public health policy and plans at the local (county) level in Croatia by educational program. Method used was the public health capacity building program "Health--Plan for it", which was developed with the aim to assist the counties to overcome recognized weaknesses and introduce more effective and efficient local public health practices. Two main instruments were used: Local Public Health Practice Performance Measures Instrument, and Basic Priority Rating System. This program has helped counties to asses population health needs in a participatory manner, to plan for health and, ultimately, assure provision of the right kind and quality of services (better tailored to population health needs). This program's benefits are going beyond and above the county level. It provides support for the Healthy Cities project locally, and facilitates changes in national policymaking body's mindset that a "one-size-fits-all" approach is sufficient.

[A few thoughts about health system transformation in Croatia]

The aim of this article was to make reader more familiar with the shift in health and society thinking which occurred during the last fifteen years. Authors are describing changes in macro environment and their impact on health and health needs in Croatia. The notion that behavior is greatly influenced by social context in which people lead their lives is demanding a new approach to health and health system policy development. The key questions they elaborate are: How to make health system aware of these changed health needs and How to make health system more capable to respond to these unmet needs? Authors are discussing two alternatives--Health system reform and health system reorientation advocating the second one as the way to go.

Challenge of goodness III: public health facing war

Using moral and empirical analysis, we analyzed and discussed the role of public health in prevention of war as well as its function during and after the war. The idea is to develop a theory and new strategy in the spirit of public health to improve practices in preserving and strengthening peace, to be prepared for the future. The experiences from the last four wars in South Eastern Europe were ethical challenges to public health. We identified and described four models of public health practice in the past wars and conflicts. Based on the recent wars, the two new models, Professional Model and Peace Model, were developed and suggested as a new public health strategy in prevention and alleviation of the health burden of war.