International Journal of Public Health

Published by Springer Verlag
Online ISSN: 1661-8564
Print ISSN: 1661-8556
Publications
To examine if and to what extent ethnic differences in diabetes-related mortality are associated with differences in education and housing status. The data consist of a cohort study linking the 2001 census to emigration and mortality data for the period 2001-05. The study population comprises all Belgian and North African inhabitants of the Brussels-Capital Region (BCR) aged 25-74. Age-standardized mortality rates (ASMRs) (direct standardization) and mortality rate ratios (MRRS) (Poisson regression) are computed. North Africans have a higher diabetes-related mortality compared to Belgians. The ASMRs for North African and Belgian women are 54.8 (95% confidence interval (CI) 31.5-78.2) and 23.8 (95% CI 20.3-27.3), respectively. These differences in diabetes-related mortality largely disappear when differences in education are taken into account. The MRRs for North African versus Belgian origin drop from 1.62 (95% CI 1.11-2.37) to 1.19 (95% CI 0.73-1.93) in men and from 3.35 (95% CI 2.08-5.41) to 1.88 (95% CI 0.95-3.69) in women. Differences in education play an important part in the excess diabetes-related mortality among North Africans in the BCR.
 
To systematically identify similarities and differences in the way preventive youth health care (YHC) is organized in 11 European countries. Questionnaire survey to EUSUHM (European Union for School and University Health and Medicine) representatives. The greatest similarities were found in the age range of the YHC target group and the separation of curative and preventive services. Croatia, Germany and Switzerland show the greatest differences when compared to other European countries, for example, in the access to medical records, YHC professional input and the number of examinations, immunizations and screenings. In eight countries YHC is financed by national insurances or taxation. In Germany, FYR Macedonia, the Netherlands, Russia and Switzerland, different forms of financing exist in parallel. The results should be interpreted as a preliminary step in mapping organizational features of YHC in Europe.
 
To assess whether immigration stage is associated with higher prevalence of dental caries among schoolchildren in Heidelberg, Germany. A cross-sectional dental examination on 570 schoolchildren, aged 11 to 14 years, in schools with high proportions of immigrant pupils (49.5%) was performed. Carious, missing and filled permanent teeth were recorded for each child, so that mean DMFT values could be calculated. The pupils were classified into three groups: M0 (children and their parents were born in Germany), M1 (children who were born in Germany but whose parents were born outside of Germany), and M2 (children and their parents were born outside of Germany). The mean DMFT values in M1 and M2 were close, and both were significantly higher than the corresponding values in M0. The proportions of caries-free children in M0, M1 and M2 were 63.7%, 40.3% and 42.3%, respectively. In Germany, migrant children have a poorer dental health status than native children coming from the same low socio-economic classes. Risk-oriented public health policies with appropriate prevention programs must be developed for these children.
 
Objectives: We studied the prevalence of self-reported diabetes mellitus in selected years from 2001 to 2008, and evaluated the factors associated with diabetes. Methods: From territory-wide household interviews in a Chinese population in the years 2001, 2002, 2005 and 2008, we evaluated the trend of self-reported diabetes with respect to age, sex and household income. Binary logistic regression analyses were conducted to study the independent factors associated with diabetes. Results: From 121,895 respondents in the household surveys, 103,367 were adults aged 15 years or older. Among male respondents, the age- and sex-adjusted prevalence of diabetes in 2001, 2002, 2005 and 2008 was 2.80, 2.87, 3.32 and 4.66 %, respectively; while among female respondents the respective prevalence was 3.25, 3.37, 3.77 and 4.31 %. In all the years, the prevalence escalated with age and increased sharply among the poor. From binary logistic regression analyses, advanced age and low monthly household income were significantly associated with self-report of diabetes. Conclusions: This study showed a rising trend of diabetes mellitus in a large Chinese population and found a strong association between population demography and diabetes.
 
Flowchart of sample selection from the Polish cohort study (1995–2008)
Mean general self-efficacy (GSE) score in 13-year-old Polish adolescents according to the change in the level of mother’s education (1998–2008)
Path model representing direct and indirect effects of changes in family socio- economic status (Poland, 1995–2008) on health-related quality of life. Numbers on paths represent standardized regression weights
Socio-economic predictors of general self-efficacy (GSE) score in 13-year-old Polish adolescents—comparisons of models including and not including life-course perspective
Objectives The aim of this study is to determine the impact that raised mother’s education and a relative change in family affluence might have on adolescent general self-efficacy (GSE). Methods Data on 600 children born in Poland in January 1995 and their families were used. Data from early childhood and adolescence (2008) were considered and the change between these two periods was determined. Results Family affluence increased in 37.3 % of families with mothers, who had raised their education level (12.6 % of the sample), in comparison to 26.8 % in the group with no change, p < 0.001. The average GSE scores in those groups were 73.4 and 68.1, respectively, p < 0.001. In the best linear regression model adjusted for gender, the independent predictors of GSE turned out to be mother’s education change and the family’s current affluence. Conclusions Raised mother’s education level may encourage building up developmental assets in older children. Based on the structural model, where self-efficacy is the mediator of the relationship between socio-economic status change and the quality of life (KIDSCREEN-10) these results may be of importance in further research.
 
We examined whether persons with spinal cord injury (SCI) from countries with differential resources and resource distribution differ in the level and structure of functioning and disability. We analysed cross-sectional data of 1,048 persons with SCI from 14 countries based on the International Classification of Functioning, Disability and Health (ICF). We used penalized logistic regression to identify ICF categories distinguishing lower- and higher-resourced countries. Hierarchical linear models were employed to predict the number of problems in functioning. The association structure of ICF categories was compared between higher- and lower-resourced countries using graphical models. A total of 96 ICF categories separated lower- and higher-resourced countries. Differences were not univocal. Lower resources and unequal distribution were predictive of more functional problems in persons with higher age or tetraplegia. In the graphical models, few associations between ICF categories persisted across countries. Higher-resourced countries do not score higher in all ICF categories. Countries' economic resources and their distribution are significant predictors of disability in vulnerable groups such as tetraplegics and the elderly. Functioning is multi-dimensional and structures of association suggest that country-specific pathways towards disability exist.
 
