The European Journal of Public Health

Published by Oxford University Press (OUP)
Online ISSN: 1464-360X
Number of English language research articles by EU authors  
Number of articles by country of corresponding author
Number of articles per million population (country of corresponding author)  
Number of articles per GDP (country of corresponding author)  
The review of European health management research was undertaken over a 10-year period, from July 1995 to June 2005, to produce an account of the state of research, including its quality, range and any gaps; and to assess the implications of the research, its potential for uptake by policy bodies and the need for future research and the direction it might take. To identify relevant research studies and bodies of work, two methods were employed: (i) a standard database search and (ii) special request to members of the European Health Management Association (EHMA) via its electronic newsletter. The results from the database search yielded a modest flow of relevant (at least in terms of the definition of health management employed) material. Only 63 relevant journal articles were finally selected out of 1047 identified. Very few have focused explicitly or primarily on mainstream management issues affecting the public's health. There is also a heavy bias towards heath care systems. Two main conclusions emerged: (i) there exists limited original research in the area of health management; outside the UK, this limitation is even more apparent and (ii) health management appears to be an underdeveloped research area throughout Europe. There exists a paucity of public health management research aimed at strengthening the evidence for effective interventions, effective decision-making and priority-setting. There needs to be support for research that not only crosses academic disciplines and institutions but which also embraces the diverse range of organizations and professions engaged in managing and delivering public health.
Characteristics of the follow-up data by educational level in men and women 
effect of adjusting for behavioural factors on educational level differences in CHD and stroke mortality in women. Ã Hazard ratios (95% CIs) and percent of reduction (%) in CHD and Stroke mortality among those with primary or secondary education as compare to higher education after adjustments of health behaviours 
Health behaviours are potential explanatory factors for socioeconomic differences in mortality. We examined the extent to which seven health behaviours covering dietary habits, smoking and physical activity, can account for relative differences in cardiovascular and all-cause mortality by educational level. Health behaviour data derived from nationwide Finnish health behaviour surveys from the years 1979 to 2001. These annually repeated cross-sectional surveys were linked to register-based information on educational level and subsequent mortality from the year of the survey until the end of 2001 (average follow-up time 11.9 years). The analyses included 29 065 men and 31 543 women of whom 4263 died. Cardiovascular disease (CVD), coronary heart disease (CHD), stroke and all-cause mortality was studied. Educational level showed a graded association with all mortality outcomes. Health behaviours explained 54% of the relative difference between primary and higher educational level in CVD mortality among in men and 22% among in women. For all-cause mortality the corresponding figures were 45 and 38%. Smoking, vegetable use and physical activity were the most important health behaviours explaining educational level differences in all mortality outcomes, while the effects of type of fat used on bread, coffee drinking, relative weight and alcohol use were small. Smoking, low vegetable use and physical inactivity explained a substantial part of educational level differences in cardiovascular and all-cause mortality among men and women. Socioeconomic trends in these behaviours are of crucial importance in determining whether socioeconomic mortality differences will widen or narrow in the future.
This study aimed to detect striking trends based on a new strategy for monitoring public health. We used data over 4 years from electronic medical records of a large, nationally representative network of general practices. Episodes were either directly recorded by general practitioners (GPs) or were constructed using a new record linkage method (EPICON). The episodes were used to estimate raw morbidity rates for all codes of the International Classification of Primary Care (ICPC). Multilevel Poisson regression models were used to analyse the trend over time for 15 health problems that showed an obvious change over time. Based on these models, we calculated adjusted incidence rates corrected for clustering, sex and age. During 2002-05, both men and women increasingly consulted the GP because of concern about a drug reaction, a change in faeces/bowel movements and urination problems. Men showed an increase in consultations for prostate problems and venereal diseases. The incidence of chronic internal knee derangement decreased for both sexes. Women consulted their GP less frequently about sterilization and fear of being pregnant. The strategy developed proved to be useful to detect trends across a short period of time. Changes in the health care market, such as the increasing availability of over-the-counter drugs and various large advertising campaigns for medications may explain some of the findings. The increasing incidence of health problems in the urogenital area deserves attention as it could reflect increases in the incidence of sexually transmitted diseases (STDs) and urinary tract infections.
