JURISDICTION OF THE MEDICAL ETHICS COMMITTEES
Božidar VOLJČ1*
1National Medical Ethics Committee, Ministry of Health of the Republic of Slovenia,1000 Ljubljana, Slovenia
Received: Apr 19, 2017
Accepted: Apr 21, 2017
Editorial
Ethical principles of assessing medical research are to the greatest extent defined by the Nuremberg Code, the 
Declarations of Geneva and Helsinki, and the Oviedo Convention. Pursuant to their directives various national 
Medical Ethics Committees (MECs) were established which assess the ethics of research according to the risk 
and benefit ratio of the persons involved. Following the example of other countries, medical ethics committees 
eventually appeared also in hospitals and some medical and educational institutions around Slovenia. Due to 
an increased number of ethical challenges, it is of great importance to define the jurisdiction of the Slovenian 
MECs in order to ensure their coordinated operation. Exclusive jurisdiction of the national MEC includes multi-
centre and multi-national research, drug research (phases 1–3), high-risk research and research related to 
doctoral theses. The jurisdiction of the sectoral MECs includes testing the conditions for research, monitoring 
the execution and overviewing the final reports. A more significant jurisdiction of the sectoral MEC is preserving 
an ethical environment in their institutions. A network of Slovenian MECs is to be organised in the form of a 
jurisdiction pyramid where each member has its own obligations and responsibilities and plays an important 
role in relation to the entire structure.
Etična načela presojanja zdravstvenih raziskav v največji meri določajo Nürnberški kodeks, Ženevska in Helsinška 
deklaracija ter Oviedska konvencija. Po njihovih usmeritvah so po državah ustanovili Komisije za medicinsko 
etiko (KME), ki etičnost raziskav presojajo predvsem po tveganjih in koristih vanje vključenih oseb. Kot 
drugod so se sčasoma tudi v Sloveniji pojavile komisije pri bolnišnicah in nekaterih zdravstveno-izobraževalnih 
ustanovah. Ker je etičnih izzivov vse več, je za usklajenost delovanja slovenskih KME potrebno določiti njihove 
pristojnosti. V izključno pristojnost državne KME sodijo multicentrične in večnacionalne raziskave, raziskave 
zdravil v fazi 1–3, raziskave z večjim tveganjem in raziskave, povezane z doktorskimi nalogami. Pristojnost 
področnih KME naj bi bilo na področju raziskav preverjanje pogojev zanje, spremljanje njihovega poteka in 
pregled zaključnih poročil. Veliko bolj pomembna pristojnost področnih KME je vzdrževanje etične kulture v 
njihovih ustanovah. Mreža slovenskih KME naj bi bila organizirana v obliki pristojnostne piramide, v kateri ima 
vsak člen s svojimi dolžnostmi in odgovornostmi pomen tudi za celoto.
ABSTRACT
Keywords: 
medical ethics 
committees,
jurisdiction
IZVLEČEK
Ključne besede: 
komisije za 
medicinsko etiko, 
pristojnosti
*Corresponding author: E-mail: bozidar.voljc@gmail.com
10.1515/sjph-2017-0026 Zdr Varst 2017; 56(4): 193-195
193
PRISTOJNOSTI KOMISIJ ZA MEDICINSKO ETIKO
Voljč B. Jurisdiction of the medical ethics committees. Zdr Varst 2017; 56(4): 193-195.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 DEVELOPMENT OF MEDICAL ETHICS COMMITTEES
After World War II Nazi doctors were being judged at 
Nuremberg trials for carrying out all sorts of research 
on prisoners in concentration camps in any way they 
wanted it. At that point it became obvious that doctors 
and their research should be monitored. The Nuremberg 
panel of judges suggested 10 principles of research in 
healthcare, also known as the Nuremberg Code (1), 
which defined the moral principles of medical research, 
prohibited any sort of violence related to research and 
introduced the concept of informed consent. In 1948, 
under the influence of the Code, the General Assembly 
of the World Medical Association adopted the Declaration 
of Geneva (2) in which they stated 11 principles defining 
the medical ethics. In 1964, the same Association adopted 
also the Declaration of Helsinki on medical research (3) 
which demands experienced researchers, respect of the 
set protocols and ethical supervision by a competent 
committee that carefully assesses the risks and benefits 
of the persons involved. The development of biomedicine 
was accompanied by updating the ethical provisions 
with the Oviedo Convention (4). Today the research is 
also influenced by other conventions and declarations, 
principles of good clinical practice and quality standards.
After the Declaration of Helsinki was adopted, the countries 
started appointing medical ethics committees (MECs) and 
introducing ethical assessment into research. One of the 
first ones was the Slovenian committee for assessing the 
ethical appropriateness of doctoral theses established in 
1966 at the initiative of Prof. Dr. Janez Milčinski. Over the 
years the number of national committees increased. With 
the development of bioethics the fields of assessment 
expanded, and many MECs appeared in hospitals, some 
also in medical and educational institutions. This was 
the case also in Slovenia where hospital committees 
for ethical consulting and monitoring were established, 
as well as various committees at medical schools and 
faculties, some of them also wishing to take over the 
ethical assessment of medical research.
2 NEED TO REORGANISE MECs IN SLOVENIA
As the jurisdiction of particular MECs in Slovenia is not 
officially determined, the situation concerning this field 
is very unstable. Plenty of research is carried out, the 
national MEC receives more than 70 applications per month, 
among which also diploma theses. Due to the increased 
workload and the lack of administrative support, the MEC 
suffers a reputation of not being responsive enough. The 
committees do not cooperate enough and it would be 
necessary to implement ethical training for its members. 
The gender ratio of its members is unequal and the field 
of nursing care is being neglected. The objective of the 
national MEC is to create an environment in which the 
Slovenian medical and ethical community would follow 
the example of well-established conditions in developed 
European countries, where Slovenian healthcare and 
society definitely belong according to their progress and 
potential. The aim of some hospital and other MECs to 
take over also the assessment of ethical appropriateness 
of suggested research increases the possibility of an 
occurring conflict of interests. By reorganising the 
national MEC, the responsibilities of both the national and 
sectoral MECs should be determined taking into account 
the development of bioethics in the past 20 years. In 
1998, the responsibilities were proposed by Prof. Dr. 
Jože Trontelj in collaboration with the presidents of the 
sectoral MECs (5), but they were never processed any 
further. Everything they proposed still holds valid today, 
however some fields need to be amended in the light of 
today’s circumstances and relations.
3 JURISDICTION, OBLIGATIONS AND RESPONSIBILITIES 
OF THE MEDICAL ETHICS COMMITTEES 
Each jurisdiction is also in the case of MEC related to the 
corresponding obligations and responsibilities. 
In the case of the national MEC, the authorities that fall 
within its exclusive jurisdiction are all types of research 
that is carried out in different institutions or countries, all 
clinical drug research in phases 1 – 3, high-risk research, 
research that is funded by public money, and research 
that is part of a doctoral thesis. For all publications of 
research results in professional literature, the date and 
the number of the positive ethical assessment of the 
national MEC should be provided to the editorial office.
The national MEC also assesses the research that can 
otherwise be assessed by the sectoral MEC, but has led to 
a conflict of interests or an insufficient unanimity in the 
assessments. In that case the national MEC is entitled to 
solve the appeals to the decisions of the sectoral MECs.
The national MEC also decides on matters of medical 
ethics on a national level, as well as carries out other 
tasks set out in the Rules of its operation.
In the field of research the sectoral or hospital MECs 
verify if the patients or persons involved in a particular 
research were notified of the intent and risk concerning 
the research, and if they are aware of their rights. They 
assess the qualifications of the researcher, as well as the 
adequacy of equipment and the number of patients or 
persons involved. They monitor if the research is carried 
out according to the initial plan, if potential professional 
or ethical complications may occur, if a change in protocol 
occurred, and in the event of occurring complications, 
10.1515/sjph-2017-0026 Zdr Varst 2017; 56(4): 193-195
194
10.1515/sjph-2017-0026 Zdr Varst 2017; 56(4): 193-195
195
the MECs decide if the research has to be interrupted or 
terminated. When the research is completed, the sectoral 
MECs revise the final report. 
A more important jurisdiction of the hospital MECs 
is to monitor and promote an ethical environment in 
healthcare institutions (6), which can be demonstrated in 
the realisation of the patients’ rights and their active role 
in the processes of medical treatment, in respecting the 
moral principle of not causing harm, as well as in carrying 
out its services with quality and justice. In the framework 
of the stated ethical fields, the hospital MECs make sure 
the patients consent to the treatment and take part in 
it after they have been informed in a comprehensible 
way about its intent, benefits and risks. They defend the 
services and procedures that would benefit the patients 
the most or are the most appropriate for them. They also 
identify conflicts between employees, which could lead 
to ethically questionable behaviour of doctors and other 
medical staff, they monitor the ethical aspects in carrying 
out “good practice” and in breaching the professional 
doctrine, including the ethical aspects of complications 
occurring in the treatment process. If needed, they 
suggest ethical improvements and measures for a better 
transparency of the procedures, services and the decision-
making process. While new diagnostic and therapeutic 
methods are being introduced, they pay attention to the 
related ethical circumstances. If needed, they discuss and 
consult regarding the appropriateness of introducing or 
suspending and continuing or terminating the treatment. 
They also advise various ad hoc committees (in cases 
of brain death, transplantation etc.) and influence the 
ethical education of trainee specialists, as well as doctors 
and other personnel.
4 CONCLUSION
While discussing the jurisdiction of particular MECs, 
the starting point cannot be their competitiveness, but 
cooperation. The network of Slovenian MECs should be 
organised in the form of a jurisdiction pyramid where 
each member plays a significant role in relation to the 
entire structure. Slovenian healthcare faces a lot of 
ethical challenges, many of them still unsolved despite 
numerous MECs. The jurisdiction of all MECs is to assess 
in a just, responsible and impartial manner not only the 
research, but also the conditions in healthcare institutions 
and in healthcare in general, with the aim to put the 
benefit of the patient first. Such standpoint should also 
be supported by the health politics and the management 
of healthcare institutions. The medical ethics should have 
a positive effect also on the Slovenian society which could 
use some encouragement after all the media and political 
negativity.
CONFLICTS OF INTEREST
The author reports no conflicts of interest. 
FUNDING
None.
ETHICAL APPROVAL
Not applicable.
REFERENCES 
1. Wikipedia. Nuremberg Code. Available Apr 16, 2017 from: https://
en.wikipedia.org/wiki/Nuremberg_Code
2. Wikipedia. Declaration of Geneva. Available Apr 16, 2017 from: 
https://www.google.si/#q=declaration+of+geneva+1948
3. Wikipedia. Declaration of Helsinki. Available Apr 16, 2017 from: 
https://www.google.si/#q=declaration+of+helsinki+health+research
4. Človekove pravice v zvezi z biomedicino. Oviedska konvencija in 
dodatni protokoli. Ljubljana: Ministrstvo za zdravje, 2009. Available 
Apr 16, 2017 from: https://www.google.si/#q=oviedska+konvencija
5. Predlog za delitev dela med področnimi (lokalnimi, bolnišničnimi) 
in državno komisijo. Komisija za medicinsko etiko pri Ministrstvu za 
zdravstvo, 1998 (unpublished).
6. Ethics committees, programs and consultation. University of 
Washington School of Medicine, 2016. Available Apr 16, 2017 from: 
https://depts.washington.edu/bioethx/topics/ethics.html
RUNNING INJURIES IN THE PARTICIPANTS OF LJUBLJANA MARATHON
Luka VITEZ1, Petra ZUPET2, Vesna ZADNIK3, Matej DROBNIČ4*
1University Medical Centre Ljubljana, Department of Internal Medicine, Zaloska 2, 1000 Ljubljana, Slovenia
2Institute for Medicine and Sports, Cesta na Poljane 24, 1000 Ljubljana, Slovenia
3Institute of Oncology Ljubljana, Epidemiology and Cancer Registry, Zaloska 2, 1000 Ljubljana, Slovenia
4University Medical Centre Ljubljana, Department of Orthopedic Surgery, Zaloska 9, 1000 Ljubljana, Slovenia
Received: Jan 30, 2017
Accepted: May 22, 2017
Original scientific article
Introduction. The aim of our study was to determine the self-reported incidence and prevalence of running-related 
injuries among participants of the 18th Ljubljana Marathon, and to identify risk factors for their occurrence.
Methods. A customized questionnaire was distributed over registration. Independent samples of t-test and chi-
square test were used to calculate the differences in risk factors occurrence in the injured and non-injured group. 
Factors which appeared significantly more frequently in the injured group were included further into multiple 
logistic regression analysis.
Results. The reported lifetime running injury (absence >2 weeks) incidence was: 46% none, 47% rarely, 4% 
occasionally, and 2% often. Most commonly injured body regions were: knee (30%), ankle and Achilles’ tendon 
(24%), foot (15%), and calf (12%). Male gender, running history of 1-3 years, and history of previous injuries were 
risk factors for life-time running injury. In the season preceding the event, 65% of participants had not experienced 
any running injuries, 19% of them reported minor problems (max 2 weeks absenteeism), but 10% and 7% suffered 
from moderate (absence 3-4 weeks) or major (more than 4 weeks pause) injuries. BMI was identified as the solely 
risk factor. 
Conclusions. This self-reported study revealed a 53% lifetime prevalence of running-related injuries, with the 
predominate involvement of knee, ankle and Achilles’ tendon. One out of three recreational runners experienced 
at least one minor running injury per season. It seems that male gender, short running experience, previous injury, 
and BMI do increase the probability for running-related injuries.
Izhodišča. V pretekli dekadi se je število rekreativnih udeležencev teka na dolge proge v Sloveniji pomembno 
zvišalo in znaša 40.000 tekačev, kar predstavlja približno 2 % prebivalstva. Leta 2013 se je 18. Ljubljanskega 
maratona udeležilo skoraj 20.000 tekačev. Več kot 1400 jih je nastopilo na maratonu, 6500 jih je teklo polmaraton, 
ostali so se udeležili teka na 10 km. Namen naše raziskave je bil določiti incidenco in prevalenco prijavljenih 
tekaških poškodb udeležencev 18. Ljubljanskega maratona in opredeliti dejavnike tveganja za njihov nastanek.
Metode. Ob prijavi smo 14.176 udeležencem po elektronski pošti poslali povezavo do spletnega vprašalnika, ki 
je vseboval splošne podatke, tekaško zgodovino in življenjsko/sezonsko prevalenco/incidenco tekaških poškodb. 
Sodelovanje v raziskavi je bilo prostovoljno in anonimno. Odgovori so predstavljeni z ustreznimi merami opisne 
statistike. Statistično značilnost razlik v dejavnikih tveganja med poškodovanimi in nepoškodovanimi udeleženci 
smo vrednotili s Studentovim t-testom oziroma testom hi-kvadrat. Za dejavnike, ki so se izkazali za značilno 
pomembne v bivariatni analizi, smo v modelu multiple logistične regresije določali njihovo neodvisno napovedno 
vrednost za tekaško poškodbo.
Rezultati. V raziskavi je sodelovalo 340 žensk in 357 moških. Njihova povprečna starost je bila 42 let, povprečen 
ITM je bil 23,1 kg/m2. Glede na pretečeno razdaljo je bila razporeditev naslednja: maraton 132, polmaraton 412 
in tek na 10 km 153 udeležencev. Življenjska incidenca tekaških poškodb (odsotnost s teka 2 tedna ali več) je bila 
naslednja: 322 (46 %) nikoli, 328 (47 %) redko, 31 (4 %) občasno in 16 (2 %) pogosto. Najpogosteje poškodovani 
telesni deli so bili: koleno (30 %), gleženj in Ahilova tetiva (24 %), stopalo (15 %) in meča (12 %). Kot dejavniki 
tveganja za življenjsko tekaško poškodbo so bili opredeljeni moški spol, ukvarjanje s tekom 1–3 leta in zgodovina 
poškodb. V sezoni pred dogodkom 65 % udeležencev ni imelo tekaške poškodbe, 19 % jih je prijavilo manjšo težavo 
(največ 2 tedna odsotnosti s teka), 10 % jih je utrpelo zmerno poškodbo (odsotnost s teka 3–4 tedne) in 7 % večjo 
(več kot 4 tedne premora). ITM je bil edini ugotovljeni dejavnik tveganja.
Zaključki. Raziskava prijavljenih poškodb udeležencev 18. Ljubljanskega maratona je pokazala 53-odstotno 
življenjsko incidenco tekaških poškodb; prevladujejo poškodbe kolena ter gležnja in Ahilove tetive. Eden od 
treh rekreativnih tekačev utrpi vsaj eno manjšo tekaško poškodbo na sezono. Dejavniki, ki povečajo tveganje za 
nastanek tekaške poškodbe, so moški spol, kratkotrajno ukvarjanje s tekom, pretekla poškodba in ITM. 
ABSTRACT
Keywords: 
sports, running, 
marathons, injuries, 
prevalence, 
incidence, 
risk factors
IZVLEČEK
Ključne besede: 
šport, tek, 
maratoni, 
poškodbe, 
prevalenca, 
incidenca, 
dejavniki tveganja
*Corresponding author: Tel: + 386 1 522 8274; E-mail: matej.drobnic@mf.uni-lj.si
Zdr Varst 2017; 56(4): 196-202
TEKAŠKE POŠKODBE UDELEŽENCEV LJUBLJANSKEGA MARATONA
Vitez L, Zupet P, Zadnik V, Drobnič M. Running injuries in the participants of Ljubljana marathon. Zdr Varst 2017; 56(4): 196-202.
10.1515/sjph-2017-0027
196
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
The public perception of running as a health promoting 
activity is important in many respects, and distance 
runners are now accepted as a significant leisure interest 
group in society. Exercise has increasingly been seen as an 
important facet of a ‘healthy society’, with leisure and 
sport providing many of the activities through which it 
is hoped this can be achieved (1). Moreover, endurance 
running has shown to be effective in providing substantial 
beneficial effects on body mass, body fat, resting 
heart rate and cholesterol levels in physically inactive 
individuals, making it an important asset for public health 
programs (2). The result is an increased popularity of 
marathon and long distance running in the last decade 
that produced around 40,000 competitive runners across 
Slovenia, which represents 2% of the population (3). The 
18th Ljubljana Marathon in 2013, recorded almost 20,000 
participants. More than 1,400 participants attended the 
42-km run, 6,500 participated in half-marathon, and the 
rest ran over 10 km distance. The increasing amount of 
runners willing to have a positive impact on their health 
is followed by an increased incidence of running-related 
injuries (RRI), ranging from 18.2% to 92.4%, and prevalence 
ranging from 6.8 to 59 injuries per 1,000 hours of training 
(4). At any given time, 25% of long distance runners are 
injured, and about a half experience an injury that stops 
their activity for a period during a year (5). Although 
some injuries are traumatic, most are due to overuse. The 
definition of an ‘‘injury’’ varies in the literature. However, 
the most common definition of RRI is: a musculoskeletal 
ailment that is attributed to running and that causes 
a restriction of running speed, distance, duration, or 
frequency for at least 1 week (6). The aetiology of RRI is 
usually related to overuse with repeated musculoskeletal 
microtrauma, and can be attributed to several risk factors 
described in the literature. Each one of them is affected 
by personal characteristics of the runner (anatomical and 
biomechanical factors), training errors (such as training 
volume, weekly distance), and running experience (4).
The aim of our study was to evaluate the frequency of RRI 
and determine the self-reported incidence and prevalence 
of those injuries among participants of the 18th Ljubljana 
Marathon. We also tried to discriminate risk factors for 
the occurrence of RRI and contribute to better prevention 
in this study population.
2 METHODS
The study was designed as a retrospective cohort study 
based on a customized questionnaire, distributed 
over registration emails to 14,176 participants of the 
18th Ljubljana Marathon (held on 27 October 2013). 
Participation in the study was voluntarily and anonymous. 
Only the runners’ race numbers were tracked. The data 
was collected prior to the race and advertised during 
registration. The customized questionnaire in Slovenian 
language contained general data, running history, running 
distance per week, previous participation at an official 
event, type of training for the event, regions of RRI, other 
sports participation, barefoot running, and life/season 
prevalence/incidence of RRI. RRI was defined as a cause 
of absence from running for 2 weeks or more due to an 
injury that was caused with running only. Questions were 
specifically designed to target RRI risk factors reported 
elsewhere (4, 7, 8). The questionnaire had to be filled 
completely to be submitted. All answers were received 
electronically and screened. Participants who did not 
appear on the race, or the ones not finishing the run, were 
excluded from the data analysis.
Simple descriptive statistics was used to present the 
characteristics of the study population. Two different 
outcomes were observed in regard to running related 
injuries, namely: runners injured during last season 
(incidence), and runners with a life-time injury 
(prevalence). We used gender, age, BMI, running 
experience, running distance per week, other sports 
participation, barefoot running, types of preparation for 
the marathon, official event experience, and history of 
previous running injuries as explanatory variables. The 
data is presented as mean±SD. Independent samples of 
t-test and chi-square test were used to calculate the 
differences in potential risk factors occurrence in the 
injured and non-injured group. Factors which appeared 
significantly more frequently in the injured than in non-
injured group were included further into multiple logistic 
regression analysis with the aim to confirm or reject 
their role as independent risk factors for running-related 
injuries. All variables were included simultaneously, 
using the ENTER method. P value of less than 0.05 was 
considered statistically significant. All analyses were 
performed using IBM SPSS Statistics version 24.
3 RESULTS
Out of 14.176 distributed questionnaires, 814 were 
returned (response rate= 5.7%). 213 runners did not 
appear and 4 did not finish the race, and were removed 
from the research. At the end, 697 were eligible for 
further analysis.
There were 340 (48.8%) females and 357 (51.2%) males 
participating in the study. Their average age was 42±11 
years, and their average body mass index (BMI) was 
23.1±2.6 kg/m2. Runners’ distribution according to the 
running distance at the event was: full marathon 132 
(18.9%), half-marathon 412 (60.1%), and 10 km run 153 
(21%) participants. The participants reported lifetime 
10.1515/sjph-2017-0027 Zdr Varst 2017; 56(4): 196-202
197
10.1515/sjph-2017-0027 Zdr Varst 2017; 56(4): 196-202
198
running injury (absence more than 2 weeks) prevalence 
as following: 322 (46%) none, 328 (47%) rarely, 31 (4%) 
occasionally, and 16 (2%) often. Most commonly injured 
body regions were: knee (30%), ankle and Achilles’ tendon 
(24%), foot (15%), and calf (12%). Incidence was observed 
in the season preceding the 18th Ljubljana Marathon 
event. 452 (65%) participants had not experienced 
Table 1. Baseline characteristics of runners in a study group at 18th Ljubljana Marathon (N=697). 
Gender 
Females vs. Males
Age (mean±SD)
10-19 years
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
BMI (mean±SD)
<25
≥25
Running distance at the 18th Ljubljana Marathon
Full marathon
Half-marathon
10 km 
Life-time running injury prevalence (more than 2 week absence)
None
Rarely
Occasionally
Often
Running injury body regions
Previous season running injury incidence
None
Minor (2 week absence)
Moderate (3-4 weeks absence)
Severe (more than 4 week absence)
Running experience
Less than 1 year
1-3 years
4-10 years
More than 10 years
Running distance per week
Less than 10 km
11 to 20 km
21 to 30 km
31 to 50 km
More than 50 km
Other sport activities participation
Yes vs. No
Previous injury
Yes vs. No
Barefoot running
Yes vs. No
340 (49%) / 357 (51%)
42±11 years (14 to 68 years)
9 (1%)
94 (13%)
184 (26%)
247 (35%)
121 (17%)
42 (6%)
23.1±2.6 kg/m2 (16.9 to 38.1 kg/m2)
545 (78%)
152 (22%)
132 (19%)
412 (60%)
143 (21%)
322 (46%)
328 (47%)
31 (4%)
16 (2%)
30% knee / 24% ankle and Achilles’ / 15% foot / 12% lower leg / 
9% thigh / 8% lower back / 6% hip / 2% pelvis / 1% shoulder / 
1% neck / 1% chest
452 (65%)
131 (19%)
66 (10%)
48 (7%)
52 (8%)
213 (30%)
293 (42%)
139 (20%)
46 (7%)
167 (24%)
237 (34%)
170 (24%)
77 (11%)
606 (87%) / 91 (13%)
387 (56%) / 310 (44%)
89 (13%) / 608 (87%)
Variable Analyzed group 
(n=697)
any running injuries, 131 (19%) of them reported minor 
problems (max 2 weeks absenteeism), but 66 (10%) and 
48 (7%) participants suffered from moderate (absence 
3-4 weeks) or major (more than 4 weeks healing pause) 
running-related injuries. The results are presented in the 
Table 1. 
10.1515/sjph-2017-0027 Zdr Varst 2017; 56(4): 196-202
199
We compared two group of runners: one with no life-time 
RRI and the other with occasional and recurrent injuries. 
A multiple regression logistic analysis revealed that male 
gender (p<0.01, ß=0.479), running experience of 1 to 3 
years (p<0.01 ß=0.348), and personal history of previous 
injuries (p<0.01, ß=1.78) were risk factors for life-time 
RRI. It also showed that higher age was a risk factor for 
lower leg life-time RRI (p<0.01, ß=0.947), and running 
distance of 21-30 km (p<0.05, ß=0.453) and 31-50 km per 
week (p<0.05, ß=0.48) were risk factors for foot lifetime 
RRI. Barefoot running was also considered a statistically 
significant risk factor for lower leg life-time RRI (p<0.05, 
ß=0.523). On the contrary, BMI, running experience of 4 
years or more, and other sports participation were not 
related to lifetime running injuries (Table 2). 
Table 2. Risk factors for running related injuries incidence among participants of 18th Ljubljana Marathon (N=697).
OI+RI - cumulative number of all injuries together; NI:OI+RI – statistical comparison between non-injured to injured runners; 
ns – no significant differences; * - significant differences are given for the whole body, unless otherwise stated.
Gender
Females
Males
Age (mean±SD)
BMI (mean±SD)
<25 kg/m2
≥25 kg/m2
Running experience
Less than 1 year
1 to 3 years
4 to 10 years
More than 10 years
Running distance per week
Less than 10 km
11 to 20 km
21 to 30 km
31 to 50 km
More than 50 km
Other sports activities 
Yes
No
Previous injury 
Yes
No
Barefoot Running 
Yes
No
189 (59%)
133 (41%)
41 years (11)
23 kg/m2 (2.7)
246 (76%)
76 (24%)
40 (12%)
109 (34%)
118 (37%)
55 (17%)
29 (9%)
91 (28%)
112 (35%)
62 (19%)
28 (9%)
282 (88%)
40 (12%)
215 (67%)
107 (33%)
31 (10%)
291 (90%)
138 (42%)
190 (58%)
42 years (11)
23.1 kg/m2 (2.6)
263 (80%)
65 (20%)
9 (3%)
99 (30%)
157 (48%)
63 (19%)
13 (4%)
69 (21%)
116 (35%)
90 (28%)
40 (12%)
284 (87%)
44 (13%)
156 (48%)
172 (52%)
51 (16%)
277 (84%)
13 (28%)
34 (72%)
44 years (10)
23.8 kg/m2 (2.3)
36 (77%)
11(23%)
3 (6%)
5 (11%)
18 (38%)
21 (45%)
4 (9%)
7 (15%)
9 (19%)
18 (38%)
9 (19%)
40 (85%)
7 (15%)
16 (34%)
31 (66%)
7 (15%)
40 (85%)
151 (40%)
224 (60%)
 42 years (11)
23,2 kg/m2 (2.6)
299 (80%)
76 (20%)
12 (3%)
104 (28%)
175 (47%)
84 (22%)
17 (5%)
76 (20%)
125 (33%)
108 (29%)
49 (13%)
324 (86%)
51 (14%)
172 (46%)
203 (54%)
58 (15%)
317 (85%)
0.006; 0.497
Lower leg only: 0.000; 
0.947
ns
ns
ns
0.007; 0.348
ns
ns
ns 
ns
Foot only: 0.038; 0.453
Foot only: 0.036; 0.480
ns
 ns
0.000; 1.78
Lower leg only: 0.035; 
0.523
Variable No injuries (NI) 
(N=322)
Occasional injuries 
(OI) (N=328)
Recurrent injuries 
(RI) (N=47)
OI+RI 
(N=375)
* NI:OI+RI
p-value; ß- factor
In the season preceding the 18th Ljubljana Marathon 
event, 452 (65%) participants had not experienced 
any running injury, 131 (19%) of them reported minor 
problems (max 2 weeks absenteeism), but 66 (10%) and 
48 (7%) participants suffered from moderate (absence 
3-4 weeks) or major (more than 4 weeks healing break) 
running-related injuries. BMI was the only risk factor for 
one-season running period incidence (increase in one 
point increases the risk for injury for 5.7%). Furthermore, 
runners that were overweight or obese had significantly 
more injures than runners with a BMI of less than 25 kg/
m2 (p<0.05). Other factors, such as gender, age, personal 
running experience, running distance per week, previous 
participation at a official event, type of training for the 
event, other sports participation, and barefoot running 
did not represent a one-season risk factor in our study 
group. Details are presented in Table 3.
10.1515/sjph-2017-0027 Zdr Varst 2017; 56(4): 196-202
200
4 DISCUSSION
This retrospective self-reporting study on Slovenian 
long-distance runners revealed that they had over 50% 
of lifetime prevalence of RRI. One out of three runners 
sustained at least one minor RRI per season. Mostly injured 
body regions were knee and ankle with Achilles’ tendon. 
Male gender, short running history, previous injury, and 
an increased BMI seem to increase risk of RRI in general. 
We also established higher risk for lower leg RRI with 
increased age and barefoot running, and increased risk 
for foot RRI in relation to weakly mileage.
Current reports show that 19%-79% sustain a RRI (7). The 
differences between studies originate from a non-uniform 
definition of RRI and from the enrolled study populations 
Table 3. Risk factors for running related injuries prevalence among participants of 18th Ljubljana Marathon (N=697).
Mil+Mal - cumulative number of all injuries together; NI:MiI+MaI – statistical comparison between non-injured to injured runners; 
ns – no significant differences
Gender
Females
Males
Age (mean±SD)
BMI (mean±SD)
<25 kg/m2
≥25 kg/m2
Running experience
Less than 1 year
1 to 3 years
4 to 10 years
More than 10 years
Running distance per week
less than 10 km
11 to 20 km
21 to 30 km
31 to 50 km
More than 50 km
Running on official event
First time
One to five times
Six to ten times
More than ten times
Preparation for marathon
No special training
Training alone
Supervised formal training
Self-organized informal group
Official running club
Other sports activities
Yes
No
Barefoot Running
Yes
No
232 (51%)
220 (49%)
42 years (11)
22.9 kg/m2 (2.5)
365 (81%)
87 (19%)
40 (9%)
141 (31%)
177 (39%)
94 (21%)
33 (7%)
112 (25%)
157 (35%)
102 (22%)
48 (11%)
89 (20%)
221 (49%)
76 (17%)
66 (14%)
46 (10%)
262 (58%)
94 (21%)
44 (10%)
6 (1%)
392 (87%)
60 (13%)
57 (13%)
395 (87%)
59 (45%)
72 (55%)
41 years (10)
23.5 kg/m2 (2.9)
93 (71%)
38 (19%)
7 (5%)
44 (34%)
62 (47%)
18 (14%)
8 (6%)
25 (19%)
47 (36%)
39 (30%)
12 (9%)
18 (14%)
80 (61%)
18 (14%)
15 (11%)
6 (4%)
81 (62%)
26 (20%)
17 (13%)
1 (1%)
114 (87%)
17 (13%)
19 (15%)
112 (85%)
49 (43%)
65 (57%)
43 years (11)
23.2 kg/m2 (2.7)
87 (76%)
27 (24%)
5 (4%)
28 (25%)
54 (47%)
27 (24%)
5 (4%)
30 (26%)
33 (29%)
29 (26%)
17 (15%)
16 (14%)
58 (51%)
17 (15%)
23 (20%)
10 (9%)
62 (54%)
27 (24%)
14 (12%)
1 (1%)
100 (88%)
14 (12%)
13 (11%)
101 (89%)
108 (44%)
137 (56%)
 42 years (11)
 23.4 kg/m2 (2.8)
180 (73%)
65 (27%)
12 (5%)
72 (30%)
116 (47%)
45 (18%)
13 (5%)
55 (22%)
80 (33%)
68 (28%)
29 (12%)
34 (14%)
138 (56%)
35 (14%)
38 (16%)
16 (7%)
143 (58%)
53 (22%)
31 (13%)
2 (1%)
214 (87%)
31 (13%)
32 (13%)
213 (87%)
ns
ns
0.036; 1.057
0.028
ns
ns
ns
ns
ns
ns
Variable No injuries (NI) 
(N=452)
Minor injuries 
(MiI) (N=131)
Major injuries (MaI) 
(N=114)
Mil+Mal
(N=245)
NI:MiI+MaI; 
p-value; ß-factor
(9). The most common conclusions that one out of two 
runners sustained an RRI in life, and that one of three 
runners was injured per season, was confirmed also in our 
data. Individual factors identified by the literature suggest 
that the majority of RRI are of multifactorial origin. Most 
commonly, reported risk factor in prospective studies is 
previous injury in the past 12 months, followed by higher 
quadriceps angle of the knee (Q angle) and a running 
distance per week (over 40 miles/64 km) (4). Increased 
BMI, male gender, running experience, participation in 
races of greater distance, increase in days of training per 
week, increase in training distance per week, shoe age, 
and running throughout the whole year have also been 
reported as limited evidence risk factors for RRI (7, 10). 
Greater training distance (30-39 miles/50-64 km), age, 
10.1515/sjph-2017-0027 Zdr Varst 2017; 56(4): 196-202
201
previous sports activity, and running on concrete surfaces 
were associated with greater RRI in female runners, 
whereas greater training frequency, running experience 
of 0-2 years, and weekly running distance of 20-29 
miles/32-49 km were associated with more RRI in men 
(7, 10). Training distance per week has been shown as 
the only protective factor for RRI of the knee (7). The 
strongest general RRI risk factors established with our 
study concur with previous publications: male gender, 
running experience of 1-3 years, previous injury, and 
weekly running distance. The later was significant only 
from 20 to 50 km; we speculate too few participants 
with weakly distance over 50 km were enrolled. An 
increased lifetime RRI risk for fresh (1 to 3 years), but 
not novice runners in comparison to runners with longer 
history was revealed. This suggests a natural selection 
bias: fresh runners who get injured early in their running 
carrier probably discontinue with this sporting activity, 
and only people with more appropriate biomechanical 
running dispositions persist. When we specifically focused 
on lower leg RRI, then higher age and barefoot running 
stood out as significant risk factors. Lower leg question 
on the distributed questionnaire was targeting body 
regions below the knee, and above the ankle. Herein, we 
would find mostly diagnoses-related shin and calf muscle-
tendons, and less likely activity-induced compartment 
syndrome or tibia/fibula stress fractures. The muscle-
tendon lower leg problems are probably related to 
degeneration and stiffness with increasing person’s age, 
as such tissue is being less resistant to overuse (11). Shin/
calf pain may also be related to foot pronation, as it has 
been previously shown that feet become flatter in older 
adults (12). Barefoot running itself has been shown to 
reduce foot soft-tissue overuse RRI, but it has a tendency 
to increase stress fractures (13). Recent studies tried 
to evaluate the effect of barefoot running on running 
injuries without any strong evidence beside supporting a 
forefoot strike pattern that improves running efficiency 
(14). Running barefooted or in minimalistic shoes requires 
higher activity of extrinsic shin/calf muscles to avoid heel 
strike and to adjust for the running terrain (13). We would 
suggest that such overload results increase lower leg RRI. 
Nevertheless, we need to interpret barefoot running with 
caution due to self-reporting of RRI and limited number of 
runners involved in barefoot running. BMI was exposed as 
a risk factor for one season injury, but not as a life-time 
prevalence risk factor. Here, we probably come across 
another natural history bias: novice/fresh overweight 
runners involved in running either quit this activity early 
due to an injury, or lose weight and continue with an 
injury free running career.
By reviewing recent studies about body parts affected 
by RRI in long-distance runners, most them can be 
attributed to the knee (7.2%-50%), followed by the 
lower leg (9%-32.2%), the foot (5.7%-39.3%), and thigh 
(3.4%-38.1%). Less common sites were the ankles (3.9%-
16.6%) and the hip (3.3%-11.5%) (7). The most common 
clinical diagnoses are represented by the iliotibial 
band syndrome, patellofemoral pain syndrome, stress 
fractures, medial tibial stress syndrome, Achilles tendon 
and calf injuries, meniscus injuries, and muscle injuries to 
the hamstrings and quadriceps (5, 15). Among marathon 
runners, men report more hamstring and calf problems, 
whereas women report more hip complains (16). Knees 
and ankles/Achilles in our study, encounter for more than 
50% of all RRI, and there seems to be good correlation to 
the other authors. Knowing the overuse problems of these 
particular regions, preventive training programs need to 
be implemented. Cross-training was previously shown to 
reduce risk for RRI (17, 18), but we were not able to prove 
this in our study population. Despite the expectations, we 
were also not able to show that supervised training in a 
club or in a dedicated training group, influences RRI risks. 
It looks like a supervised training provides motivational 
effect of running, but improvements of training protocols 
in terms of RRI prevention are required. Three main 
target groups of RRI prevention can be exposed from this 
study: males, overweight runners (BMI≥25 kg/m2), and 
previously injured runners. Lessons learned from anterior 
cruciate injuries and hamstring muscle tears have 
clearly shown that both can be reduced with dedicated 
preventive exercise (19, 20). Both injuries are quite easy 
to detect after an abrupt injury, as sportsmen are unable 
to continue with sports without medical help. On the 
other hand, RRI overuse injuries are less stressful, there 
is a wide spectrum of problems, and lots of runners do 
not seek medical attention for minor injuries. Overweight 
novice runners require soft transition into running, and 
they should be stimulated to lose weight also by other 
means, not just running itself. Although the population 
with previous RRI seems an easily accessible target 
for secondary prevention, the studies on functional 
diagnostics were not able to delineate clear criteria for 
RRI (21-23). Unfortunately, secondary prevention in such 
cases can be relied only on personal expert opinions. 
This study needs to be interpreted considering the 
following limitations: limited sample size, self-reporting 
of RRI in a form of questionnaire, voluntary participation, 
and retrospective data acquisition. But on the other hand, 
the response rate of nearly 6% and similar distribution of 
age, gender, and running distances (referring to publicly 
available data) allowed us to draw statistically important 
conclusions.
5 CONCLUSIONS
This self-reported retrospective study on Ljubljana 
Marathon participants revealed a 53% lifetime prevalence 
of running-related injuries, with the predominate 
10.1515/sjph-2017-0027 Zdr Varst 2017; 56(4): 196-202
202
involvement of knee, ankle, and Achilles tendon. One 
out of three recreational runners experienced at least 
one minor running injury per season. Male gender, 
short duration of running experience, previous injury, 
and higher BMI are linked to an increased risk of RRI in 
general. Higher age and barefoot running do increase risk 
for specific lower leg RRI, and so does the weakly running 
distance of over 20 km regarding specific foot RRI.
ACKNOWLEDGMENTS
LV received a FIMS-ASPETAR Young Investigator Award for 
the presentation entitled ‘Self-reported running injuries 
in the participants of Ljubljana marathon’ at the 34th 
FIMS WORLD Sports Medicine Congress, held in Ljubljana 
(Slovenia), from 29 September to 2 October 2016. An 
abstract, containing part of the study data, was included 
in the conference proceedings.
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
No funding has been received for the execution of this 
study and/or preparation of this manuscript.
ETHICAL APPROVAL
The study protocol was approved by the Slovenian National 
Medical Ethics Committee (No. 174/08/14).
REFERENCES
1. Shipway R, Holloway I. Running free: embracing a healthy lifestyle 
through distance running. Perspect Public Health 2010; 130: 270-6.
2. Hespanhol Junior LC, Pillay JD, van Mechelen W, Verhagen E. Meta-
analyses of the effects of habitual running on indices of health in 
physically inactive adults. Sports Med 2015; 45: 1455-68.
3. Škof B. Slovenski tekači – stranka z največ potenciala. Dnevnikov 
triatlon, 2013.
4. Saragiotto BT, Yamato TP, Hespanhol Junior LC, Rainbow MJ, Davis 
IS, Lopes AD. What are the main risk factors for running-related 
injuries? Sports Med 2014; 44: 1153-63.
5. Fields KB. Running Injuries - changing trends and demographics. Curr 
Sports Med Rep 2011; 10: 299-303.
6. Hreljac A. Etiology, prevention, and early intervention of overuse 
injuries in runners: a biomechanical perspective. Phys Med Rehabil 
Clin N Am 2005; 16: 651-67.
7. van Gent RN, Siem D, van Middelkoop M, van Os AG, Bierma-Zeinstra 
SM, Koes BW. Incidence and determinants of lower extremity running 
injuries in long distance runners: a systematic review. Br J Sports 
Med 2007; 41: 469-80.
8. Buist I, Bredeweg SW, Bessem B, van Mechelen W, Lemmink KA, 
Diercks RL. Incidence and risk factors of running-related injuries 
during preparation for a 4-mile recreational running event. Br J 
Sports Med 2010; 44: 598-604.
9. Hoeberings J. Factors related to the incidence of running injuries: a 
review. Sports Med 1992; 13: 408-22.
10. van der Worp MP, ten Haaf DS, van Cingel R, de Wijer A, Nijhuis-van 
der Sanden MW, Staal JB. Injuries in runners: a systematic review on 
risk factors and sex differences. PLoS One 2015;10: e0114937.
11. Karamanidis K, Arampatzis A. Age-related degeneration in leg-
extensor muscle-tendon units decreases recovery performance after 
a forward fall: compensation with running experience. Eur J Appl 
Physiol 2007; 99: 73-85.
12. Redmond AC, Crane YZ, Menz HB. Normative values for the Foot 
Posture Index. J Foot Ankle Res 2008; 1: 6.
13. Murphy K, Curry EJ, Matzkin EG. Barefoot running: does it prevent 
injuries? Sports Med 2013; 43: 1131-8.
14. Lorenz DS, Pontillo M. Is there evidence to support a forefoot strike 
pattern in barefoot runners?: a review. Sports Health 2012; 4: 480-4.
15. Jin J. Running injuries. JAMA 2014; 312: 202.
16. Fredericson M, Misra AK. Epidemiology and aetiology of marathon 
running injuries. Sports Med 2007; 37: 437-9.
17. Grier T, Canham-Chervak M, Anderson MK, Bushman TT, Jones BH. 
Effects of the FIFA 11 training program on injury prevention and 
performance in football players: a systematic review and meta-
analysis. US Army Med Dep J 2015: Apr-Jun: 33-41.
18. Grier T, Canham-Chervak M, Anderson MK, Bushman TT, Jones 
BH. Effects of physical training and fitness on running injuries in 
physically active young men. J Strength Cond Res 2017; 31: 207-16.
19. Taylor JB, Waxman JP, Richter SJ, Shultz SJ. Evaluation of the 
effectiveness of anterior cruciate ligament injury prevention 
programme training components: a systematic review and meta-
analysis. Br J Sports Med 2015; 49: 79-87.
20. Gomes Neto M, Conceicao CS, de Lima Brasileiro AJ, de Sousa CS, 
Carvalho VO, de Jesus FL. Effects of the FIFA 11 training program on 
injury prevention and performance in football players: a systematic 
review and meta-analysis. Clin Rehabil 2017; 31:651-9.
21. Bennell K, Wajswelner H, Lew P, Schall-Riaucour A, Leslie S, Plant D 
et al. Isokinetic strength testing does not predict hamstring injury in 
Australian Rules footballers. Br J Sports Med 1998; 32: 309-14.
22. Knapik JJ, Trone DW, Tchandja J, Jones BH. Injury-reduction 
effectiveness of prescribing running shoes on the basis of foot arch 
height: summary of military investigations. J Orthop Sports Phys 
Ther 2014; 44: 805-12.
23. Mann R, Malisoux L, Urhausen A, Meijer K, Theisen D. Plantar pressure 
measurements and running-related injury: a systematic review of 
methods and possible associations. Gait Posture 2016; 47: 1-9.
PATIENT SAFETY CULTURE IN SLOVENIAN OUT-OF-HOURS 
PRIMARY CARE CLINICS
Zalika KLEMENC-KETIŠ1,2,3*, Ellen TVETER DEILKÅS4, Dag HOFOSS5, Gunnar TSCHUDI BONDEVIK6,7
1University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska 8, 2000 Maribor, Slovenia
2University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana, Slovenia
3Community Health Centre Ljubljana, Metelkova 9, 1000 Ljubljana, Slovenia 
4Health Services Research Unit, Akershus University Hospital, Norway
5Institute of Health and Society, University of Oslo, Norway
6Department of Global Public Health and Primary Care, University of Bergen, Norway 
7National Centre for Emergency Primary Health Care, Uni Research Health, Bergen, Norway
Received: Apr 18, 2017
Accepted: Jun 23, 2017 
Original scientific article
Introduction. Patient safety culture is a concept which describes how leader and staff interaction, attitudes, 
routines and practices protect patients from adverse events in healthcare. We aimed to investigate patient 
safety culture in Slovenian out-of-hours health care (OOHC) clinics, and determine the possible factors that 
might be associated with it.
Methods. This was a cross-sectional study, which took place in Slovenian OOHC, as part of the international 
study entitled Patient Safety Culture in European Out-of-Hours Services (SAFE-EUR-OOH). All the OOHC clinics 
in Slovenia (N=60) were invited to participate, and 37 agreed to do so; 438 employees from these clinics were 
invited to participate. We used the Slovenian version of the Safety Attitudes Questionnaire – an ambulatory 
version (SAQAV) to measure the climate of safety.
Results. Out of 438 invited participants, 250 answered the questionnaire (57.1% response rate). The mean 
overall score ± standard deviation of the SAQ was 56.6±16.0 points, of Perceptions of Management 53.6±19.6 
points, of Job Satisfaction 48.5±18.3 points, of Safety Climate 59.1±22.1 points, of Teamwork Climate 72.7±16.6, 
and of Communication 51.5±23.4 points. Employees working in the Ravne na Koroškem region, employees with 
variable work shifts, and those with full-time jobs scored significantly higher on the SAQ-AV.
Conclusion. The safety culture in Slovenian OOHC clinics needs improvement. The variations in the safety 
culture factor scores in Slovenian OOHC clinics point to the need to eliminate variations and improve working 
conditions in Slovenian OOHC clinics.
Uvod. Kultura varnosti je koncept, ki opisuje, kako odnosi med vodstvom in osebjem, njihova stališča, 
postopki in praksa varujejo bolnike pred škodljivimi dogodki zaradi napake v zdravstvu. Z raziskavo smo želeli 
raziskati kulturo varnosti v slovenskih dežurnih ambulantah na primarni ravni zdravstvenega varstva in določiti 
dejavnike, ki so povezani z njo.
Metode. To je bila prečna opazovalna raziskava, ki je potekala v slovenskih dežurnih ambulantah na primarni 
zdravstveni ravni in je bila del mednarodne raziskave z naslovom Patient Safety Culture in European Out-of-
Hours services (SAFE-EUR OOH). K sodelovanju smo povabili vse dežurne ambulante v Sloveniji (N=60), 37 jih 
je sodelovanje potrdilo. V teh ambulantah je bilo k sodelovanju povabljenih 438 zaposlenih. Uporabili smo 
slovensko različico lestvice Safety Attitudes Questionnaire – ambulatory version (SAQ – AV), s katero smo merili 
raven kulture varnosti.
Rezultati. Od 438 povabljenih je vprašalnike izpolnilo 250 zaposlenih (57,1%). Povprečna vrednost lestvice 
SAQ – AV je bila 56,6±16,0 točke. Povprečna vrednost faktorja dojemanje vodstva je bila 53,6±19,6 točke, 
faktorja zadovoljstvo z delom 48,5±18,3 točke, faktorja ozračje varnosti 59,1±22,1, faktorja ozračje timskega 
dela 72,7±16,6 in faktorja sporazumevanje 51,5±23,4 točke. Zaposleni v regiji Ravne na Koroškem, zaposleni 
z izmenskim delom in zaposleni s polnim delovnim časom so imeli statistično višji seštevek točk na lestvici 
SAQ – AV.
Zaključek. Kultura varnosti v slovenskih dežurnih ambulantah potrebuje izboljšave. Različni seštevki točk 
na lestvici SAQ – AV v različnih regijah Slovenije in v različnih dežurnih ambulantah kažejo na potrebo po 
zmanjšanju razlik in izboljšanju delovnih pogojev.
ABSTRACT
Keywords: 
safety culture, 
out-of-hours medical 
care, primary health 
care, Slovenia
IZVLEČEK
Ključne besede: 
kultura varnosti, 
dežurna služba, 
primarna zdravstvena 
raven, Slovenija
*Corresponding author: Tel: + 386 41 516 067; E-mail: zalika.klemenc-ketis@uni-mb.si
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
203
KULTURA VARNOSTI V SLOVENSKIH DEŽURNIH AMBULANTAH 
NA PRIMARNI RAVNI
Klemenc-Ketiš Z, Tveter Deilkås E, Hofoss D, Tschudi Bondevik G. Patient safety culture in Slovenian out-of-hours primary care clinics. Zdr Varst 2017; 56(4): 203-210.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
In the past two decades, quality in primary care has been 
extensively studied in Europe, including Slovenia (1-7). 
Several of these studies have dealt with patient safety 
issues, which is an important part of quality improvement 
(8-14). In Slovenia, patient safety features in primary 
health care have been investigated through the study on 
Quality and Costs of Primary Care in Europe (QUALICOPC), 
dealing with the organisation and accessibility of primary 
health care services (4, 15, 16). 