Age-specific first birth-hazards by gender and five-year age groups, EU-14 
Objectives: The economic crisis that emerged after 2008 caused speculation about further postponement of fertility and a recession-induced baby-bust in countries affected by the economic downturn. This paper aims to disentangle short-term and long-term effects of economic context on entry into parenthood and explores variation of postponement and recuperation by age, gender, educational level and welfare state context. Methods: Random-effects complementary log-log models including macro-level indicators are used to analyse longitudinal microdata on 12,121 first births to 20,736 individuals observed between 1970 and 2005. Results: Adverse economic conditions and high unemployment significantly reduce first birth hazards among men and women below age 30, particularly among the higher educated. After age 30 economic context continues to affect first birth hazards of men, but not for women. Recuperation of fertility is further associated with access to labour markets and entry into cohabiting unions. Conclusions: The continuing postponement of first births has clear medical consequences and implications for health policies. Preventive policies should take access to labour markets for younger generations into account as an important factor driving postponement.
 
Descriptive information on screen time behaviours in the 2005/06 Canadian health behaviour in school-aged children survey 
Associations between screen time behaviors and violence in the longitudinal 2005/06 Canadian health behaviour in school-aged children survey 
To examine the independent associations between television, computer, and video game use with physical violence in youth. The study population consisted of a representative cross-sectional sample of 9,672 Canadian youth in grades 6-10 and a 1-year longitudinal sample of 1,861 youth in grades 9-10. The number of weekly hours watching television, playing video games, and using a computer was determined. Violence was defined as engagement in ≥2 physical fights in the previous year and/or perpetration of ≥2-3 monthly episodes of physical bullying. Logistic regression was used to examine associations. In the cross-sectional sample, computer use was associated with violence independent of television and video game use. Video game use was associated with violence in girls but not boys. Television use was not associated with violence after controlling for the other screen time measures. In the longitudinal sample, video game use was a significant predictor of violence after controlling for the other screen time measures. Computer and video game use were the screen time measures most strongly related to violence in this large sample of youth.
 
To explore health status and lifestyles in young Spanish people in 2006 and 2012, the changes between these 2 years and the influence of employment status on health and lifestyles in this period. Cross-sectional analysis of the Spanish National Health Surveys 2006 and 2011/12 in people 16-24 years old (3701). Regression analyses for pooled cross-sectional data were developed. Employment status was considered as explanatory variable of health (self-rated health, diagnosed morbidity and mental disorders) and lifestyles (overweight, tobacco and alcohol consumption). Male unemployment was associated with poor self-rated health (OR 1.88; CI 95 % 1.00-3.53), mental disorders (OR 2.42; CI 95 % 1.02-5.76) and tobacco consumption (OR 1.62; CI 95 % 1.00-2.62). During the economic recession, young people presented better health results than in 2006. Unemployed who had never worked consumed less tobacco and alcohol than short-term unemployed. Unemployment was associated in young men with poor self-rated health, mental illness and tobacco consumption. Despite the economic recession, young people presented better self-rated health, diagnosed morbidity and mental health in 2012 than in 2006, especially in women.
 
This study investigates the impact on different postpartum depressive trajectories (i.e., "non depressive symptoms", "stable depressive symptoms", "deterioration" and "improvement") from 5-17 months after childbirth exerted by emotional support that mothers receive from their partners and emotional support they provide to their partners. Postpartum depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale 5 and 17 months after delivery in a sample of 293 mothers. Emotional support received from the partners was assessed among both mothers and partners. The initial level and the change in emotional support that mothers received from their partners were related to different trajectories of postpartum depressive symptoms. Mothers who were living in a partnership with low reciprocal emotional support showed a significantly higher risk of suffering from "stable depressive symptoms" than mothers who were living in a partnership with high reciprocal emotional support. An increased risk of persistent depressive symptoms beyond the early postpartum period was observed in mothers with poor reciprocal emotional support in the partnership. Further research is needed for a better understanding of the mothers persistent depressive symptoms after childbirth associated with reciprocity of emotional support in the partnership.
 
Little is known about the prevalence of depressive symptoms in the Italian general population, nor about help-seeking behaviours among those with depressive symptoms. We used 2007 data from PASSI, the Italian behavioural risk factor surveillance system, based on telephone interviews of residents aged 18- 69 years. A modified version of the Patient Health Questionnaire-2 was used to explore the presence of depressive symptoms. Those with symptoms were asked about whether they had sought help. Association of depressive symptoms with risk factors and self-perceived health was evaluated. 9.4% of the interviewees met the case definition. Risk factors included older age, female sex, low educational attainment, unemployment, financial problems and chronic illnesses. Of those for whom information on help-seeking was available, 47.2% did not seek any help. Depressive symptoms were associated with poorer self-perceived health. Population-based surveillance systems tracking the prevalence of depressive symptoms and associated risk factors and behaviours may offer needed information for planning, implementing and evaluating promotion and prevention interventions capable of reducing the number of people who go on to experience depressive episodes.
 
To examine socioeconomic disparities in arthritis among non-remote Indigenous and non-Indigenous Australian adults aged 18-64. Weighted data on self-reported arthritis and several socioeconomic measures from two nationally representative surveys conducted in 2004-2005 were analysed using logistic regression. Current diagnosed arthritis was more commonly reported by Indigenous than non-Indigenous people across all age groups. After adjusting for age and sex, arthritis was significantly more common among those of lower socioeconomic status (SES) in the non-Indigenous population for all SES variables examined. In the Indigenous population, associations between SES and arthritis were significant for household income and employment status, but not for education, post-school qualifications, home ownership, area-level disadvantage, or area of residence. The SES disparities were less consistent in the Indigenous than the non-Indigenous population, and within the Indigenous population, they were less consistent for arthritis than those previously reported for diabetes among the same survey participants. Although some of the differences may be due to self-reporting of disease, these findings also suggest the potential salience of factors occurring across the SES spectrum, especially among Indigenous Australians.
 