Pattern of stillbirth risk (adjusted RRs) in Spain from 2007 to 2008 by maternal age, country of origin and education attainment (2464 stillbirths and 973 204 total births) 
risk and attributable fractions by maternal age, country of origin, socio-economic status, parity and gestational age in Spain, during 2007-08 (2464 stillbirths and 973 204 total births) 
Socio-economic differences are a major determinant of perinatal outcomes. The impact of low socio-economic status on the risk of stillbirth, and the association between socio-economic status and stillbirth by maternal country of origin at a national level in Spain are unknown. We aimed to analyse the effect of maternal socio-economic status on the risk of stillbirth by maternal country of origin in Spain for the years 2007 and 2008. We designed a population-based observational study that included 970,740 live births and 2464 stillbirths from 2007 to 2008. Univariate risk ratios (RRs) of stillbirth were calculated by maternal education, country of origin, age, parity, and gestational age. Adjusted stillbirth RRs were calculated using a generalized linear model with the Poisson family. Then, adjusted attributable risks and aetiological fractions in the population were calculated as measures of impact. Stillbirth rate ranged from 1.0 to 4.7 deaths per 1000 births. The stillbirth risk among mothers having secondary or lower education was double than that of mothers with a tertiary education with an adjusted RR of 2.13 [95% confidence interval (CI): 1.74-2.60]. African mothers, compared with mothers from Spain, showed an adjusted stillbirth RR of 1.75 (95% CI: 1.54-2.00). Discussion: This study confirms the differences of stillbirth risk by maternal socio-economic status. Regardless of socio-economic status, African mothers had the highest risk of stillbirth. These results point out the necessity to reduce factors related to social and health inequalities in perinatal mortality in Spain, and more specifically, to take into consideration the special vulnerability of African mothers.
Association between mortality of amenable to health care in the 0-to 74-year-old age group and the DI in Hungary, 2004-08 (Supplementary File 2)
The spatial distribution of smoothed standardized mortality ratios of mortality amenable to health care in Hungary. (A) Adjusted for age and (B) Adjusted for age and SES for males and females, 2004–08 (Supplementary File 3)  
Recently, research focus has returned to amenable mortality to health care, despite the decreasing trend, as it remains a significant contributor to social and economic loss due to premature death. This article assesses the trends of amenable mortality over time and, its spatial inequalities with respect to deprivation, in Hungary. An ecological analysis of mortality amenable to health care was carried out using smoothed indirectly standardized mortality ratios, calculated by full hierarchical Bayesian methods, at municipality level. The association between the spatial distribution of amenable mortality and deprivation was also assessed using a Hungarian specific deprivation index. Trends of mortality amenable to health care were characterized by a decreasing pattern across the studied period, 1996-2008. Areas of significantly high risk of amenable mortality were identified in the North-eastern, Eastern and South-western parts of Hungary. A statistically significant association was found between amenable mortality and deprivation status in both genders. After correcting for bias due to socio-economic confounders, the patterns of areas with excess risks significantly changed. Differences in deprivation alone cannot explain the spatial distribution of mortality amenable to health care. This study highlights the importance of exploring other factors (e.g. health-care system and individual life style) beyond socio-economic status, which affect health inequalities particularly for health policy makers, who are responsible for the mitigation of health disparities.