Out-of-hours health care (OOHC) at the primary health care 
level is a crucial part of the availability and accessibility 
of the provision of healthcare (17, 18). Several studies 
have already been published on patient safety issues in 
OOHC and primary care emergency settings (8, 13, 18-
21). Smits et al. reviewed patient records in OOHC clinics 
in the Netherlands, and determined that although patient 
safety incidents did occur in 2.4% of reviewed patients 
records in OOHC clinics, most did not harm the patients 
(8). A systematic review of the safety of telephone triage 
in OOHC clinics concluded that triage was safe in most 
cases. However, there was room for improvement in triage 
for patients who present with symptoms that indicate 
high risk (22). Patient safety culture in OOHC clinics as a 
concept, which describes how leader and staff interaction, 
attitudes, routines and practices protect patients from 
adverse events in healthcare, has been investigated in a 
few studies (13, 20, 21, 23). Bondevik et al. (13) found 
both demographic and professional differences in staff 
perception of patient safety in Norwegian OOHC clinics. 
In Slovenia, primary OOHC clinics are located in primary 
health care centres. Medical care is provided mainly by 
family physicians with their teams, who also carry out 
emergency services. Slovenian OOHC clinics are open 
24/7, enabling free access to patients on demand. In 
urgent cases, an emergency team with an ambulance is 
available. The team consists of a physician on call and two 
specialist nurses providing the emergency medical services 
(EMS). This is a major difference between Slovenian and 
most European OOHC clinics, as OOHC in the majority of 
the European countries is organised separately from the 
EMS (17). 
To date, only one paper has dealt with patient safety 
culture in Slovenian OOHC clinics (24). We therefore 
decided to study this issue further to get some insight into 
this area. We aimed to investigate patient safety culture 
in Slovenian OOHC clinics, and determine the possible 
factors that might be associated with it. 
2 METHODS
2.1 Type of Study and Settings
This was a cross-sectional study that took place in 
Slovenian OOHC clinics from 16 March to 1 May 2015. The 
study was part of an international study entitled Patient 
Safety Culture in European Out-of-Hours Services (SAFE-
EUR-OOH), which was led by a coordinating research group 
from Norway. The study was a project by the European 
research network for out-of-hours primary health care 
(EurOOHnet) (25).
In Slovenia, there are 60 OOHC clinics and all were invited 
to participate; 37 of them agreed to do so. There are 
10 health care regions in Slovenia, which correspond to 
geographical regions: Murska Sobota, Maribor, Ravne na 
Koroškem, Celje, Krško, Novo Mesto, Ljubljana, Kranj, 
Nova Gorica, and Koper. The participating OOHC clinics 
were grouped according to these regions: seven OOHC 
clinics from the Ljubljana region, five from the Kranj and 
Ravne na Koroškem regions, four from the Koper region, 
three from the Murska Sobota, Maribor, Celje, Krško, and 
Novo Mesto regions, and one from the Nova Gorica region.
2.2 Participants
In each OOHC clinic, the person in charge of data 
collection asked all the employees (physicians, nurse 
practitioners, nurse managers, trainees, practice 
nurses, radiology technicians, and office managers) to 
participate. Following this procedure, 438 people were 
invited to participate. The participation was voluntary 
and anonymous.
2.3 Data Collection
The key national researcher for Slovenia (ZKK) collected 
the e-mail addresses of all the invited employees of the 37 
participating OOHC clinics in Slovenia. An e-questionnaire 
was sent by the coordinating research group in Norway 
to these employees on 16 March 2015. After two weeks, 
an automatic reminder was sent to those who had not 
responded. The e-questionnaires were sent using the 
computer programme, Qualtrics.
We used the Slovenian version of the SAQ-AV (24), which 
has been translated from English according to standard 
procedures (26). The SAQ-AV is a 62-item questionnaire 
where the respondents rate their agreement using a 
5-point Likert scale: 1=disagree strongly, 2=disagree 
slightly, 3=neutral, 4=agree slightly, 5=agree strongly (27). 
“Not applicable” was included as a response category in 
all questions, and combined with missing values in the 
data analyses. The scores of negatively worded items 
were reversed, so that higher scores in the data set always 
indicated a more positive evaluation of the OOHC clinics’ 
patient safety culture. Additionally, there were also 
some demographic questions (sex, age, function, work 
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
204
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
205
experience, shifts, and type of employment). “Variable 
shifts” describes the different types of possible working 
hours: days, evenings, nights, and variable/rotating shifts. 
The Slovenian version of the SAQ-AV has five safety climate 
factors: Perceptions of Management, Job Satisfaction, 
Safety Climate, Teamwork Climate, and Communication 
(24). The total score of the SAQ-AV was calculated 
according to the Baker and Hershaw equation (28): 
[(Σitems 1-62) * 100/(5 * 62)] * 1.25 – 25. 
Similarly, the scores of the individual factors were 
calculated as: 
[(Σitems) * 100/(5 * N of items)] * 1.25 – 25. 
So, the minimum score was 0 and the maximum score was 
100 for the overall SAQ-AV score, as well as for each of 
the factors.
2.4 Analysis
Statistical analysis was carried out using the SPSS 22.0 
programme. We performed bivariate analysis using the 
independent t-test and one-way ANOVA, and multivariate 
analysis using linear regression. The variables that proved 
significant in the bivariate analyses were entered into 
the multivariate analysis. We set the limit of statistical 
significance at p<0.05.
3 RESULTS
3.1 Demographic Characteristics
Out of 438 invited participants, 250 answered the 
questionnaire (57.1% response rate). There were 110 
(44.0%) women in the sample (Table 1). 
3.2 Attitudes to Patient Safety Culture
The mean overall score ± standard deviation of the SAQ 
was 56.6±16.0 points; of Perceptions of Management 
53.6±19.6 points; of Job Satisfaction 48.5±18.3 points; 
of Safety Climate 59.1±22.1 points; of Teamwork Climate 
72.7±16.6; and of Communication 51.5±23.4 points.
The highest climate scores of patient safety culture were 
reported in the Nova Gorica region and the lowest in 
Koper. Perceptions of Management was scored highest in 
the Krško region, and Job Satisfaction, Safety Climate, 
Teamwork Climate, and Communication were scored 
highest in the Nova Gorica region. There were significant 
differences across regions in terms of the overall total 
SAQ-AV score, and of the climate factors Perceptions of 
Management, Job Satisfaction, and Communication (Table 
2). 
Table 1. Demographic characteristics of the Slovenian 
out-of-hours primary health care clinics’ employees 
participating in the study (N=250).
Sex
Male
Female
Not given
Age (years)
30 and lower
31-40
41-50
51-60
61 and higher
Not given
Usual shift
Days
Evenings
Nights
Variable
Not given
Type of employment
Full-time
Part-time
Contract
Not given
Work experience (years)
5 or less
6-10
11-20
21-30
31-40
41 or more
Not given 
Function
Physicians
Nurse practitioners
Nurse managers
Trainees
Practice nurses
Radiology technicians
Office managers
Not given
Region of Slovenia
Murska Sobota
Maribor
Ravne na Koroškem
Celje
Krško
Novo Mesto
Ljubljana
Kranj region
Nova Gorica region
Koper region
Not given
91 (36.4)
110 (44.0)
49 (19.6)
41 (16.4)
74 (29.6)
49 (19.6)
33 (13.2)
4 (1.6)
49 (19.6)
3 (1.2)
2 (0.8)
4 (1.6)
192 (76.8)
49 (19.6)
191 (76.4)
7 (2.8)
3 (1.2)
49 (19.6)
46 (18.4)
39 (15.6)
65 (26.0)
41 (16.4)
9 (3.6)
1 (0.4)
40 (19.6)
93 (37.2)
43 (17.2)
3 (1.2)
15 (6.0)
40 (16.0)
1 (0.4)
7 (2.8)
48 (19.2)
7 (2.8)
45 (18.0)
34 (13.6)
15 (6.0)
15 (6.0)
21 (8.4)
33 (13.2)
28 (11.2)
2 (0.8)
18 (7.2)
32 (12.8)
Characteristic N (%)
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
206
Table 2. The scores of SAQ-AV and its factors in the Slovenian out-of-hours primary health care clinics of different Slovenian regions.
Perceptions of Management
Job Satisfaction
Safety Climate
Teamwork Climate
Communication
Overall SAQ-AV score
60.7 
(27.5)
50.6 
(16.6)
54.5 
(24.1)
76.2 
(12.2)
47.6 
(26.6)
57.9 
(16.6)
62.8 
(11.0)
51.7 
(19.4)
56.7 
(31.2)
75.6 
(15.5)
52.8 
(10.8)
57.5 
(16.8)
48.0 
(22.1)
45.0 
(20.9)
63.1 
(22.7)
65.4 
(19.4)
48.2 
(26.3)
53.6 
(18.7)
49.6 
(20.7)
41.5 
(20.2)
51.8 
(22.7)
73.0 
(14.6)
49.2 
(23.7)
52.7 
(16.0)
62.5 
(11.8)
66.7 
(5.9)
71.9 
(4.4)
79.2 
(5.9)
87.5 
(17.7)
73.5 
(0.3)
60.5 
(13.5)
57.7 
(10.2)
67.4 
(14.6)
77.8 
(13.6)
59.3 
(17.9)
64.5 
(9.4)
50.3 
(18.9)
51.4 
(14.6)
59.6 
(21.3)
74.2 
(16.7)
60.1 
(22.5)
58.5 
(15.4)
41.9 
(25.6)
43.5 
(24.2)
55.5 
(24.7)
69.9 
(22.3)
44.9 
(25.4)
51.2 
(21.3)
53.9 
(16.4)
41.7 
(20.7)
55.8 
(16.1)
67.2 
(13.5)
41.1 
(22.3)
51.9 
(15.1)
60.8 
(12.5)
50.5 
(14.7)
60.3 
(19.6)
77.7 
(12.4)
51.0 
(23.5)
60.1 
(12.3)
0.005
0.018
0.309
0.055
0.033
0.035
Murska 
Sobota
Mean (SD)
KrskoMaribor Novo 
Mesto
Nova
Gorica
Ravne na 
Koroskem
Ljubljana KoperCelje Kranj P
Bivariate analyses for the overall total SAQ-AV score 
revealed that physicians (t=1.992, p<0.048), practice 
nurses (t=1.882, p=0.049), those working in variable shifts 
(t=4.842, p<0.001), those working full-time (t=5.581, 
p<0.001), and those working in the Ravne na Koroškem 
region (t=4.571, p<0.001) had significantly higher scores 
when compared to the other categories. 
For the factor Perceptions of Management, bivariate 
analyses showed that those working in variable shifts 
(t=2.139, p=0.046), full-time (t=2.930, p=0.004), in the 
Ravne na Koroškem region (t=2.918, p=0.005), in the 
Krško region (t=2.827, p=0.012), and in the Kranj region 
(t=2.835, p=0.007) had significantly higher scores when 
compared to the other categories. 
For the factor Job Satisfaction, bivariate analyses 
revealed that those working in variable shifts (t=4.022, 
p=0.001), full-time (t=4.550, p<0.001), and in the Ravne 
na Koroškem region (t=4.816, p<0.001) had significantly 
higher scores when compared to the other categories. 
Bivariate analyses for the factor Safety Climate showed 
that practice nurses (t=3.821, p<0.001), and those working 
in variable shifts (t=4.506, p<0.001), full-time (t=5.514, 
p<0.001), and in the Ravne na Koroškem region (t=3.230, 
p=0.002) had significantly higher scores when compared 
to the other categories.
For the factor Teamwork Climate, bivariate analyses 
revealed that physicians (t=3.106, p=0.002), those working 
in variable shifts (t=2.489, p<0.001) or full-time (t=4.052, 
p<0.001), and participants working in the Maribor region 
(t=-2.735, p=0.009) had significantly lower scores when 
compared to the other categories. 
Bivariate analyses for the factor Communication showed 
that physicians (t=2.075, p=0.039), those working in 
morning shifts (t=4.238, p<0.001), those not working in 
afternoon shifts (t=-6.064, p<0.001), those working in 
variable shifts (t=3.243, p=0.005), those working full-
time (t=3.328, p=0.003), and those working in the Ravne 
na Koroškem region (t=2.122, p=0.035), in the Ljubljana 
region (t=2.146, p=0.033), and in the Nova Gorica region 
(t=2.208, p=0.026) had significantly higher scores when 
compared to the other categories. Participants working 
in afternoon shifts had significantly lower scores when 
compared to those working in morning, afternoon, or 
variable shifts.
Variables significantly associated with higher SAQ-AV 
scores in the multivariate analysis were employees working 
in the Ravne na Koroškem region, those with variable 
shifts, and those with full-time jobs. Higher scores in the 
factor Job Satisfaction were significantly associated with 
variable shifts, a full-time job, and working in the Ravne 
na Koroškem region. Employees working in variable shifts 
and having a full-time job scored significantly higher on 
both the Safety Climate and Teamwork Climate factors. On 
the contrary, those working in the Maribor region scored 
significantly lower on these factors. Employees working in 
variable shifts, having a full-time job, and working in the 
Ravne na Koroškem, Ljubljana and Nova Gorica regions 
scored significantly higher in the factor Communication 
(Table 3).
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
207
Table 3. Multivariate analysis for the scores of SAQ-AV and its five factors in the Slovenian out-of-hours primary health care clinics.
1 F=19.445, df=5, p<0.001, adjusted R2=0.30
2 F=3.981, df=8, p<0.001, adjusted R2=0.10
3 F=36.790, df=3, p<0.001, adjusted R2=0.33
4 F=18.266, df=4, p<0.001, adjusted R2=0.24
5 F=11.419, df=5, p<0.001, adjusted R2=0.19
6 F=6.286, df=8, p<0.001, adjusted R2=0.16
Overall SAQ-AV score1
Perceptions of Management2
Job Satisfaction3
Safety Climate4
Teamwork Climate5
Communication6
Ravne na Koroskem region
Physicians
Practice nurses
Variable shifts
Full-time job
Afternoon shift
Variable shifts
Full-time job
Maribor region
Ravne na Koroškem region
Krsko region
Kranj region
Koper region
Variable shifts
Full-time job
Ravne na Koroskem region
Variable shifts
Full-time job
Ravne na Koroskem region
Practice nurses
Variable shifts
Full-time job
Practice nurses
Physicians
Maribor region
Variable shifts
Full-time job
Physicians
Morning shift
Afternoon shift
Ravne na Koroskem region
Ljubljana Region
Nova Gorica region
7.46
2.98
1.54
13.70
14.30
14.68
10.85
5.73
-4.60
6.62
9.19
6.93
-9.14
21.84
19.17
9.71
14.72
19.93
5.48
7.07
8.26
14.67
-3.19
2.27
-8.25
19.15
12.89
5.03
23.71
-0.82
10.70
9.39
34.03
2.82
1.43
0.56
3.63
3.93
1.00
1.88
1.07
-1.27
1.68
1.59
1.63
-1.88
5.15
4.61
3.42
2.80
3.83
1.45
1.98
1.98
3.65
-1,07
0.94
-3.03
2.44
1.98
1.64
1.39
-0.05
2.49
2.13
2.22
2.24-12.67
1.14-7.11
3.90-6.99
6.27-21.14
7.14-21.57
14.28-43.65
-0.53-22.23
-4.78-16.24
-11.72-2.51
-1.12-14.36
-2.15-20.55
-1.47-15.34
-18.72-0.43
13.48-30.20
10.98-27.36
4.11-15.32
4.37-25.07
9.67-30.19
-1.98-12.94
0.04-14.10
0.02-16.50
6.75-22.60
-9.08-2.70
-2.50-7.06
-13.62-2.87
3.65-34.65
0.06-25.73
-1.02-11.09
-9.95-57.38
-35.41-33.77
2.24-19.15
0.70-18.08
3.86-64.20
0.005
0.155
0.577
<0.001
<0.001
0.319
0.062
0.284
0.204
0.093
0.112
0.105
0.061
<0.001
<0.001
0.001
0.006
<0.001
0.149
0.049
0.049
<0.001
0.287
0.349
0.003
0.016
0.049
0.103
0.166
0.963
0.013
0.034
0.027
Independent variables B 95% CI T PDependent 
variable
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
208
4 DISCUSSION
This was the first study investigating patient safety 
culture in Slovenian OOHC clinics (24). It showed that 
the Teamwork Climate scores were the highest and Job 
Satisfaction scores were the lowest among the employees.
The fact that Teamwork Climate scores were the highest 
correlates with the results of the Slovenian study on 
ethical dilemmas in family medicine, where teamwork 
also seemed to be functioning well (29, 30). Teamwork 
as part of safety culture also scored high in hospital 
settings in Slovenia (10). Teamwork is very important 
in primary care, as health care providers with different 
professional backgrounds are engaged in the management 
of patients (31). This is also true for the OOHC clinics. 
In this setting, close cooperation between different 
professions is required (17). In fact, teamwork climate 
has been recognised as a key patient safety issue in OOHC 
clinics (24, 27, 32), and quality of performance seems to 
be associated with teamwork quality (33, 34). 
Slovenian workers in OOHC clinics are, however, often 
not satisfied with their jobs, and this also seems to be 
reflected in their perceptions of patient safety culture. 
This finding was expected, as there is a big shortage of 
both physicians and nurses in Slovenia, and many are 
overburdened (35-37). In Slovenia, OOHC and emergency 
services are usually performed by the same team. 
Physicians often work in OOHC part-time, and in addition 
to their official working hours. In some regions, they work 
at two different job posts at the same time – in their own 
practice and in OOHC (17, 36). This is especially true for 
rural settings in Slovenia. Since the organisational domain 
is important in terms of safety culture (38), the varying 
organisational models in Slovenian OOHC clinics might 
be partly responsible for the observed differences in the 
SAQ-AV factor scores across the Slovenian regions.
Several factors contributed to the variation in climate 
scores across groups of employees in Slovenian OOHC 
clinics. Employees working as physicians or nurses, 
working in variable shifts and working full-time, had the 
highest scores. Working in variable shifts could contribute 
to a higher perception of patient safety, because the 
employees that work variable shifts may feel more 
competent to manage patients in different circumstances. 
The finding that working full-time possibly contributes to 
higher perception of patient safety is interesting. Studies 
have focused more on the impact of longer working hours 
and overtime working on patient safety (39), and we could 
not find any study on the associations between patient 
safety and part/full-time working hours. We anticipate 
that employees working part-time are not so confident in 
their performance (40), and thus perceive patient safety 
lower. 
The scores of some factors varied across different 
Slovenian regions. This was especially true for the 
factors Perceptions of Management and Communication. 
Communication about safety issues in teams is very 
important and affects patient safety (41). It is probably 
connected to Perceptions of Management, as here also 
communication plays an important role. 
It seems that the factors revealed to be important for a 
culture of safety in our study explained a large degree 
of the variation of the safety culture in Slovenian OOHC 
clinics, but according to the variances, the multivariate 
models explained are not the only ones. 
Safety culture in OOHC has also been studied in Norway 
(13), and safety culture in emergency departments has 
been studied in the USA (21). In Norway and in the USA, 
the factor Job Satisfaction scored highest (13, 21), while 
in our study, it scored lowest. In our study, physicians 
scored significantly higher than nurses in Communication 
and Teamwork Climate, and in Norway (13), nurses 
scored higher in Safety Climate and Job Satisfaction. In 
the study from the USA (21), there were no differences 
between full-time and part-time workers regarding safety 
climate scores, which is not in line with the results of 
our study. It seems that safety climate in OOHC differs 
across countries, and further studies are needed to gain 
a deeper insight into these differences and their causes. 
This study has some limitations. It aimed to include all 
OOHC clinics in Slovenia; however, only two-thirds of them 
were willing to participate. Similarly, only 250 respondents 
out of 438 invited employees filled in the questionnaire. 
Even though the proportion of participating clinics and the 
response rate of employees were moderately high, one 
still has to be careful about generalising the findings to 
the OOHC clinics of the entire country. On the other hand, 
the results of this study correlated with similar Slovenian 
studies, which gives us confidence in their reliability and 
validity. 
5 CONCLUSION
Safety culture in Slovenian OOHC clinics needs 
improvement. The variations in safety culture factor 
scores in Slovenian OOHC clinics point to the need to 
unify working conditions in all Slovenian OOHC clinics. 
When planning safety culture improvements, the factors 
that were shown to be important in this study should be 
considered. We suggest reducing workload, more full-
time employment, and educating communication and 
management skills. Further studies are needed to detect 
other possible factors important in safety culture in OOHC 
clinics, and to reveal the possible causes of the current 
situation.
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
209
ACKNOWLEDGEMENTS
We thank all the workers in OOHC in Slovenia for 
participating in the study.
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
The National Centre for Emergency Primary Health 
Care, Uni Research Health, Bergen, Norway, covered 
the expenses regarding the translation/back-translation 
of the Safety Attitudes Questionnaire and the data 
collection. Further, the Norwegian coordinating research 
group covered the expenses for the statistical analyses.
This study was partially supported by an unrestricted 
programme grant from the National Research Agency, P3 
0339.
ETHICAL APPROVAL
The study was approved by the National Ethics Committee 
of the Republic of Slovenia (No. 25/11/14).
REFERENCES
1. Petek D, Kersnik J. Management of cardiovascular risk factors in high 
risk patients: correlates of quality of care. Zdr Varst 2013; 52: 263-
74.
2. Wensing M, Vedsted P, Kersnik J, Peersman W, Klingenberg A, 
Hearnshaw H et al. Patient satisfaction with availabilty of general 
practice: an international comparison. Int J Qual Health Care 2002; 
14: 111-8.
3. Petek D, Kunzi B, Kersnik J, Szecsenyi J, Wensing M. Patients’ 
evaluations of European general practice – revisited after 11 years. 
Int Int J Qual Health Care 2011; 23: 621-8.
4. Pavlic DR, Sever M, Klemenc-Ketis Z, Svab I. Process quality indicators 
in family medicine: results of an international comparison. BMC Fam 
Pract 2015; 16: 172.
5. Klemenc-Ketis Z, Petek D, Kersnik J. Associations between family 
doctors’ practices characteristics and patient evaluation of care. 
Health Policy 2012; 106: 269-75.
6. Svab I, Petek-Ster M, Kersnik J, Zivcec-Kalan G, Car J. Presečna 
študija o delu zdravnikov splošne medicine v Sloveniji. Zdr Varst 
2005; 44: 183-92.
7. Grol R, Wensing M, Mainz J, Ferreira P, Hearnshaw H, Hjortdahl P et 
al. Patients in Europe evaluate general practice: an international 
comparison. Br J Gen Pract 2000; 50: 882-7.
8. Smits M, Huibers L, Kerssemeijer B, de Feijter E, Wensing M, Giesen 
P. Patient safety in out-of-hours primary care: a review of patient 
records. BMC Health Serv Res 2010; 10: 335.
9. Sorra JS, Nieva VF. Hospital survey on patient safety culture. 
Rockville: Agency for Healthcare Research and Quality; 2004.
10. Robida A. Hospital survey on patient safety culture in Slovenia: a 
psychometric evaluation. Int J Qual Health Care 2013; 25: 469-75.
11. Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety 
climate: a review of surveys. Qual Saf Health Care 2005; 14: 364-6.
12. Deilkas ET. Patient safety culture - opportunities for healthcare 
management. Oslo: University of Oslo,  2010.
13. Bondevik GT, Hofoss D, Holm Hansen E, Deilkas ET. Patient safety 
culture in Norwegian primary care: a study in out-of-hours casualty 
clinics and GP practices. Scand J Prim Health Care 2014; 32: 132-8.
14. Kristensen S, Hammer A, Bartels P, Sunol R, Groene O, Thompson CA 
et al. Quality management and perceptions of teamwork and safety 
climate in European hospitals. Int J Qual Health Care 2015; 27: 498-
505.
15. Schafer WL, Boerma WG, Kringos DS, De Maeseneer J, Gress S, 
Heinemann S et al. QUALICOPC, a multi-country study evaluating 
quality, costs and equity in primary care. BMC Fam Pract 2011; 12: 
115.
16. Prijatelj V, Rajkovič V, Šušteršič O. A model for risk assessment in 
health care using a health care failure method and effect analysis. 
Zdr Varst 2013; 52: 316-31.
17. Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in western 
countries: assessment of different organizational models. BMC 
Health Serv Res 2009; 9: 105.
18. Huibers LAMJ, Moth G, Bondevik GT, Kersnik J, Huber CA, Christensen 
MB et al. Diagnostic scope in out-of-hours primary care services 
in eight European countries: an observational study. BMC Family 
Practice 2011; 12: 30.
19. Phillips H, Van Bergen J, Huibers L, Colliers A, Bartholomeeusen 
S, Coenen S et al. Agreement on urgency assessment between 
secretaries and general practitioners: an observational study in out-
of-hours general practice service in Belgium. Acta Clin Belg 2015; 
70: 309-14.
20. Patterson PD, Huang DT, Fairbanks RJ, Simeone S, Weaver M, Wang 
HE. Variation in emergency medical services workplace safety 
culture. Prehosp Emerg Care 2010; 14: 448-60.
21. Weaver MD, Wang HE, Fairbanks RJ, Patterson D. The association 
between EMS workplace safety culture and safety outcomes. Prehosp 
Emerg Care 2012; 16: 43-52.
22. Huibers L, Smits M, Renaud V, Giesen P, Wensing M. Safety of 
telephone triage in out-of-hours care: a systematic review. Scand J 
Prim Health Care 2011; 29: 198-209.
23. Smits M, Keizer E, Giesen P, Deilkas EC, Hofoss D, Bondevik GT. The 
psychometric properties of the ‘safety attitudes questionnaire’ in 
out-of-hours primary care services in the Netherlands. PLoS One 
2017; 12: e0172390.
24. Klemenc-Ketis Z, Maletic M, Stropnik V, Deilkås ET, Hoffos D, 
Bondevik GT. The safety attitudes questionnaire – ambulatory 
version: psychometric properties of the Slovenian version for the 
out-of-hours primary care setting. BMC Health Serv Res 2017; 17: 36.
25. Huibers L, Phillips H, Giesen P, Remmen R, Christensen MB, Bondevik 
GT. EurOOHnet - the European research network for out-of-hours 
primary health care. Eur J Gen Pract 2014; 20: 229-32.
26. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the 
process of cross-cultural adaptation of self-report measures. Spine 
2000; 25: 3186-91.
27. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J 
et al. The safety attitudes questionnaire: psychometric properties, 
benchmarking data, and emerging research. BMC Health Serv Res 
2006; 3: 44.
28. Baker R, Hearnshaw H. A method for surveying patient satisfaction 
audit protocol PS1. Leicester: Eli Lilly National Cinical Audit Centre, 
1996.
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
210
29. Klemenc-Ketis Z, Kersnik J, Ojstersek J. Perceived difficulties in 
managing ethical problems in family practice in Slovenia: cross-
sectional study. Croat Med J 2008; 49: 799-806.
30. Klemenc-Ketis Z, Kersnik J. Prevalence of ethical dilemmas in 
Slovenian family practice. Acta Medico-Biotechnica 2009; 2: 47-56.
31. Poplas-Susic T, Svab I, Kersnik J. The project of model practices in 
family medicine in Slovenia. Zdrav Vestn 2013; 82: 635-47.
32. Bondevik GT, Hofoss D, Hansen EH, Deilkas EC. The safety attitudes 
questionnaire - ambulatory version: psychometric properties of the 
Norwegian translated version for the primary care setting. BMC 
Health Serv Res 2014; 14: 139.
33. Tourani S, Hassani M, Ayoubian A, Habibi M, Zaboli R. Analyzing and 
prioritizing the dimensions of patient safety culture in emergency 
wards using the TOPSIS technique. Glob J Health Sci 2015; 7: 143-50. 
34. Meier C. Importance of good teamwork in urgent care services. 
Emerg Nurse 2014; 22: 32-6.
35. Selič P, Stegne-Ignjatović T, Klemenc-Ketis Z. Burnout among 
Slovenian family medicine trainees: a cross-sectional study. Zdrav 
Vestn 2012; 81: 218-24.
36. Močnik U, Gradišar M, Tomat L. Analysis of emergency department 
waiting lines. Zdrav Vestn 2014; 83: 587-96.
37. Živčec Kalan G, Petek Ster M, Kersnik J. Determinants of family 
physicians’ workload. Zdrav Vestn 2012; 81: 461-9.
38. Stone PW, Harrison MI, Feldman P, Linzer M, Peng T, Roblin D et al. 
Advances in patient safety organizational climate of staff working 
conditions and safety - an integrative model. In: Henriksen K, Battles 
JB, Marks ES, Lewin DI, editors. Advances in patient safety: from 
research to implementation (Vol 2: Concepts and methodology). 
Rockville (MD): Agency for Healthcare Research and Quality, 2005.
39. Griffiths P, Dall’Ora C, Simon M, Ball J, Lindqvist R, Rafferty AM et al. 
Nurses’ shift length and overtime working in 12 European countries: 
the association with perceived quality of care and patient safety. 
Med Care 2014; 52: 975-81.
40. Van De Vijver E, Devroey D. Lack of confidence in administering 
emergency care among Dutch-speaking family physicians in Belgium. 
Int J of Gen Med 2013; 6: 589-96. 
41. Thomson K, Outram S, Gilligan C, Levett-Jones T. Interprofessional 
experiences of recent healthcare graduates: a social psychology 
perspective on the barriers to effective communication, teamwork, 
and patient-centred care. J Interprof Care 2015; 29: 634-40. 
IMPLEMENTING QUALITY INDICATORS FOR DIABETES AND HYPERTENSION 
IN FAMILY MEDICINE IN SLOVENIA
Zalika KLEMENC-KETIŠ1*, Igor ŠVAB2, Antonija POPLAS SUSIČ3
1University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska 8, 2000 Maribor, Slovenia
2University of Ljubljana, Faculty of Medicine, Department of Family Medicine, 
Poljanski nasip 58, 1000 Ljubljana, Slovenia
3Community Health Centre Ljubljana, Metelkova 9, 1000 Ljubljana, Slovenia
Received: Nov 9, 2016
Accepted: Jul 6, 2017 
Original scientific article
*Corresponding author: Tel: + 386 41 516 067; E-mail: zalika.klemenc-ketis@uni-mb.si
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
211
UVAJANJE KAZALNIKOV KAKOVOSTI ZA SLADKORNO BOLEZEN 
IN ARTERIJSKO HIPERTENZIJO V DRUŽINSKI MEDICINI V SLOVENIJI
Klemenc-Ketiš Z, Švab I, Poplas Susič A. Implementing quality indicators for diabetes and hypertension in family medicine in Slovenia. Zdr Varst 2017; 56(4): 211-219.
Introduction. A new form of family practices was introduced in 2011 through a pilot project introducing nurse 
practitioners as members of team and determining a set of quality indicators. The aim of this article was to 
assess the quality of diabetes and hypertension management.
Methods. We included all family medicine practices that were participating in the project in December 2015 
(N=584). The following data were extracted from automatic electronic reports on quality indicators: gender 
and specialisation of the family physician, status (public servant/self-contracted), duration of participation in 
the project, region of Slovenia, the number of inhabitants covered by a family medicine practice, the name of 
IT provider, and levels of selected quality indicators.
Results. Out of 584 family medicine practices that were included in this project at the end of 2015, 568 (97.3%) 
had complete data and could be included in this analysis. The highest values were observed for structure 
quality indicator (list of diabetics) and the lowest for process and outcome quality indicators. The values of 
the selected quality indicators were independently associated with the duration of participation in the project, 
some regions of Slovenia where practices were located, and some IT providers of the practices.
Conclusion. First, the analysis of data on quality indicators for diabetes and hypertension in this primary care 
project pointed out the problems which are currently preventing higher quality of chronic patient management 
at the primary health care level.
Uvod. Pilotni projekt na področju družinske medicine v Sloveniji je leta 2011 uvedel novo metodo dela v 
družinski medicini, pri čemer je nov član tima postala diplomirana medicinska sestra, prav tako pa se je uvedel 
nadzor kakovosti s pomočjo kazalnikov kakovosti. Namen tega članka je bil oceniti kakovost vodenja bolnikov 
s sladkorno boleznijo in hipertenzijo.
Metode. V analizo smo vključili vse ambulante družinske medicine, ki so sodelovale v projektu konec 
decembra 2015. Iz avtomatične baze poročil smo izluščili in analizirali naslednje podatke: spol in specializacijo 
zdravnika, status zdravnika (javni uslužbenec, koncesionar), trajanje sodelovanja v projektu, regijo, v kateri 
je ambulanta, število prebivalcev na območju, ki ga pokriva ambulanta, računalniško hišo, ki nudi program, in 
raven izbranih kazalnikov kakovosti.
Rezultati. Od 584 ambulant družinske medicine jih je imelo 568 (97,3%) popolne podatke in so bile vključene 
v analizo. Najvišja vrednost kazalnikov kakovosti je bila opazovana pri kazalnikih kakovosti pogojev (register 
diabetikov), najnižja pa pri kazalnikih procesa in izida. Vrednosti izbranih kazalnikov kakovosti so bile neodvisno 
povezane s trajanjem sodelovanja v projektu, nekaterimi regijami Slovenije in nekaterimi računalniškimi 
hišami, ki nudijo elektronsko podporo.
Zaključek. Prva analiza podatkov kazalnikov kakovosti za diabetes in arterijsko hipertenzijo je pokazala 
na probleme, ki trenutno onemogočajo doseganje višje kakovosti obravnave bolnikov na primarni ravni 
zdravstvenega varstva.
ABSTRACT
Keywords: 
family practices, 
healthcare quality 
indicator, diabetes 
mellitus, hypertension, 
Slovenia
IZVLEČEK
Ključne besede: 
družinska medicina, 
kazalniki kakovosti, 
sladkorna bolezen, 
arterijska hipertenzija, 
Slovenija
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
Assessing quality of care with quality indicators is 
paramount (1) and has already become a standard for 
working in family practice in several countries (2-5). 
Various quality indicators are being used (6) and in some 
countries performance-related-pay based on quality 
indicators has been introduced (7-9). 
In Slovenia, quality assurance at the primary health care 
level is formally a priority, but the legislation that would 
ensure quality in this area is proceeding very slowly. 
External quality assessment and inspections commissioned 
by the Ministry of Health are rarely used. Supervision 
of quality in primary care is fragmented and poorly 
coordinated. Family physicians (FPs) are more involved in 
unofficial and ad hoc forms of quality improvement than 
in formalised procedures. There are formal instruments 
for assessing quality, such as attestation of physicians, 
voluntary certification and accreditation, and mandatory 
licensing of physicians or nurses, but quality of primary 
health care has not yet been systematically assessed 
by quality indicators (10), despite the fact that a set 
of quality indicators was developed for cardiovascular 
prevention (11, 12) and that there is ample scientific 
evidence in this field in the literature (1, 5-7, 13-17)
In 2011, an ongoing pilot project at the primary care level 
in Slovenia was launched with the support of the Ministry 
of Health. It introduced a new model of family medicine 
practice where the family physicians’ working team 
(consisting of one FP and one nurse with a baccalaureate 
degree – a practice nurse) was extended by a nurse 
practitioner working four hours a day or 0.5 full-time 
equivalents. The nurse practitioner is responsible for 
preventive activities (screening for and counselling on 
cardiovascular risk factors, diabetes, depression, chronic 
obstructive pulmonary disease (COPD), hypertension, and 
smoking and management of smoking and risky alcohol 
consumption) and routine management of patients with 
stable chronic diseases (COPD, asthma, hypertension, 
diabetes, benign enlargement of prostate, depression, 
osteoporosis and coronary heart disease) (18, 19). 
Preventive activities can also be carried out by physicians 
in terms of a comprehensive approach to the patients, but 
in this model of family medicine practice they are mainly 
performed by the nurse practitioners.
As part of this project, a list of quality indicators was 
introduced in order to monitor the work of family medicine 
practices participating in the project. The list included 35 
quality indicators, of which nine were structure quality 
indicators, 23 were process quality indicators, and three 
were outcome quality indicators (1, 20). 
The electronic database for collecting quality indicators 
was established at the beginning of 2015. Before that, 
data entry was manual and carried out by each practice 
itself into the Excel spreadsheets. There are five IT 
providers for family practices in Slovenia with their own 
data extraction systems, and data had to be gathered in 
one electronic database, which presented some problems 
at the start.
Hypertension and diabetes were among eight chronic 
diseases which were monitored by quality indicators, and 
are at the same time among the most common chronic 
diseases encountered in family medicine. 
The aim of this article was to assess the differences in 
the values of the selected quality indicators between 
new model family medicine practices with different 
characteristics. The objective of this article was to 
conduct a relationship analysis between values of two 
selected indicators and some important characteristics of 
practices.
2 METHODS
We included all family medicine practices that were 
participating in the project in December 2015 as the 
source of data. The data were gathered from automatic 
electronic reports on quality indicators provided monthly 
by each individual family medicine practice. The data 
are stored in a common electronic database which can 
be used by project managers. For the purpose of the 
analysis, the following data were extracted: gender and 
specialisation of the family physician, status (public 
servant/self-contracted), duration of participation in 
the project, region of Slovenia, number of inhabitants 
covered by the family physician, name of the information 
technology (IT) provider, and quality indicators. The 
units of observation were family medicine practices with 
their staff (a physician, a practice nurse and a nurse 
practitioner).
At the end of 2015, there were 35 different quality 
indicators that family medicine practices reported on 
(20). For the purpose of this study, we chose one quality 
indicator from each different type (structure, process and 
outcome quality indicator (1) (Table 1). 
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
212
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
213
Table 1. Quality indicators for diabetes and hypertension.
1 Prevalence of diabetes in Slovenia which is 6% (21)
2 The expression “registered” describes the number of patients with diabetes/hypertension on the patient list of each family medicine     
  practice
Quality indicator Calculation formula Type of quality 
indicator
Quality standard Mean value (SD) Median
Statistical analysis was carried out using IBM SPSS Statistics 
version 22.0 (Armonk, NY: IBM Corp.). We performed 
multivariate analysis with general linear models. We set 
p<0.05 as the limit for statistical significance.
We used the observed outcome variables and explanatory 
factors in the analyses. The observed outcome variables 
were: 1) the value of the quality indicator “List of patients 
with diabetes”; 2) the value of the quality indicator 
“Percentage of patients with diabetes with measured 
HbA1C once a year” (continuous variable); and 3) the 
value of the quality indicator “Percentage of patients 
with hypertension with a systolic blood pressure 140/90 
mmHg or lower” (continuous variable). Higher levels of 
observed outcome variables indicated a higher quality of 
work.
The explanatory factors were: 1) gender (nominal 
variable: male/female); 2) specialisation of family 
physician (nominal variable: has specialisation in family/
general medicine/does not have specialisation in family/
general medicine; 3) status of family medicine practice 
(nominal variable: public servant/self-contracted); 4) 
duration of participation in the project (continuous 
variable); 5) region of Slovenia (nominal variable: Celje, 
Koper, Krsko, Kranj, Ljubljana, Maribor, Murska Sobota, 
Nova Gorica, Novo Mesto, Ravne na Koroskem); 6) area 
covered by the practice (nominal variable: urban/rural); 
and 7) name of IT provider (nominal variable: IT No. 1, IT 
No. 2, IT No. 3, IT No. 4, IT No. 5). The variable “Urban/
rural area” was determined according to the definition of 
rural areas in Slovenia provided by the Statistical Office 
of Slovenia, which defines rural areas as those with less 
than 5,000 inhabitants.
The dummy variables created for the multivariate 
analyses were gender (reference category: male gender), 
the region of Slovenia (reference category: Ravne na 
Koroskem), the IT provider (reference category: IT 
provider No. 5), specialisation (reference category: no 
specialisation), area (reference category: urban), and 
status (reference category: public servant)  and were 
created by a simple coding. 
3 RESULTS
3.1 Sample Description
Out of 584 family medicine practices that were included in 
this project at the end of 2015, 568 (97.3%) had complete 
data and could be included in this analysis (Table 2). 
The mean duration of participation in the project was 
28.7±18.7 months, with a median of 33.0 months. The 
mean age of the family physicians was 51.4±9.0 years, 
median 53.0.
List of patients with 
diabetes
Percentage of patients with 
diabetes with measured 
HbA1C once a year
Percentage of patients with 
hypertension with a systolic 
blood pressure 140/90 
mmHg or lower
Number of diabetic patients/
(Number of registered patients * 
0.061) * 100
Number of patients with diabetes 
with measured HbA1C at least 
once a year/number of registered 
diabetic patients2 * 100
Number of patients with 
hypertension with blood pressure 
140/90 mmHg or lower/number 
of registered3 patients with 
hypertension * 100
Structure
Process
Outcome
0
80
50
84.2 (53.6)
25.6 (22.3)
18.2 (16.3)
84.0
21.2
14.3
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
214
Table 2.
Table 3.
Characteristics of family medicine practices included in 
the project.
Characteristics of family medicine practices included in the project.
Region
Celje
Koper
Krsko
Kranj
Ljubljana
Maribor
Murska Sobota
Nova Gorica
Novo Mesto
Ravne na Koroskem
Gender of the physician
Male
Female
Specialisation of the physician
General medicine
Family medicine
Other specialities
No specialisation
Status
Public servant
Self-contractor
IT provider
No. 1
No. 2
No. 3
No. 4
No. 5
Area
Urban
Rural 
Gender
Female
Male
Status
Self-contractor
Public servant
IT provider
No. 1
No. 2
No. 3
No. 4
No. 5
71 (12.5)
34 (6.0)
20 (3.5)
63 (11.1)
148 (26.1)
84 (14.8)
37 (6.5)
44 (7.7)
37 (6.5)
30 (5.3)
132 (23.2)
436 (76.8)
313 (55.1)
195 (34.3)
1 (0.2)
59 (10.4)
426 (75.0)
142 (25.0)
159 (28.0)
6 (1.1)
210 (37.0)
90 (15.8)
97 (17.1)
459 (80.8)
109 (19.2)
0.17
reference
6.47
reference
19.03
12.18
8.88
21.85
reference
4.66
5.22
8.13
19.57
6.53
7.79
-8.97, 9.30
-3.76, 16.70
3.10, 34.96
-26.18, 50.55
-3.92, 21.67
6.57, 37.12
0.972
0.215
0.019
0.534
0.174
0.005
Characteristic
Explanatory variables
Number (%)
Regression coefficient Standard Error Upper and lower 95% 
confidence Interval
p
3.2 Quality Indicator ‘List of Patients with Diabetes’
The mean value of this quality indicator was 84.2±53.6, 
with a median of 84.0 (Table 1).
The results of a multivariate analysis showed that the 
variables ‘IT provider No. 1 and 4’ and ‘Duration of 
participation in the project’ were significantly correlated 
with a higher value of this quality indicator, and ‘Working 
in the Maribor region’ was significantly correlated with a 
lower value of this quality indicator (Table 3).
For continuous variables regression coefficients indicate 
the change of the observed variable with each increasing 
unit of explanatory variable.
For categorical variables regression coefficients indicate 
the changes of the observed variable in comparison to a 
reference category.
3.4 Quality Indicator “Percentage of Patients with 
Diabetes with Measured HbA1C Once a Year”
The mean value of this quality indicator was 25.6±22.3, 
with a median of 21.2. 
The results of a multivariate analysis showed that the 
variable ‘Duration of participation in the project’ was 
significantly correlated with a higher value of this quality 
indicator, and ‘IT provider No. 3 and 4’ were significantly 
correlated with a lower value of this quality indicator 
(Table 4).
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
215
Table 4. Multivariate analysis for higher value of the quality indicator ‘Measured HbA1C in patients with diabetes at least once a year’.
Gender
Female
Male
Status
Self-contractor
Public servant
IT provider
No. 1
No. 2
No. 3
No. 4
No. 5
Area
Rural
Urban
Specialisation
General Practice
Family Medicine
No specialisation
Area
Rural
Urban
Specialisation
General Practice
Family Medicine
No specialisation
Region
Celje
Koper
Krsko
Kranj
Ljubljana
Maribor
Murska Sobota
Nova Gorica
Novo Mesto
Ravne na Koroskem
Age (years)
Duration of participation 
in the project
1.60
Reference
1.03
reference
-6.27
-12.00
-6.05
-14.58
reference
-0.73
reference
5.13
3.34
-2.61
reference
-2.92
-0.46
reference
-8.32
-1.99
11.18
4.02
-4.58
-35.92
-17.34
-0.40
0.37
Reference
-0.17
1.47
2.11
2.37
3.68
8.87
2.96
3.53
2.34
3.17
3.17
5.17
6.99
7.00
11.03
11.92
14.45
10.70
9.42
10.97
11.32
11.00
11.45
0.22
0.11
-2.53, 5.74
-3.61, 5.66
-13.49, 0.95
-29.38, 5.38
-11.85, -0.25
-21.50, -7.66
-5.32, 3.86
-1,07, 11.34
-2.87, 9.55
-12.74, 7.52
-16.62, 10.78
-14.17, 13.26
-29.94, 13.31
-25.36, 21.38
-17.14, 39.49
-16.95, 24.99
-23.05, 13.88
-57.42, -14.42
-39.52, 4.85
-21.95, 21.15
-22.07, 22.80
-0.61, 0.26
1.24, 1.69
0.447
0.664
0.089
0.176
0.041
< 0.001
0.757
0.105
0.292
0.614
0.676
0.948
0.451
0.868
0.439
0.707
0.627
0.001
0.126
0.971
0.975
0.435
< 0.001
Explanatory variables
Explanatory variables
Regression coefficient
Regression coefficient
Standard Error 
Standard Error 
Upper and lower 95% 
confidence Interval
Upper and lower 95% 
confidence Interval
p
p
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
216
Region
Celje
Koper
Krsko
Kranj
Ljubljana
Maribor
Murska Sobota
Nova Gorica
Novo Mesto
Ravne na Koroskem
Age (years)
Duration of participation 
in the project
-9.28
-6.55
-4.37
-6.37
0.85
3.88
7.20
-9.18
-0.40
reference
-0.11
0.30
5.00
5.40
6.54
4.85
4.27
4.97
5.13
4.98
5.18
0.10
0.05
-19.07, 0.52
-17.14, 4.04
-17.19, 8.46
-15.87, 3.13
-7.51, 9.22
-5.86, 13.62
-2.85, 17.25
-18.94, 0.58
-10.56, 9.76
-0.31, 0.08
0.20, 0.40
0.063
0.225
0.505
0.189
0.842
0.435
0.160
0.065
0.939
0.265
< 0.001
Explanatory variables Regression coefficient Standard Error Upper and lower 95% 
confidence Interval
p
For continuous variables regression coefficients indicate 
the change of the observed variable with each increasing 
unit of explanatory variable.
For categorical variables regression coefficients indicate 
the changes of the observed variable in comparison to a 
reference category.
3.3 Quality Indicator ‘Percentage of Patients with 
Hypertension with a Systolic Blood Pressure 140/90 
mmHg or Lower’
The mean value of this quality indicator was 18.2±14.3, 
with a median of 16.3 (Table 1). 
The results of a multivariate analysis showed that the 
variables ‘Duration of participation in the project,’ 
‘Female gender,’ ‘Self-contractor,’ ‘Working in the 
Maribor region’ and ‘Having IT No. 2’ were significantly 
correlated with a higher value of this quality indicator. 
Variables ‘IT provider No. 3’ and ‘IT provider No. 4’ were 
significantly correlated with lower values of this quality 
indicator (Table 5). 
Table 5. Multivariate analysis for higher value of the quality indicator ‘Percentage of patients with hypertension with a systolic blood 
pressure 140/90 mmHg or lower.’
Gender
Female
Male
Status
Self-contractor
Public servant
IT provider
No. 1
No. 2
No. 3
No. 4
No. 5
3.36
Reference
3.44
reference
-0.77
17.59
-6.64
-10.58
reference
1.48
1.65
2.57
6.20
2.07
2.47
0.47, 6.25
0.20, 6.68
-5.82, 4.27
5.45, 29.74
-10.69, -2.58
-15.42, -5.74
0.023
0.037
0.764
< 0.001
0.001
< 0.001
Explanatory variables Regression coefficient Standard Error Upper and lower 95% 
confidence Interval
p
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
217
Area
Rural
Urban
Specialisation
General Practice
Family Medicine
No specialisation
Region
Celje
Koper
Krsko
Kranj
Ljubljana
Maribor
Murska Sobota
Nova Gorica
Novo Mesto
Ravne na Koroskem
Age (years)
Duration of participation 
in the project
-1.65
reference
2.05
-0.95
reference
-2.48
1.78
-1.15
-3.76
1.65
10.77
5.33
-1.65
-0.43
reference
-0.06
0.15
1.64
2.21
2.22
3.49
3.78
4.57
3.39
2.98
3.47
3.58
3.48
3.62
0.07
0.04
-4.86, 1.56
-2.29, 6.39
-5.29, 3.39
-9.32, 4.37
-5.62, 9.18
-10.11, 7.82
-10.40, 2.88
-4.19, 7.50
3.96, 17.57
-1.69, 12.36
-8,47, 5.18
-7.54, 6.67
-0.20, 0.07
0.08, 0.23
0.314
0.354
0.668
0.478
0.637
0.802
0.267
0.579
0.002
0.137
0.636
0.905
0.368
< 0.001
Explanatory variables Regression coefficient Standard Error Upper and lower 95% 
confidence Interval
p
For continuous variables regression coefficients indicate 
the change of the observed variable with each increasing 
unit of explanatory variable.
For categorical variables regression coefficients indicate 
the changes of the observed variable in comparison to a 
reference category.