Characteristics of the sample by immigrant group; the Netherlands, 2005/2006 
Studies on the co-occurrence, 'clustering' of health and other risk behaviours among immigrants from non-industrialised countries lack until now. The aim of this study was to compare this clustering in immigrant and indigenous adults. A representative sample (N = 2,982; response 71%) of the Dutch population aged 19-40, with 247 respondents from non-industrialized countries (Turkey, Morocco, Surinam, Netherlands Antilles), was asked about health behaviours (alcohol, smoking, drugs, unsafe sex, exercise, nutrition, sleep behaviour, traffic behaviour), and about rule-breaking behaviour and aggression. Data were collected using internet questionnaires, which excluded respondents unable to read Dutch. Among indigenous adults, health and risk behaviours co-occur in three clusters (alcohol, health-enhancing behaviour, and rule-breaking behaviour), whereas among immigrant groups two clusters were found (alcohol and rule-breaking behaviour/smoking). Differences mostly concerned health-enhancing behaviours such as nutrition, which was not part of any cluster, and physical activity. This supports an integrated promotion of healthier lifestyles to immigrants who are able to read Dutch. Regarding potentially risky behaviours like alcohol use and rule-breaking behaviours, this could be similar to that for indigenous people.
 
We investigated trends in mortality in European countries by cause of death in the period 1955-1989, and studied the role of economic and political conditions. We extracted data on age-standardised mortality by country (n = 25), sex, cause of death (n = 17) and calendar year from an internationally harmonised dataset. We analysed changes in dispersion of mortality as well as changes in the association of mortality with average income and levels of democracy. After 1960, dispersion in all-cause mortality in Europe as a whole increased due to diverging trends for many specific causes of death, particularly for cerebrovascular disease. This coincided with widening disparities in average income, and strengthening of the association between levels of democracy and mortality. Divergence in Central and Eastern Europe could largely be explained from stagnating trends in average income and an increasing mortality disadvantage related to its democratic deficit. Although this was a politically stable period, mortality patterns were highly dynamic, and prefigured the more dramatic mortality trends after 1990. Economic and political stagnation probably explains the diverging trends in Central and Eastern Europe.
 
To evaluate the association of self-reported health with residential area type defined by the population density in individual's local environment using a population-based cohort in Finland. Young adults of the Northern Finland Birth Cohort 1966 (4,201 women and 3,835 men), surveyed by a postal questionnaire in 1997, were linked to population density of their resident grid (1 km(2)) depicting different types of residential areas. Self-reported health was regressed on residential area type using ordinal logistic analysis, adjusting for psychosocial well-being, social relationships, health behaviour, education and residence time. Cumulative odds ratios (COR) for poor health were lowest in high-rise centres, highest in scattered settlement areas and second highest in transitional zones. Adjustments (especially for education and time of residence) reduced the CORs to insignificance except the persistently high COR for women in scattered settlement areas. Poor self-reported health is associated with individual's residential area type, with the lowest occurrence in high-rise centres and higher elsewhere. The difference is likely explained, at least partly, by a complex of psychosocial factors, possibly different for women and men.
 
To test whether maternal mortality was higher among immigrant women than Swiss women. All maternal deaths and live births in Switzerland from 1969 to 2006 from official vital statistics were considered. We calculated maternal mortality ratios (MMRs) in four time intervals (1969-1979, 1980-1989, 1990-1999, 2000-2006) for both Swiss and immigrant women overall, and for Italian, Spanish and Turkish women. We also computed the odds ratios and 95% confidence intervals of maternal mortality over the four time periods, considering maternal deaths as cases, and live births as controls. From 1969 to 2006 there were 279 maternal deaths, 204 of Swiss women and 75 of immigrant women. Women's age, marital status and cause of death were similar in the two groups. For immigrant women, the crude odds ratio of a pregnancy ending with maternal death, not homogeneous across the four periods, was 4.38 (95% CI 1.88-10.55) in 2000-2006. Immigrant women have a higher risk of maternal mortality than Swiss women. A closer scrutiny of risk factors and quality of care is necessary to identify opportunities for prevention.
 
Although the contribution of health care to survival from cancer has been studied extensively, much less is known about its contribution to population health. We examine how medical innovations have influenced trends in cause-specific mortality at the national level. Based on literature reviews, we selected six innovations with proven effectiveness against cervical cancer, Hodgkin's disease, breast cancer, testicular cancer, and leukaemia. With data on the timing of innovations and cause-specific mortality (1970-2005) from seven European countries we identified associations between innovations and favourable changes in mortality. For none of the five specific cancers, sufficient evidence for an association between introduction of innovations and a positive change in mortality could be found. The highest association was found between the introduction of Tamoxifen and breast cancer mortality. The lack of evidence of health care effectiveness may be due to gradual improvements in treatment, to effects limited to certain age groups or cancer subtypes, and to contemporaneous changes in cancer incidence. Research on the impact of health care innovations on population health is limited by unreliable data on their introduction.
 
We examined the association between socioeconomic position (SEP) and body mass index (BMI) among Canadian men and women in 1978 and 2005. We examined both the average SEP-BMI association, and variation in this association across the distribution of BMI. We analysed data from two nationally representative surveys containing measured height and weight data: the Canada Health Survey (1978) and the Canadian Community Health Survey (2005). Ordinary least squares and quantile regression were used to examine average and distributional SEP-BMI associations, respectively, for each survey. Education was inversely associated with BMI for men and women at both time points, and there was no evidence of narrowing between 1978 and 2005. This association was stronger for women than men, and was particularly strong for heavier women. Education and income related differently to BMI. The SEP-BMI association in Canada is complex, showing variation by gender, by aspect of SEP, across the BMI distribution, and at different time points. The association departs from the more consistent social gradient in health, thereby challenging our view of BMI as a typical health issue.
 
We evaluated late pregnancy abortions from 1981 to 2006 in Québec, Canada. We extracted late abortions from the stillbirth mortality file, and calculated yearly rates per 100,000 pregnancies, including mean gestational age, birth weight, maternal age and education. There were 14.4 late abortions per 100,000 overall pregnancies [95% confidence interval 12.9, 16.1], and rates appeared to increase with time. Mean gestational age (24.7 weeks) and birth weight (886 g) suggested that abortions were performed in the late second and third trimesters. Late abortions in Québec are not common but do occur. Research is needed to determine whether the increase in rates over time reflects better reporting or a true increase. Improved surveillance of late abortions may be warranted.
 
