The present study used a mixed-methods design, combining quantitative and qualitative research methods. The quantitative component was organized as a cross-sectional study among PHCs, while the qualitative component was carried out through focus groups with medical personnel (medical doctors and nurses). The two components were conducted concurrently in December 2023, and the findings were integrated during the interpretation stage.

The sample for the quantitative research included all public healthcare centers (54 primary health centers and the outpatient health unit East Stari Grad) in the Republic of Srpska, Bosnia and Herzegovina, that provide services at the primary healthcare level in accordance with Article 36 of the Law on Healthcare of the Republic of Srpska [23]. More precisely, the target population consisted of lead physicians from the Family Medicine, Gynecology, and Pediatric departments of these facilities. All of the 54 healthcare centers and the outpatient health unit have Family Medicine departments employing 619 medical doctors, while 44 facilities have Pediatric departments with 82 medical doctors employed, and 36 facilities have Gynecology departments with 62 medical doctors employed [24]. By the end of data collection, 50 healthcare facilities had submitted complete questionnaires. The detailed sample structure and response rate are presented in Table 1.

The qualitative part of the study was carried out through focus groups involving representatives from the selected primary healthcare centers, that is, representatives of the Family Medicine, Pediatric, and Gynecology departments. The primary healthcare centers were selected according to the size of the local community and the geographical distribution of the facilities. After initial consideration, 12 facilities were invited to participate in the qualitative study and to nominate one medical doctor and one nurse from each department to participate in the focus groups. Three focus groups were conducted: one with Family Medicine personnel, one with Pediatric personnel, and one with Gynecology personnel. The number of healthcare centers and the number of participants in each focus group are presented in Table 2.

The survey questionnaire consisted of 12 questions and one scale encompassing data related to nutritional practices, such as 1) the provision of an assessment of nutritional status (0-no/1-yes) and its related services, such as monitoring of anthropometric parameters (0-no/1-yes), use of dietetic questionnaires (0-no/1-yes), assessment of laboratory parameters (0-no/1-yes), and assessment of clinical parameters (0-no/1-yes); and 2) the provision of services related to the improvement of nutrition and the prevention of NCDs (0-no/1-yes) and its related services, such as nutritional counseling (0-no/1-yes), counseling on physical activity (0-no/1-yes), counseling for women of reproductive age (0-no/1-yes), breastfeeding counseling (0-no/1-yes), counseling for overweight and obese patients (0-no/1-yes), and early detection of overweight and obesity (0-no/1-yes). The dominant barriers to the provision of nutritional services were assessed on a 5-point Likert scale (1- not important at all, to 5- the most important) comprising six items: insufficient time, financial compensation, patient cooperation, patients’ knowledge of nutrition, identification of patients in need of nutritional counseling, and medical personnel’s skills related to nutritional counseling. The questionnaire was developed based on available literature and existing recommendations from similar research in the field of nutrition [9, 11, 12, 15, 16], and was pre-tested through a panel discussion with experts from PHCs in order to establish content validity and terminological clarity prior to full-scale data collection. The same version of the questionnaire was used across all PHC departments.

The focus group guide consisted of 11 questions covering three main topics: 1) assessment of the current scope and quality of nutritional services at the PHC level; 2) proposals for improving the quality of nutritional services at the PHC level; and 3) assessment of current intersectoral cooperation, together with concrete proposals for its improvement. The questions were designed to explore barriers and obstacles related to the provision of nutritional services and to gain insight into the possibilities and solutions for improving these services and preventing NCDs at the healthcare facility and local community levels.

The first phase of this study included a meeting with the directors of all primary healthcare centers in the Republic of Srpska, BiH, which was held on 7 December 2023, to present the purpose, objectives, and methodology of the research.

The second phase involved sending the questionnaires by post to the management of the primary healthcare centers and to the Family Medicine, Pediatric, and Gynecology departments in 55 primary healthcare facilities in the Republic of Srpska, BiH. Data collection was carried out between 8 and 27 December 2023, with continuous communication via email and telephone with all facilities that did not submit the questionnaires on time. Once the questionnaire had been completed in each department in a given facility, these were returned by post to the Public Health Institute of the Republic of Srpska.

The third phase involved organizing and implementing focus groups, which were held online via the Zoom platform in December 2023, concurrently with the collection of the distributed questionnaires. The qualitative research was preceded by the delivery of an informed consent form for participation in the research, along with key information about the aims and purpose of the research and Zoom access links, to the Family Medicine, Gynecology, and Pediatric teams in the primary healthcare centers selected to participate in the focus groups.