4 DISCUSSION
This study showed that the structure quality indicator was 
achieved for diabetes (list of diabetic patients). However, 
it also showed that the values of the process and outcome 
indicators were low, which indicates that the quality of 
management of patients with diabetes and hypertension 
could be improved. The levels of the selected quality 
indicators were associated with several features, most 
commonly with the duration of participation in the 
project, the region of Slovenia where the practice was 
located, and the IT provider used by the practice.
4.1 The Assessment of Quality of the Management of 
Patients with Diabetes and Hypertension
High values of structure quality indicators are an important 
sign that the conditions for measuring quality have been 
established. On the other hand, lower levels of process 
quality indicators were found and could be attributed to 
several reasons. The lack of continuous quality control 
with feedback could be one of them; the project continued 
without continuous data analysis, feedback to practices 
on the quality of their work, or benchmarking (22), and no 
staff were employed to carry out these tasks.
It is also possible that adherence to the guidelines was low. 
A recent study from Slovenia showed that the introduction 
of this different model of chronic patient management in 
family medicine improved the process of quality of care, 
but the desired level of quality has not yet been achieved 
(23), which probably points to low adherence to the 
guidelines. Other studies have also shown that primary 
care physicians’ adherence to hypertension and diabetes 
guidelines is low (24-27). For example, adherence to 
hypertension guidelines was found to be between 10 and 
50% (24, 25). On the other hand, another study showed 
that HbA1C was measured in almost all the patients (26). 
It is also possible that the selection and development 
of the quality indicators themselves was not optimal. 
The development of quality indicators must be based 
on a systematic evidence-based approach, and expert 
consensus and guidelines should be considered. The 
indicators should be acceptable, feasible, reliable, 
sensitive to change, and valid (16). The quality indicators 
in our project have not yet been evaluated according to 
these features, and therefore it could be possible that the 
low levels of quality indicators are associated with their 
suboptimal nature. 
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
218
4.2 Associations between Quality Indicators and 
Characteristics of Providers
The most important variable that was shown to be 
associated with higher levels of quality indicators was the 
duration of participation in the project. This indicates 
that the practical introduction of quality indicators in the 
everyday work of practices might be associated with some 
problems that could influence the quality. These problems 
are yet to be recognised. The region of practices was 
also recognised as important. Some previous data from 
Slovenia indicate that there are differences between 
regions in terms of quality (10). Which factors contribute 
to that is unknown and a subject for further studies. In 
addition, IT providers proved important in our research. 
Ensuring quality of data during electronic data capture 
is always a problem, and several ways of reducing errors 
must be applied (28, 29). There are no reports about the 
quality of data gathering in this project, and it therefore 
seems that there are some problems which still need to 
be recognised and addressed. 
The quality indicator ‘List of patients with diabetes’ 
indicates the prevalence of diabetes in registered patients 
of family medicine practices in Slovenia. It should be 
mentioned here that its value could also be affected by 
the actual prevalence of diabetes in the region of Slovenia 
(30), and does not only depend on the quality of work.
Other factors can also contribute to the quality 
management of chronic patients and were not included 
in this study. These might include systemic factors, 
reimbursement, service organisation and capacity, 
cultural factors, disease epidemiology, practice systems 
in terms of incentives, practice information capacity, 
access, the use of teams in quality policy, detection of 
quality and safety problems, staff and patient safety, 
inclusion of patients’ perspectives, and the length of 
consultations (31-34). These factors should be considered 
when studying this topic further.
4.3 Limitations of the Study
We chose only a few quality indicators because we 
focused on the management of chronic diseases and not 
on their prevention. This was done to ensure the clarity 
and focus of the study. It could, however, be possible that 
by excluding some quality indicators we overlooked some 
other differences.
The other problem is the quality of the data, as the 
electronic database was only established in 2015; our 
analysis was carried out at the end of 2015, and we can, 
therefore, anticipate that some technical problems had 
not yet been resolved. Therefore, the reliability of the 
data might not be as good as if we had done the research 
later.
Our study did not include other factors that could 
influence the quality of management of chronic diseases, 
especially the characteristics of other team members, 
particularly nurse practitioners. Since nurse practitioners 
are very involved in the management of chronic patients, 
the inclusion of their characteristics could have helped 
us to build a more comprehensive view of this matter, 
and produced more reliable statistical models. Other 
limitations are the exclusion of patient data, and the 
cross-sectional nature of this study, which prevents us 
from detecting causality. This would further increase the 
comprehensibility of the results.
In our study, we did not analyse the characteristics of 
those family medicine practices that did not participate 
in the project. Therefore, we do not know if they differ 
significantly from those included in the study. 
4.4 Theoretical and Practical Implications of the Study
The study showed that the quality assessment was a 
challenge, because the values of the quality indicators 
were set empirically while preparing the new model 
of family medicine practices in Slovenia. The quality 
indicators should be re-evaluated and changed if 
necessary according to the established methodology (16). 
It was also recognised that expert supervision at the 
location is necessary to assess the process of work of the 
family medicine team at different levels (e.g. following 
protocols, regularly measuring the parameters of chronic 
diseases, recording them in the electronic database, and 
their reporting and analysis), and to discuss the obstacles 
directly with care providers. Continuous quality control and 
benchmarking should be established in order to improve 
the quality of chronic patient management in Slovenian 
family medicine practices. The study also indicated the 
need for collaboration between different professionals (e. 
g. IT specialists and health care providers) to adopt the IT 
system to fully support patient management. The quality 
indicators should be a basis for financing the practices 
according to quality standards. It may also be important 
to inform each team about their quality results every 
month, and ask for their feedback.
4.5 Suggestions for Future Research in the Field
The regional differences in quality which emerged from 
our analysis should be further explored. Other possible 
factors that could contribute to quality should be studied. 
The quality indicators should be reviewed each year, 
which would allow a comparison of indicators between 
two points in time in the same practice, or between 
practices using the new approach and those using the 
classical approach, and to observe the trend of change 
according to the existing circumstances.
10.1515/sjph-2017-0029 Zdr Varst 2017; 56(4): 211-219
219
5 CONCLUSION
The first analysis of data on quality indicators for diabetes 
and hypertension in this primary care project pointed 
out the problems which are currently preventing higher 
quality of chronic patient management at the primary 
health care level. There are problems with the quality 
of data, especially with the IT support, which should be 
recognised and eliminated. 
ACKNOWLEDGEMENTS
We thank Barbara Šturm and Sara Peklaj from the project 
office for helping us in gathering the data.
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
The authors acknowledge the financial support from the 
Slovenian Research Agency (research core funding No. P3 
0339). 
ETHICAL APPROVAL
Ethical approval was not sought as no patients were 
involved in the study. The values of quality indicators 
were extracted from the whole pool of data and other 
data were gathered from the project database. The data 
on providers were anonymous. 
REFERENCES
1. Mainz J. Defining and classifying clinical indicators for quality 
improvement. Int J Qual Health Care 2003; 15: 523-30.
2. Kringos D, Boerma W, Bourgueil Y, Cartier T, Dedeu T, Hasvold T et al. The 
strength of primary care in Europe: an international comparative study. 
Br J Gen Pract 2013; 63: e742-e50.
3. Reid RO, Friedberg MW, Adams JL, McGlynn EA, Mehrotra A. Associations 
between physician characteristics and quality of care. Arch Intern Med 
2010; 170: 1442-9.
4. Rushforth B, Stokes T, Andrews E, Willis TA, McEachan R, Faulkner S et 
al. Developing ‘high impact’ guideline-based quality indicators for UK 
primary care: a multi-stage consensus process. BMC Fam Pract 2015; 16: 
156.
5. Seddon ME, Marshall MN, Campbell SM, Roland MO. Systematic review of 
studies of quality of clinical care in general practice in the UK, Australia 
and New Zealand. Qual Health Care 2001; 10: 152-8.
6. Simou E, Pliatsika P, Koutsogeorgou E, Roumeliotou A. Quality indicators 
for primary health care: a systematic literature review. J Public Health 
Manag Pract 2015; 21: E8-16.
7. Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland 
M. Quality of primary care in England with the introduction of pay for 
performance. N Engl J Med 2007; 357: 181-90.
8. Buetow S. Pay-for-performance in New Zealand primary health care. J 
Health Organ Manag 2008; 22: 36-47.
9. Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, 
Sermeus W. Systematic review: effects, design choices, and context of 
pay-for-performance in health care. BMC Health Serv Res 2010; 10: 247.
10. Boerma W, Kringos D, Verschuuren M, Pellny M, Bulc M. Primary care 
quality management in Slovenia. Copenhagen: WHO, 2008.
11. Petek D, Campbell S, Serec M, Kersnik J. Quality indicators of 
cardiovascular disease prevention for primary care in Slovenia. Zdrav 
Vestn 2012; 81: 687-98.
12. Petek D, Kersnik J. Management of cardiovascular risk factors in high 
risk patients: correlates of quality of care. Zdr Varst 2013; 52: 263-74.
13. Pavlic DR, Sever M, Klemenc-Ketis Z, Svab I. Process quality indicators in 
family medicine: results of an international comparison. BMC Fam Pract 
2015; 16: 172.
14. Schafer WL, Boerma WG, Kringos DS, De Maeseneer J, Gress S, Heinemann 
S et al. QUALICOPC, a multi-country study evaluating quality, costs and 
equity in primary care. BMC Fam Pract 2011; 12: 115.
15. Marshall MN, Shekelle PG, McGlynn EA, Campbell S, Brook RH, Roland 
MO. Can health care quality indicators be transferred between countries? 
Qual Saf Health Care 2003; 12: 8-12.
16. Campbell SM, Braspenning J, Hutchinson A, Marshall MN. Research 
methods used in developing and applying quality indicators in primary 
care. BMJ 2003; 326: 816-9.
17. Campbell SM, Hann M, Hacker J, Burns C, Oliver D, Thapar A et al. 
Identifying predictors of high quality care in English general practice: 
observational study. BMJ 2001; 323: 784-7.
18. Poplas-Susic T, Svab I, Kersnik J. The project of model practices in family 
medicine in Slovenia. Zdrav Vestn 2013; 82: 635-47.
19. Klemenc-Ketis Z, Kravos A, Poplas-Susič T, Svab I, Kersnik J. New tool for 
patient evaluation of nurse practitioner in primary care settings. J Clin 
Nurs 2014; 23: 1323-31.
20. Anon. Poročilo o kazalnikih kakovosti. Ljubljana: MZ, 2015.
21. Nerat T, Kos M. Burden of type 2 diabetes from the healthcare payer 
perspective in Slovenia. Zdr Varst 2013; 52: 162-80.
22. Ettorchi-Tardy A, Levif M, Michel P. Benchmarking: a method for 
continuous quality improvement in health. Healthc Policy 2012; 7: e101-
19.
23. Petek D, Mlakar M. Quality of care for patients with diabetes mellitus 
type 2 in ‘model practices’ in Slovenia – first results. Zdr Varst 2016; 
55: 179-84.
24. Heneghan C, Perera R, Mant D, Glasziou P. Hypertension guideline 
recommendations in general practice: awareness, agreement, adoption, 
and adherence. Br J Gen Pract 2007; 57: 948-52.
25. Midlov P, Ekesbo R, Johansson L, Gerward S, Persson K, Nerbrand C et al. 
Barriers to adherence to hypertension guidelines among GPs in southern 
Sweden: a survey. Scand J Prim Health Care 2008; 26: 154-9.
26. Rao DT, Sunio LK, Lo YJ, Gossain VV. Comparison of the adherence to 
the American Diabetes Association guidelines of diabetes care in primary 
care and subspecialty clinics. J Diabetes Metab Disord 2015; 14: 35.
27. Seidu S, Khunti K. Non-adherence to diabetes guidelines in primary care 
- the enemy of evidence-based practice. Diabetes Res Clin Pract 2012; 
95: 301-2.
28. Ohmann C, Kuchinke W, Canham S, Lauritsen J, Salas N, Schade-Brittinger 
C et al. Standard requirements for GCP-compliant data management in 
multinational clinical trials. Trials 2011; 12: 85.
29. Kumar AM, Naik B, Guddemane DK, Bhat P, Wilson N, Sreenivas AN et al. 
Efficient, quality-assured data capture in operational research through 
innovative use of open-access technology. Public Health Action 2013; 3: 
60-2.
30. Jelić J, Drinovec J, Mrhar A. Burden of type 2 diabetes. Farm Vestn 2006; 
57: 315-24.
31. Smith PC. Measuring health system performance. Eur J Health Econ 2002; 
3: 145-8.
32. Groenewegen P, Heinemann S, Gress S, Schafer W. Primary care practice 
composition in 34 countries. Health Policy 2015; 119: 1576-83.
33. Engels Y, Campbell S, Dautzenberg M, van den Hombergh P, Brinkmann H, 
Szecsenyi J et al. Developing a framework of, and quality indicators for, 
general practice management in Europe. Fam Pract 2005; 22: 215-22.
34. Deveugele M, Derese A, van den Brink-Muinen A, Bensing J, De Maeseneer 
J. Consultation length in general practice: cross sectional study in six 
European countries. BMJ 2002; 325: 472.
THE ROLE OF HEALTH SERVICES IN ENCOURAGING DISCLOSURE 
OF VIOLENCE AGAINST WOMEN
Vesna LESKOŠEK1*, Miha LUČOVNIK2, Lucija PAVŠE2, Tanja PREMRU SRŠEN2, Megie KRAJNC2, 
Ivan VERDENIK2, Vislava GLOBEVNIK VELIKONJA2
1University of Ljubljana, Faculty of Social Work, Topniška 31, 1000 Ljubljana, Slovenia
2University Medical Centre Ljubljana, Division of Obstetrics and Gynaecology, Department of Perinatology, 
Šlajmerjeva 3, 1000 Ljubljana Slovenia
Received: Jan 26, 2017
Accepted: Jul 6, 2017 
Original scientific article
Introduction. The aim of the survey was to assess the differences in disclosure by the type of violence to better 
plan the role of health services in identifying and disclosing violence. 
Methods. A validated, anonymous screening questionnaire (NorAQ) for the identification of female victims of 
violence was offered to all postpartum women at a single maternity unit over a three-month period in 2014. 
Response rate was 80% (1018 respondents). Chi square test was used for statistical analysis (p<0.05 significant).
Results. There are differences in disclosure by type of violence. Nearly half (41.5%) of violence by health care 
services was not reported, compared to 33.7% physical, 23.4% psychological, and 32.5% sexual that was reported. 
The percentage of violence in intimate partnership reported to health care staff is low (9.3% to 20.8%), but 
almost half of the violence experienced by heath care services (44%) is reported. Intimate partnership violence 
is more often reported to the physician than to the psychologist or social worker. Violence in health care service 
is reported also to nurses. 
Conclusions. Disclosure enables various institutions to start with the procedures aimed at protecting victims 
against violence. Health workers should continuously encourage women to speak about violence rather than 
asking about it only once. It is also important that such inquiries are made on different levels of health care 
system and by different health care professions, since there are differences to whom women are willing to 
disclose violence.
Uvod. Namen raziskave je ugotoviti razlike v razkritju nasilja glede na različne vrste nasilja, da bi lahko 
ustrezneje načrtovali vlogo zdravstvenih institucij v identificiranju in razkrivanju nasilja.
Metode. Na Ginekološki kliniki v Ljubljani smo leta 2014 opravili raziskavo z naslovom Nasilje med nosečnostjo 
– NANOS. Prevod in priredbo vprašalnika The NorVold Abuse Questionnaire – NorAQ smo na poporodnem oddelku 
tri mesece v anonimizirani obliki ponujali v izpolnjevanje vsem ženskam po porodu. Vprašalnik je razdeljen v 9 
poglavij, ima 101 vprašanje in obsega 11 strani. Odzivnost je bila 80-odstotna (1018 respondentk) Rezultati so 
bili obdelani s statističnim paketom SPSS (SPSS for Windows version 21, IBM Corp., Armonk, NY, ZDA). Razlike 
med skupinami so bile testirane, upoštevajoč 95-odstotni interval zaupanja in statistično pomembnost pri p 
< 0,05.
Rezultati. Rezultati kažejo na razlike v razkritju med različnimi vrstami nasilja. Podatki so pokazali, da 
približno tretjina žensk nikoli ne razkrije nasilja, ki ga doživljajo, in manj kot polovica tistih, ki o tem 
spregovorijo, razkrije celotno dogajanje. Manj kot polovico nasilja (41,5%) zdravstvenih delavcev respondentke 
niso prijavile, kar je višji odstotek kot pri drugih vrstah nasilja, kjer niso prijavile 33,7% fizičnega, 23,4% 
psihičnega in 32,5% spolnega nasilja. Zdravstvenemu osebju razkrije psihično, fizično ali spolno nasilje v 
intimnih razmerjih od 9,3 do 20,8% anketirank in 44% jih razkrije nasilje zdravstvenega osebja. Najpogosteje 
nasilje v intimnih razmerjih razkrijejo zdravnikom, psihologom in socialnim delavcem, nasilje zdravstvenih 
delavcev pa razkrijejo zdravnikom in medicinskim sestram. Najmanj posledic doživljajo zaradi nasilja 
zdravstvenih delavcev (posledice trpi 16,2%) in največ, če doživijo spolno nasilje (posledice trpi 55,3%). Pri 
spolnem nasilju tudi največ žensk ne razkrije nasilja, vendar zelo trpijo zaradi posledic (30,3%). Pomoč poišče 
manj žensk, kot jih trpi posledice nasilje. Pri fizičnem nasilju jih pomoč poišče le 10,9%, pri psihičnem 20,4% 
in pri spolnem 25%.
Zaključek. Razkritje je ključno dejanje, ki omogoča, da različne institucije lahko sprožijo postopke zaščite 
žrtve pred nasiljem. Zdravstveni delavci bi morali kontinuirano (in ne le enkrat) spodbujati ženske, da 
spregovorijo o nasilju. Pomembno je, da o tem sprašujejo in k razkritju spodbujajo različni zdravstveni delavci 
na različnih ravneh zdravstvenega sistema. Čeprav razkritje v zdravstvu ni pogosto, se ravno zdravstvo srečuje 
z vsemi ženskami, zato lahko pomembno vpliva na razkritje.
ABSTRACT
Keywords: 
disclosure, differences 
by type of violence, 
encouraging disclosure 
of violence in health 
care
IZVLEČEK
Ključne besede: 
razkritje, razlike 
glede na vrsto nasilja, 
spodbujanje razkritja 
v zdravstvu
*Corresponding author: Tel: + 386 40 286 715; E-mail: vesna.leskosek@fsd.uni-lj.si
10.1515/sjph-2017-0030 Zdr Varst 2017; 56(4): 220-226
VLOGA ZDRAVSTVENIH USTANOV PRI SPODBUJANJU RAZKRITJA 
NASILJA NAD ŽENSKAMI
Leskošek V, Lučovnik M, Pavše L, Premru Sršen T, Krajnc M, Verdenik I, Globevnik Velikonja V. The role of health services in encouraging disclosure of violence against 
women. Zdr Varst 2017; 56(4): 220-226.
220
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION 
Violence against women during pregnancy attracted much 
professional attention in the past decades and became an 
important research topic in medicine as well. The reason 
is primarily the growing awareness of the multiple effects 
of violence on the physical and mental health of women 
and children. The World Health Organisation (WHO) 
studies on intimate partner violence (IPV)  indicate that, 
on the global level, the average incidence of violence 
during pregnancy is between 4% and 12%. These estimates 
vary significantly between countries ranging from 1% 
and 70%. Approximately one third of cases include kicks 
and punches in the abdomen (1). The consequences of 
violence during pregnancy can be long-lasting, and can 
cause a life-long trauma in children. Violence threatens 
person’s physical and mental health and may lead to 
homicide or suicide. The WHO pointed out that violence 
may lead to addictive behaviour, which causes additional 
damage to the child who may suffer the consequences of 
drug abuse and alcohol consumption (1). 
Studies of violence before and during pregnancy most 
often focus on the prevalence, incidence, consequences 
and dynamics of violence, with data gathered using both 
quantitative and qualitative methods. The findings of 
those studies show that violence during pregnancy has 
multiple effects on health of the mother and the child, 
for example, low weight at birth, premature birth, a 
low gain of weight during pregnancy, kidney infection, 
antepartum haemorrhage, caesarean section, miscarriage 
or neo-natal death (2-4). Mental health problems are 
also frequent, for example, depression, post-traumatic 
stress disorder, panic disorder, anxiety, as well as abuse of 
various substances (5, 6). Violence can also cause lack of 
attachment to the child and lower rates of breastfeeding 
(1). It can cause physical injuries to fetus, such as bruises, 
broken bones, and stab wounds, and death in extreme 
cases (7). Several meta-analyses of existing studies of 
violence during pregnancy have been conducted (8-10) as 
well as many national studies. The latter are important 
because they are conducted in specific socio-cultural 
environments and structural conditions, so they can offer 
new insights. In addition, they are an important source of 
various comparisons and trans-national analysis. 
Violence during pregnancy has not been a conspicuous 
research topic in Slovenia so far. A question referring 
to it was included in the national survey ‘Violence 
against women in Slovenia’ (11). Data showed that 
5.5% of women experienced violence during pregnancy. 
Matko (12) conducted a qualitative study on the sample 
comprising 13 women who at the time of research, lived 
in the maternity home or the shelter for women, and 
who experienced violence during pregnancy. Her results 
show that 5 (38%) children were born prematurely. This 
is a much higher proportion of preterm birth compared 
to approximately 6% of preterm deliveries in the general 
population in Slovenia (13). More than half of children 
had health or other problems, such as developmental 
disorders, hyperactivity, dyslexia, or they needed learning 
support. Her conclusion is that women experience various 
kinds of violence during pregnancy. For some of them, 
physical violence began only during pregnancy and was 
followed by a ban on breastfeeding or other forms of 
restricting contact with the new-born. The consequences 
for women were emotional distress and physical injuries 
(12).
Violence against women is an important public health 
problem also because of high expenses of treatment of 
injuries caused by it. Female victims receive hospital 
treatment and need medicines more often than women 
who have no such experience (14). In the opinion of 
the Institute of Public Health’s researchers, violence 
in Slovenia has not been sufficiently recognized as an 
important issue in public health, although there is a 
growing awareness of the problem (15). An important step 
forward was the adoption of the Rules on procedures for 
dealing with domestic violence in the implementation of 
health activities, which sets the professional and ethical 
standards of work with the victims of violence. The 
document imposes on health care workers the obligation 
to report violence, to cooperate within multi-disciplinary 
teams at centres of social work, and to assess the threat 
to the victim. The document further specifies that health 
workers should acquire relevant knowledge and skills 
through additional training programmes (16). 
In 2014, the University Medical Centre Ljubljana, 
Division of Obstetrics and Gynaecology, Department of 
Perinatology, conducted the survey ‘Violence during 
pregnancy – NANOS’ that sought to establish the incidence 
of physical, psychological and sexual violence, as well 
as violence within the health care system before and 
during pregnancy. In addition, potential influences on the 
psychological and physical health of mothers and children 
were also studied. The study is a response to the growing 
responsibility of health workers to act upon the notice 
of violence and an important step in understanding the 
country’s specific effects of violence on pregnant women. 
We used the translated and adapted NorVold Abuse 
Questionnaire – NorAQ, developed by Swahnberg and 
Wijma (17), which included questions on violence against 
women in health-care system due to negative effects that 
it might have on women and their capability of disclosing 
violence to health care workers. 
In this article, we focus on data about the disclosure of 
violence and on the role of health care workers in the 
process of disclosure. The main research question is what 
are the differences in disclosure concerning the type of 
10.1515/sjph-2017-0030 Zdr Varst 2017; 56(4): 220-226
221
10.1515/sjph-2017-0030 Zdr Varst 2017; 56(4): 220-226
222
violence and what are the differences in disclosure of 
violence experienced in intimate partnership or within 
the health care system. Results are important for future 
development of health care practices that will encourage 
women to disclose the violence. 
2 METHOD
We conducted an observational cross-sectional study among 
all women who delivered at our perinatal centre during 
a three-month period. Quantitative and investigative 
research method was applied. We used the translated and 
adapted NorVold Abuse Questionnaire – NorAQ, developed 
by Swahnberg and Wijma (17). The questionnaire is 
divided into 9 sections and comprises 101 questions. The 
main sections include general questions about pregnancy, 
childbirth and contacts with gynaecologists, health, 
psychological abuse, abuse perpetrated by health care 
system, physical abuse, sexual abuse, current partnership, 
concluding questions, and an addition comprising 9 
questions about childbirth. The questionnaire comprised 
11 pages of easily comprehensible questions. 
The anonymous questionnaire was offered to all 
postpartum women at a single maternity unit over a 
three-month period in 2014. Of the total 1272 women, 
1018 responded, which amounts to 80% response rate. 
The questionnaire was available in print and online. Only 
7 women chose online version. 
The results were processed using the SPSS software (SPSS 
for Windows version 21, IBM Corp., Armonk, NY, USA). 
Differences between groups were tested using parametric 
and non-parametric tests, with confidence interval of 95% 
and statistical significance at p<0.05.
2.1 The Main Characteristics of the Sample
The average age of respondents was 31 years (the youngest 
one was 18 and the oldest 47); 32.8% of respondents 
had university education, 31.5% had secondary school 
education, 1.8% had only elementary school, and 1.6% had 
a doctoral degree. 52.1% of respondents are cohabitating, 
46.5% were married, and 1.2% were single or divorced. 
As to the ethnic structure, 87% declared themselves as 
Slovenes, 5% as Serbs, 4.9% as Bosnians, with most of the 
remaining respondents coming from ex-Yugoslav republics 
and Eastern European countries. The percentage of 
employed women in the group was high. Of those, 72.3% 
said they were employed, 5.4% said that they were on a 
maternity leave, and 5.9% said that they were on a longer 
sick leave. Other respondents were either students or 
unemployed. Most women (85%) support their families 
along with their partners; 11% of respondents said that 
their partner was the only breadwinner in the family, 
and 2.4% said that they earned livelihood alone. As many 
as 33% said that they had no job guaranteed after the 
end of the maternity leave. Mobbing at a workplace was 
experienced by 10.4% of respondents. Sixty percent of 
respondents lived in their own dwellings, 22.1% in a rented 
accommodation, and 17.8% with their relatives or friends. 
One person lived in a maternity home. Approximately one 
quarter (25.9%) of respondents came from the rural area.
Pregnancy was unplanned or undesired for 0.3% of 
respondents, while 25.9% of them did not plan it, but 
assessed it as desired. The sex of the child was deemed 
irrelevant by 69.2% of respondents, while 12.4% wished 
for a boy, and 18.4% for a girl. In the opinion of 67.9% 
of respondents, gender was irrelevant for their partners; 
17.5% of partners wanted a boy, and 14.6% wanted a girl.
One fourth of respondents had a miscarriage before 
current pregnancy, and 15% terminated pregnancy. One 
fourth already had a gynaecological surgery. Approximately 
one tenth of respondents assessed their health during 
pregnancy as poor; 24% visited a physician more than ten 
times during pregnancy, 38.2% up to three times, and 
15.5% were hospitalised. Psychiatric help was sought by 
3.4% of respondents during pregnancy. Approximately 15% 
experienced anxiety, and 11% were depressed.
Data point to some trends that are mirroring the societal 
change. More women live in co-habitation, the extent of 
employed is high, a vast majority is sharing the financial 
support of the family, although 11% is economically 
depended on their partners. Their future employment 
status is insecure, which reflects the precariousness of 
current employment patterns. For the tenth of them the 
workplace is a source of violence as they are experiencing 
mobbing. The ethnic structure of the sample reflects the 
ethnic structure of the Slovene society. For most couples, 
the gender of a child does not matter, but there are some 
differences between those that preferred a daughter 
or a son. Women whished more to have a daughter and 
men whished more to have a son. The health of women 
is an issue to be further explored. 15% of women who 
experienced anxiety and 11% who were depressed are 
relatively high percentages. A quarter of women also 
visited physician more than 10 times during pregnancy. 
Partly their psychological and physical condition can be 
explained with the age, but more in-depth research is 
needed. 
2.2 Data on Violence Experienced in Different Life 
Periods
We sought to establish the presence of four types of 
violence, i.e. psychological, physical and sexual violence, 
as well as violence perpetrated by health care system. 
Table 1 shows the incidence of individual types of violence, 
enabling us to establish the scope of the phenomenon. 
Some women experienced violence as children and 
as adults, and some experienced several types of 
Table 1.
Table 2.
Table 3.
Incidence of individual types of violence in various periods of life.
Disclosure to anyone.
Reporting violence to health care staff.
Before the age of 18
In adulthood
During pregnancy
Whenever
No
Yes, partly
Yes, everything
Physician 
Nurse  
Psychologist
Social worker
6.1
2.0
0.0
7.6
32.5
26.0
41.6
42.9
/
42.9
14.7
2.7
10.1
5.8
16.1
41.5
10.2
48.3
65.5
27.6
3.4
3.4
14.8
14.1
3.2
26.1
23.4
29.4
47.2
28.6
4.8
57.1
9.5
22.4
9.5
1.0
29.2
33.7
21.8
44.4
46.2
/
38.5
15.4
31.2
19.1
9.2
46.9
Period of life
% of disclosure 
% of disclosure 
Sexual violence
Sexual violence
Sexual violence 
(N=7)
Violence by health 
care system 
Violence by health care 
system 
Violence by health care 
system (N=29)
Psychological 
violence
Psychological violence
Psychological violence 
(N=21)
Physical violence 
Physical violence 
Physical violence 
(N=13)
Any type 
of violence
10.1515/sjph-2017-0030 Zdr Varst 2017; 56(4): 220-226
223
violence simultaneously. Violence during pregnancy was 
experienced by 9.2% of respondents, most frequently 
by health care system. While most of the IPV is gender-
specific, meaning that most of the perpetrators are men, 
violence in health care is performed by both genders. 
Comparing to the national prevalence study on violence 
against women (11), our survey shows a slightly higher 
extent of physical violence (23% in national survey), 
significantly less psychological violence (49.9% in national 
survey), and a slightly higher extent of sexual violence 
(6.5%), which is the consequence of different methodology 
and age limits. The national study was asking for violence 
experienced after 15 years of age. The comparison is 
also difficult to make because some women experience 
more than one kind of violence at the same time, which 
is pointed out in the European survey on violence against 
women (18). 
3 RESULTS
In Table 2, we compare data on disclosure of any kind 
of violence. Approximately one third of respondents 
reported violence they experienced, but not all types 
of violence were reported at equal rate. Violence 
perpetrated by health care system was the least reported, 
in contrast to psychological violence, which was most 
frequently disclosed. Approximately half of respondents 
who reported every instance of violence most frequently 
reported violence experienced by health care system.
There are differences regarding which health worker they 
choose to disclose a specific type of violence. Table 3 
shows that while violence perpetrated by health workers 
is most often disclosed to the physician or the nurse at 
the primary level, other types of violence are more often 
reported to a psychologist, physician on a secondary or 
tertiary level, or a social worker, but not to a nurse. 
Table 4 shows that women speak about violence if 
asked about it by a physician. They more often report 
psychological violence, unlike about physical violence, 
which is rarely reported. 
The research shows differences in the extent of the 
severity of various types of violence (Table 5). Violence 
committed by health workers causes least consequences, 
and sexual violence caused severe consequences for more 
than half of women who experienced it. A significant 
proportion of women (32.5%) do not disclose sexual 
violence, but the suffering caused by it is severe. Some 
women who experienced violence did not ask for help: 
one tenth of those who experienced physical violence, 
one fifth of those who were psychologically abused, and 
one third of those who were sexually abused.
4 DISCUSSION
Disclosure is an essential step that enables various 
institutions to start with the procedures aimed at 
protecting victims against violence. However, many 
obstacles prevent victims from disclosing violence. 
Distrust, shame and fear affect women’s attitude towards 
various public services, and few women are willing to 
speak about violence. Women who have experienced 
violence seek health care due to physical injuries, 
but often they do not disclose the associated abuse or 
violence. ‘A health-care provider is likely to be the first 
professional contact for survivors of intimate partner 
violence or sexual assault. Statistics show that abused 
women use health-care services more than non-abused 
women do. […] Health professionals can provide assistance 
by facilitating disclosure; offering support and referral; 
providing the appropriate medical services and follow-
10.1515/sjph-2017-0030 Zdr Varst 2017; 56(4): 220-226
224
up care; or gathering forensic evidence, particularly in 
cases of sexual violence’ (19). Research findings show 
the tendency to downplay violence as a problem issue. 
It has been shown that most victims presenting for social 
and health care are not asked about violence and do not 
receive attention or intervention (30).
Our research data show that approximately one third 
of women never disclose violence they experienced, 
while less than half of those who do report violence are 
willing to tell everything. 9.3% (counted together all ‘yes’ 
answers in Table 4), and 20.8% of respondents disclosed 
psychological, physical, or sexual violence in intimate 
relationships to health workers, while 44% disclosed 
violence perpetrated by health workers. Data points 
to a difference between IPV and institutional violence. 
Different research shows that women often tolerate 
violence in intimate partnership, fail to recognise it, find 
it difficult to resist, and even more difficult to leave such 
a relationship, because they frequently believe that the 
perpetrator loves them and that he will change (20). They 
seek reasons for violence in the problems of their partners, 
they tend to minimise the problem, and attribute it to 
their own behaviour (provoking the partner, refusing 
sex). Other reasons of staying in violent relationship 
include fear of retribution, a lack of alternative means 
of economic support, concern for the children, emotional 
dependence, a lack of support from family and friends, 
and an abiding hope that the partner will change (14). 
Reasons for disclosing the institutional violence differ from 
IPV. The primary common feature of each type of violence 
is a wish to gain power and control, regardless of whether 
it is committed in IPV or elsewhere. It is a means taken by 
the perpetrator to acquire power over other members of 
a society and subordinate them (21). It should be noted, 
Table 5.
Table 4.
Seeking help after experiencing violence.
Disclosing violence to a health worker.
No, since it did not cause 
much suffering
No, although I suffered a lot
Yes, I sought help
No
Yes, he already knew  
Yes, when he asked about it
Yes, I told it of my own will
44.7
30.3
25.0
80.4
3.9
9.8
5.9
83.8
11.5
4.7
56.0
8.3
10.7
25.0
55.6
24.0
20.4
79.2
2.8
7.3
10.7
70.7
18.4
10.9
90.7
2.3
2.9
4.1
% of seeking 
help
% of disclosure 
Sexual violence 
(N=76)
Sexual violence 
Violence by health care 
system (N=148)
Violence by health care 
system
Psychological violence 
(N=225)
Psychological violence
Physical violence 
(N=256)
Physical violence 
10.1515/sjph-2017-0030 Zdr Varst 2017; 56(4): 220-226
225
however, that abuse in healthcare is defined by patients’ 
subjective experiences of encounters with the health care 
system, characterized by devoid of care, where patients 
suffer and feel they lose their value as human beings (22). 
Violence in health care is performed by men and women 
alike, and research shows that the most common forms 
of violence against women are neglect, verbal violence, 
including rough treatment, threats, scolding, shouting, 
and intentional humiliation, then physical violence, 
including denial of pain-relief when technically indicated, 
and sexual violence, which is similar to the forms of 
violence that occur in IPV (23). The main difference 
between IPV and institutional violence that leads to 
a higher percentage of reported violence perpetrated 
by medical staff in our survey is a lack of emotional 
attachment and, consequently, a lack of tolerance to such 
practices. The percentage of women in our survey that 
did not disclose violence committed by medical staff is 
the highest, which is a paradoxical situation that needs 
to be further examined, because it points to the specific 
relationship between a patient and a physician. Power 
relations and hierarchical structures are significant for 
medical institutions, not just between physicians and 
patients, but also between different medical professions. 
Patients often subordinate to physicians because of the 
awareness of hierarchal positions (24). Such patients 
internalize social hierarchy and subordinated positions, 
and develop fear of disclosure. Others do not have such 
fear; they understand mechanisms within power relations 
and are, accordingly, capable of resistance. They have 
trust in medical knowledge, expect professional attitude 
based on mutual respect, and respect for dignity even if 
the situation involves uneven power relations (23). They 
refuse to accept inappropriate institutional conduct 
regardless of their own position in the social hierarchy. 
They do not defy the social prestige associated with 
medical profession, but are convinced that prestige does 
not imply superiority over patients (24). 
Our research pointed to the difference between the 
disclosure of the IPV and of the violence within the health 
system, which is important when planning measures to 
prevent violence within health institutions. While physical 
and sexual violence in intimate partnerships is disclosed 
primarily to psychologists, physicians or social workers, 
violence perpetrated by medical staff is mainly disclosed 
to physicians and nurses. One of the reasons is that violence 
committed by health workers (excluding severe sexual or 
physical violence) does not cause as much suffering as 
violence in intimate partnership, so it is not reported to 
psychologists and social workers. Another reason is that 
in the case of violence perpetrated by health workers, 
the complaint procedure is better defined, which makes it 
easier for them to speak out. It is also important to stress 
that in our survey, physicians perpetrated the largest 
part of violence within the health system, so the victims 
speak about it to other health workers. This information 
is important in planning the ways to encourage disclosure 
of violence. Nonetheless, in the case of violence in health 
institutions, it is important to establish as independent as 
possible complaint procedures, and to ensure that IPV is 
reported in a personal contact with a physician. A nurse 
cannot pose questions about violence as part of routine 
inquiries before the patient encounters the physician. 
Much time and more visits are needed so that women 
can speak out, and in order to bring them to voice their 
problems, health workers’ attitude must be respectful, 
so that women are encouraged to disclose violence. They 
will not speak out unless they believe that it is safe to 
disclose violence. 
5 CONCLUSION 
Institutional violence undermines public good (25) that 
should provide every person with dignity and respect. 
Health care institutions (as much as educational, social, 
cultural and other) are responsible to treat people equally 
regardless of their personal circumstances, and to broaden 
their choices for dignified life. They should understand 
power relations that are incorporated in medical system 
as much as in the relationship between a patient and a 
physician. ‘However, addressing the problem of violence 
by health workers is necessary to support the efforts of 
dedicated staff who are committed to improving clinical 
practice’ (23). It is important to sensitize health care 
providers and encourage routine screening for abuse, as 
well as to draw up protocols for proper management of 
abuse (28, 29).
To maximize efficiency when identifying the victims of 
violence, health workers should persistently encourage 
women to speak about potential violence rather than 
asking about it only once. There are tools available to 
screen women for IPV during obstetric care (26) that can 
be adopted to Slovene situation. It is also important that 
such inquiries are made on different levels and not only in 
primary health institutions (27, 31). The WHO emphasises 
that it is the public health institutions that encounter 
almost all victims of violence, so their staff needs to 
be highly trained to recognize violence and effectively 
handle it. Accordingly, they should establish cooperation 
with other institutions trained to handle violence, 
which will enable them to avoid excessive burden that 
could reduce the likelihood of dealing suitably with the 
problem. It is important to sensitize health care providers 
and encourage routine screening for abuse, as well as 
to draw up protocols for proper management of abuse. 
Confronting deep-rooted beliefs and attitudes is also 
important. Research suggests that making procedural 
changes in patient care has the greatest effect on the 
behaviour of health care providers (14).
10.1515/sjph-2017-0030 Zdr Varst 2017; 56(4): 220-226
226
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
The research study did not receive funds. 
ETHICAL APPROVAL
Ethical approval was received by the National Medical 
Ethics Committee (no. 64/11/13). 
REFERENCES
1. WHO. Intimate partner violence during pregnancy: information 
sheet. Available Dec 25, 2016 from: http://apps.who.int/iris/
bitstream/10665/70764/1/WHO_RHR_11.35_eng.pdf  
2. Janssen PA, Holt VL, Sugg NK, Emanuel I, Critchlow CM, Henderson 
AD. Intimate partner violence and adverse pregnancy outcomes: a 
population-based study. Am J Obstet Gynecol 2003; 188: 1341-7.
3. Yost NP, Bloom SL, McIntire DD, Leveno KJ. A prospective 
observational study of domestic violence during pregnancy. Obstet 
Gynecol 2005; 106: 61-5.
4. Fried LE, Cabral H, Amaro H, Aschengrau A. Lifetime and during 
pregnancy experience of violence and the risk of low birth weight 
and preterm birth. J Midwifery Womens Health 2008; 53: 522-8. 
5. Carbone-Lopez K, Kruttschnitt C, Macmillan R. Patterns of intimate 
partner violence and their associations with physical health, 
psychological distress, and substance use over the life span. Public 
Health Rep 2006; 121: 382-92.
6. Pico-Alfonso MA, Garcia-Linares MI, Celda-Navaro N, Blasco-Ros C, 
Echeburúa E, Martinez M. The impact of physical, psychological and 
sexual intimate male partner violence on women’s mental health: 
depressive symptoms, posttraumatic stress disorder, state anxiety 
and suicide. J Womens Health 2006; 15: 599-611.
7. Jahanfar S, Malekzadegan Z. The prevalence of domestic violence 
among pregnant women who were attended in Iran University of 
Medical Science Hospitals. J Fam Viol 2007; 22: 643-8.
8. Golding JM. Intimate partner violence as a risk factor for mental 
disorders: a meta-analysis. J Fam Viol 1999; 14: 99-132.
9. Moura Bessa MM, Drezett J, Rolim M, de Abreu LC. Violence against 
women during pregnancy: sistematized revision. Reprod Clim 2014; 
29: 71-9. 
10. James L, Brody D, Hamilton Z. Risk factors for domestic violence 
during pregnancy: a meta-analytic review. Violence Vict 2013; 28, 
359-80. 
11. Leskošek V, Urek M, Zaviršek D. Nacionalna raziskava o nasilju v 
zasebni sferi in partnerskih odnosih: zaključno poročilo. Ljubljana: 
Inštitut za kriminologijo pri Pravni fakulteti, 2010. 
12. Matko K. Nasilje nad ženskami med nosečnostjo. In: Leskošek V, 
editor. Nasilje nad ženskami v Sloveniji. Maribor: Aristej, 2013: 117-
32. 
13. Lucovnik M, Bregar AT, Steblovnik L, Verdenik I, Gersak K, Blickstein 
I, Tul N. Changes in incidence of iatrogenic and spontaneous preterm 
births over time: a population-based study. J Perinat Med 2016; 44: 
505-9.
14. Krug EG, Dahlberg LL, Mercy AJ, Zwi AB, Lozano R, editors. World report 
on violence and health. Geneva: WHO, 2002.  Available Dec 3, 2016 
from: http://whqlibdoc.who.int/publications/2002/9241545615_
eng.pdf 
15. Mihevc-Ponikvar B, Tomšič S, Drev A, Drglin Z, Fajdiga-Turk Z, 
Gabrijelčič-Blenkuš M et al. Zdravje žensk med 20. in 64. letom. In: 
Hočevar Grom A, editor. Zdravje v Sloveniji. Ljubljana: Nacionalni 
inštitut za javno zdravje, 2010: 55-61. 
16. Pravilnik o pravilih in postopkih pri obravnavanju nasilja v družini pri 
izvajanju zdravstvene dejavnosti. Ur. L. RS, 38/2011. 
17. Swahnberg IM, Wijma B. The NorVold Abuse Questionnaire (NorAQ): 
validation of new measures of emotional, physical, and sexual 
abuse, and abuse in the health care system among women. Eur J 
Public Health 2003; 13: 361-6.
18. FRA. Violence against women: an EU-wide survey: main results. 
(2014) Vienna: European Union Agency for Fundamental Rights, 
2014.  Available April 28, 2017 form: http://fra.europa.eu/en/
publication/2014/vaw-survey-main-results 
19. WHO. Responding to intimate partner violence and sexual 
violence against women: WHO clinical and policy guidelines. 
Available Dec 29, 2016 from: http://apps.who.int/iris/
bitstream/10665/85240/1/9789241548595_eng.pdf?ua=1 
20. Rommelspacher B. Ali je ženski mazohizem mit? In: Zaviršek D, 
editor. Spolno nasilje: feministične raziskave za socialno delo. 
Ljubljana: Visoka šola za socialno delo, 1996: 5-32.  
21. Kelly L. Violence against women and children: vision, innovation and 
professionalism in policing. Strasbourg: Council of Europe Publishing, 
2003. 
22. Swahnberg K, Wijma B, Wingren G, Hilden M, Schei B. Women’s 
perceived experiences of abuse in the health care system: their 
relationship to childhood abuse. BJOG 2004; 111: 1429-36.
23. d’Oliveira AF, Diniz SG, Schraiber LB. Violence against women in 
health-care institutions: an emerging problem. Lancet 2002; 359: 
1681-5. 
24. Ule M. Spregledana razmerja o družbenih vidikih medicine. Maribor: 
Aristej, 2003. 
25. 25. Curtin D, Litke R. Institutional violence. Amsterdam, Atlanta: 
Radopi, 1999. 
26. Committee for Health Care of Undeserved Women. Committee 
opinion No. 518. The American College of Obstetricians and 
Gynaecology, 2012. Available Jan 24, 2017 from: http://www.acog.
org/Resources-And-Publications/Committee-Opinions/Committee-
on-Health-Care-for-Underserved-Women/Intimate-Partner-Violence
27. Sandra LM, Harris-Britt A, Li Y, Moracco EK, Kupper LL, Campbell CJ. 
Changes in intimate partner violence during pregnancy. J Fam Viol 
2004; 19: 201-10. 
28. Husso M, Virkki T, Notko M, Holma J, Laitila A, Mäntysaari, M. Making 
sense of domestic violence intervention in professional health care. 
Health Soc Care Community 2012; 20: 347-55. 
29. Virkki T, Husso M, Notko M, Holma J, Laitila A, Mäntysaari M. 
Possibilities for intervention in domestic violence: frame analysis of 
health care professionals’ attitudes. J Soc Serv Res 2015; 41: 6-24. 
30. Furniss K, McCaffrey M, Parnell V, Rovi S. Nurses and barriers to 
screening for intimate partner violence. MCN Am J Matern Child Nurs 
2007; 32: 238-43. 
31. Kopčavar Guček N, Petek D, Švab I, Selič P. Barriers to screening 
and possibilities for active detection of family medicine attendees 
exposed to intimate partner violence. Zdr Varst 2016; 55: 11-20.
32. Zorjan S, Smrke U, Šprah L. The role of attitudes to, and the 
frequency of, domestic violence encounters in the healthcare 
professionals handling of domestic violence cases. Zdr Varst 2017; 
56: 166-71.
KEY FACTORS DETERMINING INDOOR AIR PM10 CONCENTRATIONS 
IN NATURALLY VENTILATED PRIMARY SCHOOLS IN BELGRADE, SERBIA
Branislava MATIC1*, Uros RAKIC1, Verica JOVANOVIC1, Snezana DEJANOVIC1, Nela DJONOVIC2
1Institute of Public Health of Serbia “Dr Milan Jovanovic Batut”, Environmental Health and School Hygiene Department, 
Dr Subotica 5, 11000 Belgrade, Serbia
2University of Kragujevac, School of Medicine, Institute of Public Health of Kragujevac, Serbia
Received: May 31, 2016
Accepted: Jul 27, 2017 
Original scientific article
Introduction. Indoor air quality (IAQ) is rated as a serious public health issue. Knowing children are accounted 
as more vulnerable to environmental health hazards, data are needed on air quality in schools.
Methods. A project was conducted from 2007 until 2009 (SEARCH, School Environment and Respiratory Health 
of Children), aiming to verify links between IAQ and children’s respiratory health. Study was conducted in 
ten primary schools on 735 children, in 44 classrooms. Children were randomly selected. Research tools 
and indicators used for children’s exposure to school environment were indoor and outdoor pollutants, two 
standardized questionnaires for school and classroom characteristics. In both classroom air and ambient air in 
front of them we measured, during a 5-day exposure period for continuous 24h measuring: carbon monoxide, 
carbon dioxide, indoor air temperature, relative humidity, and PM10 during classes. 
Results. PM10 concentrations were significantly most frequent in an interval of ≥80.1µg/m
3, that is, in the 
interval above 50µg/m3. Mean PM10 value was 82.24±42.43 µg/m
3, ranging from 32.00µg/m3 to of 197.00µg/m3.
Conclusion. The increase of outdoor PM10 concentration significantly affects the increase of indoor PM10. A 
statistically significant difference exists for average IAQ PM10 concentrations vs. indicators of indoor thermal 
comfort zone (p<0.0001); they are lower in the classrooms with indicators within the comfort zone. Moreover, 
dominant factors for the increase of PM10 are: high occupancy rate in the classroom (<2m
2 of space per child), 
high relative humidity (>75%), and indoor temperature beyond 23°C, as well as bad ventilation habits (keeping 
windows shut most of the time).
Uvod. Kakovost notranjega zraka (IAQ) predstavlja resen javnozdravstveni problem. Ker so otroci bolj ranljivi 
za okoljska zdravstvena tveganja, so potrebni podatki o kakovosti zraka v šolah.
Metode. Med leti 2007 in 2009 se je izvajal projekt (SEARCH, School environment and respiratory health of 
children – Šolsko okolje in respiratorno zdravje otrok), katerega namen je bil dokazati povezave med IAQ 
in respiratornim zdravjem otrok. Raziskava se je izvajala med 735 otroki v 44 učilnicah desetih osnovnih 
šol. Otroci so bili izbrani naključno. Zunanji in notranji onesnaževalci ter dva standardizirana vprašalnika o 
značilnostih šol in učilnic so služili kot raziskovalna orodja in kazalniki izpostavljenosti otrok šolskemu okolju. 
V zraku pred učilnicami in v njih so v 5-dnevnem neprekinjenem obdobju merjenja merili: ogljikov monoksid, 
ogljikov dioksid, temperaturo notranjega zraka, relativno vlažnost in PM
10
.