Objectives We evaluated temporal and regional inequalities in adverse birth outcomes between Anglophones and Francophones of a Canadian province. Methods Odds ratios and rate differences in preterm birth (PTB, <37 gestational weeks) and small-for-gestational-age (SGA) birth were computed for Anglophones relative to Francophones for singleton live births in Québec from 1981 to 2008 (N = 2,292,237), adjusting for maternal characteristics. Trends over time and residential region were evaluated. Results Rates of PTB and SGA birth overall were lower for Anglophones relative to Francophones, but temporal and regional trends varied by outcome. Although PTB rates increased over time, inequalities between Francophones and Anglophones were relatively stable. In contrast, inequalities in SGA birth narrowed over time as Francophone rates declined more than Anglophones. Inequalities in SGA birth favored Anglophones overall, but the gap gradually reversed in Montréal (the largest metropolitan center) to currently favor Francophones. Conclusions PTB and SGA birth rates favored Anglophones over Francophones. The linguistic gap was generally stable over time for PTB, but narrowed or reversed for SGA birth. Language may be used to capture inequalities in perinatal health in countries where different linguistic groups predominate.
 
HBSC organisational structure.  
This paper traces the history of the HBSC study from its origins in the early 1980's to the present day describing how it was first conceptualised scientifically and how this influenced issues of study design. The challenges of managing a cross-national study are explained as are changes and adaptations over time with growth of the study from 3 to over forty country members. The key partnership with the World Health Organisation and its benefits are presented. With developments in scientific management and theoretical perspectives, HBSC has made a substantial contribution to the area of youth health. The last decade has seen increased dissemination to policy makers and evidence that scientific information arising from the study has influenced strategic policy development and practical health improvement programmes. This paper considers some of the key success factors and challenges for the study as it attempts to maximise its scientific output and channels the research findings into health improvement for young people. Future challenges for the study are also considered.
 
This paper explores the developments in the public health infrastructure in Slovenia in the context of the sociopolitical and legislative changes in health care over the last 20 years. It assesses the responsiveness of the public health institutes in Slovenia to the various plans on public health developed by health policy makers over time After an in-depth and externally validated search for key documents, we analysed the legislation, policy documents, research reports, theses, and other health policy papers related to the public health infrastructure in Slovenia. Findings were validated through consulting 3 external experts on public health in Slovenia. In the period discussed only few new services were added and health promotion was developed as an institutional field. Passivity in the past caused a lack of decisions on some traditional services in a changed economic environment. Moving from a passive supporter of the former infrastructure to an active promoter of the reform sets health policy as the main architect of the new public health building. Slovenia's "house" of public health was amended and refurbished, but a thorough reconstruction has not taken place. In order to face the future challenges in public health, the infrastructure will require increased efficiency, professional workforce development and better responsiveness.
 
Age-adjusted body mass index (BMI), waist circumference (WC), and obesity prevalence for Mexican-American foreign-born (FB) by length of US residence (\10 years, C10 years) and US-born (USB) men (a–c) and women (d–f) by National Health and Nutrition Examination Survey (NHANES) years. Estimates for whites  
Objectives: We investigated whether associations between nativity/length of US residence and body mass index (BMI) and waist circumference (WC) varied over the past two decades. Methods: Mexican-Americans aged 20-64 years from the National Health and Nutrition Survey (NHANES) III (1988-1994), and NHANES (1999-2008). Sex-stratified multivariable linear regression models further adjusted for age, education, and NHANES period. Results: We found no evidence of secular variation in the nativity/length of US residence gradient for men or women. Foreign-born Mexican-Americans, irrespective of residence length, had lower mean BMI and WC than their US-born counterparts. However among women, education modified secular trends in nativity differentials: notably, in less-educated women, nativity gradients widened over time due to alarming increases in BMI among the US-born and little increase in the foreign-born. Conclusions: Associations between nativity/length of US residence and BMI/WC did not vary over this 20-year period, but we noted important modifications by education in women. Understanding these trends is important for identifying vulnerable subpopulations among Mexican-Americans and for the development of effective health promotion strategies in this fast-growing segment of the population.
 
To examine the trends of out-of-pocket expenditure for influenza during 1989-2006 in China. Data were extracted from the China Health and Nutrition Survey (CHNS) during 1989-2006 (in seven waves). A fixed effect model with robust standard errors was employed to examine trends of out-of-pocket expenditure (adjusted to 2006 Chinese RMB). The out-of-pocket expenditure increased from 11.92 RMB in 1989 to 50.75 RMB in 2006. The final sample for fixed effect model was 23,050 households. Income elasticity of out-of-pocket expenditure was 1.6%. Using 1989 as reference, the predicted increase was 242.23% [95% confidence interval (CI): 225.79-259.50%] in 2006; it was 143.54% in city hospitals [95% CI: 130.43-157.40%] compared to village clinics. Adjusted for inflation and income elasticity, Chinese households experienced an increase of more than double the out-of-pocket expenditure during 1989-2006. The expenditure was higher in higher-level facilities. Policy implications include the government fixed-budget financing to health providers could contribute to the rapidly increased financial burden; a referral system should be rebuilt; private health providers may play an important role in containing healthcare price in China.
 
To update (1992-2004, Switzerland) trends in behaviors and opinions relative to HIV prevention among men who have sex with men. A cross sectional survey, repeated five times since 1992, among readers of the gay press and members of gay associations. An increase was observed in the median number of partners (1994: 5; 2004: 7, p < 0.05), in the proportion of participants who practiced anal penetration with their stable partner (1992: 71%; 2004: 80%, p < 0.05) or with casual partners (1994: 59% 2004: 73%; p < 0.05). Non systematic use of condoms with casual partners during anal penetration increased between 1994 and 2004 (9% to 20%; p < 0.05). Combination therapies gave rise to growing pessimism among participants regarding the decrease in preventive behaviors among homosexuals. The slow trend towards a reduction of safer sex practices continues among men who have sex with men. It is necessary to strengthen prevention interventions in this population.
 