Algoritm for the application of the TRI  
Characteristics of newly diagnosed cases of HIV infection stratified by type of infection (Catalonia, 2006-08)
Study flowchart. Ã: Patients whose HIV infection was diagnosed >6 months before sample collection (78.2%), insufficient sample volume (9.1%), duplicate samples (5.4%), no informed consent (3.6%), infected by HIV type 2 (0.9%), HIV-negative samples (0.6%) and age <16 years (0.3%)  
Background: Quantification and description of patients recently infected by HIV can provide an accurate estimate of the dynamics of HIV transmission. Between 2006 and 2008 in Catalonia, we estimated the prevalence of recent HIV infection among newly diagnosed cases, described the epidemiological characteristics of the infection according to whether it was recent, long-standing or advanced, and identified factors associated with recent infection. Methods: A Test for Recent Infection (TRI) was performed in serum samples from patients newly diagnosed with HIV. Two different TRI were used: the Vironostika-LS assay (January 2006-May 2007) and the BED-CEIA CEIA (June 2007 onwards). Samples were obtained within the first 6 months of diagnosis. Patients whose samples tested positive in the TRI were considered recently infected. Results: Of 1125 newly diagnosed patients, 79.9% were men (median age, 35.4 years), 38.7% were born outside Spain, 48.9% were men who have sex with men (MSM) and 10.6% presented other sexually transmitted infections. The overall percentage of recent infection was 23.0%, which increased significantly, from 18.1% in 2006 to 26.2% in 2008. This percentage was higher for patients from South America (27.6%). Factors associated with recent infection were acquiring infection through sexual contact between MSM [odds ratio (OR) 2.0; 95% confidence interval (95% CI) 1.1-3.9], compared with acquiring infection through heterosexual relations and being under 30 years of age (OR 5.9; 95% CI 1.9-17.4), compared with being over 50 years of age. Conclusion: The highest percentage of recent infection was identified in MSM, suggesting either a higher incidence or a greater frequency of HIV testing. Information regarding testing patterns is necessary to correctly interpret data from recently infected individuals. Systems to monitor the HIV epidemic should include both parameters.
Respondent characteristics, Gaza Strip 2009 n (%) (n = 3017) 
We document the health-related quality of life (HRQoL) of people living in the Gaza Strip 6 months after 27 December 2008 to 18 January 2009, Israeli attack. Cross-sectional survey 6 months after the Israeli attack. Households were selected by cluster sampling in two stages: a random sample of enumeration areas (EAs) and a random sample of households within each chosen EA. One randomly chosen adult from each of 3017 households included in the survey completed the World Health Organization Quality of Life instrument, in addition to reported information on distress, insecurities and threats. Mean HRQoL score (range 0-100) for the physical domain was 69.7, followed by the psychological (59.8) and the environmental domain score (48.4). Predictors of lower (worse) scores for all three domains were: lower educational levels, residence in rural areas, destruction to one's private property or high levels of distress and suffering. Worse physical and psychological domain scores were reported by people who were older and those living in North Gaza governorate. Worse physical and environmental domain scores were reported by people with no one working at home, and those with worse standard of living levels. Respondents who reported suffering stated that the main causes were the ongoing siege, the latest war on the Strip and internal Palestinian factional violence. Results reveal poor HRQoL of adult Gazans compared with the results of WHO multi-country field trials and significant associations between low HRQoL and war-related factors, especially reports of distress, insecurity and suffering.
Number of screened and diagnosed babies 
Background: Serious hearing problems appear in approximately one in 1000 newborns. In 2000, the Joint Committee on Infant Hearing defined a list of risk factors for neonatal hearing impairment relating to health, physical characteristics and family history. The aim of this study is to determine which personal, environmental and social factors are associated with the prevalence of congenital hearing impairment (CHI). Methods: The entire population of 103,835 term newborns in Flanders, Belgium, was tested by a universal neonatal hearing screening (UNHS) programme using automated auditory brainstem responses (AABR). In the case of a positive result, a CHI diagnosis was verified in specialized referral centres. Socio-demographic risk factors were investigated across the entire population to study any relationship with CHI. Results: The prevalence of bilateral CHI of 35 dB nHL (normal hearing level) or more was 0.87/1000 newborns. The sensitivity and specificity of the screening test were 94.02 and 99.96%, respectively. The socio-demographic factors of gender, birth order, birth length, feeding type, level of education and origin of the mother were found to be independent predictors of CHI. Conclusions: The socio-demographic factors found to be associated with CHI extend the list of classic risk factors as defined by the American Academy of Pediatrics (AAP). Assessment of these additional factors may alert the treating physician to the increased risk of newborn hearing impairment and urge the need for accurate follow-up. Moreover, this extended assessment may improve decision making in medical practice and screening policy.