Rezultati. Koncentracije PM
10
 so bile pomembneje najpogostejše v intervalu ≥80,1 µg/m3, torej v intervalu 
nad 50 µg/m3. Povprečna vrednost PM
10
 je bila 82,24±42,43 µg/m3 in je segala od 32,00 µg/m3 do 197,00 µg/m3. 
Zaključek. Povečanje koncentracij PM
10
 v zunanjem zraku pomembno vpliva na povečanje PM
10
 v notranjem 
zraku. Pojavljajo se statistično pomembne razlike med koncentracijami PM
10
 IAQ glede na kazalnike območja 
notranjega toplotnega ugodja (p<0,0001); nižje so v učilnicah s kazalniki znotraj območja udobja. Poleg tega 
so glavni vzroki za večje vrednosti PM
10
 sledeči: velika zasedenost učilnice (<2 m2 prostora na učenca), visoka 
relativna vlažnost (>75 %) in temperatura notranjega zraka nad 23 ºC, poleg tega pa tudi slabe prezračevalne 
navade (zaprta okna večino časa).
ABSTRACT
Keywords: 
indoor air quality, 
classrooms, particulate 
matter, PM10, primary 
schools, exposure, 
Serbia
IZVLEČEK
Ključne besede: 
kakovost notranjega 
zraka, učilnice, trdni 
delci, PM
10
, osnovne 
šole, izpostavljenost, 
Srbija 
*Corresponding author: Tel: + 381 641 771 746; E-mail: damjanko98@yahoo.com
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
227
KLJUČNI DEJAVNIKI, KI VPLIVAJO NA KONCENTRACIJO DELCEV PM10 
V NOTRANJEM ZRAKU NARAVNO PREZRAČEVANIH OSNOVNIH ŠOL 
V BEOGRADU V SRBIJI
Matic B, Rakic U, Jovanovic V, Dejanovic S, Djonovic N. Key factors determining indoor air PM10 concentrations in naturally ventilated primary schools in Belgrade, Serbia. 
Zdr Varst 2017; 56(4): 227-235.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
The quality of indoor air of homes, offices, or other public 
or private dwellings could be accounted as one of the 
essential determinants of a healthy life and wellbeing 
of each individual (1). School indoor air quality (IAQ) is 
expected to have a key role in the assessment of children’s 
personal exposure to air pollution, concerning the fact 
that they spend at least a third of their time inside school 
buildings, approximately 7 hours a day (2-5). Children are 
particularly vulnerable to all types of pollutants, because 
their breathing and metabolic rates are high. In a school, 
they have much less floor space than adults working in a 
typical office. Their breathing zone tends to be closer to 
pollutant sources, such as a new carpet, and less likely to 
be well ventilated, as it is below the window level. The 
immune system of young children is yet immature, and 
exposure to pollutants can mean allergic reactions or ill 
health (6). 
Poor indoor environment in schools may be attributed to 
three primary causes: inexistence or inadequate operation 
and maintenance of ventilation systems, infrequent and 
unthoroughly cleaned indoor surfaces, and a large number 
of students in relation to room area and volume, with 
constant re-suspension of particles from the surface (1). 
Furthermore, IAQ can be attributed to various phases of 
the building process, including poor site selection, choice 
of materials, roof design, poor construction quality, 
improper installation, or any number or combination of 
these factors (7). Therefore, it is of utmost importance 
to provide good IAQ in classrooms, to help minimize these 
effects (8, 9). Sources of IA (indoor air) pollution could 
be: furnishings, IT equipment, bio-effluents, and external 
pollutants, such as nitrogen-dioxide and carbon-monoxide 
(3, 10-12). In the indoor environment, in which people 
spend most of their time, both indoor and outdoor sources 
contribute to PM levels. Indoor PM is affected by ambient 
concentrations, air exchange rates, penetration factors, 
as well as deposition and re-suspension mechanisms. 
In this complex microenvironment, activities such as 
cleaning, walking, playing, and, particularly, smoking 
cause the formation of PM in indoor air (13,14).
The main objective of this paper was to study the 
difference of PM10 concentration values, sampled both 
inside classrooms of ten Belgrade primary schools and in 
ambient air in front of them, and relate it to different 
classroom and school characteristics, using SEARCH 
Project methodology. A specific objective was to study 
the difference of concentration of the PM10 measurements 
inside and outside the chosen classrooms. In addition, we 
aimed to correlate a specific quantitative indicator of the 
thermal comfort zone, as given by the ASHRAE Standards 
(4), that is, space occupancy (<2m2 of indoor space per 
child, not suitable), to the measured values of indoor 
PM10. 
2 METHODOLOGY
2.1 Sampling Site Description
The cross-sectional SEARCH (School Environment and 
Respiratory Health in Children) study has involved 6 
European countries (Albania, Bosnia and Herzegovina, 
Hungary, Serbia, Slovakia, and Italy). In Serbia, the 
research was undertaken in the capital city of Belgrade. 
The project has defined that a sample of 10 schools per 
country shall be enough to get a clear picture on the 
level of indoor exposure of children in primary schools. 
They were chosen (sampled) to be with heterogeneous 
characteristics. Primarily, schools were grouped by their 
location, i.e. the level of their exposure to potential 
sources of air pollution in their vicinity (be it traffic or 
industrial facility), as suburb schools, schools in broader 
urban area, and downtown ones, shown in Table 1 
(15). As for the vicinity of busy traffic, it can be easily 
comprehended by consulting the GIS map of their address, 
together with traffic characterisation (Figure 1). The 
criterion for the choice of a classroom was its orientation, 
either towards the street or to the school yard.
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
228
Figure 1. GIS map of 10 schools’ geographic distribution 
on the Belgrade City map  
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
229
windows. Measuring instruments were looked after by the 
teachers (indoor) and authors who were mostly present in 
the school to check upon the equipment. The following 
measurements took place in the chosen classrooms: 
Combination of diffuse sampling during a 4-day exposure 
period for formaldehyde (HCHO), nitrogen dioxide (NO2), 
BTX, and continuous 24h measuring for carbon monoxide 
(CO), carbon dioxide (CO2) and PM10, during school hours. 
Air temperature and relative humidity were measured as 
well. Parallel to these IAQ monitoring activities, outdoor 
air quality was followed for the same specific pollutants, 
close to school building (selected classroom). Besides 
air sampling procedures, the study protocol included 
two standardized questionnaires, namely: for school 
characteristics (filled in by the school administrator); for 
classroom characteristics (filled in by the teacher holding 
classes in it).
2.3 Statistical Methodology
Simple descriptive statistics, such as mean ± standard 
deviation, was used for continuous variables, IAQ and OAQ 
PM10, the number and % of IAQ interval distributions, by 
schools and schools’ position, while numbers (percentages) 
were used for categorical variables. The Kolmogorov–
Smirnov test was used to check if IAQ and OAQ PM10 
Table 1. Characteristics of sampling sites.
“Aca Milosavljevic”
“Kosta Abrašević”
“Nikola Tesla”
“I. G. Kovačić”
“Skadarlija”
“Stevan Sremac”
“Drinka Pavlović”
”Petar Petrović Njegoš”
“Radojka Lakić”
“Ivan Gundulić”
1
2
3
4
5
6
7
8
9
10
44°41’01,10” N
20°26’20,86” E
44°52’20,13” N
20°27’18,7” E
44°42’33,95” N
20°27’06,52” E
44°49’18,19” N
20°24’15,75” E
44°44’30,27” N
20°25’44,89” E
44°48’17,27” N
20°29’01,08” E
44°48’16,20” N
20°27’43,91” E
44°48’21,72” N
20°27’21,81” E
44°49’06,12” N
20°27’49,41” E
44°48’48,32” N
20°27’54,66” E
Suburb Rušanj village, in the valley downhill the regional highway;
Suburb Resnik, residential area, trees in between the street and school
Rakovica, suburban municipality, ex-industrial zone, ordinary urban 
traffic mode
Broad city centre, isolated from dense traffic, residential area;
Downtown, high density traffic, backyard towards pedestrian zone, 
bus stop in front
Borča III, urbanized suburb, with no heavy traffic
Downtown, close to two busy streets, 1 tunnel
Downtown, high traffic density
Squeezed between two streets with high density traffic (lots of heavy 
traffic), downtown, next to the Central Rail Station
New Belgrade, broader urban zone, frequent traffic
School name School code GIS coordinatesSpatial characteristics of the surroundings
2.2 Monitoring Campaign
For both indoor and ambient air PM10 sampling, a portable 
HAZ-DUST EPAM-5000 particulate monitor (Ambient 
Portable Direct Reading Aerosol Monitor for Measuring 
Lung Damaging Airborne Particles) was used. It uses 
light scattering to measure particle concentration and 
provide real-time determinations and data recordings of 
airborne particle concentration in mg/m3. By the model 
specification, its accuracy is ±10% to filter gravimetric SAE 
fine test dust; sensing range: .001-20.0 mg/m3 or optional 
.01-200.0 mg/m3 or 0.1-2000.0 mg/m3; particle size range 
is .1-100 µm, and precision ±.003 mg/m3 (3 µg/m3) (16). 
For indoor air monitoring, it was positioned in classrooms, 
at 1.5 m height, away from the walls, to prevent influence 
of chipping. The monitor was positioned outside of the 
school building, in front of the indicated classroom, for 
ambient air PM10 sampling. Monitoring lasted for one whole 
working week, in both school shifts, while the children 
were present indoors, only. Monitoring lasted for 4 days 
during heating season in February 2008, simultaneously 
with the procedures undertaken in Albania, Bosnia and 
Herzegovina, and Slovakia. During each of the 4 measuring 
days, authors would fill in the checklist of the questionnaire 
for the classrooms, with details on the presence of pupils, 
and conditions concerning natural ventilation through the 
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
230
had a normal distribution. Quantitative variables were 
compared using ANOVA F test, and categorical variables 
were compared using contingency tables and Chi-Square 
or Kruskal Wallis test. Chi-square test was used to 
compare IAQ PM10 between groups – schools or schools’ 
position. For correlations between variables, we used 
Pearson Correlation for the linear relationship between 
two variables, by schools. A P-value less than 0.05 were 
considered statistically significant. 
3 RESULTS 
3.1 Geographic Positions of Schools
Table 2 shows comparative values of IAQ PM10 and OAQ 
PM10 by groups of schools. Both indoor and outdoor PM10 
measured values are significantly higher in suburban 
schools than in those located in the broader urban zone: 
(for PM10 IAQ: K-W test=107.86, p<0.0001; PM10 OAQ: 
K-W test=39.43, p<0.0001). A similar level of significance 
appears when correlating values measured in suburban 
schools, with the values in schools located in the strictly 
urban zone: (K-W test=93.01; p<0.0001), and for PM10 
OAQ, (K-W test=27.74; p<0.0001). 
Table 2.
Table 3.
IAQ and OAQ PM10 concentration related to school’s geographic positions (µg/m3).
Interval distribution IAQ PM10 Concentration >50  or ≤49.9 µg/m3 by schools 
Suburb schools
Schools in broader
urban area
Downtown
Total
Suburb schools
Schools in broader
urban area
Downtown
Total
PM10 
IAQ
PM10 
ranges
PM10 
QAQ
244
220
271
735
244
220
271
735
0.0
100.0
39.7
60.3
0.0
100.0
32.1
67%
57.8
42.2
0.0
100.0
23.4
76.6
67.2
32.8
0.0
100.0
37.8
62.2
≤49.9 µg/m3
>50 µg/m3
109.18
66.08
71.09
82.24
153.90
83.46
77.30
104.57
47.66
37.36
26.90
42.43
130.39
55.77
28.53
89.85
103.17
61.12
67.88
79.17
137.46
76.05
73.89
98.07
115.19
71.05
74.31
85.31
170.34
90.87
80.72
111.08
96/164
53/126
70/79
70/165
116/515
55/168
80/89
82/527
33
32
32
32
34
22
30
22
197
158
111
197
549
190
119
549
Type of schools 
by location
No. of exposed 
children
School 1 School 5School 3 School 7 School 9School 2 School 6School 4 School 8 School 10
Mean SD Median/
Range
Min Max95% Cor Mean
Lower Upper
Indoor PM10 concentrations are significantly lower in schools 
located within a broad urban zone, when correlated to ones 
in a strictly urban zone, i.e.downtown (K-W test=12.943, 
p<0.0001). On the other hand, it does not count in the 
case of outdoor PM10 values (K-W test=2.228, p=0.135). 
PM10 IAQ measured values are significantly highest in 
suburban schools, (K-W test=133.454, p<0.0001), together 
with PM10 OAQ, (K-W test=69.86, p<0.0001).
Among schools, a statistically significant difference is 
proved for the distribution of  IAQ PM10  concentration 
(p<0.0001).  School 4 has significantly higher frequency of 
measured values IAQ PM10 in the range lower than 50 g/m
3. 
On the other hand, schools No. 1, 2, 3 and 8 had highest 
average values, and in all of them each of measured 
indoor concentrations was in the interval beyond 50 µg/
m3 (Table 3).
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
231
Table 4.
Table 5.
IAQ PM10 (µg/m
3) concentration by schools.
Outdoor PM10 (μg/m3) concentration by schools.
Suburban
Broad urban area
Downtown
Suburban
Broad urban area
Downtown
„A.Milosavljevic“
„K. Abrasevic“
„S. Sremac“
„Nikola Tesla“ 
„I. G. Kovacic“
„I. Gundulic“
„Skadarlija“
„D. Pavlovic“
„P.P. Njegos“
„R. Lakic“
„A.Milosavljevic“
„K. Abrasevic“
„S. Sremac“
„Nikola Tesla“ 
„I. G. Kovacic“
„Ivan Gundulic“
„Skadarlija“
„D. Pavlovic“
„P.P. Njegos“
„R. Lakic“
109.16
162.12
62.47
99.70
44.72
50.40
58.24
65.68
103.87
52.31
105.84
320.82
68.27
134.00
80.33
38.33
83.64
69.85
98.00
51.17
105.48
151.97
57.11
89.35
41.53
49.03
54.12
58.26
101.92
49.51
100.46
287.47
60.04
121.43
71.20
36.21
76.88
61.05
94.83
50.31
18.440
41.926
23.592
45.620
12.479
6.224
18.276
26.899
8.523
11.222
26.945
137.797
36.277
55.399
35.626
9.648
30.003
31.935
13.862
3.444
112.84
172.27
67.82
110.06
47.92
51.77
62.36
73.09
105.82
55.12
111.21
354.18
76.51
146.57
89.45
40.45
90.41
78.65
101.17
52.03
105.00
183.00
52.00
72.00
38.00
53.00
70.00
51.00
110.00
44.00
106.00
309.00
41.00
141.00
75.00
42.00
96.00
52.00
101.00
51.00
46.00
106.00
63.00
107.00
30.00
16.00
46.00
63.00
18.00
26.00
78.00
380.00
85.00
135.00
84.00
26.00
87.00
83.00
46.00
9.00
School Groups
School Groups
School 
School 
Median
Median
Range
Range
PM10 (µg/m
3)
PM10 (µg/m
3) OAQ
IAQ Ci 95% 
Ci 95% 
Mean
Mean
Lower
Lower
SD
SD
Upper
Upper
The following Table 4 presents indoor PM10 mean 
concentrations (μg/m3), standard deviation, median 
and range. The maximum concentration values of PM10 
(162.12±41.93 μg/m3) was registered in school No. 2, 
while a significantly lower concentration value of PM10 
(44.72±12.48 μg/m3) was at school 4 (p<0.001), and its 
value is below 50 μg/m3.
Ambient air mean concentration of PM10 (μg/m
3), together 
with standard deviation, median and range by groups and 
schools, is given in Table 5. The maximum concentration 
values of PM10 in ambient air (320.82±137.79 µg/m
3) were 
in front of a suburban school No.2, while significantly lower 
concentration values of PM10 OAQ (38.33±9.65 μg/m
3) were 
outside school 6, located in the broad urban area, slightly 
hidden away from frequent traffic flow (p<0.01), with a 
value below 50 μg/m3. The highest average values of both 
IAQ PM10 and OAQ PM10 concentration are accounted to 
school 2 (suburb schools).
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
232
Descriptive statistical analysis of the data for particulate 
matter mass concentrations (PM10) measured outdoors and 
in the classrooms, by schools is given in Table 6. None 
of the 10 schools satisfies the World Health Organization 
(WHO) standard for PM10 annual average of 20 µg/m
3 
(17, 18). However, they meet the National Ambient Air 
Quality Standards (12) and WHO standards for PM10 24-
hour average, which have been set at 150 µg/m3 and 50 
µg/m3, respectively (19).
Table 7 presents the distribution of the occupancy rate 
(according to ASHRAE) for each school, in m2 per present 
child in the indicated classroom. Values are given as 
the percentage of children exposed to overcrowdedness 
(<2m2/per child), or to convenient spatial conditions 
(>2m2/per child). Indicators of crowdedness are the 
number of children in the classroom (less/more than 20), 
and space available in the classroom, per one child, of 
less/more than 2m2 (4). Statistically significance is proven 
for the distribution of occupancy rate (m2/per child), for 
each school, χ2=340.70, p<0.0001.
Table 6.
Table 7.
Correlations between IAQ and OAQ by school (signif.)
Child occupancy rate per school distribution (m2/per child) vs. PM10 values (µg/m
3), by schools.
„A.Milosavljevic“
„K.Abrasevic”
„N.Tesla”
„I.G.Kovacic”
„Skadarlija”
„S.Sremac”
„D.Pavlovic”
„P.P.Njegos”
„R.Lakic”
„I.Gundulic”
„A.Milosavljevic“
„K.Abrasevic”
„N.Tesla”
„I.G.Kovacic”
„Skadarlija”
„S.Sremac”
„D.Pavlovic”
„P.P.Njegos”
„R.Lakic”
„I.Gundulic”
1
2
3
4
5
6
7
8
9
10
106.00
309.00
141.00
75.00
96.00
41.00
52.00
101.00
51.00
42.00
105.00
183.00
72.00
38.00
70.00
52.00
51.00
110.00
44.00
53.00
0.799
0.756
0.457
0.956
0.598
0.744
0.937
0.725
0.160
0.453
77.8
/
/
16.4
38.6
/
/
47.4
/
/
22.2
100
100
83.6
61.4
100
100
52.6
100
100
109.16
162.12
99.70
44.72
58.24
62.47
65.68
103.87
52.31
50.40
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.207
0.000
99
68
77
61
78
77
53
76
65
82
School
School nameSchool 
No.
PM10 outdoor median 
(µg/m3)
PM10 indoor median 
(µg/m3) R
<2 m2/child >2 m2/child IAQ PM10 mean
P N
4 DISCUSSION
As an outcome of our study, when differentiating between 
OAQ PM10 and IAQ PM10 concentration values in relation 
to some classroom and school characteristics, we singled 
out the following moments: the highest average values of 
IAQ PM10 and OAQ PM10 concentration were measured in 
the school No. 2 (suburb school), while only in one school 
measured values IAQ PM10 were below 50 µg/m3, that is 
in the school No. 4. The school No. 10, located in New 
Belgrade, in a broader urban zone with frequent traffic, 
had PM10 outdoor mean value below 50 µg/m3, which 
could be explained with the terrain’s topography. New 
Belgrade is, in geographical means, a flat terrain, with 
broad boulevards and widely spread buildings, belonging 
to the geographical entity of the Pannonian plain, enabling 
the build-up of high ambient air concentrations of traffic-
related pollutants. This particular school is located in a 
residential block, built in the 1960s. School building is 
encircled by greenery and residential buildings, acting as 
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
233
a physical barrier to three streets with very busy traffic, of 
which one is the E-75 highway. It was, moreover, reported 
by the City of Belgrade Institute of Public Health, that 
in 2008, a series of days in a row were characterized 
with SE (south-east) wind (‘Košava’), with episodes of 
wind speed reaching 12m/s, which caused a decrease of 
concentration of all ambient air pollutants measured by 
this institution (20).
A statistically significant correlation exists between 
PM10 indoor and outdoor concentration for each school 
(p<0.0001), except for the school No. 9, ‘Radojka Lakic’ 
(p=0.207), although it is located in a strictly urban zone, 
close to the juncture of two streets with very busy traffic. 
The increase of outdoor PM10 concentration is significantly 
correlated to the increase of indoor PM10 values (except 
for the school No. 9).
Considering this school, located close to the heavy traffic 
and Central rail station, with no statistical significance 
between indoor and outdoor measurement, we can 
conclude that, in this case, indoor concentration could 
be influenced by activities and movements of occupants, 
allowing re-suspension of previously deposited particles or 
their delayed deposition or settling. Fromme et al. found 
an average indoor particulate matter concentration higher 
than corresponding outdoor level in a German primary 
school (21). Similar was confirmed in a Belgian survey (22). 
Oeder et al. detected indoor PM10 concentration even 
5-fold higher than outdoor ones in six schools in Munich 
(23). In addition, the presence of children, together with 
their movements, could affect indoor PM levels through 
the interception of personal clouds (primarily comprising 
of course particles), recorded by sampling devices (1).
In the school No. 1, which is both in the suburb and 
has all its measured values of IAQ PM10 beyond 50 µg/
m3, with an average PM10 IAQ of 109.16±18.44 µg/m3, 
a significantly higher number of children is exposed to 
classroom indoor environment in a space with less than 
2 m2 per child. Concerning the fact that there is no busy 
traffic close to the school, high occupancy rate, together 
with bad ventilation habits and cleaning practice could 
be the reason for such results. This may be due to large 
number of students in relation to the room area and 
volume, whose movements cause re-suspension of settled 
particles (24). 
In the school No. 8, 47.4% of its pupils have less than 2 
m2 per child, while all measured IAQ PM10 were above 
50 µg/m3, in which case the high occupancy rate could 
be accounted for one of the reasons for it. Some authors 
have determined that re-suspension is a significant factor 
affecting indoor particle concentration with suspension 
rates increasing with the particle size (25).
The school No. 4 is worth mentioning, with only its 16.4% 
pupils residing in the space with <2 m2 per child, located 
in a broad urban zone of the city. IAQ PM10 values were 
below 50 µg/m3, with the average PM10 IAQ concentration 
being the lowest compared to other schools, 44.72±12.48 
µg/m3. 
On the contrary, the school No. 3 has 100% PM10 IAQ 
measurements in space with >2 m2 per child, located in a 
broader urban zone, with all measured values of IAQ PM10 
beyond 50 µg/m3. The average indoor PM10 concentration 
in it is 99.70±45.62 µg/m3. This school is cleaned mostly 
with the broom, and combined with the use of chemicals. 
This cleaning practice, being predominant as a cleaning 
pattern in this school, obviously facilitates the process of 
particle re-suspension (24).
As one of the defined elements of the thermal comfort 
zone, occupancy rate was chosen to be one of the 
key indicators in this study, together with CO2 indoor 
concentration, relative humidity, and classroom air 
temperature. Statistically significant smaller chances 
exist for formaldehyde indoor concentrations to be below 
1.01 mg/m3 in classrooms with more than 2 m2 of space 
per child. For indoor CO2 concentration to increase above 
1000 ppm, the number of children in the classroom above 
20 (N>20) is a statistically significant predictor. Namely, 
chances for CO2 concentrations to be higher than 1000 
ppm are 3.6-fold bigger in classrooms hosting more than 
20 children. For indoor (classroom) air temperature 
within a comfort zone, a statistically significant predictor 
is classroom crowdedness, i.e. space in square meters 
per child. In fact, chances for indoor temperature to 
be within the comfort zone are less likely to occur in 
classrooms with less than 2 m2 of space per child (4). 
For indoor values of relative air humidity, a statistically 
significant predictor is classroom crowdedness, i.e. space 
in square meters per child. In other words,, chances for 
this parameter to be within the comfort zone are close to 
18-fold higher in classrooms hosting less than 20 children.
Chances for PM10 to be below 50µg/m3 are smaller, with 
high statistical significance, in classrooms hosting more 
than 20 children, having a blackboard, with chalk to write 
on.
The average indoor PM10 concentrations are lower in 
the classrooms where indicators of thermal comfort zone 
are satisfactory. In the school No. 4, the average indoor 
PM10 concentration is lower in classrooms with achieved 
standards for indoor comfort zone indicators, with high 
statistical significance Z - test=6.540, p<0.0001, while 
in the schools No. 5 (Z=0.105, p=0.916), No. 8 (Z=1.614, 
p=0.107) and No. 10 (Z=0.948, p=0.343) it is lower, but 
with no such high significance. Significantly highest 
mean values of IAQ PM10 concentration was measured in 
the schools 1, 2, 3 and 8, where comfort zone was not 
achieved (p<0.001). 
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
234
Values of classroom indoor PM10 concentrations, from 
measurements in similar studies in different countries, 
during the heating season, are close to the values reported 
in this study in Serbia: in three schools in Portugal, PM10 
average concentrations ranged from 30 to 146 µg/m3; in a 
German study implemented in 64 urban and rural schools, 
it was 105 µg/m3 (16.3-313.2 µg/m3), while in HESE study, 
IAQ was monitored in 21 schools, both urban and rural, 
with the average PM10 concentration 112 µg/m3 (91-133 
µg/m3) (1, 10, 26). 
In most of the SEARCH1 countries, ambient PM10 
concentrations were significantly increased in school 
zones close to frequent traffic streets, compared to those 
located further from such sources of air pollution. On the 
other hand, this difference in the traffic frequency of 
streets surrounding schools, has not significantly influence 
IAQ PM10 concentrations measured in classrooms, pointing 
that key sources of this pollutant are mainly in classrooms 
themselves (15). In the case of Belgrade study, as a part 
of the mentioned research, 36.2% of pupils study in 
classrooms with I/О PM10 ratio beyond 1.0, where the key 
source of PM10 is within the room; 3.7% is in classrooms 
with the ratio equal to 1.0., while 60.1% attend classes 
in rooms with the ratio below 1.0, where the source of a 
particulate matter is in ambient air, mostly from traffic in 
the vicinity of school buildings.
Although the city is located close to two coal burning 
power plants (Obrenovac, Kolubara), traffic is seen as the 
most powerful source of air pollution. Air back trajectories 
analysis showed that the prevalence of stagnant or week 
flow regimes (calm conditions) favours the suspension and 
accumulation of particles produced locally, resulting at 
the elevation of suspended particles levels (20, 27). 
If we compare the location of Belgrade, on the banks of 
Sava River, with another region on its banks in Zasavje 
Region in Slovenia, with PM10 ambient air concentration, 
we spot some differences. Firstly, it is an issue of 
topography, as Zasavje is surrounded by steep hilly 
terrain, while Belgrade spreads in parts of the Pannonian 
Plain. Secondly, sources of air pollution are different in 
these two cases. In Zasavje, it is the case of industrial 
PM10 emissions (36.3µg/m3), while in SEARCH1 Belgrade 
study, traffic was attributed as the key source for high 
PM10 levels (104.7 µg/m3) (15, 28).
5 CONCLUSIONS
The majority of surveyed children is exposed to high indoor 
PM10 concentrations (560/735; 76.2%). Maximum PM10 
values were measured in suburban schools, away from 
busy traffic. The increase of outdoor PM10 concentration 
significantly affects the increase of indoor PM10 values. 
Concerning an insufficient achievement of standards for 
indicators of indoor thermal comfort zone, dominant 
factors for the increase of PM10 are: high occupancy rate 
in the classrooms (<2 m2 of space per child), high relative 
humidity (>75%) and indoor temperature beyond 23ºC; 
bad ventilation habits (keeping windows shut most of the 
time). 
As the authors suggest, measures for the improvement 
of conditions in classrooms are as follows: schools should 
be built in places not directly affected by heavy traffic 
or industry, or any other polluting establishments in 
the neighbourhood; crowdedness should be avoided in 
the classrooms; appropriate ventilation regime of the 
classrooms should be introduced in order to provide good 
indoor air quality during the whole period of teaching 
hours, especially in classrooms directed towards crowded 
streets with presumably high ambient air pollution; in 
schools being ventilated only through natural means, but 
located close to traffic-induced air pollution, installing 
air-conditioning units should be taken into consideration. 
Cleaning practices should be standardized.
ACKNOWLEDGMENTS
The financial support for the SEARCH project by the 
Italian Ministry for the Environment, Land and Sea is 
highly appreciated by the authors.
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
Italian Ministry for the Environment, Land and Sea.
ETHICAL APPROVAL
In the case of the Republic of Serbia, if there is no 
direct contact with body fluids, tissues, personal contact 
concerning individual dignity, through questionnaires, 
researchers are not required to apply for the permission 
to research at the Ethical Committee. This study was not 
implemented on individual subjects, but was concerned 
only with the positioning of the standardized air quality 
measuring equipment in the classrooms and outside the 
same classrooms, for which, the REC project office had 
direct communication with school directors. Especially, 
when the moment of the equipment turning on/off was 
performed while classrooms were empty, with no physical 
contact with the pupils whatsoever.
10.1515/sjph-2017-0031 Zdr Varst 2017; 56(4): 227-235
235
REFERENCES 
1. Almeida SM, Canha N, Silva A, Freitas MC, Pegas P, Alves C et al. 
Children exposure to air particulate matter in indoor of Lisbon 
primary schools. Atmos Environ 2011; 45: 7594–9.
2. Annesi-Maesano I, Hulin M, Lavaud F,  Raherison C, Kopferschmitt C, 
de Blay F et al.  Poor air quality in classrooms related to asthma and 
rhinitis in primary schoolchildren of the French 6 cities study. Thorax 
2012; 67: 682-8.
3. Annesi-Maesano I, Moreau D, Cailland D, Lavaud F, Le Moullec Y, 
Taytard A et al. Residential proximity fine particles related to 
allergic sensitations and asthma in primary school children. Respir 
Med. 2007; 101: 1721-9.
4. ASHRAE Standard 55-2004. Thermal environmental conditions 
for human occupancy. Washington: American Society of Heating, 
Refrigerating and Air-Conditioning Engineers, 2004. https://www.
ashrae.org/.../20080623_55_2004_a_b_final.pdf 
5. Bako-Biro Z, Wargocki P, Weschler CJ, Fanger PO. Effects of pollution 
from personal computers on perceived air quality, SBS symptoms and 
productivity in offices. Indoor Air 2004; 14: 178-87.
6. Bakó-Biró Z, Clements-Croome DJ, Kochhar N, Awbi HB, Williams 
MJ. Ventilation rates in schools and pupils´ performance. Building 
Environm 2012; 48: 215-23.
7. “California Portable Classroom Study Project Executive Summary”, 
Research Triangle Institute International; California Air Resources 
Board & California Department of Health Services https://www.arb.
ca.gov/research/indoor/pcs/pcs-fr/pcs-fr_v3_pes.pdf 
8. Chaloulakou A, Mavroidis I. Comparison of indoor and outdoor 
concentration of CO at a public school: evaluation of an indoor air 
quality model. Atmos Environ 2002; 36: 1769-81. 
9. Estoková A, Stevulová N, Kubincová L. Particulate matter 
investigation in indoor environment. Global NEST J 2010; 12: 20-6.
10. Fromme H, Twardella D, Dietrich S, Heitmann D, Schierl R, Liebl B et 
al. Particulate matter in the indoor air of classrooms - exploratory 
results from Munich and surrounding. Atmos Environ 2007; 41: 854-
66.
11. Janssen NAH, Hoek G, Brunekreef B, Harssema H. Mass concentration 
and elemental composition of PM10 in classrooms. Occup Environ 
Med 1999; 56: 482-7.
12. Esworthy R. The National Ambient Air Quality Standards (NAAQS) for 
Particulate Matter (PM): EPA’s 2006 Revisions and Associated Issues 
National Ambient Air Quality Standards (NAAQS). Congressional 
Research Service; 7-5700 2013: 4  https://fas.org/sgp/crs/misc/
RL34762.pdf 
13. Pegas PN, Evtyugina MG, Alves CA, Nunes T, Cerqueira M, Franchi 
M et al. Outdoor/indoor air quality in primary schools in Lisbon: a 
preliminary study. Química Nova 2010; 33: 1145-9. 
14. Seppanen OA, Fisk WJ, Mendell MJ. Association of ventilation 
rates and CO2 concentrations with health and other response in 
commercial and institutional buildings. Indoor Air 1999; 9: 226-52.
15. Csobod E, Rudnai P, Vaskovi E. School Environment and Respiratory 
Health in Children (SEARCH),  International research project report 
within the programme “Indoor air quality in European schools: 
preventing and reducing respiratory diseases”.  Available from: 
http://search.rec.org/search1/doc/SEARCH%20publication_EN_
final.pdf 
16. Model EPAM-5000 HAZ-DUST (Ambient Portable Direct Reading 
Aerosol Monitor for Measuring Lung Damaging Airborne Particles). 
http://www.skcinc.com/catalog/pdf/instructions/SKC%20EPAM-
5000%20Instruction%20Manual%20PDF.pdf 
17. World Health Organization. Declaration of the Fourth Ministerial 
Conference on Environment and Health, Budapest, Hungary, 23-25 
June 2004, EUR/04/5046267/6: 7-8. http://www.euro.who.int/__
data/assets/pdf_file/0008/88577/E83335.pdf 
18. World Health Organization, Regional Office for Europe.  Air quality 
guidelines for particulate matter, ozone, nitrogen dioxide, and sulfur 
dioxide, Global update, 2005: summary of risk assessment”, WHO/
SDE/PHE/OEH/06.02. http://whqlibdoc.who.int/hq/2006/WHO_
SDE_PHE_OEH_06.02_eng.pdf
19. World Health Organization, Regional Office for Europe: WHO 
guidelines for indoor air quality: selected pollutants. 2010. http://
jrc.ec.europa.eu/radpar/docview.cfm?docid 
20. Kvalitet životne sredine grada Beograda u 2008. godini.  Beograd: 
Sekretarijat za zaštitu životne sredine, Gradski zavod za javno 
zdravlje, Regionalni centar za životnu sredinu za Centralnu i Istočnu 
Evropu (REC). http://www.zdravlje.org.rs/publikacije/Zivotna%20
sredina%20Bgd%202008.pdf 
21. Fromme H, Diemer J, Dietrich S, Cyrys J, Heinrich J, Lang W et al. 
Chemical and morphological properties of particulate matter (PM10, 
PM2.5) in school classrooms and outdoor air. Atmos Environ 2008; 
42: 6597-605.
22. Stranger M, Potgieter-Vermaak SS, Van Grieken R. Characterization 
of indoor air quality in primary schools in Antwerp, Belgium. Indoor 
Air 2008; 18: 454-63. 
23. Oeder S, Dietrich S, Weichenmeier I, Schober W, Pusch G, Jörres RA 
et al. Toxicity and elemental composition of particulate matter from 
outdoor and indoor air of elementary schools in Munich, Germany. 
Indoor Air 2012; 22: 148-58.
24. Rovelli S, Cattaneo A, Nuzzi CP, Spinazze A, Piazza S, Carrer P et al. 
Airborne particulate matter in school classrooms of northern Italy. 
Int J Environ Res Public Health 2014; 11: 1398-421
25. Thatcher TL, Layton DW. Deposition, resuspension, and penetration 
of particles within a residence. Atmos Environ 1995; 29: 1487-97.
26. Simoni M, Annesi-Maesano I, Sigsgaard T, Norback D, Wieslander G, 
Nystad W et al. Relationships between school indoor environment 
and respiratory health in children of five European countries (HESE 
study). Eur Respir J 2012; 40(Supp 56): 1370.
27. Tasic M, Rajsic S, Tomasevic M, Mijic Z, Anicic M, Novakovic V et 
al. Assessment of air quality in an urban area of Belgrade, Serbia, 
Environmental Technologies, E. Burcu Ozkaraova Gungor (Ed.). 
2008. InTech, Available from: http://www.intechopen.com/books/
environmental_technologies/assessment_of_air_quality_in_an_
urban_area_of_belgrade__serbia  
28. Kukec A, Erzen I, Farkas J, Zaletel Kragel L. Impact of air pollution 
with PM10 on primary health care consultations for respiratory 
diseases in children in Zasavje, Slovenia: a time-trend study.  Zdr 
Varst 2014; 53: 55-68.
CLINICAL PROFILE AND MANAGEMENT OF PATIENTS WITH INCIDENT 
AND RECURRENT ACUTE MYOCARDIAL INFARCTION IN ALBANIA – 
A CALL FOR MORE FOCUS ON PREVENTION STRATEGIES
Sokol MYFTIU1, Enxhela SULO2,  Genc BURAZERI3, Bledar DAKA4, Ilir SHARKA1, 
Artan SHKOZA5, Gerhard SULO2*
1Department of Cardiology, University Hospital “Mother Teresa”, Tirana, Albania
2University of Bergen, Faculty of Medicine and Dentistry, Department of Global Public Health and Primary Care, 
Kalfarveien 31, Bergen 5018, Norway
3Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, 
Department of International Health, The Netherlands  
4University of Gothenburg, Department of Public Health and Community Medicine, Gothenburg, Sweden
5University of Medicine, Faculty of Medicine, Tirana, Albania
Received: Nov 29, 2016
Accepted: Aug 7, 2017 
Original scientific article
Background. The clinical profile of acute myocardial infarction (AMI) patients reflects the burden of risk factors in 
the general population. Differences between incident (first) and recurrent (repeated) events and their impact on 
treatment are poorly described. We studied potential differences in the clinical profile and in-hospital treatment 
between patients hospitalised with an incident and recurrent AMI. 
Methods. A total of 324 patients admitted in the Coronary Care Unit of ‘Mother Teresa’ hospital, Tirana, Albania 
(2013-2014), were included in the study. Information on AMI type, complications and risk factors was obtained from 
patient’s medical file.
Logistic regression analyses were used to explore differences between the incident and recurrent AMIs regarding 
clinical profile and in-hospital treatment. 
Results. Of all patients, 50 (15.4%) had a prior AMI. Compared to incident cases, recurrent cases were older (P=0.01), 
more often women (P=0.01), less educated (P=0.01), and smoked less (P=0.03). Recurrent cases experienced more 
often heart failure (HF) (OR=2.48; 95% CI: 1.31–4.70), impaired left ventricular ejection fraction (OR=1.97; 95% CI: 
1.05–3.71), and multivessel disease (OR=6.32; 95% CI: 1.43–28.03) than incident cases. In-hospital use of beta-blockers 
was less frequent among recurrent compared to incident cases (OR=0.45; 95% CI: 0.24–0.85), while no statistically 
significant differences between groups were observed regarding angiotensin-converting enzyme inhibitor/angiotensin 
receptor blocker, statin, aspirin or invasive procedures. 
Conclusion. A more severe clinical expression of the disease and underutilisation of treatment among recurrent AMIs 
are likely to explain their poorer prognosis compared to incident AMIs. 
Ozadje. Klinični profil pacientov z akutnim miokardnim infarktom (AMI) odraža breme dejavnikov tveganja v splošni 
populaciji. Razlike med prvim in ponovnimi pojavi in njihovim vplivom na zdravljenje so slabo opisani. Raziskali 
smo morebitne razlike v kliničnem profilu in bolnišničnim zdravljenjem pri pacientih s prvim pojavom AMI in tistih 
s ponovnim pojavom.
Metode. V raziskavo je bilo skupno vključenih 324 pacientov, ki so bili v letih 2013-2014 sprejeti na Enoto za 
koronarno nego bolnišnice Matere Terezije v Tirani v Albaniji. Iz kartotek pacientov so pridobili podatke o vrsti AMI, 
zapletih in dejavnikih tveganja.
Za ugotavljanje razlik med prvimi in ponovnimi AMI so bile uporabljene analize logistične regresije z upoštevanjem 
kliničnega profila in bolnišničnega zdravljenja.
Rezultati. Med vsemi pacienti jih je 50 (15,4%) že enkrat doživelo AMI. V primerjavi s pacienti s prvim pojavom so 
bili tisti s ponovnimi pojavi starejši (P=0,01), pogosteje so bile to ženske (P=0,01), imeli so nižjo izobrazbo (P=0,01) 
in so manj kadili (P=0,03). Pacienti s ponovnimi pojavi so v primerjavi s pacienti s prvim pojavom pogosteje izkusili 
odpoved srca (OR=2,48; 95% CI: 1,31–4,70), oslabljeno izmetno frakcijo levega prekata (OR=1,97; 95% CI: 1,05–3,71) 
in multivaskularno bolezen (OR=6,32; 95% CI: 1,43–28,03). Uporaba beta-blokatorjev v bolnišnični obravnavi je bila 
manj pogosta pri pacientih s ponovnim pojavom v primerjavi s pacienti s prvim pojavom AMI (OR=0,45; 95% CI: 
0,24–0,85), medtem ko ni bilo opaziti statistično pomembnih razlik v zvezi z uporabo zaviralcev angiotenzinske 
konvertaze/blokatorjev receptorjev angiotenzina, statinov, aspirina ali invazivnih postopkov.    
Zaključek. Resnejša klinična slika bolezni in manjša poraba zdravil med pacienti s ponovnim pojavom AMI tako lahko 
razložita njihovo slabšo prognozo v primerjavi s pacienti s prvim pojavom AMI.
ABSTRACT
Keywords: 
acute myocardial 
infarction, 
epidemiology, 
in-hospital 
treatment, 
prevention, 
Albania
IZVLEČEK
Ključne besede: 
akutni miokardni 
infarkt, 
epidemiologija, 
bolnišnično 
zdravljenje, 
preventiva, 
Albanija
*Corresponding author: Tel: + 479 3 897 901; E-mail: gerhard.sulo@uib.no
10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243
KLINIČNI PROFIL IN ZDRAVLJENJE PACIENTOV S PRVIM IN PONOVNIM 
POJAVOM AKUTNEGA MIOKARDNEGA INFARKTA V ALBANIJI – 
POZIV ZA VEČJO POZORNOST NA PODROČJU PREVENTIVNIH STRATEGIJ
Myftiu S, Sulo E,  Burazeri G, Daka B, Sharka I, Shkoza A, Sulo G. Clinical profile and management of patients with incident and recurrent acute myocardial infarction in 
Albania – a call for more focus on prevention strategies. Zdr Varst 2017; 56(4): 236-243.
236
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 BACKGROUND
Acute myocardial infarction (AMI) is the most serious 
clinical expression of coronary heart disease (CHD). The 
substantial reduction in mortality following an incident 
(first) AMI (1-4), combined with aging of the population 
has led to a growing number of AMI survivors who are 
at risk of experiencing a recurrent (repeated) event. 
Although recurrent events account for the minority of 
all AMI-related hospitalisations (5, 6), their prognosis is 
poor (7-9), contributing thus substantially to the overall 
cardiovascular mortality. 
Incident events reflect the burden of coronary risk factors 
in the population at large (10), whereas recurrences are 
further influenced by the quality of coronary care during 
the acute phase of the incident event and secondary 
prevention (11). 
In Albania, CHD death rates are among the highest in the 
Southeast Europe (12). The burden of CHD (both mortality 
and hospitalisations) has increased in the last decades 
(13), rendering it the main cause of premature mortality 
in Albania (14). Simultaneously, the prevalence of classical 
coronary risk factors in the population is high. A health 
survey conducted in 2001 in Tirana, reported that among 
1120 participants aged 25 years or older, the prevalence 
of obesity, diabetes mellitus (DM), hypertension and 
smoking (current) was 29% (15), (9.7%) (16), 31.8% (17) 
and 28% (18), respectively. Later reports confirmed the 
high burden of these risk factors; the prevalence of 
hypertension and obesity (in 2008) and smoking (in 2011) 
were 36.5%, 21.6% and 26% (19), respectively. Despite 
these unfavourable developments, the difficult transition 
from a totalitarian communist regime toward a free, 
marked-oriented economy in Albania was characterised 
by the lack of sufficient resources allocated to health 
care (20). As a consequence, preventive strategies have 
not been considered a priority. No structured national 
or regional primary prevention strategies have been 
applied at the population at large, despite their proven 
role in reducing CHD burden (21). Further, no structured 
rehabilitation programmes are available to coronary 
patients, and secondary prevention is confined to medical 
advice provided by specialists upon hospital discharge 
and, occasionally, during check-ups at the family doctor’s 
office. The consequences of such lack of preventive 
strategies on the clinical profile of AMI patients and their 
management are not studied in Albania, and are poorly 
described elsewhere. 
Thus, the objective of the current study was to explore 
the clinical profile and in-hospital treatment of patients 
hospitalized with an AMI, with a special focus on the 
differences between patients with and without history of 
prior AMI.
2. SUBJECTS AND METHODS
2.1 Study Population
This study included 324 consecutive patients hospitalized 
during 2013-2014, with an AMI in the Coronary Care Unit 
(CCU) of the University Hospital Centre ‘Mother Teresa’,’ 
the only public hospital providing specialized coronary 
care in Tirana, the capital of Albania.
2.2 Data Collection
Information on patients’ age, gender, educational 
attainment, height and weight, systolic and diastolic blood 
pressure, AMI type [ST-elevation myocardial infarction 
(STEMI) versus non-ST-elevation myocardial infarction 
(NSTEMI)], location, major complications [including heart 
failure (HF), ventricular fibrillation (VF) and 2nd or 3rd 
degree atrioventricular block (AVB)], and in-hospital 
treatment was obtained from patients’ medical charts. 
To derive the prevalence of each major risk factor, we 
combined self-reported information on risk factors 
and medication use prior to hospitalisation with blood 
pressure, fasting glucose, and total cholesterol values 
measured during admission (22). A history of prior AMI was 
defined as a previous hospitalisation with AMI as the main 
discharge diagnosis. 
2.3 Statistical Analyses
Continuous variables were presented as means and 
standard deviations (SD), and categorical variables were 
presented as percentages. Independent sample t-test was 
used to compare mean values of the continuous variables. 
Categorical variables were compared using the chi-square 
test or Fisher’s exact test in cases of small sample sizes. 
Logistic regression models were used to explore 
differences between incident and recurrent cases 
regarding AMI complications and in-hospital treatment. 
They were adjusted for covariates known to influence 
the outcome, and showed association with the exposure 
in our data. To account for the role of comorbidities in 
a potentially influencing use of beta-blockers [chronic 
obstructive pulmonary disease (COPD), systolic blood 
pressure (SBP)<85 mm Hg or AVB], angiotensin-converting 
enzyme inhibitors (ACEI)/angiotensin receptor blockers 
(ARB) (SBP<85 mm Hg) and aspirin (peptic ulcer), we 
repeated the analyses after excluding patients with any of 
these conditions. The results of these analyses (referred 
to in the text as ‘additional analyses’) are presented as 
supplemental material online. 
We tested and did not find a statistically significant 
interaction between gender and history of prior AMI. All 
models were adjusted for age and gender, and results 
expressed as odds ratios (OR) and 95% confidence 
intervals (CI) for prevalent versus incident (the reference 
10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243
237
10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243
238
category) AMIs. Two-sided tests with the 0.05 significance 
level were used. Analyses were performed using STATA 
software, version 13. 
3. RESULTS
3.1 Characteristics of the Study Population
Characteristics of the study population are summarized in 
Table 1. The mean (SD) age of the cohort was 64.4 (11.4) 
years and the majority (73.8%) were men. Overall, 44.1% 
of patients had attained only primary education and 55.9% 
secondary or tertiary education. 
The prevalence of current smoking, hypertension, 
diabetes mellitus (DM), and hypercholesterolemia was 
59.9%, 83.3%, 50.6% and 55.3%, respectively. At least 
one major risk factor was observed in 98.8%, and all four 
major risk factors in 13.9% of the study cohort.
Table 1. Characteristics of the study population.
COPD: chronic obstructive pulmonary disease; eGFR: estimated glomerular filtration rate.
* 4% of patients had missing values
Incident cases were younger (P=0.01), more often men (P=0.01), and had attained a higher education (P=0.01) than recurrent cases. No 
statistically significant differences between groups were observed regarding hypertension, DM, and hypercholesterolemia. Smoking was more 
frequent among the incident cases (P=0.03). 
Age (years), mean (SD)
Gender (male), n (%)
Education, n (%)
 Primary
 Secondary or higher
Coronary risk factors, n (%)
 Smoking
 Hypertension
 Diabetes
 Hypercholesterolemia
 At least one risk factor 
 All four risk factors
Comorbidities, n (%)
 Atrial fibrillation
 Peripheral artery disease
 Cerebrovascular disease
 COPD
 eGFR<60 mL/min/1.73m2
 Peptic ulcer
Pulse (beats/min), mean (SD)
Hemoglobin* (g/dl), mean (SD)
64.4 (11.4)
239 (73.8)
143 (44.1)
181 (55.9)
194 (59.9)
270 (83.3)
164 (50.6)
179 (55.3)
320 (98.8)
45 (13.9)
39 (12.1)
23 (7.1)
25 (7.4)
17 (5.3)
77 (23.8)
23 (7.1)
78 (16.8)
12.8 (1.9)
63.7 (11.5)
210 (76.6)
113 (41.2)
161 (58.8)
171 (62.4)
229 (83.6)
135 (49.3)
149 (54.4)
270 (98.5)
39 (14.2)
26 (9.4)
20 (7.2)
19 (6.9)
14 (5.1)
59 (21.5)
19 (6.9)
77 (16.5)
12.9 (1.8)
68.4 (10.1)
29 (58.0)
30 (60.0)
20 (40.0)
23 (46.0)
41 (82.0)
29 (58.0)
30 (60.0)
50 (100.0)
6 (12.0)
13 (27.7)
3 (6.4)
6 (12.8)
3 (6.4)
18 (36.0)
4 (8.0)
80 (18.5)
11.9 (1.9)
0.01
0.01
0.01
0.03
0.78
0.26
0.46
0.39
0.63
<0.01
0.84
0.16
0.71
0.03
0.79
0.37
<0.01
Patient 
characteristics
All patients
(n=324)
Incident 
cases (n=274)
Recurrent 
cases (n=50)
P value
3.2 The Clinical Profile of Patients
STEMI accounted for 83.9% of the study population (Table 
2). AMI was complicated with HF in 33.6% of the patients. 