Objectives: Although the past two decades have involved changes in the living conditions of the oldest old in Sweden, little is known about how health inequalities have developed in this group during the period. This study explores the educational disparities in a wide range of health outcomes among the oldest old in Sweden between 1992 and 2011. Methods: The study uses the repeated cross-sectional design of the SWEOLD survey, a nationally representative survey of the oldest old in Sweden with comparable data from 1992, 2002, and 2011. The development of educational disparities in health was tracked across the three waves. Results: The results show that although the prevalence of most health problems increased during the period, the prevalence of disability in activities of daily living decreased. Despite these changes, educational disparities in health remained largely unaffected. Conclusions: The results of the study suggest that the association between education and health is remarkably robust. It prevailed into the oldest age groups, was consistently found for a wide range of health problems, and tended to be stable over extended periods of time.
 
This study compares educational differences in the functional limitations of 55-65-year-olds in the Netherlands in 1992 and 2002 and examines whether changes are explained by cohort lifestyle and psychosocial changes. Data from two cohorts of 55-65-year-olds (n = 948 in 1992 and n = 980 in 2002) in the Longitudinal Aging Study Amsterdam are analysed. Men's disability ratios are similar in both cohorts. The women's disability ratio is higher in 2002 than in 1992. In 2002 the male and female cohorts both report unhealthier behavior than in 1992. Multivariate logistic regression analyses show that adjusted for age, cohort, lifestyle and psychosocial resources, poorly educated men have higher odds of functional limitations than well-educated men (OR = 2.62, 95% CI = 1.57-4.37). Analyses among women show a significant interaction effect between education and cohort. Poorly educated women have higher odds of functional limitations in 2002 than in 1992 (OR = 3.33, 95% CI = 1.02-10.87). The results underscore the need for policies focused on improving the health and lifestyle of the poorly educated.
 
Unemployment is a major determinant of health. We investigate whether health inequalities with regards to employment status have changed in Germany. We used longitudinal data for the years 1994-2008 from a representative panel study (GSOEP). The sample consisted of respondents aged 30-59 years (15 waves, 21,329 persons, 129,526 observations). We analyzed trends and determinants of self-rated health status by employment status using logistic regression and fixed-effects logistic panel models. Health inequalities by employment status increased significantly by 72% in men and by 16% in women after controlling covariates. The trends were partly mediated by consequences of unemployment such as income loss, income poverty, life satisfaction and economic sorrows. Using regression models for panel data we confirmed that the observed increases in health inequalities at the population level also exist at the individual level. Altogether, our findings indicate that health inequalities with regards to employment status increased among men between 1994 and 2008. This observation is in line with increasing income inequalities in Germany and with increasing health inequalities in other European countries.
 
To examine the prevalence of over-the-counter analgesic (OTCA) use and perceived stress among 25 to 44-year-old men and women from 1994 to 2005; to examine the association between stress and OTCA use over time, and to explore whether the association attenuates when controlled by stress-related symptoms. Cross-sectional studies were carried out in 1994, 2000 and 2005. The study population included men and women from ages 25 to 44 years (n (1994) = 1,781, n (2000) = 5,819, n (2005) = 4,831). The surveys were conducted by face-to-face interviews and the outcome measure was OTCA use. The independent variable was perceived stress and pain/discomfort symptoms were included as covariates. There was a significant increase in OTCA use and often feeling stressed from 1994 to 2005. Although there was a significant association between stress and OTCA use for men in all three surveys, there was no association in 2000 when adjusted for symptoms. For women stress and OTCA use were not associated in 1994, while in 2000 and 2005 the association was significant, also after adjusting for symptoms. The findings indicate that there may be an increasing overuse of OTCA in treating stress among 25 to 44-year-old men and women.
 
To determine socio-economic differences from 1994 to 2004 in the use of butter and milk in Pitkäranta in the Republic of Karelia, Russia and North Karelia, Finland. Health behaviour surveys in Pitkäranta (n = 3,599) and North Karelia (n = 3,652) in 1994, 1996, 1998, 2000 and 2004. A clear overall decrease occurred in the use of butter in cooking in Pitkäranta from 1994 to 2004. In both areas, subjects with lower education used butter in cooking and drank fat-containing milk more often. Regarding butter on bread, the educational patterns in the two areas were opposite: in Pitkäranta, subjects with lower education used butter less often but in North Karelia, they used butter on bread more often. Practically, no changes in socio-economic differences from 1994 to 2004 were observed in either area. The socio-economic differences in the use of dairy fat were stable in both areas but larger in North Karelia than in Pitkäranta. Our results support earlier assumptions of a weaker role of education as a determinant of health in Russia than in the western societies.
 
a Trends in weekly alcohol use by family affluence (a) and educational track (b) among 15-year-old German students, 1994-2006, percentages (RR) and 95 % confidence intervals. Stars 
To examine socioeconomic differences in adolescent alcohol use in Germany as well as their changes between 1994 and 2006. Data were obtained from the "Health Behaviour in School-aged Children" study conducted in North Rhine-Westphalia, Germany in 1994, 1998, 2002 and 2006. The analysis is based on 5.074 15-year-old students. Prevalence and trends were analysed for each category of family affluence and educational track separately using log-binominal regression models. An increase in weekly alcohol use between 1994 and 2002 was followed by a strong decrease from 2002 to 2006. Family affluence only had a weak effect on weekly drinking with a tendency for lower-affluent students reporting less alcohol use. Educational track showed almost no relationship with weekly alcohol use. Trend analyses within the subgroups revealed that the overall trend in alcohol use was similar in all socioeconomic and educational groups. Socioeconomic patterns in drinking behaviour are not yet developed in 15-year-old adolescents. Adolescence could therefore be an important time frame for tackling inequalities in alcohol use later in life.
 
To identify trends over 12 years in the prevalence of bullying and associated victimization among adolescents in North American and European countries. Cross-sectional self-report surveys were obtained from nationally representative samples of 11-15 year old school children in 21 countries in 1993/94 and in 27 countries in each of 1997/98, 2001/02 and 2005/06. Measures included involvement in bullying as either a perpetrator and/or victim. Consistent decreases in the prevalence of bullying were reported between 1993/94 to 2005/06 in most countries. Geographic patterns show consistent decreases in bullying in Western European countries and in most Eastern European countries. An increase or no change in prevalence was evident in almost all English speaking countries participating in the study (England, Scotland, Wales, Ireland and Canada, but not in the USA). Study findings demonstrated a significant decrease in involvement in bullying behaviour in most participating countries. This is encouraging news for policy-makers and practitioners working in the field of bullying prevention.
 