The provision of nutritional services (monitoring of nutritional status and nutritional counseling) was analyzed using descriptive statistics, together with the chi-square test to assess differences between the departments of the PHCs. Analysis of variance (ANOVA) was used to compare the level of reported barriers to providing nutritional services across departments. Statistical significance was set at p < 0.05.

Thematic analysis was undertaken in the following phases: (1) data immersion, (2) data familiarization, (3) code generation, (4) selection of themes, (5) thematic review, and (6) final selection of themes. Qualitative data analysis was not based on any specific theory; rather, data were analyzed in order to identify the themes that emerged and thus to understand the barriers to, and the potential solutions, for the improvement of nutritional services.

The Ministry of Health and Social Welfare of the Government of the Republic of Srpska (approval no. 11/08-505-193/23) and the Ethics Committee of the Public Health Institute of the Republic of Srpska (approval no. 501-1-16/23) granted consent for carrying out this research. All procedures performed in studies involving human participants were in accordance with the 1964 Declaration of Helsinki and its later amendments. Informed consent was obtained from all individual participants included in the study.

A high percentage of PHC facilities (80.5%) monitored the nutritional status of the population, although this varied across departments. The Family Medicine (91.8%) and Pediatric (91.9%) departments demonstrated a significantly higher level of engagement in nutritional status monitoring than the Gynecology departments (50.0%) (χ² = 26.043, df = 2, p < 0.001).

An analysis of the individual services related to the monitoring of nutritional status showed that PHCs most frequently monitored anthropometric parameters (75.4%), while approximately half of them (46.6%) assessed laboratory parameters related to nutritional status. A smaller percentage of facilities used dietetic questionnaires (28.0%) or assessed clinical parameters (20.3%). When these services were compared across departments, the Family Medicine and Pediatric departments demonstrated a significantly higher level of engagement in monitoring all parameters, with the exception of clinical parameters, than the Gynecology departments (p < 0.001) (Table 3).

Services related to the improvement of nutrition and the prevention of NCDs were provided by 92.4% of PHCs. Nutritional counseling was significantly more frequently provided in the Family Medicine (87.8%) and Pediatric (86.5%) departments than in the Gynecology department (50.0%) (χ² = 18.318, df = 2, p < 0.001). A similar trend was observed for counseling on physical activity (χ² = 9.928, df = 2, p < 0.01). Counseling for women of reproductive age was significantly more frequent in the Gynecology department (71.9%) than in the Family Medicine (30.6%) and Pediatric (21.6%) departments (χ² = 20.687, df = 2, p < 0.001). Breastfeeding counseling and the early detection of overweight and obesity were significantly more frequent in the Pediatric department than in the other two departments (χ² = 56.112, df = 2, p < 0.001; χ² = 20.112, df = 2, p < 0.001), whereas counseling for overweight and obese patients was significantly more frequent in the Family Medicine departments (χ² = 12.435, df = 2, p < 0.01).

Overall, among the services related to the improvement of nutrition and the prevention of NCDs, nutritional counseling (77.1%), counseling on physical activity (73.7%), and counseling for overweight and obese patients (66.1%) were more frequently provided by PHCs than the early detection of overweight and obesity (51.7%), breastfeeding counseling (46.6%), and counseling for women of reproductive age (39.0%) (Table 4).

Barriers to the provision of nutritional services were assessed on a five-point Likert scale (1 – not important at all to 5 – the most important). The most significant barriers were the lack of financial compensation for the provision of nutritional services by the Health Insurance Fund of the Republic of Srpska (Mean = 4.53, SD = 0.86), lack of time for counseling (Mean = 4.19, SD = 1.00), and patients’ knowledge of nutrition (Mean = 3.92, SD = 0.86).

ANOVA revealed significant differences between departments in the reported lack of time (F = 4.402, p < 0.05). A post hoc LSD test showed significant differences in mean values between the Gynecology (Mean = 3.68, SD = 1.21) and Family Medicine (Mean = 4.47, SD = 0.97) departments (Figure 1).

Overall, the results suggest that strengthening nutrition services in PHC requires a comprehensive approach, including capacity building among healthcare professionals, the development and implementation of standardized guidelines, improved financing mechanisms, and enhanced monitoring systems tailored to the specific profile of each department rather than applied uniformly across primary healthcare centers. The need for coordinated, system-level strengthening rather than isolated measures is consistent with recent international evidence on improving the quality of PHC services [8] and on integrating nutrition-specific interventions into routine PHC practice [18]. Greater collaboration with local communities and public health institutions is also essential in order to improve service coverage and effectiveness. Future strategies should therefore prioritize integrating multidisciplinary approaches and enhancing the use of health information systems so as to promote sustainable improvements in population nutrition and reduce the burden of NCDs.