Health Workforce Research Articles

2.K. Scientific session: Promoting organizational health literacy in healthcare organizations and beyond in Europe

Abstract Organizational health literacy (OHL) has been defined as the degree to which healthcare organizations equitably enable/empower people, through organizational structures, policies, and processes, to find, understand, appraise, and use information and services to make health-related decisions and actions for themselves and others. By adopting an OHL approach, healthcare organizations enhance health service delivery by simplifying interaction with health systems by making information and services more comprehensible. An OHL approach not only reduces health literacy demands of patients, but also of workforce and the resident population of the community that they serve. The workshop focuses on two theory-based initiatives that focus at promoting OHL in Europe: (1) the Organizational Health Literacy for All (OHL-ALL) initiative, which developed a practice-oriented OHL approach for organizations promoting equity explicitly to support people in vulnerable positions with or at risk for diabetes or other non-communicable diseases, and (2) the World Health Organization (WHO) Action Network on Measuring Population and Organizational Health Literacy (M-POHL) which aims at initiating and facilitating the (self-) assessment of OHL in healthcare organization by developing, providing, and disseminating OHL assessment tools. Both initiatives strive to support organizational change and workforce responsiveness. While the first initiative goes beyond health literacy responsiveness of healthcare organizations intending to offer guidance for organizations on how to give all individuals the best possible opportunities to achieve their optimal health and well-being, the second initiative specifically focuses on OHL in healthcare organizations using a settings approach with a focus on health care, prevention, and health promotion. The initiatives enrich and complement each other. The workshop consists of five short presentations, followed by a discussion among the presenters and the audience. The first presentation focuses on the development of the theory-informed and coherent OHL approach of the OHL-ALL initiative. The second presentation provides an overview of the M-POHL initiative and its innovative tools. Then three presentations will showcase results, experiences, and outcomes from European countries on assessing OHL in different healthcare settings. Expected impact: Theory-based guidance for implementing organizational development will be provided. Results from the M-POHL initiative will contribute to greatly needed insights into OHL needs and opportunities of healthcare organizations. The insights from these real-world assessments and implementation can inform future public health practice, policy, and research. Key messages • An OHL approach contributes to better equity. It helps meet health literacy needs of patients, health and care workforce and the resident population of the community that are served. • New tools have been developed to support management and health and care workforce in assessing and improving OHL responsiveness, to better serve patient communities.

What does routine healthcare data tell us about the diagnostic pathway for older people with heart failure in Wales: under-testing, problems with access, or poor coding?

Abstract Background United Kingdom guidelines (NICE, NG106) for suspected chronic heart failure (HF) recommend that NT pro-BNP is performed as a first-line test. The result is also used to triage individuals; when NT pro-BNP is <400ng/L, a diagnosis of HF is less likely, echocardiography (echo) and specialist assessment should be performed within 6 weeks when the result is 400-2000ng/L, and within 2 weeks if >2000ng/L. How accurately this guidance is followed in clinical practice in Wales is not known. Purpose To examine how the current diagnostic pathway is recorded in routinely-collected electronic health record (EHR) data for older people in Wales with a diagnosis of heart failure. Methods We conducted a retrospective, population-level, observational study using linked anonymised EHR data in Wales (2015-22). We included patients aged 65y+ with a HF diagnosis in their primary or secondary care records and with a minimum of 12m pre and post-diagnosis data (for assessment of diagnostic pathway). We looked back from the point of HF diagnosis for codes associated with prior cardiovascular conditions (any time prior), symptoms (within 3 years), and key diagnostic tests (within 90 days). Results The final cohort comprised 51,020 individuals 65y and over with a diagnosis of heart failure between 2015-2022. Incidence and prevalence of heart failure increased across the study period (1.4-1.5% and 8.5-9.1% respectively). HF diagnosis was first evident in secondary care records in 54.9%, in primary care 36.3%, and in both data sources on the same day in 8.8%. Preceding cardiovascular diagnoses included hypertension (69.5%), atrial fibrillation (36.7%), myocardial infarction (30.5%), coronary artery disease (25.7%), and valve disease (17.7%). The most common recorded symptoms preceding diagnosis were breathlessness (41.4%), ankle oedema (9.8%), and fatigue (8.8%). Searched for symptoms were not recorded in 43.8%. In the 90 days preceding the diagnosis, 7-30% had recorded NT pro-BNP with the number of tests increasing throughout the study period (Figure 1). In the 90 days prior to HF diagnosis, 28-31% had an echo recorded. NT pro-BNP was >2000ng/L in 51.8%, 400-2000ng/L in 38.6% and <400ng/L in 9.6%. Conclusions In Wales, a greater number of individuals with heart failure appear to be diagnosed during hospital admission, compared with primary care. Many individuals with a code for HF in their records, do not have recorded objective evidence of cardiac dysfunction. The proportion of first-line and definitive tests appears low. It is unclear whether this is because of under-referral, difficulty accessing tests in primary care, or inaccurate coding of test referrals and results. These results are important in evaluating health service delivery and workforce planning.