Objectives: This study examined socioeconomic disparities in alcohol-related mortality among Korean men aged 40-59 years during the period before and after the economic crisis in the late 1990s. Methods: We used Korean Census data (1995, 2005) and data from the National Death Files (1994-1996, 2004-2006) on education and employment status as indicators of socioeconomic position. Based on the age-standardized rates of alcohol-attributable deaths, relative discrepancies across socioeconomic positions were estimated. Results: Socially disadvantaged men were substantially disadvantaged in terms of alcohol-attributable mortality in both years. The disadvantage of men with the lowest level of education relative to the highest was worse in 2005 than in 1995. The relative disadvantage in alcohol-attributable deaths seemed to narrow over time based on the rate ratios. However, the relative index of inequality was higher in 2005 compared to 1995 for both education and occupation. Conclusions: The results showed that alcohol-attributable mortality in Korea became socioeconomically polarized during the economic crisis. The serious impact of economic polarization following the economic crisis might have been transmitted to alcohol-attributable mortality.
 
Demographic and psychiatric characteristics of study subjects: Suicides with known parasuicide history, the Czech Republic, 1996-2000
This retrospective study analyses the differences between suicide with and without previous parasuicide. The Czech Republic was one of the countries with the traditionally highest level of suicide mortality. During collapse of the communist regime and deep societal changes in the Czech Republic after the year 1989 the escalation of suicides was expected. Mortality from suicides decreased, however the gender and age differences increased. A total of 2,711 suicides in the Czech Republic (1996-2000) were studied. Effects of socioeconomic characteristics, psychiatric diagnosis and care, and lifetime history of parasuicide on the risk of death from suicide were estimated using logistic regression. Twenty-three percent of persons who committed suicide had a prior history of parasuicide and almost twenty percent of them received no psychiatric care after the attempt. Young males with basic education, economically active and diagnosed with substance abuse related disorders and the elderly were least likely to receive psychiatric care before their suicide death. Implications for age specific primary and secondary prevention are discussed.
 
Changes in high socioeconomic position/low socioeconomic position ratio in health-related behaviour between 1998 and 2006 (girls)
Objectives We aimed to assess the development of the socioeconomic gradient in health-related behaviour (HRB) among Slovak adolescents between 1998 and 2006. Methods Data were collected in 1998 (n = 2,616; 14.9 ± 0.6 years) and in 2006 (n = 1,081; 14.3 ± 0.6 years). ORs of socioeconomic differences—as measured by parental education—were calculated for each cohort in smoking, alcohol consumption and physical inactivity, and the interactions of socioeconomic position and the time period on these behaviours were calculated. Results The higher odds of smoking in the low socioeconomic group compared to the high socioeconomic group decreased among boys (interaction OR 0.54), but became evident among girls (interaction OR 1.96). In alcohol consumption, no socioeconomic differences were found among boys, but the higher odds among girls from high socioeconomic position compared with those from low socioeconomic position disappeared in 2006. In physical inactivity, socioeconomic differences increased among boys but not among girls. Conclusion During this period, socioeconomic differences in HRB developed in a different way among boys than among girls. Prevalence rates in substance use increased especially among girls from the low socioeconomic group. This group should be particularly targeted by prevention programs.
 
Monthly alcohol use for boys and girls, for countries where use increased among girls but did not change among boys, HBSC 1998, 2002, 2006*  
Sample size for the study, by gender, country and year -HSBC 1998, 2002, 2006.
Monthly alcohol use (%) for the total sample and by gender, by study year and by country, grouped by direction of trend, between 1998 and 2006 (increase, no change, decrease) § # .
Drunkenness (%) for the total sample and by gender, by study year and by country grouped by direction of trend, between 1998 and 2006 (increase, no change, decrease) * § # . 
To examine trends in the prevalence of monthly alcohol use and lifetime drunkenness among 15 year olds in 20 European countries, the Russian Federation, Israel, the United States of America, and Canada. Alcohol use prevalence and drunkenness were assessed in the Health Behavior in School-aged Children Survey conducted in each country in 1998, 2002, and 2006. Trends were determined using the Cochran-Mantel-Haenszel test for trends. Average monthly alcohol use across all countries declined from 45.3% to 43.6% and drunkenness declined from 37.2% to 34.8. There was substantial variability across countries, with decreases in some countries and increases or no change in use or drunkenness in others. The overall decline was greater among boys, from 41.2% to 36.7% than among girls, 33.3% to 31.9%. In most of the countries where drinking or drunkenness increased, it was due mainly to increases among girls. Trends in alcohol use and drunkenness varied by country. Drinking and drunkenness remained higher among boys than girls, but the gap between boys and girls declined and girls appear to be catching up with boys in some countries.
 
NCEP Adult Treatment Panel II Guidelines (1994)  
Sequential outcomes for diagnosis and management of hypercholesterolemia for the study sample  
To examine education differentials in screening, awareness, treatment and control of hypercholesterolemia overall and in 3 race/ethnic groups. We analyzed data for a nationally representative sample of 8,429 men and women ages 20 to 85 years, self-reported as white, black, Mexican American, or other race/ethnicity, who participated in the National Health and Nutrition Examination Survey from 1999-2002. Participants with < high school education were 2.5 times less likely than participants with > or = high school education to have been screened for hypercholesterolemia, after adjusting for age and gender (odds ratio: 0.4, 95 % confidence interval: 0.3-0.5, and similar across race/ethnic group). Multivariable models for awareness, treatment and control showed no significant trends associated with education after adjusting for age, gender, race and comorbidities. Higher education significantly increased the odds of being screened for hypercholesterolemia overall and within each race/ethnic group. Education differentials were strongest for hypercholesterolemia screening, and weak or no longer apparent for subsequent steps of awareness, treatment and control. Focusing public health policy on increasing screening for individuals with low education might greatly improve their chances of preventing or mitigating morbidity related to hypercholesterolemia and subsequent cardiovascular disease.
 