Prevalence of T2DM by PTSD in non-depressed and depressed individuals in men (a) and women (b)  
Prevalence of diabetes by study characteristics
Several reports have demonstrated a relationship between post-traumatic stress disorder (PTSD) and type 2 diabetes (T2DM) mainly in combat veterans. The relationship between PTSD and T2DM has not been evaluated among vulnerable migrant populations. The main objective of this study was therefore to assess the relationship between PTSD and T2DM among asylum seekers in the Netherlands. Analysis of a national electronic database of the Dutch Community Health Services for Asylum seekers aged ≥18 years (N = 105 180). Asylum seekers with PTSD had a higher prevalence of T2DM compared with those without PTSD. The age-adjusted prevalence ratios (APR) were 1.40 (95% CI, 1.12-1.76) in men and 1.22 (95% CI, 0.95-1.56) in women compared with individuals without PTSD, respectively. There was an interaction between PTSD and comorbid depression (P < 0.05) in men and women, indicating that the effect of PTSD and comorbid depression on T2DM differed. When the analyses were stratified by depression status, among non-depressed group, individuals with PTSD had a higher prevalence of T2DM compared with those without PTSD [APR = 1.47 (95% CI, 1.15-1.87) in men and APR = 1.27 (95% CI, 0.97-1.66) in women]. Among the depressed individuals, however, there was no association between PTSD and T2DM [APR = 0.87 (95% CI, 0.43-1.76) in men, and APR = 1.00, (95% CI, 0.54-1.83) in women]. The findings suggest that history of PTSD is related to high levels of T2DM among asylum seekers independent of comorbid depression. Clinicians and policy makers need to take PTSD into account when assessing and treating diabetes among vulnerable migrant populations.
A school is generally acknowledged to be a key setting for promoting pupils' health and well-being. Data from a cross-sectional questionnaire study conducted with all 10th grade pupils in 46 public schools. Depressive symptoms was defined by a positive score on Hopkin's Symptom Check List-10 (HSCL-10). Two composite variables expressing risk were established: (i) presence of negative factors (PNF), consisting of self-reported pressure to succeed, sexual violation, and exposure to bullying and violence; and (ii) absence of positive factors (APF), comprising respondents' self-reported physical activity, educational aspirations, and family's valuing their opinions. Out of 7505 pupils, complete data were obtained for 6207. The prevalence of symptoms of depression varied greatly among different schools (boys, from 0 to 19%; girls, from 3.3 to 39%). The PNF varied from 12.3 to 45.5% for boys, and from 4.2 to 38.8% for girls. Corresponding figures for APF were 2.4-23.1% for boys and 4.3-37.5% for girls. Among boys, we found significant associations between PNF and symptoms of depression, odds ratio (95% CI) 4.5 (3.5-5.8), and between APF and depressive symptoms, 3.1 (2.3-4.1). For girls, corresponding odds ratios were 3.5 (2.9-4.2) and 2.1 (1.7-2.6), respectively. The proportion of pupils with depressive symptoms varies greatly among Oslo public schools. This variation is associated with features of the pupils' social context.
The purpose of this study was to examine the association between weight status and exposure to bullying among 11-, 13- and 15-year-old Danish school children. Furthermore, the purpose was to investigate the potentially mediating effect of body image. Data from the Danish contribution to the international cross-sectional research project Health Behaviour in School-aged Children (HBSC) 2002 was used. Data were assessed from questionnaires and 4781 students aged 11-, 13- and 15-years old were included in the analyses. Logistic regression was used for the analyses. The regression analyses showed that overweight and obese students were more exposed to bullying than their normal weight peers. Among boys, odds ratios (ORs) for exposure to bullying were 1.75 (1.18-2.61) in overweight and 1.98 (0.79-4.95) in obese boys compared with normal weight. Among girls, the corresponding ORs were 1.89 (1.25-2.85) in overweight and 2.74 (0.96-7.82) in obese girls. The mediation analyses showed that body image fully mediated the associations between weight status and exposure to bullying in both boys and girls. This study shows that overweight and obese boys and girls are of higher odds of being exposed to bullying than their normal weight peers. Moreover, this study finds that body image may statistically explain this association between overweight and exposure to bullying. However, the study is cross-sectional, and hypotheses of possibilities for opposite causality are possible.