Analysis of medical doctor supply in Bulgaria, Croatia, Romania, and Serbia in the last two decades

Abstract Introduction The shortage of medical doctors in Europe has become a priority issue, especially in the Eastern European region, where many countries are making large investments to ensure adequate supply. Training future medical professionals is a lengthy and costly process that significantly impacts healthcare accessibility and quality. As part of the project of the Laboratory for Strengthening Capacity and Performance of Health System and Workforce for Health Equity, we aimed to assess the changes in the medical doctor supply in several Balkan countries over the last two decades. Methods Data on the total number of graduated medical doctors (MD) and their rate per 100,000 population from 2000 to 2021 was retrieved from the Eurostat database. This open-access database contains the reported number of students who have graduated from medical schools for each year and selected countries (Bulgaria, Croatia, Romania, and Serbia). The standard methods of descriptive statistics were used to perform the analysis. Results During the observed period, the number of MDs graduating annually and their rates per 100,000 population have increased in all countries. Romania leads with the highest rate of MD graduates at 26.18 per 100,000 people, followed by Bulgaria (22.74), Serbia (19.15), and Croatia (16.56). From 2000 to 2021, Bulgaria experienced the highest increase in the number of medical doctor graduates, with a rise of 169.1% in absolute numbers and 200.9% in rate. In contrast, Serbia had the lowest increase, with only a 135.5% rise in the total number of medical doctor graduates and a rate increase of 152.3%. Conclusions In the last 20 years, Bulgaria, Croatia, Romania, and Serbia have seen an increase in the number of MD graduates and their rate per 100,000 population. Policymakers should consider the investments and education trends of medical professionals in relation to their employment and migrations to predict the future supply of doctors in this region. Key messages • Bulgaria, Croatia, Romania, and Serbia have seen an increase in the number of MD graduates and their rate per 100,000 population in the last twenty years. • Considering the trends in the number of newly graduated doctors, policymakers should address additional factors to ensure an adequate supply of medical doctors.

Mortality due to ischemic stroke in Serbia after redistribution of the inaccurately coded deaths

Abstract Background Ischemic stroke is a major common cause of death not only in Serbia but worldwide. Mortality statistics commonly include ill-defined, impossible and insufficiently specified causes of death among the underlying causes of death (CoDs). In the activities of the Laboratory for Strengthening the Capacity and Performance of the Health System and Workforce for Health Equity, we examined mortality due to ischemic stroke either as well-defined underlying CoDs or garbage codes (GCs - including the ill-defined, unspecified or impossible CoDs) in Belgrade in 2015 and 2020. Methods Anonymous mortality data of the City Institute of Public Health Belgrade were analyzed, and the GCs were redistributed to ischemic stroke as underlying CoDs (ICD-10 codes I63-I63.9), based on the principles of the Global Burden of Disease study, using the three-step approach: 1) exploration and analysis of GCs; 2) modelling of the underlying, antecedent and immediate causes of death; 3) proportionate redistribution. Results 17% of the total of all deaths in Belgrade in 2015 and 20.9% in 2020 were GCs. Before the redistribution, the share of ischemic stroke as the well-coded CoDs of total mortality was 7.3% (1443/19641) in 2015 and 4.6% (1022/21957) in 2020. A total of GCs - 309 deaths in 2015 and 322 in 2020 were identified for redistribution to ischemic stroke. Based on the type of GCs, in 2015, a total of 139 cases were redistributed in type 1 GCs, 83 in type 2 GCs and 87 in type 3 GCs. In 2020, 141 cases were redistributed due to type 1 GCs, 62 type 2 GCs and 119 type 3 GCs. Conclusions This study underscores the significant proportion of all ischemic deaths in Belgrade that were coded with the GCs. After the redistribution, almost one-fifth of the ischemic strokes, previously known as GCs, were added, emphasizing the crucial role of accurate coding in understanding mortality patterns. Improving the coding of deaths is necessary to have reliable information for health policymaking. Key messages • One-fifth of the ischemic strokes in Belgrade were previously GCs. • Accurate coding is essential for understanding mortality patterns and developing valid health policies.

COVID-19 premature mortality in Serbia: Does the place of death matter?