The aim of this study was to examine the effect of socioeconomic status and demographic factors on infant mortality, classified by cause of death, in a group of children born in Seoul, Korea during 1999-2003. Linked infant birth and death data were collected from the Korea National Statistical Office. Logistic regression models were used to investigate the effect of socioeconomic and demographic factors on infant mortality. The results were adjusted to take into account the infants' length of gestation and birth weight. Infant death rates from all causes tended to decrease as the parents' educational level increased. We observed a similar pattern for deaths from other specific causes. We also found higher mortality rates for mothers less than 20 years of age and over 35. Our analysis shows that socioeconomic and demographic factors affect infant mortality. In the case of postneonatal infant death, we confirmed that adequate follow-up care can reduce the risks of death from these acquired factors. This suggests that these are important factors to consider in reducing infant mortality.
 
Empirical studies have confirmed that a trusting physician-patient interaction promotes patient satisfaction, adherence to treatment and improved health outcomes. The objective of this analysis was to investigate the relationship between social support, shared decision-making and inpatient's trust in physicians in a hospital setting. A written questionnaire was completed by 2,197 patients who were treated in the year 2000 in six hospitals in Germany. Logistic regression was performed with a dichotomized index for patient's trust in physicians. The logistic regression model identified significant relationships (p < 0.05) in terms of emotional support (standardized effect coefficient [sc], 3.65), informational support (sc, 1.70), shared decision-making (sc, 1.40), age (sc, 1.14), socioeconomic status (sc, 1.15) and gender (sc, 1.15). We found no significant relationship between 'tendency to excuse' and trust. The last regression model accounted for 49.1% of Nagelkerke's R-square. Insufficient physician communication skills can lead to extensive negative effects on the trust of patients in their physicians. Thus, it becomes clear that medical support requires not only biomedical, but also psychosocial skills.
 
To examine change from 2000 to 2006 in obesity and overweight by gender, school year and school socioeconomic status (SES) in a national sample of students from Australia. Survey of students aged 6-18 years from the same 32 schools in 2000 (N = 3,819) and 2006 (N = 5,524) with measured height and weight. All analyses were adjusted for the cluster survey design. Main outcome measures were height, weight, Z-score distribution of BMI, overweight and obesity [International Obesity Task Force (IOTF) cut-offs], school SES. Obesity and overweight were similar to previous Australian findings with 5.2% and 6.1% obese in 2000 and 2006, respectively, and 16.3 and 19.0% overweight. Significant increase in obesity was observed in students from low SES schools which increased from 5.8 to 8.6% (P < 0.05) compared to 5.5 to 6.3% (P = 0.32) in middle SES and 3.3 to 4.2% (P = 0.92) in high SES schools. Obesity increased significantly among children in low SES schools and preventive efforts should urgently and carefully target preventive efforts to assist schools, families and communities which are socially and economically, disadvantaged using culturally appropriate physical activity and nutrition promotion interventions.
 
Established in 2001-2005 then extended to 2010, the French National Nutrition and Health Program (PNNS) is a nutrition policy whose objective is to improve the health status of the population by acting on one of its major determinants, nutrition. Nine priority objectives focusing on diet, physical activity and nutritional status were determined. Program strategies are based on fundamental principles including food culture, pleasure, and gastronomy. This multidisciplinary program involves stakeholders from ministries, research and educational institutions, food industry, healthcare, and consumers. More than 75% of the public health actions planned were accomplished or in progress by the end of 2005, particularly those concerning nutrition communication, education, research and nutritional surveillance. Dietary guidelines were established and are now considered the official reference in France. Actions focusing on the healthcare system, economic actors and players and specific population groups need further development. The success of a public health program like the PNNS requires a combination of synergistic and complementary actions, measures, regulations and laws. A national study at the end of the PNNS will determine if objectives were achieved.
 
Proportion of TV viewing, computers/videogames use and of total screen time C2 h/day in 2001 and 2011, by sex (a Male; b Female). Santa Catarina, Brazil  
Objectives: To compare the prevalence of television (TV) watching and of computer/videogame use among high school students (15-19 years) from Southern Brazil between 2001 and 2011 and to identify associated socio-demographic factors. Methods: Panel studies were conducted with high school students in the state of Santa Catarina, Brazil, in 2001 (n = 5,028) and 2011 (n = 6,529). TV watching and computer/videogame use were collected using questionnaires. Results: Prevalence of ≥2 h/day of TV watching dropped from 76.8 to 61.5 % and ≥2 h/day of computer/videogame use increased from 37.9 to 60.6 %. In both surveys, those aged 15-16 and those who did not work had higher likelihoods of being exposed to ≥2 h/day of TV watching. Boys, those with higher family income, and those who were living in urban areas had higher likelihoods of ≥2 h/day of computer/videogame use. Older age, studying at night and not working were protective factors to these behaviors. Conclusions: After a decade, there was a decrease in the prevalence of TV viewing and an increase in computer/videogame use. Socio-demographic factors were differently associated with these behaviors.
 
To present comparative data on sexual initiation, and condom use and contraceptive pill use at last intercourse among adolescents in Europe, Israel and Canada. Data were collected by self-report questionnaire from nationally representative samples of 15 year olds in school classrooms in two cross-national surveys undertaken in 24 countries in 2001/02 and 30 countries in 2005/06. In 2005/06 almost 27% of those surveyed had had sex and almost 86% reported using condoms or the contraceptive pill at last intercourse. This reflects little change since 2001/02 in prevalence of sexual initiation and a general increase in being well-protected at last intercourse. There were wide variations with up to a third of sexually active 15 year olds in some countries at risk for either Sexually Transmitted Infections or pregnancy, or both. Most adolescents were well protected against Sexually Transmitted Infections and pregnancy, but an important minority remain at risk, with very wide cross-national differences.
 
This analysis estimated alcohol-attributable burden of disease for Switzerland. Exposure distributions were taken from the 2002 Swiss Health Survey and adjusted for per capita consumption. Risk relations were taken from meta-analyses. Mortality and burden of disease data were taken from the World Health Organization. Overall consumption and alcohol-attributable mortality and burden of disease in Switzerland were high compared to European and global averages, especially among women. Overall in Switzerland in 2002, 2016 deaths (5.2% of all deaths in men, 1.4% in women), 28,939 years of life lost (men: 10.5%, women: 4.9%) and 70,256 disability adjusted life years (men: 12.9%, women: 4.2%) were attributable to alcohol. These numbers are net numbers already incorporating the cardioprotective and other beneficial effects of alcohol. Limitations of the approach used are discussed. In addition, questions of causality and confounding are addressed.
 