The proportion of impaired LVEF, 2nd or 3rd degree AVB 
or VF in the study population were 31.2%, 4.0% and 4.9%, 
respectively. Compared to incident cases, recurrent cases 
had multivessel CHD (P=0.03), HF (P<0.01), or impaired 
LVEF (P=0.01) (Table 2).
Table 2.
Figure 1.
Clinical profile and in-hospital treatment of patients with an acute myocardial infarction. 
Differences in the clinical profile between patients 
hospitalized with an incident and recurrent acute 
myocardial infarction.
STEMI: ST-segment elevation myocardial infarction; CAD: coronary artery disease; LVEF: left ventricular ejection fraction; AVB: 
atrioventricular block; VF: ventricular fibrillation; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker.
* Percutaneous coronary intervention or coronary artery bypass grafting among patients
undergoing coronary angiography.
STEMI, n (%)
Multivessel CAD, n (%)
Heart failure, n (%)
LVEF<0.45, n (%)
AVB (2nd/3rd degree), n (%)
VF, n (%)
Beta-blockers
ACEI/ARBs
Statins
Aspirin
All four drug classes
Invasive procedures
 Coronary angiography
 Revascularization*
271 (83.9)
164 (75.9)
109 (33.6)
101 (31.2)
13 (4.0)
16 (4.9)
 
192 (59.3)
206 (63.6)
314 (96.9)
308 (95.1)
144 (44.4)
222 (68.5)
139 (64.4)
230 (84.3)
136 (73.1)
81 (29.6)
77 (28.1)
10 (3.7)
11 (4.0)
172 (62.8)
179 (65.3)
268 (97.8)
261 (95.3)
128 (46.7)
192 (70.1)
122 (65.6)
41 (82.0)
28 (93.3)
28 (56.0)
24 (48.0)
3 (6.0)
5 (10.0)
20 (40.0)
27 (54.0)
46 (92.0)
47 (94.0)
16 (32.0)
30 (60.0)
17 (56.7)
0.69
0.03
<0.01
0.01
0.44
0.07
0.01
0.12
0.05
0.71
0.05
0.16
0.34
All patients
(n=324)
Clinical profile
In-hospital treatment
Incident 
cases (n=274)
Recurrent 
cases (n=50)
P value
10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243
239
The results of age and gender-adjusted analyses revealed 
an increase in the odds of HF (OR=2.48; 95% CI: 1.31–4.70), 
impaired LVEF (OR=1.97; 95% CI: 1.05–3.71), or multivessel 
CAD (OR=6.32; 95% CI: 1.43–28.03) among recurrent cases 
compared to incident ones. No statistically significant 
differences were observed between groups regarding AMI 
type and other complications (Figure 1).
3.3 In-Hospital Treatment
The utilisation rates for beta-blockers, angiotensin-
converting enzyme inhibitors (ACEIs)/angiotensin 
receptor blockers (ARBs), statins, and aspirin were 59.3%, 
63.6%, 96.9%, and 95.1%, respectively (Table 2). 
Less than half (44.4%) of the study population received all 
four drug classes. Only 68.5% of the patients underwent 
coronary angiography. Of those, 64.4% received coronary 
revascularisation. The proportion of patients receiving 
a beta-blocker or statin was lower among recurrent 
compared to incident cases (P=0.01 and P=0.03, 
respectively). No statistically significant differences in 
the utilisation of other drug classes or invasive diagnostic 
and treatment procedures were observed between the 
two groups. 
Adjusted analyses revealed lower utilisation rates of beta-
blockers among recurrent cases as compared to incident 
cases (OR=0.45; 95% CI: 0.24–0.85) (Figure 2). 
10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243
240
Figure 2. Differences in the in-hospital treatment between 
patients hospitalized with incident and recurrent acute 
myocardial infarction.
No statistically significant differences between groups 
were observed regarding ACEIs/ARBs, statins or aspirin 
use [(OR=0.67; 95% CI: 0.36–1.26), (OR=0.34; 95% CI: 0.12–
1.31) and (OR=1.15; 95% CI: 0.30–1.31), respectively]. 
A similar pattern was observed in the use of invasive 
diagnostic and treatment procedures. No statistically 
significant differences between the two groups were 
found with regard to coronary angiography (OR=0.88; 
95% CI: 0.45–1.71) or revascularisation (OR=0.67; 95% CI: 
0.30–1.49). 
The results of additional analyses were similar to those of 
the main analyses in terms of direction of the association 
and level of significance (Table 1, supplementary material 
online).
4. DISCUSSION
4.1 Main Findings
The burden of coronary risk factors in our study was 
very high among both incident and recurrent cases. The 
prevalence of HF, impaired LVEF, and multivessel CAD 
(all reliable indications of AMI’s clinical severity) were 
higher among recurrent compared to incident cases. 
The use of evidence-based drugs in our study varied 
widely and, compared to incident cases, recurrent cases 
seemed to use less often evidence-based treatment, 
including revascularisation. However, the differences 
were statistically significant only with regard to the use 
of beta-blockers. 
4.2 A Comparison with Other Studies
Data from a case-control study conducted in Tirana between 
2003 and 2006, and enrolling 467 acute coronary syndrome 
(ACS) patients (i.e., a combination of AMI and unstable 
angina pectoris – UAP), revealed that the prevalence of 
obesity (BMI≥30), hypertension, DM, and current smoking 
were 20.6%, 29.6%, 15.8%, and 42.2%, respectively (23). 
Among 809 incident ACS cases admitted to CCU in Tirana 
in 2009, the prevalence of current smoking, hypertension, 
family history of CHD, and overweight/obesity were 63%, 
58%, 33%, and 30%, respectively. All patients had at least 
two coronary risk factors (24). 
Several factors may have contributed to the higher 
burden of coronary risk factors in our study, compared to 
other studies conducted in Albania (23, 24). We included 
in the analyses, only AMI patients, while others combined 
AMI and UAP patients. Further, the study by Balla et 
al. (24) included only incident cases, while our study 
population was a mixture of incident and prevalent cases. 
Our study population comprised severely ill patients 
requiring hospitalisation in CCU, whereas in the study 
by Burazeri et al. (23), patients were recruited from 
CCU and hospital wards. Despite these differences in the 
populations studied, a worrying increase in the burden 
of risk factors over time cannot be rule out, and needs 
further investigation.
Internationally, the prevalence of smoking, hypertension, 
DM, and hyperlipidaemia among 122 458 CHD patients 
enrolled in 14 randomised control trials was 37.9%, 43.2%, 
17.5%, and 34.8%, respectively. Eighty-two percent of 
patients had at least one, whereas 1.0% of the cohort had 
all four major coronary risk factors (25). Data from the 
National Cardiovascular Registry (NCDR) showed that 71.4% 
of AMI patients reported to suffer from hypertension, and 
30.5% from DM (26). 
We could not identify previous publication from Albania 
comparing incident and recurrent cases regarding their 
clinical profile or in-hospital treatment. International 
studies have suggested that recurrent cases presented 
10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243
241
more often with pulmonary oedema, cardiogenic shock 
and asystole (27), and have a higher incidence of HF (28), 
compared to incident cases. 
The results of the analyses comparing in-hospital 
treatment between incident and recurrent cases have 
been less consistent. In the Netherlands, utilisation rates 
of aspirin, beta-blockers, and statins among 4718 STEMI 
patients were higher in incident, compared to recurrent 
cases (9). In the USA, similar rates were reported 
in incident and recurrent cases (28). With regard to 
revascularisation procedures, higher rates were observed 
in incident, compared to recurrent cases in the USA (28) 
and Israel (27). The direction of the association in our study 
suggests a more severe clinical expression of the disease 
with concurrent lower utilisation rates of medications in 
recurrent compared to incident cases. However, due to 
the lack of statistical significance (possibly affected by 
the relatively small sample size), these findings should be 
interpreted with caution.
A direct comparison of our findings with previously 
published analyses on the use of invasive procedures is 
challenging, as the use of these procedures is largely 
influenced by patients’ age, gender, comorbidities, prior 
AMI status, and the study period – all factors that differ 
widely between the published studies. 
4.3 Potential Mechanisms and Implications
The high burden of coronary risk factors reflects the 
lack of prevention measures in the population at large 
in Albania. Interventions aiming at reducing the burden 
of coronary risk factors have proven to be cost-effective 
(29), and can reduce CHD mortality up to 75% (30-33). 
Nevertheless, the majority of resources in the past 2-3 
decades were allocated into tertiary care institutions, 
aiming at modernising the system and improving the 
quality of care. The observed unfavourable trends in CHD 
mortality in Albania, combined with our findings, point out 
to the immediate need for a shift in the focus of attention 
toward preventive measures. In 2014, health authorities 
launched a nationwide health campaign, inviting citizens 
aged 40-65 years (expanded lately to include those aged 
35-70 years) to undergo a medical examination aiming at 
screening for CVD (with a special focus on CHD), cancer, 
and other relevant conditions. This was the first step in 
the long process of identifying the burden of coronary 
risk factors in the population. This campaign can lay the 
ground for policy and legislative changes to tackle many 
aspects related to diet and lifestyle, aiming at reducing 
the burden of risk factors and, subsequently, CHD in 
Albania. 
Another worrying finding is the prevalence of risk factors 
among recurrent cases, which – with an exception of 
smoking – is similar to (if not higher than) that of incident 
cases. This reflects the failure of patients with overt CHD 
to change their risk profile and conduct a healthy lifestyle. 
Many factors may have contributed to this failure, 
including i) the lack of personalised recommendations 
upon discharge from the hospital, ii) lack of rehabilitation 
programs, iii) poor adherence to treatment, iv) no 
coordination between different actors involved in the 
health care system (i.e., the family doctor and specialist) 
during the follow up. Further studies are needed to tackle 
each potential component individually and provide a new 
insight into this phenomenon. Further, national guidelines 
specifying treatment goals, frequency of follow up visits 
and role of specialist (versus the family doctor) during the 
follow up are needed to optimise medical care and reduce 
the rate of new coronary events in this vulnerable subset 
of population. 
Recurrent cases present with a more severe form of the 
disease, yet, the medication use among them tend to 
be suboptimal compared to that in incident cases. The 
reasons for these differences are not clearly explained. 
One hypothesis is that certain comorbidities and/or AMI 
complications represent contraindications to individual 
cardiac drugs. We addressed this issue by conducting 
additional analyses where we excluded patients with 
such comorbidities and/or AMI complications. This was 
associated with a slight increase in the use of beta-
blockers (+ 2.4%), ACEI/ARBs (+2.4%), statins (+0.9%), and 
all four drug classes (+3.8%). However, the differences in 
the use of cardiac drugs between recurrent and incident 
cases did not change substantially, indicating that factors 
other than comorbidities might be involved.
Another reason might be related to the fact that medical 
staff is reluctant to perform revascularisation procedures 
among severely ill patients due to a poorer outcome 
compared to that in uncomplicated AMI cases (34). 
4.4 Study Limitations
Our study has several limitations. The relatively small 
sample size and low number of patients with a recurrent 
event, is most probably responsible for the statistically 
non-significant findings, even though the point estimates 
indicate that recurrent AMIs present at the hospital with 
a more severe clinical expression, and underutilise the 
recommended drug classes compared to incident AMIs. 
Our sample size did not allow us to explore the role 
of medications taken prior to hospitalisation on the 
burden of risk factors, either. Furthermore, we could 
not determine the proportion of patients with controlled 
level of risk factors. In addition, we did not know the 
proportion of patients who might have been scheduled to 
receive revascularisation upon AMI discharge, as follow-
up information was not available. We therefore restricted 
our focus on treatment during MI hospitalization. The 
10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243
242
distinction between ‘never’ and ‘former’ smokers was 
not available in our study. Consequently, we could not 
discriminate between patients who smoked and gave up 
smoking, and those who never smoked. This distinction 
would have been of particular interest among recurrent 
cases. We also lacked information on the time from 
symptom onset to arrival at the hospital; an important 
factor influencing the decision to perform coronary 
angiography and revascularisation. 
5 CONCLUSIONS
Recurrent cases seemed to be admitted with a more severe 
clinical form of AMI and received optimal treatment less 
often, compared to incident cases. A more aggressive 
treatment approach combined with the implementation of 
preventive strategies would help improving the prognosis 
of patients suffering a recurrent AMI. 
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
None
ETHICAL APPROVAL
The study was approved by the National Committee for 
Bio-Medical Ethics in Albania.
REFERENCES
1. Sulo E, Vollset SE, Nygard O, Sulo G, Igland J, Egeland GM et al. 
Trends in 28-day and 1-year mortality rates in patients hospitalized 
for a first acute myocardial infarction in Norway during 2001-2009: a 
“Cardiovascular disease in Norway” (CVDNOR) project. J Intern Med 
2015; 277: 353-61.
2. Koopman C, Bots ML, van Oeffelen AA, van Dis I, Verschuren WM, 
Engelfriet PM et al. Population trends and inequalities in incidence 
and short-term outcome of acute myocardial infarction between 
1998 and 2007. Int J Cardiol 2013; 168: 993-8.
3. Schmidt M, Jacobsen JB, Lash TL, Botker HE, Sorensen HT. 25 year 
trends in first time hospitalisation for acute myocardial infarction, 
subsequent short and long term mortality, and the prognostic impact 
of sex and comorbidity: a Danish nationwide cohort study. BMJ 2012; 
344: e356.
4. Dudas K, Lappas G, Rosengren A. Long-term prognosis after hospital 
admission for acute myocardial infarction from 1987 to 2006. Int J 
Cardiol 2012; 155: 400-5.
5. Messner T, Lundberg V, Bostrom S, Huhtasaari F, Wikstrom B. Trends 
in event rates of first and recurrent, fatal and non-fatal acute 
myocardial infarction, and 28-day case fatality in the Northern 
Sweden MONICA area 1985-98. Scand J Public Health Suppl 2003; 
61: 51-9.
6. Sulo G, Vollset SE, Nygard O, Igland J, Egeland GM, Ebbing M et 
al. Trends in acute myocardial infarction event rates and risk of 
recurrences after an incident event in Norway 1994 to 2009 (from a 
Cardiovascular Disease in Norway Project). Am J Cardiol 2014; 113: 
1777-81.
7. Shotan A, Gottlieb S, Goldbourt U, Boyko V, Reicher-Reiss H, Arad 
M et al. Prognosis of patients with a recurrent acute myocardial 
infarction before and in the reperfusion era--a national study. Am 
Heart J 2001; 141: 478-84.
8. Orn S, Cleland JG, Romo M, Kjekshus J, Dickstein K. Recurrent 
infarction causes the most deaths following myocardial infarction 
with left ventricular dysfunction. Am J Med 2005; 118: 752-8.
9. Rasoul S, Ottervanger JP, de Boer MJ, Dambrink JH, Hoorntje JC, 
Gosselink AT et al. Poor outcome after recurrent acute myocardial 
infarction: a plea for optimal secondary prevention. Int J Cardiol 
2011; 147: 298-300.
10. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F et al. Effect 
of potentially modifiable risk factors associated with myocardial 
infarction in 52 countries (the INTERHEART study): case-control 
study. Lancet 2004; 364: 937-52.
11. Kangovi S, Grande D. Hospital readmissions-not just a measure of 
quality. JAMA 2011; 306: 1796-7.
12. Evaluation IfHMa. Global burden of disease database. Available Nov 
29th 2016 from: http://www.healthdata.org.
13. Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular 
disease in Europe 2014: epidemiological update. Eur Heart J 2014; 
35: 2950-9.
14. Global, regional, and national life expectancy, all-cause mortality, 
and cause-specific mortality for 249 causes of death, 1980-2015: 
a systematic analysis for the Global Burden of Disease Study 2015. 
Lancet 2016; 388: 1459-544.
15. Shapo L, Pomerleau J, McKee M, Coker R, Ylli A. Body weight patterns 
in a country in transition: a population-based survey in Tirana City, 
Albania. Public Health Nutr 2003; 6: 471-7.
16. Shapo L, McKee M, Coker R, Ylli A. Type 2 diabetes in Tirana City, 
Albania: a rapid increase in a country in transition. Diabet Med 2004; 
21: 77-83.
17. Shapo L, Pomerleau J, McKee M. Epidemiology of hypertension and 
associated cardiovascular risk factors in a country in transition: 
a population based survey in Tirana City, Albania. J Epidemiol 
Community Health 2003; 57: 734-9.
18. Shapo L, Gilmore AB, Coker R, McKee M, Shapo E. Prevalence and 
determinants of smoking in Tirana city, Albania: a population-based 
survey. Public Health 2003; 117: 228-36.
19. WHO. Global Health Observatory (GHO) data - Albania: country 
profiles 2017. Available Nov 29th 2016 from: http://www.who.int/
nmh/countries/alb_en.pdf?ua=1.
20. Bank TW. Health expenditure, total (% of GDP) 2015. Available Nov 
29th 2016 from: http://data.worldbank.org/indicator/SH.XPD.
TOTL.ZS/countries/AL-AT?display=default.
21. Rose G. Strategy of prevention: lessons from cardiovascular disease. 
Br Med J (Clin Res Ed) 1981; 282: 1847-51.
22. Myftiu S, Sulo E, Burazeri G, Sharka I, Shkoza A, Sulo G. A higher 
burden of metabolic risk factors and underutilization of therapy 
among women compared to men might influence a poorer prognosis: 
a study among acute myocardial patients in Albania, a transitional 
country in Southeastern Europe. Croat Med J 2015; 56: 542-9.
10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243
243
23. Burazeri G, Goda A, Sulo G, Stefa J, Roshi E, Kark JD. Conventional 
risk factors and acute coronary syndrome during a period of 
socioeconomic transition: population-based case-control study in 
Tirana, Albania. Croat Med J 2007; 48: 225-33.
24. Balla I, Kondili LA, Kondili A. Risk factors among coronary heart 
disease patients in the context of the Albanian paradox. Anadolu 
Kardiyol Derg 2012; 12: 82.
25. Khot UN, Khot MB, Bajzer CT, Sapp SK, Ohman EM, Brener SJ et al. 
Prevalence of conventional risk factors in patients with coronary 
heart disease. JAMA 2003; 290: 898-904.
26. Paixao AR, Enriquez JR, Wang TY, Li S, Berry JD, Khera A et al. Risk 
factor burden and control at the time of admission in patients with 
acute myocardial infarction: results from the NCDR. Am Heart J 
2015; 170: 173-9, 9 e1.
27. Shotan A, Blondheim DS, Gottlieb S, Kazatsker M, Frimerman A, 
Shochat M et al. Comparison of outcome of recurrent versus first 
ST-segment elevation myocardial infarction (from national Israel 
surveys 1998 to 2006). Am J Cardiol 2011; 107: 1730-7.
28. Shen L, Shah BR, Nam A, Holmes D, Alexander KP, Bhatt DL et al. 
Implications of prior myocardial infarction for patients presenting 
with an acute myocardial infarction. Am Heart J 2014; 167: 840-5.
29. Masters R, Anwar E, Collins B, Cookson R, Capewell S. Return on 
investment of public health interventions: a systematic review. J 
Epidemiol Community Health. 2017; 71: 827-34.
30. Koopman C, Vaartjes I, van Dis I, Verschuren WM, Engelfriet P, 
Heintjes EM et al. Explaining the decline in coronary heart disease 
mortality in the Netherlands between 1997 and 2007. PLoS One 2016; 
11: e0166139.
31. Pereira M, Azevedo A, Lunet N, Carreira H, O’Flaherty M, Capewell 
S et al. Explaining the decline in coronary heart disease mortality 
in Portugal between 1995 and 2008. Circ Cardiovasc Qual Outcomes 
2013; 6: 634-42.
32. Unal B, Sozmen K, Arik H, Gerceklioglu G, Altun DU, Simsek H et al. 
Explaining the decline in coronary heart disease mortality in Turkey 
between 1995 and 2008. BMC public health 2013; 13: 1135.
33. O’Flaherty M, Buchan I, Capewell S. Contributions of treatment and 
lifestyle to declining CVD mortality: why have CVD mortality rates 
declined so much since the 1960s? Heart 2013; 99: 159-62.
34. Lu KJ, Yan BP, Ajani AE, Wilson WM, Duffy SJ, Gurvitch R et al. Impact 
of concomitant heart failure on outcomes in patients undergoing 
percutaneous coronary interventions: analysis of the Melbourne 
Interventional Group registry. Eur J Heart Fail 2011; 13: 416-22.
SELF-REPORTED HYPOGLYCAEMIA IN PATIENTS TREATED WITH INSULIN: 
A LARGE SLOVENIAN RETROSPECTIVELY-PROSPECTIVE STUDY
Draženka PONGRAC BARLOVIČ1*, Andrej ZAVRATNIK2, Aleš SKVARČA1, Karmen JANŠA3, 
Bojana VUKELIČ4, Marjeta TOMAŽIČ1, Maja RAVNIK OBLAK1
1University Medical Centre Ljubljana, Clinical Department of Endocrinology, Diabetes and Metabolic Diseases, 
Zaloska 7, 1000 Ljubljana, Slovenia
2University Medical Centre Maribor, Ljubljanska 5,  2000 Maribor, Slovenia
3General Hospital Jesenice, Cesta marsala Tita 112, 4270 Jesenice, Slovenia
4General Hospital Novo Mesto, Smihelska cesta 1, 8000 Novo Mesto, Slovenia
Received: Feb 14, 2017
Accepted: Aug 10, 2017 
Original scientific article
Introduction. Hypoglycaemia is the major barrier for glycaemic target achievement in patients treated with 
insulin. The aim of the present study was to investigate real-world incidence and predictors of hypoglycaemia 
in insulin-treated patients.
Methods. More than 300 consecutive patients with type 1 or type 2 diabetes treated with insulin were 
enrolled during regular out-patient visits from 36 diabetes practices throughout the whole country. They 
completed a comprehensive questionnaire on hypoglycaemia knowledge, awareness, and incidence in the last 
month and last six months. In addition, in the prospective part, patients recorded incidence of hypoglycaemic 
events using a special diary prospectively on a daily basis, through 4 weeks.
Results. At least one hypoglycaemic event was self-reported in 84.1%, and 56.4% of patients with type 1 and 
type 2 diabetes, respectively, during the prospective period of 4 weeks. 43.4% and 26.2% of patients with 
type 1 and type 2 diabetes, respectively, experienced a nocturnal hypoglycaemic event. In the same time-
period, severe hypoglycaemia was experienced by 15.9% and 7.1% of patients with type 1 and type 2 diabetes, 
respectively. Lower glycated haemoglobin was not a significant predictor of hypoglycaemia.
Conclusions. Rates of self-reported hypoglycaemia in patients treated with insulin in the largest and 
most comprehensive study in Slovenia so far are higher than reported from randomised control trials, but 
comparable to data from observational studies. Hypoglycaemia incidence was high even with high glycated 
haemoglobin values.
Uvod. Hipoglikemije so glavni omejujoči dejavnik varnega doseganja glikemičnih ciljev pri bolnikih s 
sladkorno boleznijo, ki se zdravijo z insulinom. Namen te raziskave je bil raziskati pojavnost hipoglikemij in 
napovedne dejavnike hipoglikemij v vsakodnevnem življenju bolnikov s sladkorno boleznijo.
Metode. V raziskavo smo vključili več kot 300 zaporednih bolnikov s sladkorno boleznijo tipa 1 ali 2, 
zdravljenih z insulinom, iz 36 diabetoloških ambulant po državi. Bolniki so izpolnili natančen vprašalnik, ki 
je poizvedoval o znanju o hipoglikemijah, njihovemu zaznavanju in pojavnosti v zadnjem mesecu in v zadnjih 
šestih mesecih. V nadaljevalnem, prospektivnem delu raziskave, ki je trajal 1 mesec, so bolniki vsakodnevno 
beležili dnevnik hipoglikemij, kamor so sproti vpisovali, ali so doživeli hipoglikemijo.
Rezultati. V raziskavo je bilo vključenih 84 bolnikov s sladkorno boleznijo tipa 1 in 227 bolnikov s sladkorno 
boleznijo tipa 2. Med enomesečnim prospektivnim delom raziskave je 84,1% bolnikov s sladkorno boleznijo 
tipa 1 in 56,4% bolnikov s sladkorno boleznijo tipa 2 poročalo, da so doživeli vsaj eno hipoglikemijo. Nočno 
hipoglikemijo je doživelo 43,4% bolnikov s sladkorno boleznijo tipa 1 in 26,2% bolnikov s sladkorno boleznijo 
tipa 2. Hudo hipoglikemijo je doživelo 15,9 % bolnikov s sladkorno boleznijo tipa 1 in 7,1% bolnikov s 
sladkorno boleznijo tipa 2. Nižji glikiran hemoglobin ni bil napovedni dejavnik za pojav hipoglikemij.
Zaključki. Incidenca hipoglikemij, o katerih so poročali sami bolniki, zdravljeni z insulinom, je v doslej 
največji raziskavi o hipoglikemijah na Slovenskem višja kot v velikih randomiziranih prospektivnih raziskavah, 
a primerljiva kot v podobnih opazovalnih raziskavah iz vsakodnevnega življenja. Incidenca hipoglikemij je 
visoka tudi pri bolnikih z visokim glikiranim hemoglobinom.
ABSTRACT
Keywords: 
hypoglycaemia, 
type 1 diabetes, 
type 2 diabetes, 
insulin treatment, 
Slovenia
IZVLEČEK
Ključne besede: 
hipoglikemija, 
sladkorna bolezen tipa 1, 
sladkorna bolezen tipa 2, 
insulinsko zdravljenje, 
Slovenija
*Corresponding author: Tel: + 386 1 522 39 90; E-mail: drazenka.pongrac@gmail.com
10.1515/sjph-2017-0033 Zdr Varst 2017; 56(4): 244-250
HIPOGLIKEMIJE PRI BOLNIKIH, ZDRAVLJENIH Z INSULINOM: 
VELIKA SLOVENSKA RETROSPEKTIVNOPROSPEKTIVNA RAZISKAVA
Pongrac Barlovič D, Zavratnik A, Skvarča A, Janša K, Vukelič B, Tomažič M, Ravnik Oblak M. Self-reported hypoglycaemia in patients treated with insulin: a large 
Slovenian retrospectively-prospective study. Zdr Varst 2017; 56(4): 244-250.
244
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
Intensive hyperglycaemia treatment reduces the risk 
of development of chronic diabetes complications. 
However, the main obstacle to attain tight glycaemic 
goals is the risk of hypoglycaemia (1). In addition, 
experiencing hypoglycaemia, especially a nocturnal one, 
decreases quality of life substantially (2). Moreover, 
severe hypoglycaemia, requiring external assistance for 
recovery, was associated with increased cardiovascular 
and overall mortality (3).
Data on hypoglycaemia incidence are variable, mainly 
because of the lack of a single threshold plasma glucose 
concentration that defines hypoglycaemia in diabetes. 
Typically, it is believed that hypoglycaemia incidence 
is high in type 1 diabetes, but not in type 2 diabetes. 
Yet, incidence of hypoglycaemia increases with type 2 
diabetes duration (4, 5). Reported incidence of severe 
hypoglycaemia in retrospective observational studies in 
patients with longstanding type 1 diabetes was 320 cases 
per 100 patient-years (6). Of note, substantially lower 
incidence was established from a prospective randomised 
DCCT trial, with 62 cases per 100 patient-years (7). On 
the other hand, in patients with type 2 diabetes, severe 
hypoglycaemia incidence was 70 per 100 patient-years in 
observational studies (6), whereas it was only 3.1 per 100 
patient-years in a multicentre, prospective, randomised 
ACCORD study (8).
Hypoglycaemia incidence in patients treated with insulin 
in Slovenia was never systematically studied. Therefore, 
the aim of the present study was to assess hypoglycaemia 
incidence in insulin-treated patients with type 1 and type 
2 diabetes mellitus as patients report it, and to investigate 
factors, associated with hypoglycaemia risk.
2 METHODS
This was a multicentre, non-interventional study, designed 
to assess hypoglycaemia incidence in patients with type 
1 and type 2 diabetes, treated with insulin. The study 
protocol, with hypoglycaemia classification and statistical 
analyses was in detail described elsewhere (9).
During the routine, out-patient visits with diabetologists, 
from 474 consecutive patients from 36 clinical sites in 
Slovenia invited to participate, 311 were enrolled in 
the study. The sites were quite uniformly distributed 
throughout Slovenia. The biggest number of patients 
was recruited from the north-western Slovenia, the only 
region without any patients included was the Slovenj 
Gradec region. The average number of patients per site 
was 8.6, per region 39. Minimal number of patients per 
region was 10 (Murska Sobota), maximal 75 (Gorenjska). 
Patients included were more than 18 years old, had type 
1 or type 2 diabetes mellitus, with at least 12 months 
of insulin treatment experience, and had signed the 
informed consent. The exclusion criterion was the inability 
to complete a written questionnaire and a hypoglycaemia 
diary. Patients were not given any financial payment for 
the participation in the study.
Baseline characteristics of the patients analysed are 
presented in Table 1. More than two thirds of patients had 
type 2 diabetes mellitus.
10.1515/sjph-2017-0033 Zdr Varst 2017; 56(4): 244-250
245
Table 1. Baseline characteristics of patients included.
*Non-normally distributed variables are represented as median 
(25th, 75th percentile) 
Age (years)
Gender (male/female, %)
Diabetes duration (years)
Insulin therapy duration (years)
HbA1c (%)
Employed/unemployed/retired/other (%)
Diabetes treatment
 Short-acting insulin
 Long-acting insulin
 Pre-mixed insulin
Oral therapy
 Injectable non-insulin therapy
 Insulin pump
Self-measurement of blood glucose (%)
Continuous glucose measurement (%)
Hypoglycaemia experience (%)
49±13
57/43
21±11
19±12
9.2±2.7
65/5/28/12
85.7
60.7
1.2
4.8
3.6
32.1
98.8
34.2
98.8
64±10
62/38
16±9
6 (3, 10)*
9.3±2.8
15/8/75/2
48.9
63.1
35.1
24.9
10.2
4.9
99.6
38.4
89.2
DM type 1
N=84
DM type 2
N=227
The study was comprised of two parts: a retrospective 
6-month period and a prospective 4-week period. In 
the retrospective part, patients were asked to recall a 
6-month history of severe hypoglycaemia and a 4-week 
history of non-severe and severe hypoglycaemia. In the 
prospective period, they were asked to complete a special 
diary of hypoglycaemia on a daily basis. 
The primary endpoint of the study was the percentage 
of patients experiencing at least one hypoglycaemic 
event during the 4-week follow-up period. The majority 
of statistical analyses were prepared on data from the 
prospective part, in order to avoid a recall bias. 
The study was performed from March to September 2013. 
It was conducted in accordance with the Declaration of 
Helsinki and was also approved by the Slovenian Ethics 
Committee. 
 
2.1 Statistical Analyses
The majority of analyses were descriptive in nature. All 
statistical tests were two-sided. A p-value of less than 
10.1515/sjph-2017-0033 Zdr Varst 2017; 56(4): 244-250
246
0.05 was considered as statistically significant. Univariate 
binomial regression models were used to examine the 
relationship between hypoglycaemia and factors, including 
age, gender, HbA1c at baseline, diabetes duration, 
duration of insulin therapy, type of insulin therapy, 
frequency of blood glucose monitoring, knowledge of 
hypoglycaemia, hypoglycaemia unawareness, fear of 
hypoglycaemia, period, and diabetes type. Differences 
in retrospective versus prospective data reporting were 
assessed using a paired t-test. 
Definitions used: non-severe hypoglycaemia was defined 
as a hypoglycaemic event managed by the patient alone, 
whereas severe hypoglycaemia was defined as any 
hypoglycaemic event that requires external assistance 
for recovery. Nocturnal hypoglycaemia was defined as a 
hypoglycaemic event occurring between midnight and 6 
in the morning. Documented symptomatic hypoglycaemia 
was defined as any event reported by the patient as a 
symptomatic hypoglycaemia, regardless of the glucose 
level. Patients who answered the question ‘Do you have 
symptoms when you have a low blood sugar measurement?’ 
with ‘never’ or ‘occasionally,’ were said to have ‘severely 
impaired’ or ‘impaired’ hypoglycaemia awareness, 
respectively.
3 RESULTS
Ninety-nine % of patients with type 1 diabetes and 89% 
of patients with type 2 diabetes reported that they had 
experienced hypoglycaemia in their life. In addition, 30% 
of patients with type 1 diabetes and 27% of patients with 
type 2 diabetes reported impaired or severely impaired 
hypoglycaemia awareness. 
At least one hypoglycaemic event (with or without 
measured glucose value) was self-reported in 84.1% 
and 56.4% of patients with type 1 and type 2 diabetes, 
respectively, during the prospective period of 4 weeks. 
43.4% and 26.2% of patients with type 1 and type 2 diabetes, 
respectively, experienced a nocturnal hypoglycaemic 
event. In the same time-period severe hypoglycaemia was 
experienced by 15.9% and 7.1% of patients with type 1 
and type 2 diabetes, respectively. 
Estimated annual incidence rate of documented 
symptomatic hypoglycaemic events (with blood glucose 
3.9 mmol/l or less), calculated from patient diaries in the 
prospective follow-up was 48 events (95% CI 43 to 53) and 11 
events (95% CI 9 to 13) per patient-year in type 1 and type 
2 diabetes, respectively. Also, estimated annual incidence 
rate of severe hypoglycaemia was 6 events (95% CI 4 to 8) 
and 1 event (95% CI 1 to 2) per patient-year in type 1 and 
type 2 diabetes, respectively. There were altogether 62 
episodes of severe hypoglycaemia documented in 4 weeks 
period in 29 patients with type 1 and type 2 diabetes. 
Compared to type 2 diabetes, the percentage of patients 
experiencing severe hypoglycaemia was more than double 
in type 1 diabetes. Nocturnal hypoglycaemia was reported 
with an estimated annual rate 12 (95% CI 9 to 15) and 8 
(95% CI 5 to 8) patient-years in type 1 and type 2 diabetes, 
respectively.
When asked about their definition of hypoglycaemia, 
only 40% of type 1 and of type 2 diabetes patients 
define hypoglycaemia depending on both, blood glucose 
measurement and symptoms, whereas 33% of type 1 and 
37% of type 2 diabetes patients define hypoglycaemia only 
depending on the presence of symptoms. The mean blood 
glucose value below, which patients considered a glucose 
value to be a marker of hypoglycaemia, was 3.18 ±0.64 
mmol/l and 3.41±0.83 mmol/l in type 1 diabetes and type 
2 diabetes, respectively.
Differences on hypoglycaemia recall were noted when data 
on hypoglycaemia from the prospective and retrospective 
part of the study were compared, depending on diabetes 
type (Figure 1). Specifically, a large difference in recall 
was noted in the case of mild hypoglycaemia in type 1 
diabetes patients, with significantly less hypoglycaemias 
reported by the patients from the past 4 weeks compared 
to prospective 4 weeks (37 vs.77 cases, p<0.001). There was 
a much smaller, but still statistically significant difference 
seen in type 2 diabetes, and mild hypoglycaemia reporting, 
with lower reporting for the past 4 weeks, compared to 
the prospective reporting (18 vs. 24 cases, p=0.027). Of 
note, in type 2 diabetes, there was also a difference in 
nocturnal hypoglycaemia reporting, but in the opposite 
direction, reporting more nocturnal hypoglycaemia in a 
retrospective time period (12 vs.6 cases, p=0.007).
Figure 1. Hypoglycaemia incidence depending on the 
retrospective or prospective recall by patients.
R-retrospective, P-prospective
10.1515/sjph-2017-0033 Zdr Varst 2017; 56(4): 244-250
247
Figure 2.
Figure 3.
Hypoglycaemia incidence and HbA1c.
Actions resulting from hypoglycaemia in patients with 
Type 1 and Type 2 diabetes. (Statistically significant 
differences are marked with *).
Using a negative binomial model, adjusted for several 
factors, including duration of diabetes, age, hypoglycaemia 
awareness, and type of insulin therapy, we studied possible 
predictors of hypoglycaemia incidence. From all the 
variables studied, only fear of hypoglycaemia predicted 
severe hypoglycaemia incidence. Neither HbA1c, age, 
diabetes duration nor hypoglycaemia awareness were 
predictors of severe hypoglycaemia (Figure 2, Table 2). 
After experiencing hypoglycaemia in the prospective 4 
weeks of the study, patient actions differed substantially 
between Type 1 and Type 2 diabetes, as represented in 
Figure 3. 
Table 2. Predictors of severe hypoglycaemia in a fully adjusted 
negative binomial model.
NC-not calculable. Model adjusted for: age, gender, HbA1c at 
baseline, duration of diabetes, duration of insulin therapy, 
type of Insulin therapy, frequency of blood glucose monitoring, 
knowledge of hypoglycaemia, hypoglycaemia unawareness, 
fear of hypoglycaemia, period, diabetes type.
Age (years)
Female gender
HbA1c (%)
Diabetes duration (years) 
Type of insulin therapy 
   Short-acting (reference)
   Long-acting
   Long and short-acting
   Mixed
   Other
Blood glucose testing (per day)
Hypoglycaemia unawareness
Fear of hypoglycaemia
Diabetes type 2
0.99
0.80
1.01
1.02
 
 -
0.54
0.70
NC
0.36
1.08
1.00
1.20
0.72
0.556
0.585
0.441
0.594
 
 -
0.489
0.550
NC
0.175
0.555
0.996
0.009
0.627
0.96, 1.02 
0.36, 1.78
0.98, 1.04
0.94, 1.11
 
 -
0.10, 3.07
0.21, 2.28
NC
0.08, 1.57
0.84, 1.38
0.44, 2.24
1.05, 1.37
0.20, 2.67
HR P-
VALUE
95% C.I.VARIABLES
4 DISCUSSION
This is the first study that reports hypoglycaemia 
incidence in a large cohort of insulin-treated patients 
with type 1 and type 2 diabetes mellitus in Slovenia. The 
self-reported rates of hypoglycaemia in this study are 
substantially higher than previously observed in other 
studies, especially in randomised controlled trials. 
Hypoglycaemia is considered a major obstacle for optimal 
glycaemic control achievement in insulin-treated patients 
with diabetes. Moreover, a severe hypoglycaemia is 
strongly associated with a series of negative outcomes, 
including the increased risk of a major macrovascular 
event, as well as the increased risk of a cardiovascular or 
non-cardiovascular death (3,10). Therefore, prevention 
of severe hypoglycaemia is of central importance 
in delivering care to insulin-treated patients with 
diabetes. Interestingly, severe hypoglycaemia could 
not be predicted in our patients by any measured 
factor, including gender, diabetes duration, HbA1c, age, 
frequency of blood glucose measurement, or type of 
insulin therapy. The only factor that was significantly 
and independently associated with severe hypoglycaemia 
incidence in the fully adjusted multivariate model was 
greater fear of hypoglycaemia. Although from our model 
we cannot conclude that greater fear of hypoglycaemia 
was the direct consequence of severe hypoglycaemia 
experience in the past, it is the possible explanation, and 
in line with other studies (11, 12). Even more importantly, 
recognising fear of hypoglycaemia as a predictor of future 
severe hypoglycaemia gives us an important message – 
that addressing that fear by a tailored education we could 
potentially avoid severe hypoglycaemia. 
10.1515/sjph-2017-0033 Zdr Varst 2017; 56(4): 244-250
248
The incidence of non-severe hypoglycaemia is not easily 
assessed in everyday life of insulin-treated patients, which 
is at least partly due to different levels of hypoglycaemia 
awareness. However, data on severe hypoglycaemia 
incidence is much more reliable (13). Nonetheless, in our 
study, severe hypoglycaemia incidence in type 2 diabetes 
was more than 20-times greater than, for example, in 
the ACCORD study (8), and more than 10-times greater 
than in the observational UK Hypoglycaemia study (6). In 
type 1 diabetes, on the other hand, difference in severe 
hypoglycaemia rate was smaller, but still 10-times higher 
in our study compared to the intensive arm of the DCCT 
trial (14), and almost 2-times higher compared to the 
UK Hypoglycaemia study (6). Not surprisingly, our data 
are very near to other real-world patient cohort studies 
(12, 15). Such a pronounced difference in hypoglycaemia 
incidence is likely due to the nature of the studies and 
study methodology. In other words,, results of our study 
reflect data on patients from the everyday practice, 
whereas patients with concomitant diseases, recurrent 
hypoglycaemia, or hypoglycaemia unawareness are 
usually excluded from randomised controlled trials. In 
addition, the incidence of severe hypoglycaemia was self- 
reported in our study, as experienced by the patients, 
and was not confirmed by means of patient medical 
files. Moreover, our patient population, especially with 
type 2 diabetes, was rather older and had, on average, 
diabetes for a substantially longer time period, compared 
to similar studies. The other important fact is also that 
the definitions of hypoglycaemia changed over the last 
years, even in the last few years (13, 16); however, the 
findings of our study go beyond the definitions and reveal 
what patients consider relevant for their everyday life 
with insulin. 
However, comparing results from the Slovenian cohort 
to the recently published results of the study analysing 
hypoglycaemia incidence in more than 27,000 patients 
globally (9), the incidence of severe hypoglycemia in 
Slovenian type 1 diabetes was higher (5.9 vs. 4.9 events-
patient-year) and in type 2 diabetes was lower (1.5 vs. 
2.5 events-patient-year). The incidence of nocturnal 
hypoglycaemia in type 1 diabetes was similar in Slovenia 
and globally, whereas in type 2 diabetes, it was almost 
twice as common as elsewhere (6.4 vs. 3.67 events-
patient-year) (9). Data on nocturnal hypoglycaemia is 
quite of a concern. Firstly, nocturnal hypoglycaemias can 
lead to sleep deprivation, lower quality of life, lower work 
performance, worse driving skills, etc. (17). Secondly, 
nocturnal hypoglycaemias are characterised by the 
lower intensity and recognizability of counterregulatory 
responses, thereby depriving individuals of the adequate 
stimulus to counteract hypoglycaemia. Therefore, 
nocturnal hypoglycaemias can pass by unrecognized and 
lead to lower hypoglycaemia awareness (18). Lastly, 
awakening response after nocturnal hypoglycaemia is 
lower and may affect the patient’s ability to intake 
adequate amount of carbohydrates, especially in elderly 
people with possibly pre-existing cognitive impairment 
(17). 
In type 1 diabetes, comparing prospective hypoglycaemia 
count with a retrospective recall, we detect a large 
discrepancy, especially in mild hypoglycaemia. Because 
it is a frequent event, patients probably consider it 
normal and devote less attention to it. However, the 
way the mild hypoglycaemia is perceived might be 
crucial to prevent hypoglycaemia desensitisation and 
even hypoglycaemia unawareness, often stemming 
from repetitive hypoglycaemia (19). A similar trend 
in mild hypoglycaemia was seen in our type 2 diabetes 
patients. However, in this group, reported past incidence 
of nocturnal hypoglycaemia was higher than in the 
prospective part of the study, possibly indicating that 
experience of nocturnal hypoglycaemia is more stressful 
than day hypoglycaemia, and leads to oversizing its 
appearance. Nocturnal hypoglycaemia, in particular, 
impacts one’s sense of well-being because of its impact on 
sleep quality and quantity (20). Fear of hypoglycaemia, 
especially nocturnal one, may be one of the important 
reasons patients rather choose higher glycaemic targets 
(21). 
From the DCCT trial, the association between lower HbA1c 
and higher hypoglycaemia incidence is well established 
(22). Yet, the results of our study underline that higher 
HbA1c values are not protective from experiencing 
hypoglycaemia, since hypoglycaemia was reported with 
similar frequency with low as well as with high levels 
of glycated haemoglobin. The association is easily 
understood with low levels of glycated haemoglobin, since 
frequent hypoglycaemias lower average glucose levels. 
On the other hand, it may be quite surprising to see that 
hypoglycaemias are no less frequent in patients with high 
glycated haemoglobin values. A possible explanation could 
be that patients experiencing hypoglycaemia deliberately 
lower insulin dose, as also reported in Figure 3 in our 
cohort of patients, or maybe even skip insulin application 
(23). 
In our study, a very high average glycated haemoglobin 
value was reported, even substantially higher from the 
global report of the same study (9). If this value holds 
true, it is very alarming for the diabetes patient care in 
Slovenia, and definitely deserves further assessments. 
However, due to the study design, where data were not 
captured by patient medical files, but rather by a patient 
recall, there is a possibility that patients reported values 
of average plasma glucose concentration rather than 
glycated haemoglobin percentages. Similarly, we explain 
a very high reported percentage of continuous glucose 
monitoring usage in type 2 diabetes with misunderstanding 
of the meaning of the question. Furthermore, in this 
10.1515/sjph-2017-0033 Zdr Varst 2017; 56(4): 244-250
249
study, we did not collect data on education level, which 
is, together with low socioeconomic status, a very well 
recognised factor associated with higher hypoglycaemia 
risk in patients with diabetes (13, 24, 25). This patient 
population could also comprise a large part of the group of 
non-responders. Unfortunately, we do not have exact data 
on them, since they did not complete any questionnaire. 
We observed that the non-respondent population is of 
two categories. One is a working population, which 
did not decide to participate in the study due to lack 
of time. For this group, we expect it to be of younger 
age and not to have increased the number of overall 
hypoglycaemia incidence. The second group is a group of 
patients who could not be included because of illiteracy 
or other issues resulting in the inability to complete the 
written questionnaire, like vision impairment and the 
lack of language understanding. We expect this group of 
patients to be even more vulnerable to hypoglycaemia 
and, if included, would be expected to further increase 
hypoglycaemia incidence reported in the study. 
Despite some limitations of the design of the present 
study, this study design gives unique insights into the issue 
of hypoglycaemia through patient experience. In this way, 
new strategies can be employed that address this iatrogenic 
diabetes treatment complication more efficiently. Firstly, 
at the patient and the patient organisations level, the 
awareness of hypoglycaemia incidence should be raised, 
and instructions on the ways to decrease their occurrence 
should be given in a number of different formats, including 
visual and auditory message modes. In addition, fear of 
hypoglycaemia as a predictor of severe hypoglycaemia 
should be further addressed in the future studies as well 
as in routine clinical practice. Diabetes educators and 
medical doctors should become even more sensitised to 
the issue of high hypoglycaemia incidence, accurately 
assess it at every patient visit, and learn about the ways 
patients engage with them. Moreover, development of new 
treatment modules that include cognitive restructuring 
for addressing fear of hypoglycaemia should be welcomed. 
Furthermore, research with innovative methodological 
approach (26) and deep understanding of possibly 
preventable socioeconomic inequalities (27) could lead 
to a creation of patient-tailored, most probably region-
specific approaches to deliver the maximally efficient 
education on hypoglycaemia for its prevention. 
5 CONCLUSIONS
In conclusion, our study is the first comprehensive report 
on patient-reported hypoglycaemia incidence in Slovenian 
insulin-treated type 1 and type 2 diabetes patients that 
highlights several important aspects. Firstly, the incidence 
of hypoglycaemia, especially severe ones, is substantially 
higher than the ones reported from randomised controlled 
trials. Secondly, higher glycated haemoglobin values do not 
exclude high hypoglycaemia event rate. Thirdly, nocturnal 
hypoglycaemia needs special consideration in everyday 
management of insulin-treated patients, especially type 
2. Fourthly, since factors associated with hypoglycaemia 
remained largely unidentified, especially in the context 
of the socioeconomic status, such as education level, 
addressing hypoglycaemia efficiently in the future calls 
for a much broader mixed research method approach, 
including qualitative research. 
ACKNOWLEDGEMENTS
Acknowledgements to investigators, who participated in 
the study: Anja Babič, Kristina Cerk Porenta, Miro Čokolič, 
Kristina Groti Resman, Lidija Kaučevič Pohar, Renata 
Verboten Kopriva, Lučka Leskovšek, Mitja Krajnc, Stojan 
Kralj, Jana Kreč Šorli, Marjan Kristanc, Urša Kšela, Iris 
Marolt, Metka Mesec Staut, Maja Navodnik Preložnik, Ana 
Ogrič Lapajne, Tatjana Martinjak Perčič, Milivoj Piletič, 
Jana Plavc, Marta Simonič, Gorazd Staut, Borut Stravnik, 
Nika Šatej, Lucas Gaudencio Triep, Zorancho Trpkovski, 
Katarina Vukelič, Matej Završnik, Vanda Zorko Kostevc, 
Barbara Zupančič.
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
The study was financed by NovoNordisk.
ETHICAL APPROVAL
The study was approved by the Slovenian Ethics 
Committee, reference number 116/02/13.
REFERENCES
1. Cryer PE. The barrier of hypoglycemia in diabetes. Diabetes 2008; 
57: 3169-76. 
2. Harris S, Mamdani M, Galbo-Jorgensen CB, Bogelund M, Gundgaard 
J, Groleau D. The effect of hypoglycemia on health-related quality 
of life: Canadian results from a multinational time trade-off survey. 
Can J Diabetes 2014; 38: 45-52.
3. Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L. et al. 
Severe hypoglycemia and risks of vascular events and death. N Engl 
J Med 2010; 363: 1410-8. 
4. Desouza CV, Bolli GB, Fonseca V. Hypoglycemia, diabetes, and 
cardiovascular events. Diabetes Care 2010; 33: 1389-94.
10.1515/sjph-2017-0033 Zdr Varst 2017; 56(4): 244-250
250
5. Cryer P. Hypoglycemia: still the limiting factor in the glycemic 
management of diabetes. Endocr Pract 2008; 14: 750-6.