Abstract Background The COVID-19 pandemic has significantly impacted healthcare services provision in Serbia and globally. Many people did not seek or reach healthcare due to various reasons, and a significant number of COVID-19 deaths were not confirmed by laboratory testing. Within the project of the Laboratory for Strengthening Capacity and Performance of Health System and Workforce for Health Equity, we assessed the differences in years of life lost (YLL) of COVID-19 death cases according to the place of death. Methods The Statistical Office of the Republic of Serbia provided average life expectancy and anonymous individual mortality data of the Serbian population in 2020, 2021, and 2022, where COVID-19 was the underlying cause of death (ICD-X codes: laboratory confirmed - U07.1 and clinically diagnosed - U07.2), also disaggregated by the place of death (at home or in a hospital). Analytical statistics and nonparametric tests were used to assess the differences in premature mortality by place of death with a significance level set at p < 0.05. Results In all observed years, a total of 45,632 death cases due to COVID-19 occurred (94.3% in hospital and 5.7% at home). Most COVID-19 deaths were coded as U07.1 (93.8% in hospital, 91.3% at home). An average of 12.12±7.50 YLLs was estimated per death, with a median of 11.50. There was a significant difference (p < 0.001) in the median number of YLLs between those who died in the hospital (11.50) and those who died at home (6.78). Furthermore, deaths occurring at home had fewer YLLs but were more frequently coded as U07.2 (p < 0.001). Conclusions The place of death is relevant when assessing the impact of COVID-19 on premature mortality in Serbia. On average, persons who died at home due to COVID-19 had a lower number of YLLs compared to those who died in a hospital. More research is necessary on the other factors contributing to premature mortality and inequalities in the COVID-19 burden in Serbia. Key messages • During the first three years of the COVID-19 pandemic in Serbia, 5.7% of COVID-19 deaths occurred at home, resulting in an average of 9.89 years of life lost. • The COVID-19 pandemic highlights the need to investigate deaths that occur at home and improve pandemic preparedness.

Does staffing impact health and work conditions of staff in long-term care homes?: a scoping review

Abstract Background Long-Term Care (LTC) homes are highly regulated and task oriented, with demanding work and insufficient resources. Chronic underfunding of the sector, coupled with increased complexity of care, has deteriorated working conditions, resulting in precarious employment, intensified and stressful work, and decreased job satisfaction. These work conditions have contributed to severe staffing shortages of healthcare workers globally. To meet increased labour demands, OECD countries on average will need to increase the proportion of overall employment dedicated to LTC by 32% over the next decade. While reviews of literature have examined the association between staffing and care outcomes for residents in LTC, they have not examined how staffing structures affect the healthcare staff themselves. This scoping review asks: How does staffing impact the health of staff and working conditions in LTC? Methods A scoping review of empirical peer reviewed and grey literature was conducted to examine the association between LTC staffing practices and how they impact working conditions and the health and well-being of staff. PubMed, CINHAL, and Scopus databases were searched for relevant articles published within the past 10 years. Results Searches yielded 3994 unique articles, which were independently screened by pairs of reviewers. Preliminary results highlight that staffing levels are not optimized for healthy, sustainable work conditions. The level of staff, their skill mix, and ratios all impact the ability to provide care. In circumstances where there is inadequate staffing, care workers are more likely to experience stress, burnout, job dissatisfaction, and increased injury and illness. Conclusions Staffing practices shape working conditions which impact healthcare workers own health outcomes. To facilitate a strong LTC workforce, working conditions and occupational health need to be a priority in improvement initiatives. Key messages • With extreme staffing shortages challenging the healthcare sector, this review highlights the need for heightened attention to the impact of staffing practices on the healthcare workforce. • Improving working conditions and attuning to the needs of the workforce, ultimately improves quality of care.

Public Health In Conflict And War: A Response To An Ever Evolving Landscape

Abstract Background The bases for this proposal are the current and ongoing conflict and war situations around the world, causing turmoil for nations and hardship and public health crises for people. We can no longer ignore the critical and time-sensitive need to address issues of Public Health (PH) in conflict and war in our education and training programmes. Objectives To consider appropriate themes and topics in Conflict and War that should be included in PH education and training programmes; and to consider how and where they are best represented. Member schools of the Association of Schools of PH in the European Region (ASPHER) were asked to provide details of their curricula relating PH in Conflict and War. Submissions on this topic were received from over 10 schools. Information was collated into logical themes, to which elements of the curriculum were mapped. In a modified Delphi process, respondents were asked for their level of agreement for inclusion in a curriculum and at what level content should be delivered. Results Findings from the survey allowed identification of seven main themes from topics provided: Contextual Factors; Preventive Strategies; Emergency Preparedness; Impact and Response; Conflict Resolution and Solidarity, Rehabilitation and Recovery. Respondents had high levels of agreement that content should be included in curricula and be delivered at every level in PH education and training. Conclusions PH education and training have been deficient in not including PH in Conflict and War as a subject area in programmes. The knowledge and expertise developed of necessity in some places can be shared across the ASPHER network and beyond to increase awareness of the PH considerations of conflict and war. Key messages • Public health in war and conflict zones is critical due to unique challenges and urgent needs of affected populations. • An Integrated curriculum is vital for addressing conflict’s long-term health impact and preparing skilled workforce for health, resilience, action and laying the path to peace.