Because the potential for electronic media communication (EMC) has increased greatly, it is of interest to describe trends in EMC between adolescents and their friends and to investigate whether EMC facilitate or supersede face-to-face contacts among peers. Answers of 275,571 adolescents concerning contacting friends by means of the phone, text messages, and the internet (i. e. EMC), the number of close friends, and the number of afternoons and evenings per week spent out with friends were analysed by means of chi(2)-tests and multiple regression. In 2006, between more than one third (11-year olds) and nearly two thirds (15-year olds) communicated electronically with their friends daily or nearly daily. From 2002 to 2006, EMC increased in almost all participating countries. Particularly high increases were found in Eastern Europe. Across countries, the higher the frequency of EMC the higher the number of afternoons and evenings spent with friends. The results are surprisingly consistent across the 31 countries and suggest that EMC among adolescents facilitate rather than supersede face-to-face peer contacts.
 
Objectives: To examine the socioeconomic gradients in birth outcomes among singleton infants in Argentina, 2003-2007. Methods: We analyzed data of 3,230,031 singleton infants born in 2003-2007, obtained from vital statistics. Associations between birth outcomes [small for gestational age (SGA), low birth weight (LBW), and preterm birth (PTB)] and socioeconomic indicators (maternal education and area-based material deprivation quintiles) were assessed with logistic regression. Results: The risk of SGA increased with higher socioeconomic disadvantage, but that of PTB decreased. Compared to mothers who attained a tertiary or university degree, mothers who did not complete primary school were more likely to have a SGA infant [adjusted OR (95 % CI): 1.65 (1.62, 1.68)], but less likely to deliver preterm [0.92 (0.90, 0.94)]. As a result of the conflicting trends in SGA and PTB, LBW exhibited inconsistent socioeconomic gradients. Conclusions: The excess risk of adverse birth outcomes associated with socioeconomic disadvantage was consistently reflected by SGA, but not by LBW and PTB. These findings challenge the usefulness of LBW as an indicator population health. Further research is needed to explain the reverse socioeconomic gradients in PTB.
 
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Summary of systematic review and assessment of methodology of quantitative studies of Roma health and health care utilization between 2003 and 2012 in Europe 
Diagram of study selection 
continued 
To conduct a systematic review of the epidemiological and health service utilization literature related to the Roma population between 2003 and 2012. Systematic review of empirical research related to Roma health and health care utilization published between 2003 and 2012 identified through electronic databases (PsycInfo, Medline, Google Scholar). Methodological rigor was evaluated using a six-point set of design criteria. We found evidence for lower self-reported health and significantly higher mortality risk for Roma compared to non-Roma, and greater prevalence of health risk factors for Roma children, including environmental risks, low birth weight, and lower vaccination coverage. Studies of non-communicable and infectious disease remain insufficient to make firm conclusions on disparities. Barriers to care include lack of documentation and affordability of care, though more studies on health care utilization are needed. Roma youth and adults are in need of programs that reduce health disparities and their increased mortality risk. Reducing exposure to risk factors such as smoking, obesity, and poor living conditions may be a target for interventions. More intervention studies and rigorous evaluations are needed.
 
Sampling characteristics, Bangladesh, India and Sri Lanka, World Health Survey, 2003
Distribution of population by chronic disease status based on World Health Survey for South Asia, 2003
Bivariate Analyses of factors associated with the prevalence of chronic disease(%), World Health Survey, South Asia, 2003 (N = 22,264)
Odds ratio between chronic illness status and self-rated health descriptions, World Health Survey, South Asia, 2003
Objectives: Measuring disease prevalence poses challenges in countries where information systems are poorly developed. Population surveys soliciting information on self-reported diagnosis also have limited capacity since they are influenced by informational and recall biases. Our aim is to propose a method to assess the prevalence of chronic disease by combining information on self-reported diagnosis, self-reported treatment and highly suggestive symptoms. Methods: An expanded measure of prevalence was developed using data from the World Health Survey for Bangladesh, India and Sri Lanka. Algorithms were constructed for six chronic diseases. Results: The expanded measures of chronic disease increase the prevalence estimates. Prevalence varies across socio-demographic characteristics, such as age, education, socioeconomic status (SES), and country. Finally, the association, as also risk factor, between chronic disease status and poor self-rated health descriptions increases significantly when one takes into account highly suggestive symptoms of diseases. Conclusions: Our expanded measure of chronic disease could form a basis for surveillance of chronic diseases in countries where health information systems have been poorly developed. It represents an interesting trade-off between the bias associated with usual surveillance data and costs.
 
This study aimed to investigate the associations of combined parental low educational level and combined parental unemployment on the risk of preterm birth (PTB) in Korea. Data on 427,857 singleton births were obtained from the National Birth Registration (NBR) database in 2003 and analyzed. Parental education and parental employment status were combined as exposure for analysis. Place of birth, sex, marital status, parental age and parity were included for analysis of unconditional multiple logistic regressions. PTB was defined as birth before a gestational age of 37 complete weeks. Group of the lowest educational level, below high school, had the highest odds of PTB in both father and mother in multivariable analysis [odds ratio (OR) 1.15 and 1.16, respectively]. After combining parental educational status for the multivariable analysis, the highest probability of PTB was in families where both parents had below college level education (OR 1.22). As for paternal employment, the multivariable analysis showed an increased rate of PTB occurred where the father was unemployed (OR 1.11). After combining the employment status of both parents, the multivariable analysis revealed that PTB was only significant in families where both parents were unemployed (OR 1.09). We found that combined parental low educational level and combined parental unemployment increased the likelihood of preterm birth.
 
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Manfred Grotenhuis
  • Radboud University
Ben Pelzer
  • Radboud University
Rob Eisinga
  • Radboud University
Margarida Gaspar de Matos
  • University of Lisbon
Michal Molcho
  • National University of Ireland, Galway