6. UK hypoglycemia study group. Risk of hypoglycaemia in types 1 
and 2 diabetes: effects of treatment modalities and their duration. 
Diabetologia 2007; 50: 1140-7. 
7. Diabetes control and complications trial (DCCT): results of feasibility 
study. The DCCT research group. Diabetes Care 1987; 10: 1-19.
8. Gerstein HC, Miller ME, Byington RP. Effects of intensive glucose 
lowering in type 2 diabetes. N Engl JMed 2008; 358: 2545-59.
9. Khunti K, Alsifri S, Aronson R, Cigrovski Berkovic M, Enters-Weijnen 
C, Forsen T et al. Rates and predictors of hypoglycaemia in 27 585 
people from 24 countries with insulin-treated type 1 and type 2 
diabetes: the global HAT study. Diabetes Obes Metab 2016; 18: 907-
15.
10. Zoungas  S, Patel  A, Chalmers  J, de Galan  BE, Li  Q, Billot  L et al. 
Severe hypoglycemia and risks of vascular events and death. N Engl 
J Med 2010; 363: 1410-8.
11. Gonder-Frederick LA, Fisher CD, Ritterband LM, Cox DJ, Hou L, 
DasGupta AA et al. Predictors of fear of hypoglycemia in adolescents 
with Type 1 diabetes and their parents. Pediatric Diabetes 2006; 7: 
215-22.
12. Cariou B, Fontaine P, Eschwege E, Lievre M, Gouet D, Huet D et 
al. Frequency and predictors of confirmed hypoglycaemia in type 1 
and insulin-treated type 2 diabetes mellitus patients in a real-life 
setting: results from the DIALOG study. Diabetes Metab 2015; 41: 
116-25.
13. Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L 
et al. Hypoglycemia and diabetes: a report of a workgroup of the 
American Diabetes Association and The Endocrine Society. Diabetes 
Care 2013; 36: 1384-95.
14. DCCT study group. The effect of intensive treatment of diabetes 
on the development and progression of long-term complications in 
insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86. 
15. Peene B, D’Hooge D, Vandebrouck T, Mathieu C. Patient-reported 
frequency, awareness and patient-physician communication of 
hypoglycaemia in Belgium. Acta Clin Belgica 2014; 69: 439-45. 
16. ADA. Standards of medical care in diabetes – 2017. Diabetes Care 
2017; 40(Suppl 1): 53-4.
17. Jennum P, Stender-Petersen K, Rabol R, Jorgensen NR, Chu PL, 
Madsbad S. The impact of nocturnal hypoglycemia on sleep in 
subjects with type 2 diabetes. Diabetes Care 2015; 38: 2151-7. 
18. Banarer S, Cryer PE. Sleep-related hypoglycemia-associated 
autonomic failure in type 1 diabetes: reduced awakening from sleep 
during hypoglycemia. Diabetes 2003; 52: 1195-203.
19. Lingenfelser T, Renn W, Sommerwerck U, Jung MF, Buettner UW, 
Zaiser-Kaschel H et al. Compromised hormonal counterregulation, 
symptom awareness, and neurophysiological function after recurrent 
short-term episodes of insulin-induced hypoglycemia in IDDM 
patients. Diabetes 1993; 42: 610-8.
20. King P, Kong MF, Parkin H, Macdonald IA, Tattersall RB. Well-being, 
cerebral function, and physical fatigue after nocturnal hypoglycemia 
in IDDM. Diabetes Care 1998; 21: 341-5. 
21. Perlmuter LC, Flanagan BP, Shah PH, Singh SP. Glycemic control and 
hypoglycemia: is the loser the winner? Diabetes Care 2008; 31: 2072-
6. 
22. The diabetes control and complications trial research group. 
Hypoglycemia in the diabetes control and complications trial. 
Diabetes 1997; 46: 271-86.
23. Brod M, Rana A, Barnett AH. Adherence patterns in patients with 
type 2 diabetes on basal insulin analogues: missed, mistimed and 
reduced doses. Curr Med Res Opin 2012; 28: 1933-46.
24. Berkowitz SA, Karter AJ, Lyles CR, Liu JY, Schillinger D, Adler NE et 
al. Low socioeconomic status is associated with increased risk for 
hypoglycemia in diabetes patients: the Diabetes Study of Northern 
California (DISTANCE). J Health Care Poor Underserved 2014; 25: 
478–90.
25. Elliott J, Jacques RM, Kruger J, Campbell MJ, Amiel SA, Mansell P 
et al. Substantial reductions in the number of diabetic ketoacidosis 
and severe hypoglycaemia episodes requiring emergency treatment 
lead to reduced costs after structured education in adults with Type 
1 diabetes. Diabet Med 2014; 31: 847–53.
26. Urbančič Rovan V, Rovan J. An exploration of diabetic foot screening 
procedures data by a multiple correspondence analysis. Zdr Varst 
2017; 56: 65-73.
27. Buzeti T, Djomba JK, Gabrijelčič Blenkuš M, Ivanuša M, Jeriček 
Klanšček H, Kelšin N et al. Health inequalities in Slovenia, 2011. 
Available June 10th, 2017 from: http://www.nijz.si/en/publication-
health-inequalities-in-slovenia
SELF- PERCEIVED STRESS IN RELATION TO ANXIETY, DEPRESSION AND 
HEALTH-RELATED QUALITY OF LIFE AMONG HEALTH PROFESSIONS 
STUDENTS: A CROSS-SECTIONAL STUDY FROM BOSNIA AND HERZEGOVINA
Maja RACIC1*, Radica TODOROVIC2, Nedeljka IVKOVIC1, Srdjan MASIC1, Bojan JOKSIMOVIC1, Milan KULIC1
1University of East Sarajevo, Faculty of Medicine, Department for PC and Public Health, 
Studentska 5, 73300 Foca, Bosnia and Herzegovina 
2Health Center Han Pijesak, Bosnia and Herzegovina
Received: Apr 20, 2017
Accepted: Aug 11, 2017 
Original scientific article
Introduction. The purpose of the present study was to examine self-perceived stress of health professions 
students at the Faculty of Medicine Foča, and to explore its association with anxiety, depression and health-
related quality of life.
Methods. The cross-sectional study enrolled 451 students at the Faculty of Medicine (medicine, dentistry, 
nursing and speech therapy). Survey instruments were distributed at the conclusion of the spring semester 
during the last required lecture for each year and study programme class. Perceived stress was assessed using 
the 14-item Perceived Stress Scale. The students were evaluated for symptoms of depression and anxiety, 
using Zung’s self-assessment inventory for depression and the Spielberger State-Trait Anxiety Inventory (STAI). 
European Quality of Life-5 dimensions were used for describing and evaluating health. Multivariate analyses 
were carried out using logistic regression to examine the relationship between the outcome variable and 
selected determinant factors.
Results. A high degree of stress was reported by 1.6% of students, while the majority of students had either 
moderate (70.6%) or low degree (27.5%) of stress. The significant independent factors associated with perceived 
stress were anxiety score (OR, 0.339; CI 95%, 0.276-0.403) and EQ-5D score (OR, 0.044; CI 95%, 0.033-0.085). A 
high degree of perceived stress (OR, 0.624; CI 95%, 0.507-0.704), the presence of depression (OR, 0.800; CI 95%, 
0.513-1.087), and low quality of life were associated with anxiety (OR, 0.073; CI 95%, 0.018-0.128).
Conclusion. Higher levels of perceived stress predispose health professions students for anxiety and lower 
quality of life. The study programme was not a significant determinant of perceived stress sore.
Uvod. Namen študije je bil preučiti samo-zaznan stres študentov zdravstvenih ved na Medicinski fakulteti Foča 
in raziskati njegovo povezavo z anksioznostjo, depresijo in z zdravjem povezano kakovostjo življenja.
Metode. Presečna študija je vključevala 451 študentov Medicinske fakultete (medicina, zobozdravstvo, 
zdravstvena nega in govorna terapija). Raziskovalna orodja so bila razdeljena ob koncu spomladanskega 
semestra med zadnjimi obveznimi predavanji za vsak letnik in študijski program. Zaznan stres je bil ocenjen 
z uporabo 14-stopenjske lestvice za zaznavanje stresa. Med študenti smo ocenili simptome depresije in 
aksioznosti z uporabo Zungovega vprašalnika za samooceno depresije in orodja Spielbergerjevega vprašalnika 
za oceno anksioznosti (STAI). Za opis in vrednotenje zdravja so bili uporabljeni vprašalniki o kakovosti življenja 
EQ-5D. Za proučevanje povezav med spremenljivko izidov in izbranimi determinantami so bile izvedene 
multivariatne analize z uporabo logistične represije.
Rezultati. O visoki stopnji stresa je poročalo 1,6% študentov, medtem ko je večina študentov poročala o srednji 
(70,6%) ali nizki (27,5%) stopnji stresa. Pomembni neodvisni dejavniki, ki so bili povezani z zaznavanjem stresa, 
so bili rezultati vprašalnika o anksioznosti (OR 0,339; CI 95%, 0,276-0,403) in rezultati vprašalnika EQ-5D 
(OR 0,044; CI 95%, 0,033-0,085). Visoke stopnje zaznanega stresa (OR 0,624; CI 95%, 0,507-0,704), prisotnost 
depresije (OR 0,800; CI 95%, 0,513-1,087) in slaba kakovost življenja so bili povezani z anksioznostjo (OR 0,073; 
CI 95%, 0,018-0,128). 
Zaključek. Višje stopnje zaznanega stresa so predispozicija za anksioznost in nižjo kakovost življenja študentov 
zdravstvenih ved. Študijski program ni bil bistvena determinanta za zaznavanje stopnje stresa.  
ABSTRACT
Keywords: 
assessment, stress, 
anxiety, students, 
quality of life
IZVLEČEK
Ključne besede: 
ocena, stres, 
anksioznost, študenti, 
kakovost življenja
*Corresponding author: Tel: + 387 65 593 714; E-mail: maja.racic@ues.rs.ba
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
251
SAMO-ZAZNAVA STRESA V POVEZAVI Z ANKSIOZNOSTJO, DEPRESIJO 
IN Z ZDRAVJEM POVEZANO KAKOVOSTJO ŽIVLJENJA MED ŠTUDENTI 
ZDRAVSTVENIH VED: PRESEČNA ŠTUDIJA IZ BOSNE IN HERCEGOVINE
Racic M, Todorovic R, Ivkovic N, Masic S, Joksimovic B, Kulic M. Self-perceived stress in relation to anxiety, depression and health-related quality of life among health 
professions students: a cross-sectional study from Bosnia and Herzegovina. Zdr Varst 2017; 56(4): 251-259.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
The beginning of university life represents an important 
period of transition from adolescence to young adulthood 
that could be very often difficult due to interactions 
between individual psychological characteristics and 
common stressors, such as academic demands, changes in 
lifestyle, moving away from home, separating from family, 
inadequate living conditions, physical and emotional 
problems, and financial concerns (1-3). Stress in university 
students may also be related to examination (4), pressure 
of expectation to succeed or to be competitive, and an 
uncertain future (5, 6). Numerous studies analysed the 
correlation between exposure to aforementioned stressors 
and students’ health (7, 8). It has been shown that stress 
has a significant, negative impact on overall health (7-
9) and may cause mental problems, deleterious dietary 
changes (10) as well as generate poor coping skills leading 
to aggressive behaviour and somatic disorders (11). 
Although it is not well-known whether health professions 
education differs from other higher education, it is 
generally considered as highly demanding, and students 
perceive it as a source of significant psychological and 
emotional distress (12-20).
Previous studies have shown that students who chose 
medical profession because they wish to help people have 
greater predisposition to the stress over the students 
driven by professional respect or material benefit (21). 
Besides being exposed to academic-related stress, caused 
by curriculum overload, constant assessments, little time 
available or variable hour shift for clinical rotations (22), 
health professions students also encounter occupational 
stress because they deal with people, their health and 
their lives. In order to reach the personal and professional 
maturity the health professions jobs require, the students 
partake of handling their own mind, attitudes or emotions, 
and coping with the stress in different, sometimes even 
difficult, clinical situations (23). Inadequate teaching 
methods or lack of mentor’s support often unable students 
to adopt required skills, empathy and professionalism 
manners, ultimately leading to poor coping mechanisms 
and greater proneness to stress (24).
Increased perception of stress might be associated 
with moderate level of anxiety, depression symptoms, 
interpersonal sensitivity, frustration and powerlessness 
(25). When associated with anxiety and depression, 
occupational stress, as experienced by the student, can 
influence his or her quality of life and decrease his or her 
academic performance due to anxiety-induced difficult 
cognitive functioning, such as memory disorders, blockage, 
incapacity to make decisions, and increased sensitivity to 
appraisals of others (26, 27). Previous research found that 
the students and residents who frequently experience 
stress, also exhibit higher degree of burnout (20, 28) and 
future professional impairment (29).
As a psychological and physiological state, anxiety 
is considered to be a normal response to stress, but 
prolonged exposure and higher levels of perceived 
stress may lead to adverse consequences, including the 
development of anxiety disorder (30). When experiencing 
high levels of anxiety during their studies, the students 
are frequently inclined to achieve lower quality of total 
performance, which usually makes them feel that the 
situational demands exceed their competences, which 
further deepens perceived stress, ultimately resulting in 
the individual’s psychological distress (31). Situational 
stress, showed to be a factor that elevates state anxiety, 
probably because students realise that they will be judged 
and that their achievements will be compared with the 
achievements of others. Highly trait-anxious students 
often experienced stronger state-anxiety compared to 
low trait-anxious students, which implies that students 
with anxiety tendencies are more predisposed to state 
anxiety in stressful situation (32).
Very little is known about perceived stress among 
health professions students in Bosnia and Herzegovina 
(BiH), especially students of medicine. At the Faculty 
of Medicine, University of East Sarajevo, the study 
programme of medicine still has traditional curriculum. 
The students begin their training with three years of 
pre-clinical course, involving the basic medical sciences. 
This is followed by the three years of clinical courses 
and clinical rotations. Students attend lectures on all 
aspects of medical practice during the whole training. 
The programme is considered demanding, but up to now, 
aspects of study stress and generally students’ health and 
behaviour have not yet been studied much (33). 
The purpose of the present study was to examine perceived 
stress of students at the Faculty of Medicine Foča, and 
to explore its association with anxiety, depression, 
and health-related quality of life. The questions were 
formulated into the following hypothesis. The symptoms 
of depression and anxiety among undergraduate students 
are associated with perceived stress and self-perceived 
health. The perceived stress in students of medicine differs 
from that in the students of similar study programmes, 
such as dentistry, nursing, and speech language therapy.
2 METHODS
2.1 Study Design and Participants
The cross-sectional study was conducted in June 2015. 
Data were collected from 18-year-old students or older 
enrolled in one of four study programmes at the Faculty of 
Medicine (medicine, dentistry, nursing, speech therapy). 
All first-year through sixth-year students (fourth-year for 
nursing and speech therapy) were invited to participate 
in the study. Survey instruments were distributed at the 
conclusion of the spring semester during the last required 
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
252
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
253
The Spielberger State-Trait Anxiety Inventory (STAI) 
was used to evaluate anxiety symptoms. The STAI is 
composed of two different scales: one related to state 
anxiety (STAI-S) and the other to trait anxiety (STAI-T). 
The State Anxiety Scale evaluated a transitory emotional 
state characterised by subjective feelings that may vary 
in intensity over time (transient manifest feelings of 
insecurity.). The Trait Anxiety Scale measured anxiety 
proneness and tendency to perceive a wider range of 
situations as threatening (personality characteristic). 
There are 20 items in each scale that are answered on 
a 4-point Likert scale (36). Two subscales were scored 
separately. The results of the scores were compared with 
scores predetermined for the questionnaire, classifying 
the anxiety levels as low (20 to 34 points); moderate (35-
49 points); and high/serious (≥50).
European Quality of Life-5 dimensions (EQ-5D) was used 
for describing and evaluating health (37). The first part 
of EQ-5D describes five dimensions, namely: 1) mobility, 
2) self-care, 3) usual activity, 4) pain/discomfort, and 5) 
anxiety/depression. For each dimension, there are three 
categories of answers; no problem (0), some problems 
(1) and severe problems (2). The composite score ranges 
from 0 to 10 points. The EQ Visual Analogue Scale (EQ-5D 
VAS) was used as a measure of general self-assessment 
of Health-Related Quality of Life (HRQoL). The students 
were asked to circle the best answers that apply to them 
on the scale from 0 (the worst health imaginable) to 100 
(the best health imaginable). 
2.3 Statistical Analysis
Data analysis was performed using the Software Package 
for Statistical Analysis – The IBM SPSS 21 (Chicago, IL, 
2012). Differences between more than two groups were 
calculated using ANOVA. Multivariate analyses were 
carried out using logistic regression to examine the 
relationship between the outcome variable and selected 
determinant factors. Unadjusted odds ratios (OR) and 
their 95% confidence intervals (CI) were used as indicators 
of the strength of association. A p-value of 0.05 or less 
was used as the cut-off level for statistical significance.
3 RESULTS
The study involved 426 students with the mean age of 
21.5±2.26 years. Most students were female (69.2%), born 
in an urban place (75.8%), and had good financial status 
(86.9%). 
A high degree of stress was reported by 1.6% of students, 
while the majority of students had either a moderate 
(70.6%) or low degree (27.5%) of stress. There was a 
tendency toward higher stress ratings by female students, 
and this was statistically significant (p=0.046). Statistically 
lecture for each year and study programme class. The 
study was extensively introduced to students by research 
assistants. It was explained that the refusal to participate 
in the survey would have no academic consequences. Each 
student received a short description of research objectives 
and paper-and-pencil survey instruments. The survey 
instruments took approximately 15 minutes to complete. 
Responses were anonymous, but survey instruments and 
questionnaires were numbered and collated for data 
analysis. 
Students were informed that by completing the 
questionnaire, they agreed to participate in the study. No 
incentives were provided. 
Out of the total 640 invited students, 451 agreed to 
participate in the survey and complete questionnaires 
(response rate was 70.5%). Twenty-five students were 
excluded from the analysis due to incompletely filled out 
questionnaire. Therefore, the final sample consisted of 
426 students.
The study was conducted according to the principles of 
the Declaration of Helsinki.
2.2 Instruments 
Age, gender, place of birth, financial status and social 
support were surveyed for social background. 
Perceived stress was assessed using the 14-item Perceived 
Stress Scale (PSS) (34). The PSS consists of multiple 
choice questions and measures stressful experiences and 
responses to stress over the previous 4 weeks. Items used a 
4-point Likert scale response format, ranging from ‘never’ 
(0) to ‘very often’ (4). Questions that relate negative 
events or responses were scored in reverse manner. Scores 
were obtained by averaging their responses to all the items 
of the scale. The results of the scores were compared 
with scores predetermined for the questionnaire, and 
were classified as low (15-28), moderate (29-42), and high 
degree of stress (>43). Bosnian translation of the PSS was 
performed employing two independent interpreters. For 
both translations, cases of disagreement were resolved by 
the appropriate researchers, who were native speakers 
in Bosnian and had expertise in research methodology. 
Cronbach alpha value of 0.82 for PSS was found to be 
adequate. 
For the assessment of depressive symptoms, the Zung 
self-rating depression scale was used. The scale consists 
of 20 questions that should be answered according to 4 
statements (most of the time/always/rarely/never). 
The composite score ranges from 20 to 80 points. The 
results were compared with scores predetermined for the 
questionnaire, classifying depressive symptoms as mild 
(45 to 59 points); moderate (60-69 points); and severe 
(≥70). The score ranging from 20 to 44 was considered 
normal (35). 
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
254
significant difference in degree of stress was also found 
between four study programmes. Students of medicine 
reported moderate and high degree of stress more 
frequently as compared to dentistry, speech therapy and 
nursing students (p=0.035). No significant difference was 
detected in the perceived stress degree among different 
years of study (p=0.313) (Table 1). 
The students with moderate and high perceived stress 
degree reported a significantly lower quality of life 
assessed by EQ-5D (p<0.001). However, statistical 
difference between the groups with low, moderate, and 
high degree of perceived stress was not found in general 
self-assessment of HRQoL, as measured with EQ-5D VAS 
(p=0.161) (Table 2).
We compared the frequency of depression symptoms in 
students with different perceived stress degrees. Only 
16 (3.7%) students scored positive for the presence of 
depression (mild), whereby the frequency of symptoms 
increased with the increase of the perceived stress 
Table 1. Degree of perceived stress assessed by 14-item Perceived Stress Scale, depending on different characteristics of examined 
students.
Gender
     Male
     Female
Study program
     Medicine
     Dentistry
     Speech therapy
     Nursing
Year of study
     Y1
     Y2
     Y3
     Y4
     Y5
     Y6
Place of birth
     Urban
     Rural
Financial status
     Good
     Poor
Social support
     Good
     Poor
46 (39.3)
71 (60.7)
29 (27.8)
46 (39.3)
23 (19.7)
19 (16.2 )
41 (35.0)
24 (20.5)
21 (17.9)
11 (9.4)
10 (8.5)
10 (8.5)
91 (77.8)
26 (22.2)
107 (91.5)
10 (8.5)
116 (99.1)
1(0.9)
84 (28.8)
218 (71.2 )
114 (37.7)
73 (24.2)
68 (22.5)
47 (15.6)
120 (39.7)
78 (25.8)
39 (12.9)
21 (7.0)
23 (7.6)
21 (7.0 )
226 (74.8)
75 (24.8)
258 (85.4)
44 (14.6)
292 (96.7)
10 (3.3)
1 (14.3)
6 (85.7)
4 (51.1)
2 (28.6)
1(14.3)
0
1 (14.3)
3 (42.9)
0
0
2 (28.6)
1(14.3)
6 (85.7)
1 (14.1)
5 (71.4)
2 (28.6)
6 (85.7)
1 ( 14.3)
0.046
0.035
0.313
0.892
0.125
0.071
Variable P-value
Perceived stress degree
Low
n (%)
Moderate
n (%)
High
n (%)
degree (p=0.019) (Table 2). Females reported depression 
more frequently compared with their male counterparts 
(p=0.042).
The majority of students reported either mild (50%) 
or moderate (38%) levels of trait anxiety. Similarly to 
depression symptoms, there was an apparent stepladder 
appearance in distribution of trait anxiety levels according 
to perceived stress degree (p<0.001) (Table 2).
The state scale was used to assess how students anticipate 
their feelings in a variety of hypothetical situations. 
Students with higher levels of stress scored higher in 
the Stale Anxiety Scale than the students with low stress 
levels (p<0.001) (Table 2). Unlike trait anxiety, none of 
the students reported state anxiety level as severe.
A weak, statistically significant correlation (r=0.245, 
p<0.001) was found between state and trait anxiety. 
Greater elevation of state anxiety was detected in 
moderate and severe trait-anxious students.
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
255
Table 2. Perceived stress degree of examined students depending on quality of life, depression and anxiety symptoms.
EQ-5D
     no problem
     light difficulties
     moderate difficulties
     severe difficulties
     extreme difficulties
EQ-5D VAS
     0-40
     41-70
     71-100
Depression
     no problem
     mild 
Trait anxiety
     no problem
     mild  
     moderate
     severe
State anxiety
     no problem
     mild  
     moderate
99 (34.3)
14(3.3)
2 (0.5)
2 (0.5)
0
2 (0.5)
6 (1.4)
109 (25.6)
117 (20.5)
0
10 (2.3)
97 (22.8)
10(2.3)
0
117(27.5)
0
0
190 (44.6)
59 (13.8)
25 (5.9)
15 (3.5)
13 (3)
8 (1.9)
38 (8.9)
256 (60.1)
287 (67.4)
15 (3.5)
1 (0.2)
116 (27.2)
149 (35)
36 (8.5)
290 (68.1)
12 (1.8)
0
3 (0.7)
3 (0.7)
0
0
5 (1.1)
0
0
7(1.6)
6 (1.4)
1 (0.2)
0
0
3 (0.7)
4 (0.9)
5(1.2)
1(0.2)
1(0.2)
0.001
0.161
0.019
         
0.001
0.001
Variable P-value
Perceived stress degree
Low
n (%)
Moderate
n (%)
High
n (%)
The multivariate linear regression analysis was used to 
find independent factors associated with the following 
outcome variables: perceived stress score, self-reported 
depression score, self-reported anxiety score, and HRQoL 
score. The results of the analysis presented in Tables 3 
and 4 shows that the sociodemographic factors were not 
associated with any of analysed variables (p>0.05).
The significant independent factors associated with 
perceived stress were trait anxiety (OR, 0.339; CI 95%, 
0.276-0.403, p<0.001) and EQ-5D score (OR, 0.044; CI 
95%, 0.033-0.085, p=0.036). The presence of anxiety was 
the only significant determinant of depression score (OR, 
0.085; CI 95%, 0.054-0.115, p<0.001) (Table 3). EQ-5D 
score was associated with perceived stress degree (OR, 
0.243; CI 95%, 0.16-0.467, p=0.036) and high trait anxiety 
level (OR, 0.220; CI 95%, 0.053-0.386, p=0.010). Poor 
general health assessment was a risk factor for health-
related quality of life (OR, -0.604; CI 95%, -0.833-0.374, 
p<0.001).
Table 3.
Table 4.
Factors associated with perceived stress, depression, and HRQoL score (Multivariate linear regression analysis).
Factors associated with trait and state anxiety score (Multivariate linear regression analysis).
P-value <0.05 is considered significant and bolded.
+Wald Chi-square=392.26, p<0.001; SE (0.133) 
*Wald Chi-square=256.76, p=0.006; SE (0.175)
P-value <0.05 is considered significant and bolded.
*Wald Chi-square=71.546, p<0.001; based on n=393 observations; SE (0.242) 
+Wald Chi-square=19.606, p<0.001; based on n=225 observations; SE (0.334)
º Wald Chi-square=128.627, p<0.001; based on n=426 observations; SE (0.135)
Gender
Age
Study program
Study year
Place of birth
Financial status
Social support
Perceived stress
Depression
Trait anxiety
EQ-5D score
EQ-5D VAS score
Gender
Age
Study program
Perceived stress
Depression
Trait Anxiety
State Anxiety
EQ-5D score
0.076 (-0.012-0.165)
0.019 (-0.098-0.192)
0.019 (-0.021-0.59)
-0.017 (-0.065-0.032)
0.002 (-0.36-0.40)
0.012 (-0.116-0.139)
0.054 (-0.201-0.309)
-
-0.078 (-0.297-0.140)
0.339 (0.276-0.403)
0.044 (0.033-0.085)
0.87 (-0.013-0.187)
0.56 (-0.065-0.176)
-0.003 (-0.051-0.045)
0.039 (-0.093-0.015)
0.624 (0.507-0.740)
0.800 (0.513-1.087)
-
-0.046 (-0.084—0.007)
-0.240 (-0.375-0.106)
0.033 (-0.007-0.072)
0.05 (-0.10-0.21)
-0.002 (-0.20-0.015)
-0003 (-0.024-0.019)
-0.004 (0.092-0.021)
-0.035 (-0.21-0.12)
-0.023 (-0.089-0.136)
-0.015 (-0.058-0.027)
-
0.85 ( 0.054-0.115
0.008 (-0.010-0.026)
-0.36 (-0.88-0.009)
0.061(-0.032-0.003)
-0.015 (-0.026-0.148)
0.022 (-0.108-0.079)
0.696 (0.579-0.812)
-0.081 (-0.298-     0.137)
-0.351 (-0.546--0. 157)
-
-0.018 (-0.009-0.046)
-0.150 (-0.035-0.059)
-0.315 (-0.654-0.025)
-0.014 (-0.108-0.079)
0.042 (-0.073-0.157)
0.023 (-0.67-0.112)
0.226 (-0.075-0.525)
0.067 (-0.533-0.668)
0.243 (0.16-0.467)
0.218 (-0.297-0.734)
0.220 (0.053-0.386)
-
-0.604 (-0.833-0.374)
0.091
0.524
0.352
0.507
0.920
0.858
0.678
0.481
0.000
0.036
0.089
0.365
0.822
0.157
0.000
0.000
-
0.020
0.000
0.102
0.515
0.803
0.803
0.617
0.215
0.686
0.481
-
0.000
0.405
0.115
0.171
0.103
0.256
0.000
0.466
0.002
-
0.187
0.160
0.069
0.764
0.475
0.618
0.139
0.826
0.036
0.405
.010
-
.000
Factor
Factor
Perceived stress score*
Perceived stress score*
Depression+
Depression+
Health-related quality of lifeº
OR 
(95% CI)
OR 
(95% CI)
OR 
(95% CI)
OR 
(95% CI)
OR 
(95% CI)
P
P
P
P
P-value
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
256
A high degree of perceived stress (OR, 0.624; CI 95%, 
0.507-0.704, p<0.001), the presence of depression (OR, 
0.800; CI 95%, 0.513-1.087, p<0.001), and low quality of 
life were predictors of the trait anxiety (OR, 0.073; CI 
95%, 0.018-0.128, p=0.020). State anxiety was a strong 
risk factor for trait anxiety (OR, 0.046; CI 95%, -0.084-
0.007, p<0.001).
Perceived stress degree had a significant impact on the 
state anxiety level (OR, 0.696; CI 95%, 0.579-0.812, 
p<0.001) among Bosnian health professions students. A 
significant association was found between trait and state 
anxiety score (OR,-0.351; CI95%, -0.546--0.157, p=0.002).
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
257
4 DISCUSSION
The current study was conducted to assess the perceived 
stress and its association with anxiety, depression, and 
HRQoL in health professions students. As presented in 
Table 2, the majority of students perceived moderate 
stress (70.6%) and only 1.6% of them perceived a high 
degree of stress. This is consistent with the results of other 
studies demonstrating that university students around the 
globe are exposed to high levels of stress (38, 39). The 
reported prevalence of perceived stress among health 
professions students ranged from 31.2% in the United 
Kingdom (12) to 83.9% in Australia (39). This difference 
in the prevalence between the countries is considered to 
be the result of culturally different perception of stress 
or stressful event, but also of environmental factors, such 
as economic burden of studying, very high tuition fees, 
lack of family support, and higher or lower ‘readiness’ to 
report the stress or any other complaint (7). 
Perceived stress was significantly associated with anxiety 
levels in the current study (Table 3 and 4), and was an 
independent determinant of both, state and trait anxiety. 
This is in line with the study of Bunevicius et al., showing 
independent association of anxiety symptoms with higher 
vulnerability to stress and lower level of emotional 
stability in medical students (40). High, significant 
correlation between perceived stress and anxiety level 
was also found in the study of Heinen at al., conducted 
on the sample of 385 first-year medical students (19), as 
well as in the studies carried out among dentistry (41) and 
nursing students (42). High trait-anxiety could have led to 
greater sensitivity to stress because of students’ attention 
being aimed toward threats to self-worth and self-esteem 
(43), while negative relationship between state and trait 
anxiety might have exacerbated the encumbrance of 
manifest anxiety (32). The results of the aforementioned 
research emphasise that counselling focusing on anxiety 
during health profession education might be a possible 
option for stress reduction. The autogenous training and 
progressive muscle relaxation showed to be effective in 
reducing trait and state anxiety levels in medical students 
(44).
Although ANOVA analysis showed that the frequency of 
depression symptoms increased with the increase of stress 
(Table 2), the association between self-rated depression 
and perceived stress was not found, as presented in Table 
3. This is contrary to several other studies reporting very 
strong associations between these two outcome variables 
(10, 26, 45). However, merely 3.7 % of students examined 
here fulfilled the criteria for self-rated depression, in 
all cases it was rated as mild, which could explain why 
depression was not found to be the determinant of 
perceived stress. 
A strong association was found between trait anxiety and 
depression score (Tables 3 and 4). Living in a constant state 
of anxiety can make the individual feel there is no hope 
for ever getting better and that life is not good, which 
creates a direct path to depression. Having depression 
during undergraduate studies can cause academic, 
psychosocial, physical, or academic related hindrances, 
as it is has been previously detected (46). 
Regarding the role of quality of life, its relatedness to 
perceived stress, trait anxiety, and self-assessment of 
general health was demonstrated in the current study 
(Table 3). A portrait of stress levels and HRQoL has been 
provided in previous analyses, accentuating that higher 
vulnerability to stress in health professions students 
may be a predisposing risk factor for mental distress and 
poor physical heath (47). Our findings further support 
the necessity of providing predisposed students with 
programmes to alleviate their stress and boost their 
overall health (47).
ANOVA analysis showed higher levels of perceived stress 
in females than in males, and in medical students than 
in those of other programmes (Table 2). However, in a 
multivariate regression analysis neither gender nor study 
programme appeared as significant independent factors 
associated with perceived stress (Table 3). No association 
between gender and perceived stress was also reported in 
studies from Norway (48) and Germany (49), but studies 
from Sweden (14), Ethiopia (45), and Middle East (50) 
reported gender difference regarding stress perception. 
Different results in the studies may be subjected to a 
different degree of female discrimination, community 
pressure, and cultural habits. 
The perceived stress in students of medicine did not differ 
from that in the students of dentistry, nursing, and speech 
language therapy. Controversial results were published on 
the relationship between health professions programmes 
of study and students’ stress perception. Some found 
higher incidence of stress in medical students than in 
dental and nursing students (51), but the other reported 
lower stress levels in medical than in dental students (52, 
53). These inconsistent findings indicate that in addition 
to the study programme, there are other independent 
factors that might increase one’s proneness to stress.
4.1 Limitations of the Study
The current study has several limitations. The results 
may not be generalised, as the study was conducted in 
health professions students of one faculty of medicine, 
the socio-demographic structure of which was not 
necessarily the same as at the other faculties in Bosnia 
and Herzegovina. This was a cross-sectional study that 
assessed perceived stress degree of students at one point 
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
258
in time. The association between stress and academic 
performance was not analysed, although it would be 
interesting and important. Future research should be 
directed towards identifying personal and occupational 
stressors that contribute the most to the stress, as well 
as possible intervention to help students cope with them 
better. Longitudinal study through study years could show 
changes in perceived stress over time. Studies to identify 
factors that may mediate the relationship between 
perceived stress and depression in health professions 
students have to be conducted.
4.2 Study Implications
Decision-makers in academic programmes should focus 
more on students’ well-being and provision of counselling 
services, which could help the students to effectively 
cope with, and manage the stress. These programmes 
will provide the opportunity to identify the students 
who are at greatest risk for psychological maladjustment 
during undergraduate training, and protect them against 
negative effects of stress, such as development of anxiety 
or depression.
Less stressful learning environment should be created, 
and help-seeking behaviour promoted. Starting a high-
impact mentoring programme could potentially improve 
social support and affect perceived stress levels. Medical 
education should encourage resilience against stress, by 
increasing and maintaining empathy throughout whole 
undergraduate studies (54, 55).
 
5 CONCLUSION
Higher levels of perceived stress predispose students for 
anxiety and lower HRQoL. Although medical students 
reported higher levels of stress compared to the students 
of dentistry, nursing, and speech language therapy, the 
study programme was not a significant determinant of 
perceived stress score. The screening of stress among 
health professions students should become a regular 
practice, and those students experiencing high levels of 
stress should be undergoing screening for anxiety and 
depression. Interconnection of stress, trait and state 
anxiety, and HRQoL merits further investigation and 
development of appropriate interventions. 
ACKNOWLEDGMENT
The authors wish to thank Prof. Ljubica Đukanović for 
editing the text.
CONFLICTS OF INTEREST 
The authors declare that no conflicts of interest exist.
FUNDING 
No funding has been received for the conduction of this 
study and preparation of the manuscript.
ETHICAL APPROVAL 
The research protocol was approved for each survey by 
the Ethical Committee of the Faculty of Medicine Foča. 
All personal data were anonymised.
REFERENCES
1. Baumann M, Ionescu I, Chau N. Psychological quality of life and 
its association with academic employability skills among newly 
registered students from three European faculties. BMC Psychiatry 
2011; 11: 63.
2. Legleye S, Beck F, Peretti-Watel P, Chau N, Firdion JM. Suicidal 
ideation among French young adults: association with occupation, 
family, personal background and drug use. J Affect Disord 2010; 123: 
108-15.
3. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A 
et al. Cross-national prevalence and risk factors for suicidal ideation, 
plans and attempts. Br J Psychiatry 2008; 192: 98-105.
4. Murphy L, Denis R, Ward CP, Tartar JL. Academic stress differentially 
influences perceived stress, salivary cortisol, and immunoglobulin-A 
in undergraduate students. Stress 2010; 13: 365-70.
5. Chew-Graham CA, Rogers A, Yassin N. ‘I wouldn’t want it on my CV 
or their records’medical students’ experiences of help-seeking for 
mental health problems. Med Educ 2003; 37: 873-80. 
6. Yusoff MS, Abdul Rahim AF, Baba AA, Ismail SB, Mat Pa MN, Esa AR. 
Prevalence and associated factors of stress, anxiety and depression 
among prospective medical students. Asian J Psychiatr 2013; 6: 128-
33.
7. El Ansarni W, Oskrochi R, Haghgoo G. Are students’ symptoms and 
health complains associated with perceive stress at the university?: 
perspectives from United Kingdom and Egypt. Int J Environ Res 
Public Health 2014; 11: 9981-10002.
8. Sundblad GB, Jansson A, Saartok T, Renstrom P, Engstrom LM. Self-
rated pain and perceived health in relation to stress and physical 
activity among school-students: a 3-year follow-up. Pain 2008; 136: 
239-49.
9. Piko B, Piczil M. Study of stress, coping and psychosomatic health 
among baccalaureate nurses to-be. Orv Hetil 2012; 153: 1225-33.
10. Eisenberg D, Speer N, Hunt JB.  Attitudes and beliefs about treatment 
among college students with untreated mental health problems. 
Psychiatr Serv 2012; 63: 711-13.
11. Niemi SM, Levoska S, Rekola KE, Keinanen-Kiukaanniemi S. Neck 
and shoulder symptoms of high school students and associated 
psychosocial factors.  J Adolesc Health 1997; 20: 238-42.
12. Firth-Cozens J. Medical students stress. Med Educ 2001; 35; 6-7.
13. Jeong Y, Kim JY, Ryu JS, eun Lee K, Ha EH, Park H. The association 
between social suport, health-relatedbehaviors, socioeconomic 
status and depression in medical students. Epidemiol Health 2010; 
32: e2010009.
10.1515/sjph-2017-0034 Zdr Varst 2017; 56(4): 251-259
259
14. Dahlin M, Joneborg N, Runeson B. Stress and depression among 
medical students: a cross-sectional study. Med Educ 2005; 39: 594-
604.
15. Rahimi B, Baetz M, Bowen R, Balbuena L. Resilience, stress, and 
coping among Canadian medical students. Can Med Educ J 2014; 5: 
e5–12.
16. Matheson KM, Barrett T, LandineB, Alan McLuckie, Li-WehSoh N, 
Walter G. Experiences of psychological distress and sources of stress 
and support during medical training: a survey of medical students. 
Acad Psychiatry 2016; 40: 63-8.
17. Sandover S, Jonas-Dwyer D, Marr T. Graduate entry and undergraduate 
medical students study approaches, stress levels and ways of coping: 
a five year longitudinal study. BMC Med Educ 2015; 15: 5. 
18. Ludwig AB, Burton W, Weingarten J, Milan F, Kligler B. Depression 
and stress amongst undergraduate medical students. BMC Med Educ 
2015; 15: 141-5.
19. Heinen I, Bullinger M, Kocalevent RD. Perceived stress in first 
year medical students - associations with personal resources and 
emotional distress. Med Educ 2017; 17: 4.
20. Krokter Kogoj T, Cebasek-Travnik Z, Zaletel-Kragelj L. Role of stress 
in burnout among students of medicine and dentistry – a study in 
Ljubljana, Slovenia, Faculty of Medicine. Coll Antropol 2014; 3: 
879–87.
21. Crumpei I, Dafinoiu I. Secondary traumatic stress in medical students. 
Procedia Soc Behav Sci 2012; 46: 1465-9.
22. Kuhn L, Kranz PL, Koo F, Cossio G, Lund NL. Assessment of stress in 
physician assistant students. J Instruct Psych 2005; 32: 167-77.
23. Nechita F, Strba CT, Vere CC, Nechita D, Rogoveanu I. Stress in 
Romanian first year nursing students. Curr Health Sci J  2014; 40: 
210-13.
24. Firth J. Levels and sources of stress in medical students. Br Med J 
(Clin Res Ed) 1986; 292: 1177-80.
25. Firth J, Mamo C, Buttigieg R, Vassallo D, Azzopardi L. Psychological 
stress amongst Maltese undergraduate medical students. Int J Collab 
Res Internal Med Public Health 2012; 4: 840-9.
26. Mikolajzyk RT, Maxwell AE, Naydenova V, Meier S, El Ansari W. 
Depressive symptoms and perceived burdens related to being 
student: survey in three European countries. Clin Pract Epidemiol 
Ment Health  2008; 4: 19.
27. Nechita F, Nechita D, Prilog MC, Rogoveanu I. Stress in medical 
students. Rom J Morphol Embryol 2014; 55: 1263-6.
28. Selič P, Stegne Ignjatovic T, Klemens-Ketis Z. Burnout among 
Slovenian family medicine trainees: a cross sectional study. Zdrav 
Vest 2012; 81: 218-24.
29. Henning K, Ey S, Shaw D. Perfectionism, the impostor phenomenon 
and psychological adjustment in medical, dental, nursing and 
pharmacy students. Med  Edu 1998; 932: 456-64.
30. Wiegner L, Hange D, Björkelund C, Ahlborg G Jr. Prevalence of 
perceived stress and associations to symptoms of exhaustion, 
depression and anxiety in a working age population seeking primary 
care - an observational study. BMC Fam Pract 2015; 16: 38.
31. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and 
disease. JAMA 2007; 298: 1685-7.
32. Meijer J. Stress in the relation between trait and state anxiety. 
Psychol Rep 2001; 88: 947-64.
33. Kulić M. Dvadeset godina Medicinskog fakulteta u Foči. Foča: 
Medicinski fakultet, 2013.
34. Cohen S, Kamarck T, Marmelstein R. A global measurement of 
perceived stress. J Health Soc Behav 1983; 24: 385-96.
35. Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965; 
12: 63-70.
36. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual 
for state-trait anxiety inventory. Palo Alto: Consulting Psychologist 
Press, 1983.
37. The EuroQol Group. EuroQol – a new facility for the measurement of 
health-related quality of life. Health Policy 1990; 16: 199-208.
38. Stewart-Brown S, Evans J, Patterson J, Petersen S, Doll  H, Balding 
J et al. The health of students in institutes of higher education: an 
important and neglected public health problem.  J Public Health 
Med 2000; 22: 492.
39. Stallman HM. Psychological distress in university students: a 
comparison with general population data. Aust Psychol 2010; 45: 
249-57.
40. Bunevicius A, Katkute A, Bunevicius R. Symptoms of anxiety 
and depression in medicalstudents and in humanities students: 
relationship with big-five personality dimensions and vulnerability to 
stress. IJSP 2008; 54: 494-501.
41. Harris M, Wilson JC, Holmes S, Radford DR. Perceived stress and 
well-being among dental hygiene and dental therapy students. Br 
Dent J 2017; 27, 222: 101-1.
42. Chernomas WM, Shapiro C. Stress, depression, and anxiety among 
undergraduate nursing students. Int J Nurs Educ Scholarsh 2013; 10. 
43. Covington MV. Making the grade: a self-worth perspective on 
motivation and school reform. Cambridge, UK: Cambridge University 
Press, 1992.
44. Wild K, Scholz M, Ropohl A, Brauer L, Paulsen F, Burger PH. Strategies 
against  burnout and anxiety in medical education - implementation 
and evaluation of a new course on relaxation techniques (Relacs) for 
medical students. PLoS One 2014; 9: e114967.
45. Madebo WE, Yosef TT, Tesfaye MS. Assessment of perceived stress 
level and associated factors among health care students at Debre 
Birehane University, North Shoa Zone of Amgara Region, Ethiopia. 
HCCR 2016; 4: 2.
46. Pidgeon AM, McGrath S, Magya HB, Stapleton P, Lo BCY. Psychosocial 
moderators of perceived stress, anxiety and depression in university 
students: an international studies. Open J Soc Sci 2014; 2: 23-31.
47. Geslani GP, Gaebelein CJ.  Perceived stress, stressors, and mental 
distress among doctor of pharmacy students. Soc Behav Pers 2013; 
41: 1457-68.
48. Bramness JG, Fixdal TC, Vaglum P. Effect of medical school stress 
on the mental health of medical students in early and late clinical 
curriculum. Acta Psychiatr Scand 1991; 84: 340–5.
49. Kocalevent RD, Hinz A, Brahler E, Klapp BF. Regional and 
individual factors of stress experience in Germany: results of a 
representative survey with the perceived stress questionnaire (PSQ). 
Gesundheitswesen 2011; 73: 829–34.
50. Abdulghani HM, Al Kanhal AA, Mahmoud ES, Ponnamperuma GG, 
Alfaris EA. Stress and its effects on medical students: a cross-
sectional study at a college of medicine in Saudi Arabia. J Health 
Popul Nutr 2011; 29: 516-22.
51. Dutta AP, Pyles MA, Miederhoff PA. Stress in health professions 
students: myth or reality?: a review of the existing literature. J Natl 
Black Nurses Assoc 2005; 16: 63-8.
52. Birks Y, McKendree J, Watt I. Emotional intelligence and perceived 
stress in healthcare students: a multi-institutional, multi-
professional survey. BMC Med Educ 2009; 9: 61-7. 
53. Murphy RJ, Gray SA, Sterling G, Reeves K, DuCette J. A comparative 
study of professional student stress. J Dent Educ 2009; 73: 328-37.
54. Park KH, Kim DH, Kim SK, Yi YH, Jeong JH, Chae  J et al.  The 
relationships between empathy, stress and social support among 
medical students. Int J Med Educ 2015; 6: 103–8.
55. Petek-Ster M, Selic P. Assessing empathic attitudes in medical 
students: the re-validation of the Jefferson Scale of Empathy - 
student version report. Zdr Varst 2015; 54: 282-92.
VALIDATION OF THE SLOVENIAN VERSION OF MULTIPLE SCLEROSIS QUALITY 
OF LIFE (MSQOL-54) INSTRUMENT
Biljana STERN1, Tanja HOJS FABJAN1, Ksenija RENER-SITAR2, Lijana ZALETEL-KRAGELJ3*
1University Medical Centre Maribor, Department of Neurologic Diseases, Ljubljanska 5,  2000 Maribor, Slovenia
2University of Ljubljana, Faculty of Medicine, Department of Prosthodontics, Hrvatski trg 8, 1000 Ljubljana, Slovenia
3University of Ljubljana, Faculty of Medicine, Department of Public Health, Zaloška 4, 1000 Ljubljana, Slovenia
Received: Feb 17, 2017
Accepted: Aug 22, 2017 
Original scientific article
Purpose. To cross-culturally adapt and validate Multiple Sclerosis Quality of Life-54 (MSQOL-54) instrument.
Methods. The study which enrolled 134 Slovenian multiple sclerosis (MS) patients was conducted from March 
to December 2013. The internal consistency of the MSQOL-54 instrument was evaluated by Cronbach’s alpha 
coefficient (α), and its dimensionality assessed by the principal component analysis (PCA).
Results. The whole instrument had high internal consistency (α=0.88), as well as the majority of its twelve 
subscales (α=0.83-0.94). The results of the PCA showed two components with eigenvalue greater than 1, 
explaining 59.4% of the cumulative variance. Further results indicated good construct validity of the instrument 
with the physical health-related-quality-of-life subscales loading highly on the physical component, and mental 
health-related-quality-of-life subscales loading highly on the mental component.
Conclusion. The Slovenian version of the MSQOL-54 instrument proved to be an internally consistent and 
accurate tool, well accepted by the Slovenian MS patients. The adequate psychometric properties warrant 
the scientifically sound version of the MSQOL-54 instrument, which is from now on at disposal to all health 
professionals dealing with MS patients in Slovenia.
Namen. Medkulturno prilagoditi in potrditi Vprašalnik o kakovosti življenja pri multipli sklerozi (MSQOL-54).
Metode. Študija, ki je vključevala 134 slovenskih bolnikov z multiplo sklerozo (MS), je potekala od marca do 
decembra 2013. Notranja skladnost prevedenega vprašalnika je bila ocenjena s Cronbachovim koeficientom 
alfa (α), njegova dimenzionalnost pa z analizo glavnih komponent (AGK).
Rezultati. Prevedeni vprašalnik kot celota je imel visoko notranjo skladnost (α=0,88), prav tako tudi večina 
njegovih dvanajstih podlestvic (α=0,83-0,94). Rezultati AGK so pokazali na dve pomembni komponenti, s 
katerima je moč pojasniti 59,4% skupne variance. Rezultati so pokazali tudi dobro konstruktno veljavnost 
instrumenta, saj so se podlestvice, ki merijo telesno komponento z zdravjem povezane kvalitete življenja 
dobro skladale s telesno komponento, ugotovljeno v analizi, podlestvice, ki merijo duševno komponento z 
zdravjem povezane kvalitete življenja, pa dobro z duševno komponento, ugotovljeno v analizi.
Zaključek. Slovenska različica MSQOL-54 se je izkazala za notranje skladno in natančno orodje, ki so ga 
slovenski bolniki z MS dobro sprejeli. Ustrezne psihometrične lastnosti kažejo na znanstveno zanesljivo različico 
instrumenta MSQOL- 54, ki je zdaj na razpolago vsem zdravstvenim delavcem, ki se v Sloveniji ukvarjajo z 
bolniki z MS.