Incentives to attract and retain physicians to underserved areas - a case study from Portugal

Abstract Issue Physician shortages in underserved areas are a common challenge for governments and policymakers worldwide, including in Europe. Meanwhile, a knowledge gap exists on effective measures to address the issue. Description According to WHO Europe, one of ten actions to strengthen the healthcare workforce is to develop strategies to attract and retain health workers in rural and remote areas. Portugal faces geographical asymmetries in the distribution of physicians, and difficulties in retaining them in certain areas of the country. This case study seeks to describe and analyse the impact of an incentives package introduced in 2015 that aimed to attract and retain physicians in underserved areas. Financial incentives data was gathered via a national health human resources information system. Non-financial incentives data was reported by health institutions through an online form. Document analysis was conducted to understand the scope of the incentives package and its amendments. Results The incentives package implemented in Portugal effectively deployed physicians to underserved areas, since it led to a fourteen-fold increase in physicians settling in underserved areas. In terms of retention, an average of 59% of the physicians that took up the incentives package are still practicing in the same underserved area. However, the difference between the retention levels of physicians under the incentives package and those not covered is minimal. To further reduce health inequities and achieve universal health coverage, a need exists to review the financial and non-financial incentives to better suit physicians’ needs and expectations, as well as those of the National Health Service. Lessons The incentives package introduced in Portugal makes it clear that flexibility in the design of attraction and retention measures is crucial. It requires a long-term commitment and a recognition that each intervention should be assessed and adapted to local circumstances and context. Key messages • The incentives package introduced in Portugal attracted physicians to underserved areas and led to a fourteen-fold increase in physicians settling in underserved areas. • More than half of the physicians are still practicing in the same underserved health institution but the difference in retention against those not covered by the incentives package is minimal.

7.Q. Round table: Developing public health workforce in the European Region. Cases of Ukraine, Georgia, and Azerbaijan

Abstract In the dynamic landscape of public health, World Health Organization Regional Office for Europe (WHO) and the Association of Schools of Public Health in the European Region (ASPHER) have devised the European competency framework and the roadmap to professionalizing public health workforce (PHW) in the European region aiming to guide stakeholders with competency standards and actionable recommendations for strengthening PHW. This workshop presents actions taken in Azerbaijan, Georgia, and Ukraine to strengthen their public health workforce, showcasing how mentioned tools can be effectively applied in different contexts. The workshop aims to equip participants with practical strategies and tools to enhance the professionalization of the PHW, ultimately contributing to improved public health outcomes across the region. In Ukraine, public health system faces multifaceted challenges, ranging from epidemics to war. In 2019, Ukraine piloted a Competency Framework with key stakeholders, incorporating competencies missing in job descriptions for public health specialists. Subsequently, a review of educational programs for master’s degrees in public health was conducted. Based on the Competency Framework, the first state qualification exam for master’s in public health was introduced in 2021. Guided by the Roadmap, a PHW situational analysis was conducted by the WHO Country Office, and the elaboration of a national programme for the PHW development is close to completion. Furthermore, recognizing the need for capable public health leaders, a national Public Health Leadership Programme has been initiated based on the Competency Framework. In Georgia, following global trends, in 2023 the Ministries of Internally Displaced Persons, Labour, Health, and Social Protection planned to prepare a comprehensive public health human resource strategy, based on the Competency Framework, which has led to the development of a number of policy processes and platforms, including a public health human resources survey to get a better understanding of the composition of the public health workforce in the country. In Azerbaijan, within the framework of the Azerbaijan Pandemic Response Project initiated in 2022, the WHO Country Office has actively sought to bolster the capabilities of the public health workforce. Utilizing the Competency Framework, a detailed self-assessment tool was developed, enabling both current public health professionals and students to evaluate their skills across various competencies. Alongside, a Professional Learning Plan was crafted to support a holistic learning cycle of Public Health Champions, which guides them through stages of identifying learning needs, engaging in relevant activities, and critically assessing the outcomes. Each presentation will offer valuable insights for European countries on how to strengthen public health workforce, how to adapt the tools to serve national priorities, and to foster collaboration among stakeholders. Key messages • The workshop aims to equip participants with tools designed by the WHO and ASPHER to enhance the professionalization of the PHW across the region. • The workshop will contribute to exchange of PHW professionalization practices at the European level by raising awareness among the audience of how the specific tools can be used in different contexts. Speakers/Panelists Nataliia Piven WHO Country Office in Ukraine, Kyiv, Ukraine Elene Godziashvili National Center for Disease Control and Public Health, Tbilisi, Georgia Halil ibrahim Durak WHO, Baku, Azerbaijan Olga Aleksandrova WHO Country Office in Ukraine, Kyiv, Ukraine Karolina Airapetian WHO Country Office in Ukraine, Kyiv, Ukraine

