Table 1 Methodology quantitative needs assessment

Quantitative needs assessment design

The needs assessment team obtained a list of the physicians and nurses in the family health centres in Kosovo. Physicians and nurses in each region were invited to participate in the needs assessment on a particular date, and the assessment team travelled to the regions to meet with the participants

Sample selection

The total number of staff within the family medicine system that met the inclusion criteria (primary health care workers in all 8 districts in Kosovo) was 361 physicians and 972 nurses. The sampling frame was stratified by physicians and nurses; the assessment team attempted to include every eligible physician and a systematic random sample of nurses equal to 50 % of the population. Sample size calculations were based on the following assumptions:

 ● The limit of statistical significance (alpha) is 0.05 (95 % confidence interval),

 ● The power (beta) equals 0.8

 ● The prevalence of stress-related mental health problems among PHC workers is unknown and estimated conservatively at 50 %

Based on these assumptions a sample of 341 nurses was required; taking into consideration refusals, and dropouts, the sample size was calculated to be 450 nurses. Because the sample would be stratified by doctors and nurses, and because every eligible doctor would be included in the needs assessment (original estimated n = 500), the assessment team elected to sample an equal number of nurses; however, the estimate of the number of physicians proved to be high, and there were only 361 physicians working in the family medicine system at the time of the needs assessment who were available to participate. Thus, the final sample for the needs assessment included 361 physicians and 486 nurses; of these, 716 individuals (85.0 %) participated. The sample chosen of nurses in each district was proportional to the number of nurses employed in that district

Study instruments

A rapid qualitative assessment of key informants, including representatives from the Ministry of Health and the mental health professionals and representatives of local staff not participating in the needs assessment, was completed in order to provide assurance that all key variables were included and culturally appropriate for Kosovo. The questionnaire included: demographics, organizational support and work experience [16], support measures for local staff and management (climate within the organization) [16], chronic stressors [16], trauma experiences [17], possible secondary trauma transmission [18, 19], social support [20, 21], and coping strategies [22]. Some possible study outcomes include mental health measures such as the Harvard Trauma Questionnaire to measure posttraumatic stress disorder [17], the Hopkins Symptom Checklist-25 measuring anxiety and depression [23], compassion fatigue [18], burnout [24], and job and life satisfaction [25–27]

Data management and analysis

Data were entered in Prishtina, Kosovo in a Microsoft Excel database under supervision of the survey team. Data analyses were performed using SPSS 17.0. Chi square tests were used to assess categorical variables; student’s t-test to assess continuous variables. P values < 0.05 were considered statistically significant. Data were analysed and displayed only as general results and are not identifiable to any specific individual

Limitations

The selection of participants of this needs assessment was based on a previous decision between Antares Foundation, KRCT and the Ministry of Health to focus on physicians and nurses, working at the Family Health Centres. Other health professionals in Kosovo were not included in this needs assessment. Although we made every effort to find complete list of physicians and nurses, it was difficult to establish a complete list of physicians in Kosovo at the time of the needs assessment. The original list contained persons who were deceased, or had left the country temporarily. Therefore some selection bias may have occurred. Because not all the instruments used in the needs assessment were specifically developed for the Kosovo context, interpretation and comprehension of these instruments may have introduced bias in some responses. However, these instruments had been used previously in Kosovo among the general population and aid workers shortly after the end of the war [10, 11], and we had no indication that there was difficulty in understanding of the needs assessment questions. We also used similar instruments and questionnaires successfully, for surveys among national staff in Sri Lanka, Uganda, and Jordan [2–6]. Another limitation is that because of the cross-sectional needs assessment design, no causal relations can be inferred