ABSTRACT
Keywords: 
multiple sclerosis, 
MSQOL-54 instrument, 
reliability, validity, 
Slovenia
IZVLEČEK
Ključne besede: 
multipla skleroza, 
vprašalnik MSQOL-54, 
zanesljivost, 
veljavnost, Slovenija
*Corresponding author: Tel: + 386 31 662 592; E-mail: lijana.zaletel-kragelj@mf.uni-lj.si
Zdr Varst 2017; 56(4): 260-267
POTRDITEV SLOVENSKE VERZIJE VPRAŠALNIKA O KAKOVOSTI 
ŽIVLJENJA PRI MULTIPLI SKLEROZI (MSQOL-54)
Stern B, Hojs Fabjan T, Rener-Sitar K, Zaletel-Kragelj L. Validation of the Slovenian version of Multiple Sclerosis Quality of Life (MSQOL-54) instrument. 
Zdr Varst 2017; 56(4): 260-267.
10.1515/sjph-2017-0035
260
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
Multiple sclerosis (MS) is a chronic neurological disease 
complexly deteriorating the health of the patients (1). 
According to the World Health Organisation MS is classified 
among major public health problems (2) and in Europe, it 
is considered the leading cause of non-traumatic disability 
in young adults (3). The effect of disability in daily living 
is reported to be greater in comparison to other chronic 
diseases (4-6). 
The impact of MS on health has been determined mainly 
through the physical disability measures over the past 
years. The gold standard for assessing physical disability 
in clinical settings has been the Kurtzke’s Expanded 
Disability Status Scale (EDSS) (7). However, health has 
not only the physical component, but is rather a state 
of complete physical, mental, and social well-being (8). 
Conventional physical disability scales omit mental and 
social health dimensions that substantially contribute 
to the patient’s overall quality of life. Moreover, the 
difficulties which are perceived important by patients 
substantially differ from those ones which doctors assess 
based on physical disability measures (9). Health-related-
quality-of-life (HRQoL) instruments are increasingly 
recognized as indispensable tools for clinicians, not only 
to systematically assess patients’ self-perceived HRQoL, 
but also to tailor care and therapy programmes according 
to the patient’s individual needs (10), which is a novel 
treatment approach in the increasingly important new 
field of medicine, i.e. a personalised medicine. Patient-
reported outcomes are also known to improve a patient-
doctor communication, because the patients receive a 
positive signal that the physicians are interested in an 
array of issues concerning their illness, which, in turn, 
makes them feel understood. In addition, the patients 
are empowered being able to participate in the decision-
making process related to the personalized treatment 
approach (5).
There exist a wide range of instruments for measuring 
the HRQoL concept. The generic ones are applicable to 
different populations and allow comparisons among them, 
but they do not address specific areas of concern to specific 
population groups, e.g. MS patients. The instrument 
Multiple Sclerosis Quality of Life-54 (MSQOL-54) was the 
first disease-specific HRQoL instrument which included 
items covering specific MS symptoms and signs (11). This 
instrument captures the whole burden experienced by MS 
patients and provides a more complete picture of their 
health and well-being (1). The instrument was initially 
developed in the US in the English language, and ever 
since it has been adapted to, and validated in numerous 
other languages (12-20). 
Information about the burden of MS in Slovenia is sparse. 
The existing data showed the prevalence of 83/100,000 in 
early 1990s (3), while the newest available data showed 
even higher prevalence (>100/100,000) (21), classifying 
Slovenia among countries with the highest prevalence 
worldwide. In addition, due to a long life-span, the 
disability burden of the Slovenian MS patients is even 
higher nowadays (22). 
To our knowledge, the HRQoL construct was not assessed 
among Slovenian MS patients yet, and no translated, 
adapted, and psychometrically sound Slovenian version 
of MSQOL-54 exists. So far, only two generic instruments 
measuring HRQoL were translated into Slovenian language 
and psychometrically tested, i.e. the generic SF-36 
instrument (23) and the EQ-5D instrument (24).
It is very important for clinical as well as for research 
purposes to know whether the psychometric instrument 
reliably and validly measures what it intends to measure 
in each specific population within a specific culture.
Therefore, the aim of the present study was to prepare 
a valid Slovenian translation of the MSQOL-54 instrument 
for measurement of HRQoL of Slovenian MS patients in 
a context of a salutogenic approach to this vulnerable 
population group. In this frame, the objectives of the 
study were a forward-backward translation and linguistic 
validation of MS-18 module as well as psychometric testing 
of the complete MSQOL-54 instrument.
2 METHODS
The present cross-sectional study, in which the 
methodological approach similar to other comparable 
studies was used (12,14-19,25,26), was a part of a larger 
research project on the impact of the sense of coherence 
on quality of life and self-rated health in MS patients in 
Slovenia. In this project, it was planned to measure the 
quality of life with the MSQOL-54 instrument. Before 
using it for this purpose, the instrument was required to 
be validated in the observed population.
2.1 Observed Population
Out of all consecutive 207 patients, scheduled for a 
regular follow-up at the Department of Neurology of the 
University Clinical Centre Maribor between March and 
December 2013, all those who met the inclusion criteria, 
being the diagnosis of MS according to McDonald’s criteria 
(27) and age 18+ years, were invited to participate in the 
study. Exacerbation of MS in the period of 30 days prior 
the scheduled neurological examination (a current, on-
going active phase of the disease) and co-existing other 
chronic diseases were considered as exclusion criteria 
(12, 16-19). 
10.1515/sjph-2017-0035 Zdr Varst 2017; 56(4): 260-267
261
262
10.1515/sjph-2017-0035 Zdr Varst 2017; 56(4): 260-267
2.2 Translation and Linguistic Validation
2.2.1 Description of MSQOL-54 Instrument
The MSQOL-54 is an instrument, developed by the UCLA 
Department of Neurology (28), created by adding 18 
items relevant to MS patients, i.e. MS-18 module, to 
the generic HRQoL instrument, i.e. the Short-Form-36 
Health Survey (SF-36) (11, 29). The instrument has 
two main dimensions and several sub-dimensions (28); 
consequently, it is comprised of 12 subscales (physical 
health, role limitations due to physical problems, role 
limitations due to emotional problems, pain, emotional 
well-being, energy, health perceptions, social function, 
cognitive function, health distress, sexual function, the 
overall quality of life) and two single-item measures 
(change in health, satisfaction with sexual function) (28). 
These subscales are summarized into the two summary 
composite scores: the physical health composite score 
(PHC) (comprised of physical health, role limitations due 
to physical problems, pain, energy, health perceptions, 
social function, health distress and sexual function 
subscales) and the mental health composite score (MHC) 
(comprised of role limitations due to emotional problems, 
emotional well-being, cognitive function, health distress 
and the overall quality of life subscales) (28).
2.1.2 The Translation into the Slovenian Language
After obtaining the written permission of the author of 
the original MS-18 module, two well-qualified translators 
performed the translation of this module into Slovenian. 
The translators were certified, bilingual, bicultural, 
with distinct professional backgrounds, the first being 
a professional literary translator and the second one a 
professional medical translator. A single preliminary draft 
was synthesized from the two forward translations by a 
group consisting of the members of the narrower research 
team (all of them being physicians), nurses, specialized 
in care for MS patients, MS patients, and translators. 
Afterwards, a certified translator, native in English, who 
had never seen the original English instrument, translated 
the preliminary version back into English. 
Finally, the aforementioned group compared the original 
and the back-translated version to identify semantic and 
conceptual discrepancies. Subsequently, the differences 
between the original and the translated versions were 
addressed in a group discussion by using the method of 
voting and ranking. The solutions with the highest total 
ranking were accepted in the final version. This stage 
led to the Slovenian version of MS-18 module which 
was linguistically most equivalent to the original. The 
Slovenian version of MSQOL-54 was created by adding the 
Slovenian SF-36 questionnaire (23) to the linguistically 
adapted Slovenian MS-18 module.
2.3 Administration of the Instrument and Other Data 
Acquisition
In the presence of the neurology resident and two MS 
nurses, each participant completed the Slovenian version 
of MSQOL-54 instrument. Assistance in reading, writing, 
and explanation was provided, if required. 
Along with the MSQOL-54 instrument the socio-
demographic data (gender: male, female; age; education: 
primary, secondary, college or higher; employment status: 
employed, unemployed, retired; marital status: single, 
married/cohabiting; area of living: rural, urban) were 
also collected. The clinical data, i.e. the MS duration in 
years, the disease course (primary progressive, secondary 
progressive, relapsing-remitting), clinical worsening of 
MS in the past year prior the neurological examination, 
excluding the period of 30 days prior the examination (a 
relapse of relapsing-remitting type of MS or an increase 
of the EDSS score by 1 point in progressive type of MS; 
yes, no), the immunomodulatory therapy (yes, no), and 
the EDSS score were extracted from the patients’ medical 
records.
2.4 Acceptability of the Instrument
Acceptability was assessed by estimating the mean 
time-to-complete the questionnaire (recommended 
administration time 11-18 min (30)), the percentage of 
missing data, and the assistance required by the patients 
in terms of reading, writing, or explanation of the 
questionnaire’s items. 
2.5 Psychometric Validation
The Expectation-Maximization technique was used to 
replace the missing values, and the descriptive statistics 
to describe the study participants’ characteristics. 
In order to assess the instrument’s reliability, the internal 
consistency was assessed by calculating the Cronbach’s 
alpha coefficient (α), ranging from 0-1, the latter 
meaning perfect internal consistency. The instrument was 
considered as internally consistent, if α≥0.70 (31).
In order to assess the construct validity, the dimensionality 
of the instrument was assessed by conducting the principal 
component analysis (PCA) on 12 instrument subscales with 
varimax orthogonal rotation (32). A preliminary analysis 
concerning the data screening, assumption testing and 
sampling adequacy was performed using the Kaiser-
Meyer-Olkin (KMO) statistic with appropriate values 
>0.5 and the Bartlett’s sphericity test with p≤0.05. The 
components with associated eigenvalues >1 were retained 
in the analysis. Component loadings were used to indicate 
the inclusion of variables into the separate components.
SPSS statistical software version 19.0 was used as 
statistical tool (SPSS Inc., Chicago, IL, USA).
10.1515/sjph-2017-0035 Zdr Varst 2017; 56(4): 260-267
263
3 RESULTS
3.1 Study Group Characteristics
Out of 207 MS patients initially considered for inclusion, 
134 were finally enrolled in the study, while 73 did not 
meet inclusion criteria: 55 (75.3%) had comorbidity, 2 
(2.7%) had a recent exacerbation of MS, and 16 (21.9%) 
refused to participate in the study. 
Among participants, there were 42 males (31.3%) and 92 
(68.7%) females. The mean age was 43.2±11.1 years (age 
range: 21-72 years). All other participants’ characteristics 
are presented in the Table 1. 
Table 1.
Table 2.
Characteristics of the multiple sclerosis (MS) patients for 
validation of the Slovenian version of Multiple Sclerosis 
Quality of Life-54 questionnaire (n=134).
The total number and percentage of missing answers 
within a subscale/single item measure in the Slovenian 
version of Multiple Sclerosis Quality of Life-54 
questionnaire validation study.
LEGEND: Q1 – the first quartile; Q3 - the third quartile; *- clinical 
worsening of the disease in the past year prior the neurological 
examination, excluding the period of 30 days prior the examination 
(a relapse of relapsing-remitting type of MS or an increase of the 
EDSS score by 1 point in progressive type of MS; EDSS - Expanded 
Disability Status Scale score
Education
Employment status
Marital status
Area of living
Disease duration 
(years)
Disease course
Clinical worsening 
of the disease*
Immunomodulatory 
therapy
EDSS
Subscales
Physical health
Role limitations due 
to physical problems
Role limitations due 
to emotional problems
Pain
Emotional well-being
Energy
Health perceptions
Social function
Cognitive function
Health distress
Sexual function
Overall quality of life
Single-item measures
Change in health
Satisfaction with 
sexual function
Primary 
Secondary
College or higher
Employed
Unemployed
Retired
Single
Married/
cohabiting
Rural
Urban
Primary 
progressive
Secondary 
progressive 
Relapsing-
remitting
Yes
No
Yes
No
10
4
3
3
5
5
5
3
4
4
4
2
1
1
17
11
6
5
15
10
6
7
5
4
16
4
1
5
1323
525
396
397
655
660
664
395
531
532
520
264
133
129
1.3
2.1
1.5
1.2
2.2
1.5
0.9
1.7
0.9
0.8
3.0
1.5
0.8
3.7
16 (11.9)
94 (70.1)
24 (17.9)
63 (47.0)
18 (13.4)
53 (39.6)
44 (32.8)
90 (67.2)
80 (59.7)
54 (40.3)
8; 0-33; 4-12.25
  6 (4.5)
  23 (17.2)
105 (78.4)
51 (38.1)
83 (61.9)
92 (68.7)
42 (31.3)
3.0; 0.0-8.0; 1.625-4.5
Category
N of 
items
N of 
missing 
answers
Total N of 
answers
% of 
missing 
answers
Characteristic
Subscale/Item
No. (%)/
Median; Min-Max; 
Q1-Q3
3.2 Acceptability Analysis Results
The average time to complete the questionnaire was 
15.9±8.9 minutes. Most of the participating patients 
(94.8%) did not require additional explanation of the 
translated items. Thirty-two patients (23.9%) needed 
assistance in reading and writing due to the visual or 
upper extremity impairments. The percentage of missing 
data was generally low, ranging from 0.8% to 3.7% (Table 
2).
3.3 Psychometric Validation Results
3.3.1 Reliability
The whole instrument had a high internal consistency 
(α=0.88), as well as the majority of the separate subscales. 
Exceptions were the health perception, and the social 
function subscales (Table 3).
3.3.2 Validity
The KMO statistic verified a sampling adequacy for the 
analysis (KMO=0.88), and the Bartlett’s test indicated 
sufficiently large correlations between the subscales 
for the PCA (p<0.001). The results of the PCA showed 
that only the first two components had the eigenvalues 
exceeding 1, accounting for 59.4% of the total variance 
(Table 4). Consequently, only these two components 
were retained in the analysis. In Table 5, the component 
loadings after rotation are shown. The emotional well-
being, the cognitive function, the health distress, and the 
overall quality of life subscales all related to the mental 
dimension of MSQOL-54 and loaded highly on component 
1, suggesting this component is, in fact, the mental 
component. The physical health, the role limitations due 
to physical problems, the pain, the health perceptions, 
the social, and the sexual function subscales all related 
to the physical dimension of MSQOL-54 and loaded 
highly on component 2, suggesting this component as 
the physical component. The energy subscale, originally 
the subcomponent in the physical health component, 
also showed a high loading on mental health. The role 
limitations due to emotional problems subscale was the 
only subscale loading about equally on both components.
264
10.1515/sjph-2017-0035 Zdr Varst 2017; 56(4): 260-267
Table 3.
Table 4.
Statistical description and the Cronbach’s Alpha (α) for 
the Slovenian version of Multiple Sclerosis Quality of 
Life-54 questionnaire subscales/single item measures 
(n=134).
Component loadings after rotation in the Slovenian version of Multiple Sclerosis Quality of Life-54 questionnaire validation study 
(n=134).
LEGEND: SD - standard deviation; *- α was not computed because 
the scale is based on a single item.
Subscales
Physical health
Role limitations due 
to physical problems
Role limitations due 
to emotional problems
Pain
Emotional well-being
Energy
Health perceptions
Social function
Cognitive function
Health distress
Sexual function
Overall quality of life
Single-item measures
Change in health*
Satisfaction with 
sexual function*
1
2
3
4
5
6
7
8
9
10
11
12
10
4
3
3
5
5
5
3
4
4
4
2
1
1
5.906
1.219
0.938
0.765
0.625
0.564
0.479
0.423
0.349
0.277
0.257
0.198
5.906
1.219
3.659
3.466
49.2
10.2
  7.8
  6.4
  5.2
  4.7
  4.0
  3.5
  2.9
  2.3
  2.1
  1.6
49.2
10.2
30.5
28.9
  49.2
  59.4
  67.2
  73.6
  78.8
  83.5
  87.5
  91.0
  93.9
  96.2
  98.4
100.0
49.2
59.4
30.5
59.4
29.6
41.0
41.3
24.0
15.9
19.2
14.8
19.3
23.2
19.9
28.2
15.9
22.6
25.7
55.7
33.1
62.7
65.9
74.4
55.2
44.6
72.8
71.4
72.0
71.4
67.8
45.3
61.4
0.94
0.90
0.83
0.89
0.84
0.84
0.58
0.68
0.91
0.85
0.90
0.86
N of 
items
Initial Eigenvalues Extraction Sums of Squared Loadings Rotation Sums of Squared Loadings
Total Total Total% of 
variance
% of 
variance
% of 
variance
Cum.
%
Cum.
%
Cum.
%
SDMean αSubscale/Item
Component
10.1515/sjph-2017-0035 Zdr Varst 2017; 56(4): 260-267
265
Table 5. Component loadings after rotation in the Slovenian 
version of Multiple Sclerosis Quality of Life-54 
questionnaire validation study (n=134).
Physical health
Role limitations due 
to physical problems
Role limitations due 
to emotional problems
Pain
Emotional well-being
Energy
Health perceptions
Social function
Cognitive function
Health distress
Sexual function
Overall quality of life
0.129
0.184
0.472
0.275
0.874
0.750
0.415
0.474
0.754
0.698
0.202
0.701
0.854
0.792
0.475
0.570
0.104
0.407
0.536
0.654
0.174
0.320
0.590
0.432
Component 1
Mental component
Component 2
Physical component
Subscale
Rotated factor 
loadings
4 DISCUSSION
The results of this study showed that the Slovenian version 
of the MSQOL-54 instrument successfully passed the 
evaluation for cultural equivalence as well as fulfilled the 
required psychometric criteria. The instrument was well 
accepted by the Slovenian MS patients, with the majority 
of them stating there were no items difficult to interpret. 
Almost all the patients completed the questionnaire within 
the recommended period, indicating that it was easy to 
understand and manageable to accomplish. The greater 
portion of participants could fill in the questionnaire 
without any intervention by the research team, which 
is in line with the preferred self-administered mode. 
Nevertheless, in one sixth of the patients, the MSQOL-54 
instrument was administered as an interview due to the 
visual or upper extremity impairments. Therefore, the 
acceptability is likely to improve if the questionnaire is 
administered in settings where help is accessible. The 
percentage of the missing answers was low, except for 
the items referring to the sexual function and satisfaction 
with the sexual function. A pattern of a higher percentage 
of the missing answers in the sexual function subscale was 
detected in the original US study as well as in other similar 
studies dealing with MSQOL-54 validation (11, 12, 15, 18, 
19). This could be explained by a traditional perception of 
sexuality as a taboo in many cultures. 
The individual subscales and the complete instrument 
had a high internal consistency, indicating an internally 
consistent instrument. However, in the health perception 
and the social function subscales, it was below the 
recommended cut-off point. The aforementioned 
subscales also had the lowest coefficients in the original 
US study and in several other published MSQOL-54 
validation studies (11, 14, 17-19). The health perception 
subscale contains items that cover quite broad aspects of 
health self-evaluation, and this might explain the relative 
lack of consistency. Furthermore, the social function 
subscale contains only three items, therefore its reduced 
reliability could be attributed to the low number of items.
In this study, two underlying dimensions of the instrument’s 
construct have been confirmed. The two extracted 
components by the PCA represented the physical and the 
mental HRQoL dimensions. The analysis also revealed 
that subscales, which in the original US study (11) are 
related to the physical HRQoL dimension and unrelated 
to mental HRQoL dimension, loaded highly on the physical 
component. Likewise, the subscales originally intended 
to pertain in the mental dimension, made up the mental 
component in our study, too. Therefore, the Slovenian 
MSQOL-54 instrument has good discriminant validity. 
An exception from the aforementioned was the energy 
subscale, which was originally stapled as the physical 
dimension subscale, while in our study, it appeared to fit 
more into the mental component. Similarly, to our finding, 
two other studies evidenced that the energy subscale 
measured by MSQOL-54 was primarily an emotional 
component (14, 17). Moreover, in our study, the role 
limitations due to emotional problems subscale had equal 
loadings on both components. Likewise, in the Israeli 
validation study (14), this subscale emerged together with 
the role limitations due to physical problems subscale as 
a separate dimension, suggesting that patients view role 
limitations as unitary, tending to overlook the source of 
the limitations.
There are some limitations of this study. Firstly, a 
relatively small number of participants were included 
in the study; however, the number was still sufficient 
to permit fair conclusions. Moreover, one could argue 
that item response theory statistics has not been used in 
the present study since this methodology is increasingly 
used for the purpose of psychometric validation of 
instruments. However, most of the studies reporting the 
validation of the translated versions of the MSQOL-54 
instrument in the past used the classical methodology. 
In order to make our results comparable to the results 
of other similar studies, a classic methodology was used 
in our study as well. Furthermore, one could argue 
that no method of measurement of the stability of the 
instrument over time, e.g. the test-retest method, was 
used in the present study. However, the reliability of 
266
10.1515/sjph-2017-0035 Zdr Varst 2017; 56(4): 260-267
the measurement can be evaluated using measurement 
stability methods and/or measurement equivalence 
methods. The later were developed in the social science 
research for the situations in which it is not possible to 
perform repeated measurements, because the measured 
phenomenon changes or could change over time (33). As 
we assumed that the phenomenon measured in our study 
could change over time, the measurement at the same 
time was used and the internal consistency method was 
used as an appropriate method (33). Finally, only the 
exploratory factor analysis was performed; however, the 
intention of the study was to explore if data collected by 
the translated version of the instrument fit the expected 
pattern. 
Nonetheless, the study has also some important strengths. 
Firstly, the rigorously performed forward-backward 
translation process provided a good quality translation 
of the MSQOL-54 instrument to the Slovenian language, 
making it available to all Slovenian experts dealing with 
MS patients in clinical settings as well as for the research 
purposes. Secondly, this study provided the information 
on the psychometric properties when used in Slovenian 
MS patients. According to the results of this study, the 
Slovenian MSQOL-54 instrument is valid and reliable, and 
the users can trust it, and use it as a valid and reliable 
measurement tool. These benefits give the opportunity 
for treating MS patients in Slovenia in accordance to 
personalised medicine approach. Finally, the study could 
be another step in the implementation of a comprehensive 
approach to managing major public health problems in 
Slovenia.
There are still many challenges left in researching both 
the properties of the MSQOL-54 instrument and the 
content of the instrument itself. With a focus on studying 
the properties of the Slovenian version of the instrument, 
further evaluation is needed. Our work can be continued 
by assessing the instrument’s responsiveness, exploring 
the relations between the MSQOL-54 dimensions and 
another HRQoL instrument, as well as by performing the 
confirmatory factor analysis, while working on larger 
clinical data sets. With a wider focus, at the content level 
of the instrument, another challenge for researchers 
could be to combine the MS-18 module with another 
HRQoL instrument than SF-36, e.g. the EQ-5D (34). 
5 CONCLUSION
The Slovenian version of the MSQOL-54 proved to be 
internally consistent and accurate tool, well accepted by 
the Slovenian MS patients. The adequate psychometric 
properties warrant the scientifically sound Slovenian 
version of the MSQOL-54 instrument, which is from now 
on at disposal to all health professionals dealing with MS 
patients in Slovenia.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
FUNDING
The study received no funding.
ETHICAL CONSIDERATIONS AND PERMISSIONS
The study was launched after receiving permissions to use 
MSQOL-54 and SF-36 instruments from their developers. 
It was approved by the Medical Ethics Committee of 
the Republic of Slovenia on 17 July 2012 (approval No. 
24k/07/12).
REFERENCES
1. Benito-Leon J, Manuel Morales J, Rivera-Navarro J, Mitchell A. 
A review about the impact of multiple sclerosis on health-related 
quality of life. Disabil Rehabil 2003; 25: 1291-1303.
2. WHO. Neurological disorders: public health challenges. Geneva: 
WHO, 2006.
3. Pugliatti M, Rosati G, Carton H, Riise T, Drulovic J, Vecsei L, Milanov 
I. The epidemiology of multiple sclerosis in Europe. Eur J Neurol 
2006; 13: 700-22.
4. Hermann BP, Vickrey B, Hays RD, Cramer J, Devinsky O, Meador K 
et al. A comparison of health-related quality of life in patients with 
epilepsy, diabetes and multiple sclerosis. Epilepsy Res 1996; 25: 113-
8.
5. Rudick R. Multiple sclerosis therapeutics. Boca Raton, FL: CRC Press, 
1999.
6. Murphy N, Confavreux C, Haas J, Konig N, Roullet E, Sailer M et 
al. Quality of life in multiple sclerosis in France, Germany, and the 
United Kingdom: cost of multiple sclerosis study group. J Neurol 
Neurosurg Psychiatry 1998; 65: 460-6.
7. Kurtzke J. Rating neurologic impairment in multiple sclerosis: an 
expanded disability status scale (EDSS). Neurology 1983; 33: 1444-
52.
8. Nutbeam D. Health promotion glossary. Geneva: WHO Collaborating 
Centre for Health Promotion, 1998.
9. Rothwell PM, McDowell Z, Wong CK, Dorman PJ. Doctors and 
patients don’t agree: cross sectional study of patients’ and doctors’ 
perceptions and assessments of disability in multiple sclerosis. BMJ 
1997; 314: 1580-3.
10. Provinciali L, Ceravolo MG, Bartolini M, Logullo F, Danni M. A 
multidimensional assessment of multiple sclerosis: relationships 
between disability domains. Acta Neurol Scand 1999; 100: 156-62.
11. Vickrey BG, Hays RD, Harooni R, Myers LW, Ellison GW.  A health-
related quality of life measure for multiple sclerosis. Qual Life Res 
1995; 4: 187-206.
12. Solari A, Filippini G, Mendozzi L, Ghezzi A, Cifani S, Barbieri E et al. 
Validation of Italian multiple sclerosis quality of life 54 questionnaire. 
J Neurol Neurosurg Psychiatry 1999; 67: 158-62.
13. Acquadro C, Lafortune L, Mear I. Quality of life in multiple sclerosis: 
translation in French Canadian of the MSQoL-54. Health Qual Life 
Outcomes 2003; 1: 70.
14. Miller A, Dishon S. Health-related quality of life in multiple sclerosis: 
psychometric analysis of inventories Mult Scler 2005; 11: 450-8.
10.1515/sjph-2017-0035 Zdr Varst 2017; 56(4): 260-267
267
15. Idiman E, Uzunel F, Ozakbas S, Yozbatiran N, Oguz M, Callioglu B 
et al. Cross-cultural adaptation and validation of multiple sclerosis 
quality of life questionnaire (MSQOL-54) in a Turkish multiple 
sclerosis sample. J Neurol Sci 2006; 240: 77-80.
16. Heiskanen S, Merilainen P, Pietila AM. Health-related quality of 
life-testing the reliability of the MSQOL-54 instrument among MS 
patients. Scand J Caring Sci 2007; 21: 199-206.
17. Ghaem H, Borhani Haghighi A, Jafari P, Nikseresht AR. Validity and 
reliability of the Persian version of the multiple sclerosis quality of 
life questionnaire. Neurol India 2007; 55: 369-75.
18. Pekmezovic T, Kisic Tepavcevic D, Kostic J, Drulovic J. Validation 
and cross-cultural adaptation of the disease-specific questionnaire 
MSQOL-54 in Serbian multiple sclerosis patients sample. Qual Life 
Res 2007; 16: 1383-7.
19. Fuvesi J, Bencsik K, Benedek K, Matyas K, Meszaros E, Rajda C et al. 
Cross-cultural adaptation and validation of the “Multiple sclerosis 
quality of life instrument” in Hungarian. Mult Scler 2008; 14: 391-8.
20. Tadic D, Dajic V. Quality of life in patients with multiple sclerosis in 
Republic of Srpska. Med Glas (Zenica) 2013; 10: 113-9.
21. Multiple Sclerosis International Federation. Atlas of MS 2013: 
mapping multiple sclerosis around the world. London: Multiple 
Sclerosis International Federation, 2013.
22. Vidmar G, Burger H, Marincek C. Time trends in ability level and 
functional outcome of stroke and multiple sclerosis patients 
undergoing comprehensive rehabilitation in Slovenia. Zdr Varst 2011; 
50: 24-33.
23. Marn-Vukadinovic D, Jamnik H. Validation of the short form-36 
health survey supported with isokinetic strength testing after sport 
knee injury. J Sport Rehabil 2011; 20: 261-76.
24. Prevolnik Rupel V, Ogorevc M. The EQ-5D health states value set for 
Slovenia. Zdr Varst 2012; 51: 128-40.
25. Rosato R, Testa S, Bertolotto A, Confalonieri P, Patti F, Lugaresi A et 
al. Development of a short version of MSQOL-54 using factor analysis 
and item response theory. PLoS One 2016; 11: e0153466.
26. Vucic L, Glisic B, Kisic-Tepavcevic D, Vucic U, Drulovic J, Pekmezovic 
T. Cross-cultural adaptation and validation of the disease specific 
questionnaire OQLQ in Serbian patients with malocclusions. Zdr 
Varst 2016; 55: 166-73.
27. Polman CH, Reingold SC, Banwell B, Clanet M, Cohen JA, Filippi M et 
al.. Diagnostic criteria for multiple sclerosis: 2010 revisions to the 
McDonald criteria. Ann Neurol 2011; 69: 292-302.
28. UCLA. Multiple sclerosis quality of life (MSQOL)-54 instrument. Los 
Angeles, CA: UCLA, 1995. Available Feb 1, 2017 from: https://www.
nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/
Brochures/MSQOL54_995.pdf.
29. Ware J, Snow K, Kosinski M, Grandek B. SF-36 health survey: manual 
and interpretation guide. Boston, MA: The Health Institute, New 
England Medical Center, 1993.
30. National Multiple Sclerosis Society. Multiple Sclerosis Quality of 
Life-54 (MSQOL-54). Available Feb 1, 2017 from: http://www.
nationalmssociety.org/For-Professionals/Researchers/Resources-
for-Researchers/Clinical-Study-Measures/Multiple-Sclerosis-Quality-
of-Life-54-(MSQOL-54).
31. Kline P. Handbook of psychological testing. 2nd ed. London: 
Routledge, 1999.
32. Schmitt TA. Current methodological considerations in exploratory 
and confirmatory factor analysis. J Psychoeduc Assess 2011; 29: 304-
21.
33. Ferligoj A, Leskošek K, Kogovšek T. Zanesljivost in veljavnost 
merjenja. Metodološki zvezki 10. Ljubljana: Univerza v Ljubljani, 
FDV, 1995.
34. AAOS. EQ-5D. Available Jul 22, 2017 from: https://www.aaos.org/
uploadedFiles/EQ5D3L.pdf.
THE OUTCOMES OF PREGNANCY AND CHILDBIRTH 
IN ADOLESCENTS IN SLOVENIA
Simona KORENČAN1, Bojana PINTER1*, Mojca GREBENC2, Ivan VERDENIK1
1University Medical Centre Ljubljana, Division of Gynecology and Obstetrics, Šlajmerjeva 3, 1000 Ljubljana, Slovenia
2Community Health Centre, Female Healthcare Service, Derčeva ulica 5, 1000 Ljubljana, Slovenia
Received: Feb 28, 2017
Accepted: Aug 17, 2017 
Original scientific article
Introduction. The objective of the study was to determine the course and outcomes of pregnancy and childbirth 
in adolescents compared to women aged 20-24 years in Slovenia.
Methods. In the retrospective study, the course of pregnancy and labour and the perinatal outcome of newborns 
in primiparous adolescents aged ≤19 years (study group) have been compared to the control group of primiparous 
women aged 20-24 years. The study group was further divided into a study subgroup of adolescents aged ≤17 
years. Data were retrieved from the National Perinatal Information System in Slovenia for the period 2008-2012. 
Altogether, 13,663 women and their newborns were included.
Results. Adolescent pregnancy was associated with increased rates of unknown estimated date of delivery, 
preterm labour, low birth weight newborns, small for gestational age newborns and low gestational weight 
gain. Spontaneous labour was more common in adolescents, while emergency and elective Caesarean sections 
were less common than in women aged 20-24 years. In addition, pregnancy in adolescents aged ≤17 years 
was associated with increased rate of maternal anaemia and labour without complications. Higher rates of 
smoking, lower rates of parenting school attendance, lower rates of pregnancy check-ups and screening tests 
in pregnancy such as nuchal translucency in adolescents were found.
Conclusions. The results of the study show that adolescent pregnancy is related to higher health risks for 
pregnant adolescents and their newborns. In addition, adolescents are subject to poorer prenatal care 
comparing to older women.
Uvod. Namen dela je bil na nacionalni ravni analizirati podatke o poteku nosečnosti in poroda ter podatke 
o izidu za novorojenčka slovenskih mladostnic. Želeli smo ugotoviti pojavnost zapletov v nosečnosti, med 
porodom in pri novorojenčku ter značilnosti predporodnega varstva med slovenskimi prvesnicami, starimi do 
19 let, v primerjavi s prvesnicami, starimi med 20 in 24 let.
Metode. V retrospektivni raziskavi smo ugotavljali pojavnost zapletov v nosečnosti, med porodom ter izid za 
novorojenčka in značilnosti predporodnega varstva pri mladostnicah prvesnicah, starih do 19 let (študijska 
skupina), in mlajših od 17 let (študijska podskupina), ter ugotovitve primerjali s kontrolno skupino prvesnic, 
starih med 20 in 24 let. Podatke smo pridobili iz Nacionalnega perinatalnega informacijskega sistema Slovenije 
(NPIS) za obdobje od leta 2008 do leta 2012. Skupno je bilo v raziskavo vključenih 13.663 prvesnic in njihovih 
novorojenčkov.
Rezultati. Nosečnost pri mladostnicah je povezana s povečanim tveganjem za nejasen predvideni datum 
poroda, prezgodnji porod, nizko porodno težo novorojenčka, novorojenčka, majhnega za gestacijsko starost 
in nizko pridobitvijo telesne teže med nosečnostjo. Spontan porod je pogostejši pri mladostnicah, medtem 
ko sta nujni in elektivni carski rez pri tej skupini manj pogosta kot pri ženskah, starih med 20 in 24 let. 
Nosečnost pri mladostnicah, mlajših od 17 let, je povezana s pogostejšo anemijo matere ter porodom brez 
zapletov. Mladostnice med nosečnostjo pogosteje kadijo, imajo med nosečnostjo manj pregledov in prenatalne 
diagnostike, kot je na primer nuhalna svetlina, redkeje tudi obiskujejo šolo za starše.
Zaključki. Rezultati raziskave kažejo, da je nosečnost pri mladostnicah povezana z višjim tveganjem za 
zdravje nosečnice in novorojenčka. Mladostnice imajo tudi slabše predporodno varstvo kot starejše ženske.
ABSTRACT
Keywords: 
teenagers, delivery, 
birth, labour, 
complications, 
newborn, birth weight, 
gestational weight gain
IZVLEČEK
Ključne besede: 
adolescentke, 
najstnice, porod, 
rojstvo, zapleti, 
novorojenčki, 
porodna teža, 
pridobitev telesne teže
*Corresponding author: Tel: + 386 41 718 923; E-mail: bojana.pinter@guest.arnes.si
Zdr Varst 2017; 56(4): 268-275
IZIDI NOSEČNOSTI IN PORODA PRI MLADOSTNICAH V SLOVENIJI
Korenčan S, Pinter B, Grebenc M, Verdenik I. The outcomes of pregnancy and childbirth in adolescents in Slovenia. Zdr Varst 2017; 56(4): 268-275.
10.1515/sjph-2017-0036
268
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
Adolescence is a period of human growth and development 
between childhood and adulthood, from ages 10 to 19 
years. Many adolescents face pressures to initiate sexual 
relationships at earlier age, putting themselves at high risk 
for consequences from sexually transmitted infections to 
unintended pregnancies (1). Early childbearing increases 
the risks for both mothers and their newborns, and can 
also have negative social and economic effects on girls, 
their families and communities (2). Therefore, the 
adolescent pregnancy is a public health problem.
The research on sexual behaviour of secondary–school 
students in Slovenia in 1996, showed that median age of 
first sexual intercourse was 18.5 years (3) and dropped 
to 17.0 years in 2004 (4), and 17.6 years in 2012 (5). 
In 2012, contraceptive methods used at last sexual 
intercourse by 3rd grade secondary–school students were 
condom (54.1%), the pill (27.1%), double method (4.2%), 
withdrawal (4.0%), other methods (3.5%) and no method 
(7.1%) (5). 
In Slovenia, abortion rates in women of reproductive age 
(aged 15–49 years) have decreased from 25.9 in 1992, 
to 8.8 in 2012; in women aged 15–19 years, from 12.7 in 
1992, to 5.8 in 2012; in women aged 20–24 years, from 
33.5 in 1992, to 11.1 in 2012. In the same period, fertility 
rates in women aged 15–49 years have increased from 
39.1 in 1992, to 46.2 in 2012; however, in women aged 
15–19 years, fertility rates decreased from 13.9 in 1992, 
to 4.6 in 2012, and in women aged 20–24 years, from 98.2 
in 1992, to 43.7 in 2012 (6, 7). Slovenia had one of the 
lowest ratios of all live births to mothers aged below 20 
years, 1.01 % in 2012 (8).
The studies showed that adolescents’ pregnancy and 
childbirth were related to increased health risk for 
adolescents and newborns. Girls who got pregnant at 
the age of 14 years or younger, and, to a lesser extent, 
at 15–17 years and 18–19 years, were at higher risk of 
complications during pregnancy (9). They were more 
likely to experience obstructed labour, fistula, premature 
birth, and gave birth to low birth weight newborns 
than older women (10). Moreover, medical risks of 
adolescent pregnancy could include higher rates of 
anaemia, pregnancy-induced hypertension, cephalopelvic 
disproportion, problems with progression of labour, and 
higher perinatal morbidity (11–14). On the other hand, 
some studies showed that adolescent mothers had lower 
risks of third trimester bleeding, gestational diabetes (15) 
and preeclampsia (16).
Aiming at getting new insights in characteristics of 
adolescent pregnancy in Slovenia, the objective of our 
study was to determine the course and outcomes of 
pregnancy and childbirth in primiparous adolescents 
compared to primiparous women aged 20–24 years.
2 MATERIAL AND METHODS 
The study was done on the total population of observed 
population groups of primiparous women aged up to 24 
years, and their newborns in Slovenia for the period 
2008–2012. In the retrospective study, the incidence 
of complications during pregnancy and labour and the 
perinatal outcome in primiparous adolescents aged up to 
19 years (study group) was compared to the control group 
of primiparous women aged 20–24 years. 
In the study, 13,663 primiparous women aged up to 24 
years who gave birth during 2008–2012 in Slovenia, and 
their newborns were included: 1,413 adolescents aged up 
to 19 years and their 1,423 newborns, and 12,112 women 
aged 20–24 years and their 12,240 newborns. The study 
group of primiparous adolescents (≤19 years) was further 
divided into a subgroup of adolescents aged up to 17 
years (≤17 years, 318 women, 318 newborns). Data were 
retrieved from the National Perinatal Information System. 
In the study, the variables for the course of pregnancy, the 
course of labour, the status of the newborn and prenatal 
care were used. The majority of variables were observed 
outcomes, except for participants’ age and gestational 
age at childbirth. Participants’ age was an explanatory 
factor. In multivariate analyses, gestational age was the 
confounding factor. All dichotomous variables were coded 
accordingly (e.g. hypertension: 0=no, 1=yes).
Variables on body weight gain during pregnancy (i.e. 
gestational weight gain) in relation to body mass index 
(BMI) before pregnancy were used according to the 
Institute of Medicine guidelines (US) (17). The data were 
analysed by SPSS programme. Descriptive analysis, analysis 
of variance (ANOVA), χ² test, correlation and multivariate 
analyses (multiple linear and multiple logistic regression) 
were applied where appropriate. Statistical significance 
was set at p<0.05.
3 RESULTS
3. 1 The Course of Pregnancy
Gestational diabetes and bleeding during pregnancy 
were less common in the study group of adolescents 
aged ≤19 years, while anaemia was more common only in 
the younger subgroup of adolescents aged ≤17 years. In 
addition, unknown estimated date of delivery, threatened 
preterm labour and preterm labour were more common in 
adolescents. It was more common for adolescents to have 
a low and appropriate gestational weight gain compared 
to women in the control group. No statistically significant 
differences regarding hypertension, intrauterine growth 
restriction (IUGR) and foetal anomalies were found (Table 
1). 
10.1515/sjph-2017-0036 Zdr Varst 2017; 56(4): 268-275
269
270
10.1515/sjph-2017-0036 Zdr Varst 2017; 56(4): 268-275
3.2 The Course of Labour
The onset of labour was more commonly spontaneous 
in adolescents; it was less common for adolescents 
to need either an administration of PGE2, artificial 
rupture of membranes or an elective Caesarean section. 
No differences were found regarding augmentation 
with oxytocin or regarding foetal position and breech 
presentations. It was less common for adolescents 
to have an incorrect descent of the presenting part, 
emergency Caesarean section and minor maternal 
injuries. Instrumental interventions were more frequent 
in adolescents. No statistically significant differences 
were found in delay of cervical dilatation, foetal distress, 
rates of labour dystocia, episiotomy, uterine cervix and 
severe maternal injuries and complications of the third 
stage of labour (Table 2). 
Table 1. Results of univariate analysis of the course of pregnancy group of observed outcomes between the study group (age ≤19 years) 
or the study subgroup (age ≤17 years) and the control group (age 20–24 years) of primiparous women, Slovenia, 2008–2012.
Legend: * comparison to the control group – χ2 test
Hypertension
Anaemia
Gestational diabetes
Unknown estimated date of delivery
Bleeding during pregnancy
Intrauterine growth restriction (IUGR)
Foetal anomalies
Threatened  preterm labour
Duration of pregnancy 
 Birth at ≤31 weeks
 Birth at  32–36 weeks
 Birth at  ≥37 weeks
Gestational weight gain in relation 
to BMI before pregnancy 
 Appropriate gestational weight gain
 Low gestational weight gain
 High gestational weight gain
598 (4.9)
273 (2.3)
265 (2.2)
55 (0.5)
616 (5.1)
291 (2.4)
33 (0.3)
473 (3.9)
124 (1.0)
649 (5.4)
11338 (93.6)
3135 (26.0)
1986 (16.4)
6953 (57.6)
68 (4.8)
43 (3.0)
10 (0.7)
27 (1.9)
41 (2.9)
43 (3.0)
4 (0.3)
82 (5.8)
28 (2.0)
94 (6.7)
1290 (91.4)
341 (24.2)
357 (25.3)
712 (50.5)
15 (4.7)
14 (4.4)
1 (0.3)
18 (5.7)
8 (2.5)
12 (3.8)
2 (0.6)
21 (6.6)
7 (2.2)
25 (7.9)
286 (89.9)
81 (25.6)
104 (32.8)
132 (41.6)
0.837
0.063
<0.001
<0.001
<0.001
0.142
0.942
0.001
0.001
<0.001
0.858
0.012
0.023
<0.001
0.038
0.118
0.236
0.015
0.017
<0.001
Control group
20–24 years
(N=12,112)
n (%)
Study group 
≤19 years
(N=1,413)
n (%) n (%)P* P*
Study subgroup
≤17 years
(N=318)
The course 
of pregnancy
10.1515/sjph-2017-0036 Zdr Varst 2017; 56(4): 268-275
271
Median duration of labour was 4 hours in all the study 
and control groups, while the interquartile range was 3–6 
hours. Mann-Whitney test did not show any statistically 
significant difference among the groups.
3.3 The Status of the Newborn
Newborns of adolescents have had more commonly very 
low birth weight, and were more commonly small for 
gestational age (SGA). Furthermore, it was less common 
for newborns of adolescents to have an appropriate 
newborn’s birth weight as well as excessive newborn’s 
birth weight. There was no statistically significant 
difference in stillbirth or in Apgar score <7 at 1st minute 
(Table 3).
Table 2. Results of univariate analysis of the course of labour group of observed outcomes between the study group (age ≤19 years) or the 
study subgroup (age ≤17 years) and the control group (age 20–24 years) of primiparous women, Slovenia, 2008–2012.
Legend: * comparison to the control group – χ2 test
Onset of labour 
 Spontaneous 
 Administration of PGE2
 Artificial rupture of membranes
 Elective Caesarean section
 Augmentation with oxytocin
Foetal position 
 Occipito–anterior foetal position
 Other foetal head positions
 Breech presentations
Delay of cervical dilatation
Incorrect descent of the presenting part
Foetal distress
Labour dystocia 
Instrumental intervention (vacuum, forceps)
Emergency Caesarean section
Episiotomy
Maternal injuries 
 Minor injuries
 Uterine cervix injury
 Severe injuries
Complications of the third stage of labour 
Labour without complications
9197 (76.1)
1.451 (12.0)
971 (8.0)
465 (3.8)
7751 (64.0)
10857 (88.7)
785 (7.4)
567 (4.6)
252 (2.1)
754 (6.2)
503 (4.2)
84 (0.7)
556 (4.5)
2006 (16.4)
5432 (44.9)
2937 (24.2)
199 (1.6)
46 (0.4)
420 (3.5)
8902 (73.5)
1.152 (81.7)
139 (9.9)
79 (5.6)
40 (2.8)
875 (61.9)
1270 (89.2)
89 (6.3)
61 (4.3)
15 (1.1)
67 (4.7)
62 (4.4)
9 (0.6)
62 (4.4)
180 (12.6)
482 (44.0)
298 (21.1)
25 (1.8)
4 (0.3)
48 (3.4)
1061 (75.1)
269 (84.6)
25 (7.9)
16 (5.0)
8 (2.5)
188 (59.1)
280 (87.8)
25 (7.8)
14 (4.4)
1 (0.3)
16 (5)
13 (4.1)
5 (1.6)
18 (5.6)
36 (11.3)
155 (48.7)
75 (23.6)
9 (2.8)
0 (0.0)
17 (5.3)
255 (80.2)
<0.001
<0.001
<0.001
<0.001
0.126
0.927
0.927
0.927
0.09
0.027
0.676
0.808
0.001
0.001
0.872
0.008
0.725
0.571
0.891
0.199
0.006
0.006
0.006
0.006
0.074
0.614
0.614
0.614
0.028
0.383
0.954
0.067
0.040
0.040
0.169
0.785
0.103
0.271
0.073
0.007
Control group
20–24 years
(N=12,112)
n (%)
Study group 
≤19 years
(N=1,413)
n (%) n (%)P* P*
Study subgroup
≤17 years
(N=318)
The course 
of labour
272
10.1515/sjph-2017-0036 Zdr Varst 2017; 56(4): 268-275
Regarding the newborn’s birth weight, the results 
of multivariate analysis showed that newborns of 
adolescents aged ≤17 years were on average 120 g lighter, 
and newborns of adolescent aged 18–19 years were 49 g 
lighter when adjusted for gestational age, compared to 
newborns of women aged 20–24 years (β=-0.04 for age 
group ≤17 years, β=-0.03 for age group 18–19 years; both 
were statistically significant, p<0.001). 
Regarding SGA newborns, the results of multivariate 
analysis showed that full-term newborns were SGA in 
10.1% if born to adolescents aged ≤17 years, and in 5.8% if 
born to adolescents aged 18–19 years, compared to 5.3% if 
born to women aged 20–24 years. Odds ratio for SGA was 
1.8 (1.2–2.8) for adolescents aged ≤17years (p=0.002) and 
1.1 (0.8–1.4) for adolescents aged 18–19 years (p=0.533).
3.4 Prenatal Care
Adolescents have had their first check-up at gynaecologist 
later in pregnancy; have had less check-ups at 
gynaecologist and less ultrasonography check-ups during 
pregnancy. Adolescents also less commonly attended 
parenting school, but more frequently smoked during 
pregnancy. It was less common for adolescents to get 
prenatal screening tests: nuchal translucency or cervix 
uteri measurement (Table 4).
4 DISCUSSION
4.1 Summary of the Most Important Results of the Study
Our study revealed that in Slovenia, anaemia in pregnancy 
was more common in adolescents aged ≤17 years than in 
women aged 20–24 years. Unknown estimated date of 
delivery was more common in adolescents, particularly 
Table 3. Results of univariate analysis of the newborn status group of observed outcomes between the study group (age ≤19 years) or the 
study subgroup (age ≤17 years) and the control group (age 20–24 years) of primiparous women, Slovenia, 2008–2012.
Legend: * comparison to the control group – χ2 test
Stillbirth
Apgar score <7 at 1st minute
Apgar score <7 at 5th minute
Newborn’s birth weight  
 Very low newborn’s birth weight <1500 g
 Low newborn’s birth weight 1500–2499 g
 Appropriate newborn’s birth weight 2500–3999 g
 Excessive newborn’s birth weight ≥4000 g 
 Small for gestational age (SGA)
62 (0.5)
453 (3.7)
156 (1.3)
133 (1.1)
642 (5.2)
10488 (85.7)
972 (7.9)
708 (5.8)
7 (0.5)
56 (3.9)
33 (2.3)
25 (1.8)
108 (7.6)
1193 (83.8)
97 (6.8)
104 (7.3)
0 (0.0)
14 (4.4)
7 (2.2)
6 (1.9)
35 (11.0)
265 (83.1)
13 (4.1)
31 (9.7)
0.941
0.659
0.001
<0.001
0.022
0.202
0.522
0.152
<0.001
0.003
Control group
20–24 years
(N=12,112)
n (%)
Study group 
≤19 years
(N=1,413)
n (%) n (%)P* P*
Study subgroup
≤17 years
(N=318)
Status of the 
newborn
in the adolescents aged ≤17 years. Preterm birth was also 
more common in adolescents. Adolescents’ newborns 
had more commonly very low birth weight and low birth 
weight, they were lighter then newborns of women aged 
20–24 years even after adjustment for gestational week. 