Large scale system transformation: Ukraine

Abstract In the context of the EU-Ukraine Accession agreement, Ukraine started large scale public health systems reform back in 2015. The COVID-19 pandemic tested the response capacity of the national public health system and led to some improvement during the pandemic such as on laboratory capacity. It also generated lessons for strengthening national and subnational health emergency preparedness and response. Multiple interventions, including a Joint External Evaluation led to the adoption of the Public Health System Law in 2022, laying the foundation to bolster health promotion, disease prevention, and health protection. The Ukrainian Public Health Centre was substantially strengthened, partly oriented on models in other European countries. Corresponding centers for diseases control and prevention at the oblast level were reformed and a subnational network of these centers was created. While the war has a significant impact on the public health system, infrastructure, people and more, decision makers and professionals keep working on sustaining and moving forward the achievements on public health reforms, for example with the adoption of the National Health Strategy 2030 and the adoption of the National Health Security Plan. Further legal and strategic preparations are afoot to strengthen public health services governance capacity, financing, institutional innovation and development, and public health workforce development.

The process of developing a framework for code of ethics

Abstract Issue/Problem The World Health Organisation (WHO) and Association of Schools of Public Health in the European Region (ASPHER) roadmap for the professionalisation of the public health workforce has noted ethics as a pillar for professionalisation. It also highlights the need for code of ethics and professional conduct for all public health professionals and institutions. The Global Network for Academic Public Health (GNAPH), in collaboration with EUPHA, ASPHER, and the UK Faculty of Public Health has been working together for a code of ethics. Description of the problem The WHO/ASPHER group asked for a framework to be developed by the expert group as part of the rollout of the professionalisation agenda. The objective of this work was to develop a guide that is applicable to different countries within Europe to develop their own of code of ethics and conduct. A modified Delphi approach to building consensus amongst professionals in ethics included law, academia, and public health professionals. The questions sought to be answered were what and how to develop a framework and what should be included in the guide for creating a public health code of ethics. Results Throughout this method we developed five values, and twelve principles that are essential for the development of a code of ethics through a consensus building exercise. This framework was the first of its kind as part of the professionalisation agenda for different regions. There will be ongoing work piloting this framework in practice with various professional groups and institutions. Lessons Throughout this process, the need and demand across the public health community for ethical education and development of code of ethics was made evident. Collaboration between academics, ethicist, lawyers, and public health professionals and policy makers were key in developing a public health code of ethics. Identifying the challenges with monitoring and evaluating of its implementation a public health code of ethics. Key messages • Ethics, and a code of ethics are an essential component of the professionalisation agenda of the public health workforce. • There is need for continued collaboration and partnership with public health professionals and institutions in enacting its implementation and evaluation.

Balancing public health and public safety: a situational analysis of a substance use pathway

Abstract Background Public health solutions to substance use harms are of interest across Europe, where the level of health need among detainee populations is broadly consistent. A need for multiagency working is widely recognised, as well as role changes with a view to the police engaging in health generating activity, as part of the wider public health workforce. This qualitative study explores the prospect for a multiagency, public health pathway in an English county district. This involved multiagency working across the community and custody settings. Methods 25 semi-structured interviews with senior and frontline staff of diverse agencies involved in pathway development, including public health, police, treatment providers and the NHS. A ‘frame-critical’ situational analysis sought to understand the strengths, weaknesses, opportunities and threats presented by the pathway. Data were organised into themes. Results Three themes highlighted the challenges and opportunities for addressing substance use harms via multiagency collaboration across the community and custody settings. The themes highlighted how 1) agencies’ shared commitment to public health was unsettled by subtle differences on the meaning of prevention; 2) community police were more accepting of new health activity than custody police; 3) a trade-off impeded a proactive approach: the need for substance worker capacity to support police in the custody suite (a reactive approach) meant that limited community outreach was possible, despite opportunities for preventative community work involving substance workers and community police. Conclusions Public health solutions are challenging to develop in a context of contrasting understandings of ‘public health’, unclear national policy and resource constraints. The design of multiagency public health pathways must be participatory and inclusive to ensure staff buy-in: in particular, new health activities need to align with police staff’s sense of role congruence. Key messages • Multiagency public health collaborations should start by establishing a shared understanding of what ‘public health’ and ‘prevention’ mean. • A long-term perspective on training and motivational alignment (e.g., via feedback) is necessary to implement health-related activity among custody police staff.

The Urgent Need for Disaster Education as a Core Competency in Accredited Schools and Colleges of Public Health by the Council on Education for Public Health.

Public Health is essential to disaster preparedness, mitigation, response, and recovery. This has never been more evident than during the COVID-19 pandemic when public health was the disaster response lead. However, students are graduating from accredited schools and colleges of public health with limited or no education in disaster management. This is a crisis unto itself, and it is incumbent upon The Council on Education for Public Health (CEPH) to take immediate action. Public health preparedness should be recognized as a core element in public health curricula, and practical experiences, such as drills and simulations, are necessary to equip students with the confidence and competencies needed in high-stress situations. The need for such preparedness education extends beyond the COVID-19 pandemic. It is a crucial step for creating a resilient and competent public health workforce capable of safeguarding community health in the face of complex and emerging challenges.

Public health resilience and recovery in Ukraine: Academic partnerships to improve population health

Abstract Background Strengthening the public health workforce is among top priorities for the transformation of Ukraine’s public health system. As part of the USAID Public Health System Recovery and Resilience Activity, an Academic Partnership Collaborative brought together three Ukrainian universities (National University Kyiv-Mohyla Academy, I. Horbachevsky Ternopil National Medical University, Sumy State University), two American universities (Temple University and Drexel University), and the All-Ukrainian Association of Public Health Specialists (UPHA) to enhance the competencies of public health graduates in Ukraine. Objectives The collaborative focuses on strengthening the Ukrainian universities’ public health curricula and the teaching and research competencies of the Ukrainian faculty, making the curricular changes in Ukraine better aligned with US and European academic standards. The university partners are collaborating with the newly established UPHA in building partnerships with peer organizations in the US (American Public Health Association) and Europe (EuPHA) and sharing advancements in public health education with the broader community of public health practitioners in Ukraine to enhance their competencies to improve population health and align with European systems of public health. Results We have established linkages among all partners via an initial meeting in Uzhhorod, Ukraine in April 2024. We anticipate results by November 2024 to include curriculum review recommendations, coaching on prioritized topics for the Ukrainian partners, faculty development plans, and the establishment of continuing professional development programs in collaboration with UPHA. Conclusions Through this partnership, selected Ukrainian universities will have an enhanced and sustainable capacity to train the public health workforce and will become leading examples for other public health programs to simulate and collaborate with beyond the project. Key messages • Ukraine’s resilience and recovery relies upon the strength of the current and future public health workforce; mechanisms for building public health training are essential to a healthy population. • A collaborative process of strategic activities among American and Ukrainian universities and professional associations can be effective in building a resilient public health system in Ukraine.

6.I. Round table: Strengthening preparedness for public health emergencies: lessons learned and future perspectives

Abstract In the face of intensifying global health threats, robust health security measures in Europe and worldwide have never been more pressing. The COVID-19 pandemic has underscored the critical need for coordinated action, adaptive strategies, and robust collaborative mechanisms to effectively respond to emerging infectious diseases and other public health emergencies. This workshop serves as a platform to examine the multifaceted landscape of health security actors, focusing on collaborative initiatives and lessons learned from recent crises. By convening experts and stakeholders from across Europe, the workshop aims to achieve several key objectives: i) To provide an overview of collaborative initiatives established to strengthen European and international health security. By showcasing successful models of cooperation, participants will gain insights into effective strategies for fostering collaboration among diverse stakeholders. ii) Emphasize the role of European and international institutions, such as the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO), in supporting states both in coordinating regional response efforts and in developing the necessary health workforce competencies and capabilities to respond to health emergencies. iii) Drawing on experiences from recent health emergencies, including outbreaks of high-risk pathogens, such as Ebola, the workshop will facilitate a critical examination of lessons learned. Through interactive discussions, participants will identify challenges, best practices, and opportunities for enhancing preparedness and response capacity. iv) By interactive presentations and panel discussions, the workshop will provide a platform for knowledge exchange and networking among participants. By sharing experiences, expertise, and innovative approaches, participants will contribute to a collective understanding of the challenges and opportunities in strengthening health security. This workshop seeks to illuminate key strategies, capacity-building efforts, and real-world lessons learnt that contribute to enhancing response capabilities to public health emergencies. Participants will gain a deeper understanding of emergency participation mechanisms, essential skills required, and available training resources to enhance preparedness. Key messages • Collaboration and adaptive strategies are essential for strengthening international health security in the face of emerging infectious diseases and other public health emergencies. • Lessons learned from recent crises provide valuable insights into effective response strategies and opportunities for enhancing preparedness and response capacity.