Additionally, full term newborns of adolescents aged ≤17 
years were more frequently SGA, odds ratio for SGA was 
1.8 (1.2–2.8), compared to full-term newborns of women 
aged 20–24 years. Last but not least, adolescents had 
poorer prenatal care. On the other hand, gestational 
diabetes was less common in adolescents, it was less 
common for adolescents to have a high gestational 
weight gain, there was more common spontaneous onset 
of labour, lower incidences of elective and emergency 
Caesarean sections in adolescents, and more commonly 
labour without complications in adolescents aged ≤17 
years. There was no statistically significant difference in 
rates of hypertension and IUGR, nor in the presence of 
foetal anomalies.
4.2 Comparison and Contrast with the Findings 
of Similar Studies
Our findings on anaemia are congruent with other studies; 
anaemia is usually attributed to a lower socio-economic 
status and prenatal care in these women, as well as to a 
growing need for iron and other haemoglobin substrates 
(18, 19).Unknown estimated date of delivery could be 
attributable to the fact that a lot of adolescent women 
have their first check-up at gynaecologist later than older 
women, as it was obvious also in our study, and that it is 
common for adolescent women not to know the date of 
their last period, since their periods tend to be irregular 
(20). More frequent preterm birth in adolescents was found 
also in other studies (21). The mechanisms responsible for 
10.1515/sjph-2017-0036 Zdr Varst 2017; 56(4): 268-275
273
Table 4. Results of univariate analysis of prenatal care group of observed outcomes between the study group (age ≤19 years) or the study 
subgroup (age ≤17 years) and the control group (age 20–24 years) of primiparous women, Slovenia, 2008–2012.
Legend: * comparison to the control group – χ2 test
Week of the first check-up at gynaecologist 
 First check-up at gynaecologist <12 weeks of pregnancy
 First check-up at gynaecologist at 12–22 weeks of pregnancy
 First check-up at gynaecologist ≥23 weeks of pregnancy
 No check-ups during pregnancy
Number of check-ups during pregnancy
 1–7 check-ups during pregnancy
 8–12 check-ups during pregnancy
 ≥13 check-ups during pregnancy
Number of ultrasonography check-ups 
 0–1 ultrasonography check-up
 2 ultrasonography check-ups
 ≥3 ultrasonography check-ups
Parenting school attendance
Smoking during pregnancy
Nuchal translucency
Cervix uteri measurement
9966 (82.3)
1800 (14.9)
342 (2.8)
50 (0.4)
1.773 (14.6)
8305 (68.6)
1.983 (16.4)
333 (2.8)
1660 (13.7)
10116 (83.5)
8431 (69.6)
2213 (18.3)
8007 (66.1)
937 (7.7)
888 (62.9)
370 (26.2)
154 (10.9)
30 (2.1)
426 (30.1)
810 (57.2)
147 (10.4)
122 (8.6)
284 (20.1)
1006 (71.2)
543 (38.5)
457 (32.4)
455 (32.0)
61 (4.3)
1174 (54.7)
95 (29.9)
49 (15.4)
18 (5.7)
124 (39.0)
154 (48.4)
22 (6.9)
42 (13.2)
78 (24.5)
198 (62.3)
68 (21.4)
121 (38.1)
45 (14.1)
10 (3.1)
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.002
Control group
20–24 years
(N=12,112)
n (%)
Study group 
≤19 years
(N=1,413)
n (%) n (%)P* P*
Study subgroup
≤17 years
(N=318)
Prenatal care
preterm birth are still unclear: the immaturity of cervical 
blood supply in young mothers stimulates prostaglandin 
production that could lead to a preterm birth (22). 
More common spontaneous onset of labour in adolescents 
was observed also by other studies (16, 21). Some 
researches attributed a lower incidence of Caesarean 
sections to a lower newborns’ birth weight and size of 
newborns of adolescents (21). There was no difference 
in foetal positions, breech presentations or in delay of 
cervical dilatation, which contrasts with studies founding 
breech presentations to be more common in adolescents 
(23). Maternal injuries were more common in adolescents, 
mostly due to higher rates of minor injuries. The study 
from Sweden, however, showed a significantly lower 
incidence of perineal rupture in adolescents (24). 
We found no statistically significant difference in stillbirth 
or in Apgar score <7 at 1st minute. Apgar score <7 at 5th 
minute was more common in newborns of adolescents, 
compared to women aged 20–24 years. Some studies 
have found similarly lower Apgar scores in adolescents’ 
newborns (25), while others have not (16). More commonly, 
very low birth weight and low birth weight in adolescents’ 
newborns was found in many other studies (10, 11, 26), as 
well as SGA newborns of adolescents (15), but others found 
no difference regarding SGA newborns, when comparing 
adolescents to older women (23). It is interesting that 
we observed a higher incidence of SGA newborns and 
preterm births in adolescents, yet we did not observe any 
statistically significant difference regarding IUGR. This 
could be attributable to adolescents’ late first check-up 
and poorer follow-up regarding growth restriction, due to 
a lower number of check-ups in adolescents overall. Not 
knowing the date of their last period and, consequently, 
unknown estimated date of delivery also attributes to a 
higher risk for missed IUGR diagnosis.
In general, adolescent women had their first check-up at 
the gynaecologist later than older women and a lower 
rate of regular check-ups and ultrasonography check-ups 
during pregnancy. A lower number of pregnancy check-ups 
could be due to the fact that adolescents make a later first 
check-up at the gynaecologist than older women, have 
higher incidence of preterm births, and that their check-
ups are most frequent towards the end of pregnancy. More 
than two thirds of women aged 20–24 years and only one 
third of adolescents attended parenting school. A similar 
study has shown that adolescents in Slovenia have a poorer 
psychological readiness for pregnancy, lower education, 
and often live in rural areas and have poorer prenatal care 
274
10.1515/sjph-2017-0036 Zdr Varst 2017; 56(4): 268-275
compared to older women. All of this attributes to a lower 
percentage of parenting school attendance (27). A higher 
prevalence of smoking during pregnancy in adolescents 
is congruent with other studies (28). Smoking has been 
recognised as an important risk factors for having SGA 
newborns (29) and has also been linked to a higher 
incidence of low birth weight newborns (30). We observed 
a much higher incidence in nuchal translucency in women 
aged 20–24 years than in adolescents. This could be due 
to a later first check-up in adolescents and, therefore, a 
missed time frame for nuchal translucency. Also, cervix 
uteri measurement was more common in women aged 20–
24 years than in adolescents, which we could not explain 
with the current data.
Adolescents were more frequently underweight before 
pregnancy than older women. Moreover, the incidence of 
a low gestational weight gain was higher in adolescents. 
Studies have shown that adolescents with gestational 
weight gain under the recommendations, however, had 
decreased odds of having an LGA newborn and increased 
odds of having an SGA newborn (31). Moreover, they had 
increased odds of preterm birth and infant death (32). 
A lower gestational weight gain in adolescents could be 
attributable to the fact that many adolescents exhibit 
long bone growth during pregnancy and pelvic immaturity. 
This growth may lead to competition between mother 
and foetus for nutrients, suggesting that adolescents may 
require greater gestational weight gain than adult women 
to optimize outcomes in pregnancy (33). 
4.3 Limitations and Strengths of the Study 
Limitations of our study could be found in mainly only 
univariate analysis and less proper comparison of two 
distant age groups; more data could be additionally 
analysed with multiple regression. With our study, 
we gained new insights into population of pregnant 
adolescents in Slovenia; new knowledge is the strength 
of this study.
4.4 Implications of the Study Results for Obstetrics and 
Public Health
The results of our study confirmed that adolescent 
pregnancy is related to higher health risks for pregnant 
adolescents and their newborns. Poor prenatal care 
of adolescents could be improved with better health 
education and counselling of adolescents in reproductive 
health (e.g. reproductive cycle, contraception, nutrition, 
smoking…), in addition to more frequent and intense 
health and social service given to pregnant adolescents.
4.5 Suggestions for Future Research in the Field
The research on factors of poorer prenatal care in 
adolescents could be the challenge for future research. 
5 CONCLUSIONS 
There are differences regarding pregnancy and pregnancy 
outcomes between adolescents and women aged 
20–24 years. These differences should be taken into 
consideration by health professionals when encountering 
adolescent pregnant women. Health professionals should 
intensify prenatal care at first encounter with pregnant 
adolescents in terms of regular medical check-ups and 
psychosocial counselling and support. 
CONFLICT OF INTEREST 
The authors declare that no conflicts of interest exist.
FUNDING
The study had no accessional financial support.
ETHICAL APPROVAL
Received from the Republic of Slovenia National Medical 
Ethics Committee, reference number 0120-732/2015-2. 
REFERENCES
1. World Health Organization. Maternal, newborn, child and adolescent 
health. AvailableAug 31, 2016 from: http://www.who.int/maternal_
child_adolescent/topics/adolescence/dev/en/.
2. World Health Organization. Adolescent pregnancy. Available Apr 11, 
2017 from: http://www.who.int/mediacentre/factsheets/fs364/
en/.
3. Pinter B, Tomori M. Sexual behavior of secondary-school students in 
Slovenia. Eur J Contracept Reprod Health Care 2000; 5: 71–6.
4. Pinter B, Verdnik I, Grebenc M, Ceh F. Sexual activity and 
contraceptive use among secondary-school students in Slovenia. Eur 
J Contracept Reprod Health Care 2009; 14: 127–33.
5. Pinter B. Spolno vedenje slovenskih srednješolcev 2012. In: Juričič 
M. Šolska, adolescentna medicina: celosten pristop in vloga javnega 
zdravja. Zbornik člankov in izvlečkov. VI. kongres šolske, študentske 
in adolescentne medicine Slovenije in IX. Cvahtetovi dnevi javnega 
zdravja. Debeli Rtič,  27. –29. september 2013. Ljubljana: Slovensko 
zdravniško društvo, Sekcija za šolsko, študentsko in adolescentno 
medicino,  2013:  147–55. 
6. Nacionalni inštitut za javno zdravje. NIJZ podatkovni portal. 
Zdravstveno stanje prebivalstva. Available Aug 31, 2016 from: 
https://podatki.nijz.si/pxweb/sl/NIJZ%20podatkovni%20portal/.
7. Inštitut za varovanje zdravja Republike Slovenije. Informacijski 
sistem spremljanja fetalnih smrti v Sloveniji 2009. Ljubljana: Inštitut 
za varovanje zdravja Republike Slovenije, 2011: 10–1.  
8. World Health Organization. Regional Office for Europe. European 
health for all database WHO/Europe July 2016. Available 31 Aug, 
2016 from: http://data.euro.who.int/hfadb/.
9. Senderowitz J. Adolescent health: reassessing the passage 
to adulthood. World Bank discussion papers; no. WDP 272. 
Washington, DC: The World Bank. Available 31 Aug, 2016 from: 
http://documents.worldbank.org/curated/en/27808146873 
9243027/Adolescent-health-reassessing-the-passage-to-adulthood.
10.1515/sjph-2017-0036 Zdr Varst 2017; 56(4): 268-275
275
10. Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, 
Zhang J et al. Pregnancy and childbirth outcomes among adolescent 
mothers: a World Health Organization multicountry study.  BJOG 
2014; 121(Suppl 1): 40–8. 
11. Kumar A, Singh T, Basu S, Pandey S, Bhargava V. Outcome of teenage 
pregnancy. Indian J Pediatr 2007; 74: 927–31.
12. Glynn  LM, Scjetter CD, Hobel CJ, Sandman CA. Pattern of percieved 
stress and anxiety in pregnancy predicts pretermbirth. Health 
Psychol 2008; 27: 43–51.
13. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and 
causes of pretermbirth.  Lancet 2008; 371: 75–84. 
14. Mahavarkar SH, Madhu CK, Mule VD. A comparative study of teenage 
pregnancy. J Obstet Gynaecol 2008; 28: 604–7.
15. Conde-Agudelo A, Belizán JM, Lammers C. Maternal-perinatal 
morbidity and mortality associated with adolescent pregnancy in 
Latin America: cross-sectional study. Am J Obstet Gynecol 2005; 192: 
342–9. 
16. Thato S, Rachukul S, Sopajaree C. Obstetrics and perinatal outcomes 
of Thai pregnant adolescents: a retrospective study. Int J Nurs Stud 
2007; 44: 1158–64.
17. Institute of Medicine. Weight gain during pregnancy: reexamining 
the guidelines. Washington, DC: National Academies Press, 2009.
18. Scholl TO, Hediger ML, Belsky DH. Prenatal care and maternal health 
during adolescent pregnancy: a review and meta–analysis. J Adolesc 
Health 1994; 15: 444–54.
19. Peterlin A. Nosečnost in porod v adolescenci, vpliv mladoletnosti 
matere na  novorojenčka: magistarski rad. Zagreb: Medicinski 
fakultet sveučilišta u Zagrebu, 1978.             
20. Chen XK, Wen SW, Fleming N, Demisse K, Rhoads G, Walker M. 
Teenage pregnancy and adverse birth outcomes: a large population 
based retrospective cohort study. Int J Epidemiol 2007; 36: 368–73.
21. Lao TT, Ho LF. The obstetric implications of teenage pregnancy. Hum 
Reprod 1997; 12: 2303–5.
22. de Vienne CM, Chreveuill C, Dreyfus M. Does young maternal age 
increase the risk of adverse obstetric, fetal and neonatal outcomes: 
a cohort study. Eur J Obstet Gynecol Reprod Biol 2009; 147: 151–6.
23. Khwaja SS, Al-Sibai H, Al-Suleiman SA, El-Zibdeh MY. Obstetric 
implication of pregnancy in adolescence. Acta Obstet Gynecol Scand 
1986; 65: 57–61.
24. Tyrberg RB, Blomberg M, Kjølhede P. Deliveries among teenage 
women – with emphasis on incidence and mode of delivery: a Swedish 
national survey from 1973 to 2010. BMC Pregnancy Childbirth 2013; 
13: 204.e1–10.
25. Mayor S. Pregnancy and childbirth are leading causes of death in 
teenage girls in developing countries. BMJ 2004; 328: 1152.
26. Bai J, Wong F, Stewart H. The obstetric and neonatal performance 
of teenage mothers in an Australian community. J Obstet Gynaecol 
1999; 19: 345–8.
27. Rajgelj U. Mladostniške nosečnosti v Sloveniji.  Ljubljana: Založba 
ZRC, ZRC SAZU, 2005: 39–74. 
28. Mohsin M, Wong F, Bauman A, Bai J. Maternal and neonatal factors 
influencing premature birth and low birth weight in Australia. J 
Biosoc Sci 2003; 35: 161–74.
29. Treffers PE, Olukoya AA, Fergoson BJ, Liljestrand J. Care for 
adolescent pregnancy and childbirth. Int J Obstet Gynaecol 2001; 
75: 111–21.
30. Mannocci A, Vaschetto C, Semyonov L, Poppa G, Massimi A, Rabacchi 
G et al. Maternal smoking and socio-demographic characteristics in 
correlation with low birth weight: a Turin (Piedmont) study. Zdr Varst 
2014;  53: 221–5. 
31. Wilhelmova R, Hruba D, Vesela L. Key determinants influencing the 
health literacy of pregnant women in the Czech Republic. Zdr Varst 
2015; 54:  27–36. 
32. Harper LM, Chang JJ, Macones GA. Adolescent pregnancy and 
gestational weight gain: do the Institute of Medicine recommendations 
apply? Am J Obstet Gynecol  2011; 205: 140.e1–8. 
33. Scholl TO, Hediger ML. Weightgain, nutrition, and pregnancy 
outcome: findings from the Camden study of teenage and minority 
gravidas. Semin Perinatol 1995; 19: 171–81.
OBJAVLJENE ČLANKE V REVIJI ZDRAVSTVENO VARSTVO V LETU 2017 
SO OCENJEVALI NASLEDNJI RECENZENTI:
VJacek Pyżalski, Polona Selič, Marija Molan, Zlata Ozvačić Adžic, Andrej S Robida, Eva Turk, Olivera Zivota Radanović, 
Marija Jevtić, Iztok Takač, Tatjana Pekmezović, Helena Burger, Valentina Prevolnik Rupel, Tamara Poljičanin, Jelka Zaletel, 
Mojca Gabrijelčič Blenkuš, Andreja Kukec, Janet Klara Djomba, Jovica Milivoje Jovanović, Jasna Podreka, Marita Husso, 
Mojca Urek, Maja Sočan, Irena Klavs, Y. F. M. Seng, Giuseppe La Torre, Jerneja Farkaš Lainščak, Željko Metelko, Lijana 
Zaletel Kragelj, Helena Koprivnikar, Mojca Juričič, Ervin Toci, Nena Kopčavar Guček, Hrvoje Tiljak, Andrej Srakar, Klára 
Hulíková Tesárková, Boris Majcen, Davorina Petek, Marija Petek Šter, Venija Cerovečki, Mirko Bizjak, Krunoslav Čapak, Mario 
Sekerija, Niikka Huovinen, Milena Sant, Anja Černe, Milica Katić, Ljiljana Kezunović, Pierluigi Struzzo, Marko Radovan, 
Zoltan Jancso, Vlatka Mejaski Bošnjak, Mojca Žagar Okorn, David Vodušek, Urška Blaznik, Marzena Jezewska-Zychowicz, 
Tamara Poklar Vatovec, Marta Pentek, Zalika Klemenc-Ketiš, Silvio Brusaferro, Mircha Poldrugovac, Janez Lavre, Vincent 
Vigneron, Jadranka Božikov, Ernest Newbrun, Marjan Premik, Zlatko Ulovec, Barbara Artnik, Viktorija Tomič, Marta Grgič 
Vitek, Ada Hočevar Grom, Karl Andriessen, Vesna Švab, Nuša Konec Juričič, Tomaž Čakš, Marina Kuzman, Alem Maksuti, 
Erika Zelko, Imre Rurik, Boštjan Lanišnik, Francisco Larrosa, Marko Polič, Metoda Dodič Fikfak, Bojan Žlender, Helena 
Ribič, Zoran Simonović, Stojan Kostanjevec, Matej Majerič, Stefano Lazzer in Matej Plevnik.
Za njihovo vestno in ažurno delo se jim iskreno zahvaljujemo!
Uredništvo revije Zdravstveno varstvo
National Institute of Public Health
Trubarjeva 2, 1000 Ljubljana, Slovenia
zdrav.var@nijz.si
http://www.nijz.si/sl/nijz/revija-zdravstveno-varstvo 
++386 1 2441 543
INSTRUCTIONS FOR AUTHORS
Journal: Zdravstveno varstvo (ZV) ISSN 0351-0026 (print edition) / Slovenian Journal of Public Health (SJPH)
ISSN 1854-2476 (electronic edition)
Slovenian Journal of Public Health publishes internationally oriented articles on the broad area of public health and 
encourages interdisciplinary approach to public health. It focuses on all specific issues in public health especially 
in Central and South East Europe, i.e. primary care, prevention of communicable and noncommunicable diseases, 
health promotion, environmental and occupational health, organization and management in public health, social and 
economical aspects of public health. 
The journal publishes original invited editorials, research papers, study protocols, and systematic reviews in English 
language only.
Instructions are in accordance with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. 
Complete instructions are published in N Engl J Med 1997; 336: 309-15 and in Ann Intern Med 1997; 126: 36-47 and on 
the URL address: http://www.icmje.org.
Editorial Office accepts only articles, that have not been published elsewhere and are not being considered for 
publication in other journals. Parts of the article, summarized after other sources (especially illustrations and tables) 
should include the author’s and publisher’s permission for reproduction.
ETHICAL GUIDELINES 
Submission of a manuscript to ZV/SJPH implies that all authors have read and agreed to its content. Research 
involving human subjects (including human material or human data) that is reported in the manuscript must have 
been performed in accordance with the Declaration of Helsinki of 1975, as revised in 2000 and must have been 
approved by an appropriate ethics committee. A statement detailing this, including the name of the ethics committee 
and the reference number where appropriate, must appear at the end of all manuscripts reporting research on human 
subjects. If a study has been granted an exemption from requiring ethics approval, this should also be detailed at 
the end of the manuscript. The authors must explain the rationale for their approach, and demonstrate that the 
institutional review body explicitly approved the doubtful aspects of the study. Further information and documentation 
to support this should be made available to editors on request. Manuscripts may be rejected if the editors consider 
that the research has not been carried out within an ethical framework. In rare cases, the editors may contact the 
ethics committee for further information. 
For all research involving human subjects, informed consent to participate in the study should be obtained from 
participants (or their parent or guardian in the case of children) and a statement to this effect should appear in the 
manuscript. 
For all articles that include information or images relating to individual participants, written informed consent for the 
publication of these images must be obtained from the participant (or their parent or guardian in the case of children) 
and a statement to this effect should be included in the manuscript. These documents must be made available to 
editors if requested, and will be treated confidentially. 
For research carried out on animals, authors are encouraged to comply with the “Animal Research: Reporting In Vivo 
Experiments” (ARRIVE) guidelines and must comply with local or institutional ethics approval requirements on the 
care and use of animals for research. A statement detailing such ethics approval and/or guidelines must be included 
in the manuscript. Relevant information should be included in the article as outlined in the guidelines. 
Authors who have done the project with the support of a company, should indicate this in the statement at the end 
of the manuscript. 
ZV/SJPH requires authors to declare any competing financial or other interest in relation to their work. All competing 
interests that are declared must be listed at the end of the manuscript. 
Required statements at the end of the manuscript are:  
CONFLICTS OF INTEREST (The authors declare that no conflicts of interest exist.) 
FUNDING (The study was financed by ... ) 
ETHICAL APPROVAL (Received from the ... )
PLAGIARISM DETECTION 
ZV/SJPH publisher is a member of the CrossCheck plagiarism detection initiative. In cases of suspected plagiarism 
CrossCheck report is available to the editors of the ZV/SJPH to detect instances of overlapping and similar text in 
submitted manuscripts. CrossCheck is a multi-publisher initiative allowing screening of published and submitted 
content for originality.  
MANUSCRIPT SUBMISSION 
We recommend the use of video instructions for authors. The ZV/SJPH welcomes submissions in electronic form to 
the Web-based peer review system, Editorial Manager at http://www.editorialmanager.com/sjph/ to receive all 
submissions and no longer accepts submissions by e-mail or post. The Editorial Office will only accept the post 
delivery of the Authorship and Copyright Transfer Agreement which requires the authors’ signatures. Kindly send 
them together with the electronic submission of the manuscript to the address: National Institute of Public Health, 
Zdravstveno varstvo, Trubarjeva 2, 1000 Ljubljana, Slovenia. 
Please register in Editorial Manager as ‘author’. The first registration will require the entry of the author’s data. 
All further entries will only require the entry of login data, which will be sent to your e-mail address after the first 
registration in the system. 
After a successful login, complete all the required structured fields. Confirm the statement that your contribution 
has not yet been published or considered for publication in any other journal, and that the contribution was read 
and approved by other authors, and that if the contribution includes experiments on humans or animals, these were 
performed in accordance with the principles of the Helsinki-Tokyo Declaration or in accordance with the ethical 
principles. 
Complete the data on the author and co-authors accurately and in full. Provide the corresponding author (with full 
address, telephone number and e-mail address), who will communicate with the Editorial Office and other authors. 
The language of the manuscript is English. Original studies and reviews must include Slovenian language translations 
of the title, the abstract and key words. English speaking authors submit all the text only in English, obligatory 
secondary abstract is the same as the first abstract (please repeat it in English). 
A special field for translation is provided only for the second language (Slovenian language) version of the abstract; 
other data must be written in the requested fields bilingually. The first abstract is always in English (limit 250 words), 
the secondary abstract is in Slovenian language with limitation of 400 words (extended abstract). English speaking 
authors submit all the text only in English! 
After the entry of the structured data, please submit the attachment - the manuscript (from the Introduction part 
onward), which may not include author’s data already written in the structured fields. The name of the file may not 
include the author’s personal data or titles of institutions included in the preparation of the manuscript. Include 
graphic and image material in the text where it should be positioned. Submit only one document (one attached file). 
Please use Line counter in the Word program. 
When submitting the manuscript, follow the instructions provided by the system; you can also use ‘Editorial Manager’s 
Tutorial for Authors’. 
The system works best with the latest version of Acrobat. 
If you have difficulties submitting your manuscript, please contact the journal office at zdrav.var@nijz.si. 
Our Web-based system provides full electronic capabilities not only for submission, but also for peer review and 
status updates. It also speeds manuscript turnaround and provides global access for authors, reviewers, and editors. 
Authors, reviewers, and editors receive automatic e-mail messages from Editorial Manager when significant events 
occur. 
We give some detailed instructions in the continuation. 
Manuscript should be written in Word for Windows word processor. Contribution should be typed with double-spaced 
with margins of at least 25 mm. 
Original scientific articles should be divided into following headings: 1 lntroduction, 2 Methods, 3 Results, 4 Discussion 
and 5 Conclusions (this is also the structure of the abstract). Other types of articles and systematic review articles 
can be designed differently, but the division in headings and subheadings should be clearly evident from the size of 
characters in the titles. Headings and subheadings should be numbered decadally by standard SIST ISO 2145 and SIST 
ISO 690 (e. g. 1, 1.1, 1.1.1 etc.). 
LENGTH
Required length for invited editorial is 250 to 1000 words and for research article 2000 to 4500 words with tables and 
references.
TITLE AND AUTHORS
The title of the article should be short and concise, descriptive and not affirmative (statements are not allowed 
in the title). Names of authors with concise academic and professional degrees and full adress of the department, 
institution or clinic where the work has been performed should be cited. Authors should be qualified for authorship. 
They should contribute to the conception, design, analysis and interpretation of data, and they should approve the 
final version of the contribution.
ABSTRACT AND KEY WORDS
The abstract of the original scientific article should be structured (Introduction, Methods, Results, Conclusions) and 
of no more than 250 words (Slovenian language abstracts are limited to 400 words). The abstract should be written 
in third person. The abstract of a original scientific article should state the purpose of the investigation, basic 
procedures, main findings together with their statistical significance, and principal conclusions. 3 - 10 key words 
should be cited for the purpose of indexing. Terms from MeSH - Medical Subject Headings listed in Index Medicus 
should be used. The abstract should normally be written in one paragraph, only exceptionally in several. The author 
propose the type of the artlice, but the final decision is adopted by the editor on the base of the suggestions of the 
professional reviewers. 
REFERENCES 
We recommend authors to review prior issues of our journal (the last five years) for any relevant literature on their 
paper’s topic. 
Each mentioning of the statements or findings by other authors should be supported by a reference. References 
should be numbered consecutively in the same order in which they appear in the text. Reference should be cited at 
the end of the cited statement. References in text, illustrations and tables should be indicated by Arabic numerals in 
parentheses ((1), (2, 3), (4-7) etc). References, cited only in tables or illustrations should be numbered in the same 
sequence as they will appear in the text. Avoid using abstracts and personal communications as references (the latter 
can be cited in the text). The list of the cited literature should be added at the end of the manuscript. Literature 
should be cited accordingto the enclosed instructions that are in accordance with those used by U. S. National Library 
of Medicine in Index Medicus. The titles of journals should be abbreviated according to the style used in Index Medicus 
(complete list on the URL address: http://www.nlm.nih.gov). List the names of all authors, if there are six authors or 
more, list the first six authors than add et al.
EXAMPLES FOR LITERATURE CITATION 
example for a book: 
1. Premik M. Uvod v epidemiologijo. Ljubljana: Medicinska fakulteta, 1998.
example for the chapter in a book: 
2. Goldberg BW. Population-based health care. In: Taylor RB, editor. Family medicine. 5th ed. New York: Springer, 
1999: 32-6.
example for the article in a journal: 
3. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A randomized controlled trial of telephone management of suspected 
urinary tract infections in women. J Fam Pract 2001; 50: 589-94.
example for the article in a journal with no author given: 
4. Anon. Early drinking said to increase alcoholism risk. Globe 1998; 2: 8-10. 
example for the article in a journal with organization as author: 
5. Women’s Concerns Study Group. Raising concerns about family history of breast cancer in primary care 
consultations: prospective, population based study. Br Med J 2001; 322: 27-8.
example for the article from journal volume with supplement and with number:
6. Payne DK, Sullivan MD, Massie MJ. Women’s psychological reactions to breast cancer. Semin Oncol 1996; 23(Suppl 
2): 89-97.
example for the article from collection of scientific papers:
7. Hickner J, Barry HC, Ebell MH, Ettenhofer T, Eliot R, Sugden K et al. Suicides and non-suicidal deaths in Slovenia: 
molecular genetic investigation. In: 9th European Symposium on Suicide and Suicidal Behaviour. Warwick: 
University of Oxford, 2002: 76.
example for master theses, doctor theses:
8. Bartol T. Vrednotenje biotehniških informacij o rastlinskih drogah v dostopnih virih v Sloveniji: doktorska 
disertacija. Ljubljana: Biotehniška fakulteta, 1998.
example for electronic sources:
9. Mendels P. Textbook publishers extend lessons online. Available Sept 23, 1999 from:  
http://www.nytimes.com/library/tech/99/09.
TABLES 
Type on the place in the text where they belong. Tables should be composed by lines and columns which intersect in 
fields. Number tables consecutively. Each table should be cited in the text and supplied with a brief title. Explain all 
the abbreviations and non-standard units in the table.  
ILLUSTRATIONS 
Illustrations should be professionally drawn. When preparing the illustrations consider the black-and-white print. 
Illustration material should be prepared in black-and-white (not in color!). Surfaces should have no tone-fills, 
hatchings should be chosen instead (in case of bar-charts, so called pie-charts or maps). In linear graphs the individual 
lines should also be separated by various kinds of hatching or by different markers (triangles, asterisks ... ), but not 
by color. Graphs should have white background (i. e. without background). 
Letters, numbers or symbols should be clear, even and of sufficient size to be still legible on a reduced illustration. 
Freehand or typewritten lettering in the illustration is unacceptable. 
Each figure should be cited in the text. 
Accompanying text to the illustration should contain its title and the necessary explanation of its content. Illustration 
should be intelligible also without reading the manuscript. Ali the abbreviations from the figure should be explained. 
The use of abbreviations in the accompanying text to the illustration is unacceptable. Accompanying texts to 
illustrations should be written in the place of their appearing in the text. 
lf the identity of the patient can be recognized on the photograph, a written permission of the patient for its 
reproduction should be submitted.  
UNITS OF MEASUREMENT 
Should be in accordance with International System of Units (SI).
 
ABBREVIATIONS 
Avoid abbreviations, with the exception of internationally valid signs for units of measurement. Avoid abbreviations 
in the title and abstract. The full term for which an abbreviation stands should precede its first use in the text, 
abbreviation used in further text should be cited in parentheses.
EDITORIAL WORK
The received manuscript is submitted by the editor to three international professional reviewers. After the reviewing 
process, the contribution is sent to the author for approval and consideration of corrections. The final copy is than 
again submitted to the Editorial Office. During the editorial process, the secrecy of the contribution content is 
guaranteed. All the articles are language edited. Author receives in consideration also the first print, but at this stage 
corrigenda (printing errors) only are to be considered. Proofreading should be returned in three days, otherwise it is 
considered that the author has no remarks. 
The journal office strives for rapid editorial process. Authors should adhere to the deadlines set by them in letters; 
otherwise it may happen that the article will be withdrawn from the editorial process. 
Any appeal of the authors deals the Editorial Board of the ZV/SJPH. 
When the manuscript is accepted for publication, the author must assigns copyright ownership of the material to the 
National Institute of Public Health as a publisher. Any violation of the copyright will be legally persecuted. 
ZV/SJPH does not have article processing charges (APCs) nor article submission charges. 
The author receives one copy of the print issue in which the article is published.
Nacionalni inštitut za javno zdravje
Trubarjeva 2, 1000 Ljubljana, Slovenija
zdrav.var@nijz.si
http://www.nijz.si/sl/nijz/revija-zdravstveno-varstvo 
++386 1 2441 543
NAVODILA AVTORJEM
Revija: Zdravstveno varstvo (ZV) ISSN 0351-0026 (tiskana izdaja) / Slovenian Journal of Public Health (SJPH)
ISSN 1854-2476 (elektronska izdaja)
Navodila so v skladu z Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Popolna 
navodila so objavljena v N Engl J Med 1997; 336: 309-15 in v Ann Intern Med 1997; 126: 36-47 in na spletni strani 
http://www.icmje.org.
ETIČNI STANDARDI
Uredništvo sprejema v obdelavo le članke s širšo mednarodno javnozdravstveno tematiko, ki še niso bili in ne bodo 
objavljeni drugje. Dele članka, ki so povzeti po drugi literaturi (predvsem slike in tabele), mora spremljati dovoljenje 
avtorja in založnika prispevka, da dovoli naši reviji reprodukcijo. 
Oddan rokopis morajo prebrati vsi avtorji in se z njegovo vsebino strinjati. 
Raziskave na ljudeh (vključno s človeškimi materiali in osebnimi podatki) morajo biti izpeljane v skladu s Helsinško 
deklaracijo in potrjene s strani nacionalne etične komisije. V izjavi na koncu rokopisa morajo avtorji podati izjavo o 
etiki raziskav na ljudeh, ki mora vsebovati ime etične komisije in referenčno števiko obravnave. Poročanje o raziskavah 
na ljudeh brez potrdila etične komisije zahteva dodatno razlago v poglavju o metodah dela. Na zahtevo Uredništva je 
avtor dolžan predložiti vso dokumentacijo o obravnavi raziskovalne etike njegovega rokopisa. Uredništvo si pridržuje 
pravico, da kontaktira etično komisijo.
Prav tako morajo avtorji, ki poročajo o ljudeh ali posredujejo javnosti njihovo slikovno gradivo, pridobiti dovoljenja 
vseh sodelujočih, da se z vključitvijo v raziskavo strinjajo (v primeru otrok so to starši ali skrbniki). Izjavo o pridobitvi 
teh dovoljenj morajo avtorji podati v poglavju o metodah dela. Uredništvo si pridržuje pravico vpogleda v to 
dokumentacijo.
Raziskave na živalih morajo biti izpeljane v skladu z navodili “Animal Research: Reporting In Vivo Experiments” 
(ARRIVE) in potrjene s strani nacionalne etične komisije. V poglavju o metodah dela in v izjavi na koncu rokopisa 
morajo avtorji podati izjavo o etiki raziskav na živalih z veljavno številko dovoljenja.
V izjavi na koncu rokopisa morajo biti zapisani morebitni finančni ali drugi interesi farmacevtske industrije ali 
proizvajalcev opreme ter inštitucij, povezani z objavo v ZV/SJPH. 
Avtorji morajo na koncu rokopisa zapisati sledeče izjave: 
CONFLICTS OF INTEREST (The authors declare that no conflicts of interest exist.) 
FUNDING (The study was financed by ... ) 
ETHICAL APPROVAL (Received from the… ali opis etičnega vidika raziskave)
PLAGIATI 
Kadar uredništvo ugotovi, da je rokopis plagiat, se rokopis takoj izloči iz uredniškega postopka. Plagiatorstvo 
ugotavljamo s programom za odkrivanje plagiatov CrossCheck plagiarism detection system. 
ELEKTRONSKA ODDAJA PRISPEVKA 
Priporočamo uporabo videoposnetka z navodili za avtorje. Prispevke oddajte v elektronski obliki s pomočjo spletne 
aplikacije Editorial Manager, ki se nahaja na spletnem naslovu http://www.editorialmanager.com/sjph/. V uredništvo 
sprejemamo po pošti le še Izjave o avtorstvu in avtorskih pravicah, ki zahtevajo lastnoročni podpis. Prosimo, da jih 
pošljete hkrati z elektronsko oddajo prispevka na naslov: Nacionalni inštitut za javno zdravje, za revijo Zdravstveno 
varstvo, Trubarjeva 2, 1000 Ljubljana. 
V spletno uredniško aplikacijo se prijavite kot ‘avtor’. Prva prijava zahteva vnos podatkov o avtorju, vse naslednje 
prijave pa le še vnos podatkov za prijavo, ki jih na svoj elektronski naslov prejmete po prvi prijavi v sistem.
Po uspešni prijavi izpolnite vsa zahtevana strukturirana polja. Potrdite izjavo, da vaš prispevek še ni bil objavljen ali 
poslan v objavo kakšni drugi reviji, da so prispevek prebrali in se z njim strinjajo vsi avtorji, da so raziskave na ljudeh 
oz. živalih opravljene v skladu z načeli Helsinško-Tokijske deklaracije oz. v skladu z etičnimi načeli. 
Avtorji, ki v objavo pošiljate raziskovalno delo, opravljeno s pomočjo nekega podjetja, to navedite na koncu rokopisa 
v izjavi o financiranju. 
Polje ‘Comments’ je namenjeno vašim dodatnim razlagam, navedete lahko tudi predlog recenzentov z imeni, nazivi, 
e-naslovi in zaposlitvijo.
Podatke o avtorju in soavtorjih vnesite kar se da natančno in popolno. Naveden naj bo korespondenčni avtor (s polnim 
naslovom, telefonsko številko in elektronskim naslovom), ki bo skrbel za komunikacijo z uredništvom in ostalimi 
avtorji. 
Jezik prispevka je angleščina. Objavljamo izvirne znanstvene članke, sistematične pregledne znanstvene članke, 
metodologije raziskav in vabljene uvodnike. Pri izvirnih, metodoloških in sistematičnih preglednih znanstvenih 
prispevkih morajo biti naslov, izvleček in ključne besede prevedeni tudi v slovenščino.  
Naslov, ključne besede in izvleček se oddajajo dvojezično v angleščini in slovenščini v strukturirana polja. Posebno 
polje za zapis v drugem jeziku obstaja le za izvleček, preostale podatke vnesite v obeh jezikih v ustrezno isto polje. 
Prvi izvleček je vselej v angleškem jeziku (do 250 besed - sistem vam besede sproti šteje), drugi pa v slovenskem 
jeziku (razširjen izvleček - do 400 besed).
Po vnosu strukturiranih podatkov oddajte še priponko - rokopis (od 1 Uvod naprej), ki ne sme zajemati podatkov, ki ste 
jih vnesli že pred tem v strukturirana polja, zlasti ne podatkov o avtorjih. Ime datoteke ne sme vključevati avtorjevih 
osebnih podatkov, prav tako ne imen ustanov, vključenih v pripravo rokopisa. Grafično in slikovno gradivo je kot ves 
rokopis v angleškem jeziku. Vključite ga v besedilo na mesto, kamor le-to sodi in ga opremite z naslovom. Oddate 
torej le en sam dokument, eno priponko. V Wordu uporabite možnost Postavitev strani/Številke vrstic (tako bo na 
robu vsake vrstice dokumenta dodana številka vrstice).
Pri oddaji sledite napotkom, ki vam jih ponuja sistem, pomagate pa si lahko tudi z ‘Editorial Manager’s Tutorial for 
Autors’.
Sistem najbolje deluje, če uporabljate zadnjo različico Acrobata.
Če pri oddajanju rokopisa naletite na nepremostljive težave, se za pomoč obrnite na naslov uredništva: 
zdrav.var@nijz.si.
V nadaljevanju podajamo še nekaj natančnejših napotkov.
ROKOPIS
Besedila naj bodo napisana z urejevalnikom Word for Windows 97-2003. Robovi naj bodo široki najmanj 25 mm. 
Znanstveni članki naj imajo naslednja poglavja: uvod, metode, rezultati, razpravljanje in zaključek. Uvodniki in 
sistematični pregledni članki so lahko zasnovani drugače, vendar naj bo razdelitev na poglavja in podpoglavja jasno 
razvidna iz velikosti črk naslovov. Poglavja in podpoglavja naj bodo številčena dekadno po standardu SIST ISO 2145 in 
SIST ISO 690 (npr. 1, 1.1, 1.1.1 itd.). 
DOLŽINA PRISPEVKOV
Zahtevana dolžina prispevka je za vabljen uvodnik od 250 do 1000 besed, za znanstveni članek (originalni, metodološki 
ali sistematični pregledni) pa od 2000 do 4500 besed s slikovnim gradivom in literaturo vred.
NASLOV IN AVTORSTVO
Naslov v angleškem in slovenskem jeziku naj bo kratek in natančen, opisen in ne trdilen (povedi v naslovih niso 
dopustne). Navedena naj bodo imena piscev z natančnimi akademskimi in strokovnimi naslovi ter popoln naslov 
ustanove, inštituta ali klinike, kjer je delo nastalo. Avtorji morajo izpolnjevati pogoje za avtorstvo. Prispevati morajo 
k zasnovi in oblikovanju oz. analizi in interpretaciji podatkov, rokopis morajo intelektualno zasnovati oz. ga kritično 
pregledati, strinjati se morajo s končno različico rokopisa. Samo zbiranje podatkov ne zadostuje za avtorstvo.
IZVLEČEK IN KLJUČNE BESEDE
Izvleček v angleškem in slovenskem jeziku naj bo pri znanstvenem in metodološkem članku strukturiran in naj ne bo 
daljši od 250 besed v angleščini in 400 besed v slovenščini, izvlečki ostalih člankov so lahko nestrukturirani. Izvleček 
naj vsebinsko povzema in ne le našteva bistvene vsebine dela. Izogibajte se kraticam in okrajšavam. Napisan naj bo 
v 3. osebi. 
Izvleček znanstvenega članka naj povzema namen dela, osnovne metode, glavne izsledke in njihovo statistično 
pomembnost ter poglavitne sklepe (struktura IMRC - Introduction, Methods, Results, Conclusions).
Navedenih naj bo 3-10 ključnih besed, ki nam bodo v pomoč pri indeksiranju. Uporabljajte izraze iz MeSH - Medical 
Subject Headings, ki jih navaja Index Medicus. 
KATEGORIJA PRISPEVKA 
Kategorijo prispevka predlaga z vnosom v ustrezno polje avtor sam, končno odločitev pa sprejme urednik na 
osnovi predlogov recenzentov. Objavljamo izvirne znanstvene članke, metodološke članke, sistematične pregledne 
znanstvene članke in vabljene uvodnike.
REFERENCE 
Avtorjem priporočamo, da pregledajo objavljene članke na temo svojega rokopisa v predhodnih številkah naše revije 
(za obdobje zadnjih pet let).
Vsako navajanje trditev ali dognanj drugih morate podpreti z referenco. Reference naj bodo v besedilu navedene po 
vrstnem redu, tako kot se pojavljajo. Referenca naj bo navedena na koncu citirane trditve. Reference v besedilu, 
slikah in tabelah navedite v oklepaju z arabskimi številkami ((1), (2, 3), (4-7)). Reference, ki se pojavljajo samo v 
tabelah ali slikah, naj bodo oštevilčene tako, kot se bodo pojavile v besedilu. Kot referenc ne navajajte izvlečkov in 
osebnih dogovorov (slednje je lahko navedeno v besedilu). Seznam citirane literature dodajte na koncu prispevka. 
Literaturo citirajte po priloženih navodilih, ki so v skladu s tistimi, ki jih uporablja ameriška National Library of 
Medicine v Index Medicus. Uporabljajte numerično citiranje. Imena revij krajšajte tako, kot določa Index Medicus 
(popoln seznam na naslovu URL: http://www.nlm.nih.gov). 
Navedite imena vseh avtorjev, v primeru, da je avtorjev šest ali več, navedite prvih šest avtorjev in dodajte et al.
 
PRIMERI ZA CITIRANJE LITERATURE 
primer za knjigo: 
1. Premik M. Uvod v epidemiologijo. Ljubljana: Medicinska fakulteta, 1998.
2. Mahy BWJ. A dictionary of virology. 2nd ed. San Diego: Academic Press, 1997.
primer za poglavje iz knjige: 
3. Urlep F. Razvoj osnovnega zdravstva v Sloveniji zadnjih 130 let. In: Švab I, Rotar-Pavlič D, editors. Družinska 
medicina. Ljubljana: Združenje zdravnikov družinske medicine, 2002: 18-27.
4. Goldberg BW. Population-based health care. In: Taylor RB, editor. Family medicine. 5th ed. New York: Springer, 
1999: 32-6.
primer za članek iz revije: 
5. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A randomized controlled trial of telephone management of suspected 
urinary tract infections in women. J Fam Pract 2001; 50: 589-94.
primer za članek iz revije, kjer avtor ni znan: 
6. Anon. Early drinking said to increase alcoholism risk. Globe 1998; 2: 8-10. 
primer za članek iz revije, kjer je avtor organizacija: 
7. Women’s Concerns Study Group. Raising concerns about family history of breast cancer in primary care 
consultations: prospective, population based study. Br Med J 2001; 322: 27-8.
primer za članek iz suplementa revije z volumnom in s številko:
8. Shen HM, Zhang QF. Risk assessment of nickel carcinogenicity and occupational lung cancer. Environ Health 
Perspect 1994; 102(Suppl 2): 275-82.
9. Payne DK, Sullivan MD, Massie MJ. Women’s psychological reactions to breast cancer. Semin Oncol 1996; 23(Suppl 
2): 89-97.
primer za članek iz zbornika referatov:
10. Sugden K, Kirk R, Barry HC, Hickner J, Ebell MH, Ettenhofer T et al. Suicides and non-suicidal deaths in Slovenia: 
molecular genetic investigation. In: 9th European Symposium on Suicide and Suicidal Behaviour. Warwick: 
University of Oxford, 2002: 76.
primer za magistrske naloge, doktorske disertacije in Prešernove nagrade:
11. Bartol T. Vrednotenje biotehniških informacij o rastlinskih drogah v dostopnih virih v Sloveniji: doktorska 
disertacija. Ljubljana: Biotehniška fakulteta, 1998.
TABELE 
Tabele v angleškem jeziku naj bodo v besedilu prispevka na mestu, kamor sodijo. Tabele naj sestavljajo vrstice in 
stolpci, ki se sekajo v poljih. Tabele oštevilčite po vrstnem redu, vsaka tabela mora biti citirana v besedilu. Tabela naj 
bo opremljena s kratkim angleškim naslovom. V legendi naj bodo pojasnjene vse kratice, okrajšave in nestandardne 
enote, ki se pojavljajo v tabeli. 
SLIKE 
Slike morajo biti profesionalno izdelane. Pri pripravi slik upoštevajte, da gre za črno-beli tisk. Slikovno gradivo naj 
bo pripravljeno: 
• črno-belo (ne v barvah!);
• brez polnih površin, namesto tega je treba izbrati šrafure (če gre za stolpce, t. i. tortice ali zemljevide);
• v linijskih grafih naj se posamezne linije prav tako ločijo med samo z različnim črtkanjem ali različnim 
označevanjem (s trikotniki, z zvezdicami...), ne pa z barvo;
• v grafih naj bo ozadje belo (tj. brez ozadja).
Črke, številke ali simboli na sliki morajo biti jasni, enotni in dovolj veliki, da so berljivi tudi na pomanjšani sliki. Ročno 
ali na pisalni stroj izpisano besedilo v sliki je nedopustno. 
Vsaka slika mora biti navedena v besedilu. Besedilo k sliki naj vsebuje naslov slike in potrebno razlago vsebine. 
Slika naj bo razumljiva tudi brez branja ostalega besedila. Pojasniti morate vse okrajšave v sliki. Uporaba okrajšav v 
besedilu k sliki je nedopustna. Besedila k slikam naj bodo napisana na mestu pojavljanja v besedilu. 
Fotografijam, na katerih se lahko prepozna identiteta bolnika, priložite pisno dovoljenje bolnika. 
MERSKE ENOTE 
Naj bodo v skladu z mednarodnim sistemom enot (SI).
 
KRATICE IN OKRAJŠAVE 
Kraticam in okrajšavam se izogibajte, izjema so mednarodno veljavne oznake merskih enot. V naslovih in izvlečku 
naj ne bo kratic. Na mestu, kjer se kratica prvič pojavi v besedilu, naj bo izraz, ki ga nadomešča, polno izpisan, v 
nadaljnjem besedilu uporabljano kratico navajajte v oklepaju.
UREDNIŠKO DELO 
Prispelo gradivo z javnozdravstveno tematiko mednarodnega pomena posreduje uredništvo po tehnični brezhibnosti 
v strokovno recenzijo trem mednarodno priznanim strokovnjakom. Recenzijski postopek je dvojno slep. Po končanem 
uredniškem delu vrnemo prispevek korespondenčnemu avtorju, da popravke odobri in upošteva. Popravljen čistopis 
vrne v uredništvo po spletni aplikaciji Editorial Manager. Sledi jezikovna lektura, katere stroške krije založnik. Med 
redakcijskim postopkom je zagotovljena tajnost vsebine prispevka. Avtor dobi v pogled tudi prve, t. i. krtačne odtise, 
vendar na tej stopnji upoštevamo samo še popravke tiskarskih napak. Krtačne odtise je treba vrniti v treh dneh, sicer 
menimo, da avtor nima pripomb. 
V uredništvu se trudimo za čim hitrejši uredniški postopek. Avtorji se morajo držati rokov, ki jih dobijo v dopisih, sicer 
se lahko zgodi, da bo članek odstranjen iz postopka. 
Morebitne pritožbe avtorjev obravnava uredniški odbor revije. 
Za objavo članka prenese avtor avtorske pravice na Nacionalni inštitut za javno zdravje kot založnika revije (podpiše 
Pogodbo o avtorstvu in avtorskih pravicah).  Kršenje avtorskih in drugih sorodnih pravic je kaznivo.
Prispevkov ne honoriramo in tudi ne zaračunavamo stroškov uredniškega postopka. 
Avtor dobi izvod tiskane revije, v kateri je objavljen njegov članek.
primer za elektronske vire:
12. Mendels P. Textbook publishers extend lessons online. Available Sept 23, 1999 from:  
http://www.nytimes.com/library/tech/99/09.