Building Resilience: Strengthening European public health workforce through ECDC Fellowship Programs

Abstract The European Centre for Disease Prevention and Control (ECDC) Fellowship programmes offer a two-year training in field epidemiology (EPIET) and in public health microbiology (EUPHEM) aiming to create and maintain a network of highly trained field epidemiologists and public health microbiologists and strengthen the public health epidemiology workforce in the European Union (EU) and beyond. The Mediterranean and Black Sea Programme for Intervention Epidemiology Training (MediPIET) also aims to strengthen the public health workforce in countries neighboring the EU. During the training, fellows who are based in different public health institutes in the EU and neighboring countries, set-up, implement and evaluate surveillance of communicable diseases, investigate outbreaks and conduct operational research directly linked to public health actions. The programmes facilitate knowledge exchange and collaboration across borders, building a foundation for participants and their institutions and promoting long-term collaboration through the alumni network. Participants from diverse disciplinary and cultural backgrounds enable interdisciplinary and multi-sectoral knowledge transfer, enhancing the effectiveness of public health responses. By facilitating collaboration and networking, exchanging experiences, disseminating best practices and assimilating lessons learned, these programmes contribute to addressing contemporary health challenges, including emerging vector-borne diseases and strengthening public health systems in Europe and neighboring regions. In the face of global challenges such as climate change and globalization, the fellowships exemplify how collaboration can strengthen Europe’s defenses against emerging health threats.

Working conditions in OOH-PC centres in Romania: an interview study with healthcare professionals

Abstract Considering the amplifying primary care workforce shortage, the existing knowledge gaps in out-of-hours primary care delivery (OOH-PC) in Romania, as well as the extreme county-to-county variation in the number of functioning OOH-PC centers across the country, from 0 to 32, we set out to document health workers’ perspectives on existing challenges in after hours primary care. Using a qualitative study design, we conducted semi-structured interviews with a purposive sample of 20 healthcare professionals (HCPs): family doctors and nurses providing clinical services in urban and rural OOH-PC centres, family doctors with coordinating and administrative roles, representatives of professional associations and health authorities, as well as emergency doctors and paediatricians. We examined interview transcripts employing thematic analysis. The data collected and analysed revealed several challenges in the provision of care, including physician shortages, increasing workload, low payments, and an organisational model that lacks coordination with other levels of care and services. The analysis of the interview data identified five key themes related to adverse working conditions in OOH-PC: working hours and shift length, increasing workload and patient influx, obstacles to achieving work-life balance, inconveniences related to OOH centre premises (rest space, security), and insufficient financial compensation for after-hours health service provision. Working conditions in OOH-PC centers in Romania constitute a drawback to after hours primary care service provision. Health workers shortage and extreme variation in the number of functioning centres across the country suggest inconsistencies in the governance of OOH-PC. Improving working conditions to recruit and retain health professionals in OOH-PC, combined with targeted policies to optimise organisation and coordination of OOH-PC with other levels of care are as timely as ever to ensure equitable services to the population. Key messages • Current working conditions in OOH-PC Romania impact negatively the health workforce and lead to uneven access for the population. • Improvements in working conditions, service integration, and organisation model are timely for the alleviation of OOH-PC provision.

11.Q. Round table: A Guide for creating a code of ethics for public health professionals and institutions

Abstract The professional discipline of public health is driven by its values. Public health professionals face decisions that have far-reaching ethical implications. Our norms, values, beliefs and the way we see the world, as individuals, communities and institutions which serve us, do matter and fundamentally affect our decisions, behaviours, policies, and practice. The ability to be aware and reflect on norms and values when taking decisions, is a decisive professional virtue in public health practice. The World Health Organisation (WHO) and Association of Schools of Public Health in the European Region (ASPHER) Roadmap for the professionalisation of the public health workforce, has highlighted ethics as an essential pillar for professionalisation, a core competency, and the need for a Code of Ethics and Professional Conduct for good public health practice. In order to further advance the issue the Global Network for Academic Public Health (GNAPH), ASPHER, the European Public Health Association (EUPHA), the UK Faculty of Public Health and other partners set up an expert international joint working group on public health ethics and law (PHELWG). The PHEL expert working group - which includes senior public health professionals, ethicists, lawyers and academics - has been working to carry out research and develop a guide for creating a Code of Ethics and Professional Conduct for public health professionals and institutions. This has included consideration of the competencies, principles and values for good public health practice. The project has involved literature review, research and the wide professional experience of the international group of experts who have been working on the issue.The development of a guide for creating a code of ethics for public health professionals and institutions is part of the overall objective of the PHELWG to build a ethico-legal competency, capacity and resilience of public health workforce. The proposed Guide and related resources will be a timely resource, practical tool and support for public health professionals, organisations, or regulatory bodies to develop their own local country code of ethics and build further ethico-legal capacity of their public health professional workforce and institutions. Purpose of the roundtable workshop will be to: - present the guide on creating a code of ethics for public health public health professionals and institutions, which will be launched at that time - Share the proposed ethical competencies/skills, principles and values for good public health practice, with particular consideration of Indigenous knowledge and world views - reflect and consult with the workshop participants around the guide and the proposed pilot sites for implementing the Codes in various centres. Key messages • Development of Code of ethics and professional conduct is a key requirement for public health professionalization. • The Guide for creating code of ethics by international expert group provides significant resource for development of codes locally. Speakers/Panelists Kasia Czabanowska Maastricht University, Maastricht, Netherlands Farhang Tahzib Faculty of Public Health, Haywards heath, UK Paul Athanasopoulos Public Health Department, Stirling, UK

Making integration happen: managers’ views on multidisciplinary work in Finnish health system

Abstract Background In Finland, a large-scale health and social service reform was implemented in 2023. The structural reform centralised the organising of health and social services from some 200 organisations to 22 wellbeing services counties (WBSC). One goal of the reform was to promote service integration between and within health and social services. The reform offers a unique opportunity for investigating how such change unfolds. This study addresses the integration aspirations of those who are responsible for implementing the change, that is middle managers in WBSCs. We focus on micro and meso levels and explore how the aim of multidisciplinary collaboration is interpreted as part of advancing service integration by middle managers in one newly formed WBSC. Methods The data for this qualitative study were derived from 11 semi-structured interviews with senior and middle managers responsible for various fields of health and social care services in a single WBSC between October 2022 and June 2023. Inductive thematic analysis was applied. Results The managers framed multidisciplinary collaboration very positively and easier to achieve in the new organisation with health and social services united under the same management. The managers acknowledged the need to form collaborative structures (e.g. meetings) and processes at all levels of organisation. Leadership plays a crucial role in creating space for the professionals to form an experience of a shared every-day work. However, previous structures and patterns of work still seemed to limit these endeavours. Tensions between, for example, professional groups or units were left essentially untouched. Multidisciplinary collaboration will serve especially persons with complex and multiple needs and was framed key to cost savings. Conclusions While the structural reform opens a window of opportunity to new collaborative patterns, competing logics and interests as well as power imbalances may hamper the development if not addressed. Key messages • Middle managers had high hopes for multidisciplinary work after the health system reform, including effects on the difficult issues concerning costs and health workforce availability. • While the managers were prepared to promote multidisciplinary work, the prior organisational boundaries and logics hindered integration. Different tensions between stakeholders need more attention.

A Good Practice for Learning with Public Health Professionals Globally: Humphrey Fellowship Program

Abstract Background International collaborations are valuable yet often undervalued assets that enhance the quality of public health education and bolster the development of the public health workforce. Objectives The Humphrey Fellowship Program, part of the Fulbright Exchange Program, facilitates mid-career professionals’ visits to US-based host universities for an academic year. Fellows engage in a semi-structured fellowship period to achieve self-defined goals, emphasizing professional development, expanded experience, and intercultural exchange. This study advocates for the program’s contribution to enhancing public health education. Results Currently, two universities host fellows in public health. Over decades, fellows have engaged with faculty and professionals, participated in classes and meetings, visited institutions for development purposes, and completed US-based affiliations, contributing significantly to their own and the public health workforce’s advancement. This interaction-based learning approach aids in navigating social and ethical challenges by fostering a deeper understanding of public and global health issues across countries. Conclusions The Humphrey Fellowship Program in public health stands as a commendable model. Similar initiatives could be beneficially replicated in the European region, leveraging local and global successes to strengthen ties with public health education institutions, student communities, and beyond. Key messages • Programs that facilitate international interactions can enhance public health professionals’ understanding of global perspectives. • The Humphrey Fellowship Program in the US stands as a commendable practice for mid-career public health professionals, contributing significant value to the education at host universities.