The predicted probability of overall alcohol drinking and drinking patterns (frequent, binge and heavy drinking) within age cohorts among those consuming alcohol during the preceding year of examination. Examination periods: 1 = Baseline, 2 = 4-year and 3 = 11-year; overall drinking = any alcohol during the preceding year; frequent drinking = alcohol at least twice a week; binge drinking = at least six alcoholic drinks at one occasion; heavy drinking = alcohol more than 14 units weekly (one unit contains 12 g of ethanol) 
Percentages of overall drinking and drinking patterns in examination periods, and odds ratios from cohort-stratified Generalized Estimating Equations Models over the 11-year period
Mean weekly alcohol consumption during the preceding year of examination within age cohorts among those consuming alcohol. Examination periods: 1 = Baseline, 2 = 4-year and 3 = 11-year (one unit contains 12 g of ethanol) 
Alcohol consumption is often reported to decrease with ageing. We investigated alcohol consumption and drinking patterns in an ageing population-based male sample during an 11-year follow-up period. This study with baseline and two follow-up examinations (at 4 and 11 years) included 1516 randomly selected participants, aged 42, 48, 54 and 60 years from Eastern Finland. Alcohol consumption and drinking patterns during the year preceding the examination were assessed. Data were analysed using Generalized Estimating Equations and Mixed Models. Over the 11-year study period, the amount of alcohol consumed weekly increased among the 42-year-olds (P < 0.001) and remained constant among the older cohorts. The risk of frequent drinking (alcohol consumption at least twice weekly) increased among all cohorts (OR = 2.04, 95% CI = 1.50-2.79 for 42-year-olds; OR = 1.71, 95% CI = 1.13-2.58 for 48-year-olds; OR = 1.67, 95% CI = 1.16-2.39 for 54-year-olds and OR = 1.67, 95% CI = 1.21-2.29 for 60-year-olds). There was also an increasing probability of heavy consumption (more than 14 weekly drinks) among the 42-year-olds (OR = 1.47, 95% CI = 1.09-2.00). The risk of binging (six-plus drinks at one occasion) decreased among the older participants (OR = 0.65, 95% CI = 0.47-0.89 for 54-year-olds, and OR = 0.56, 95% CI = 0.39-0.81 for 60-year-olds). Finnish men born in 1926-1946 do not seem to decrease drinking while ageing. In contrast those born in 1944-1946 increase drinking until their 60's. This should be taken into consideration in planning health services for aged men in the near future.
Many women stop smoking while they are pregnant, but the majority resume smoking in the postpartum. The objective is to describe postpartum tobacco use of women who quit during pregnancy and factors predicting postpartum smoking relapse. Secondary analysis of two surveys of new mothers. Survey A conducted in three maternity hospitals, including 685 women interviewed after birth and who answered a postal questionnaire at 5 months postpartum; survey B conducted in four 'départements' (administrative areas), including 636 women who answered a postal questionnaire at 6 months postpartum. Response rates were respectively 90% and 68%. Smoking status was recorded for three time periods: before pregnancy, during pregnancy, and at 5-6 months. Social characteristics and preventive behaviour were compared for regular smokers who had quit smoking during pregnancy and those who had not, and among quitters, who had resumed smoking postpartum and those who had not. In survey A, 37% were smokers before pregnancy, 34% of them stopped during pregnancy, and among the latter, 48% had resumed smoking 5-6 months after delivery. In survey B, the percentages were respectively 43, 54 and 57%. The most predictive factor of postpartum smoking relapse was the partner's smoking behaviour. Return to smoking after delivery is frequent, but nearly half of the regular smokers who had stopped during pregnancy were still non-smokers 5-6 months after the birth. However, to increase this proportion, interventions need to include partners, especially if they are smokers.
Description of variables used in analysis 
Binomial multilevel models of girls' and boys' well-being, adjusting for age and family structure; 1998, 2002 and 2006 
Promoting young people's mental well-being and reducing socioeconomic inequalities are priority areas for WHO and the Scottish Government. This article describes changes in the subjective health and mental well-being of adolescents living in Scotland between 1994 and 2006, and investigates socioeconomic inequalities in mental well-being and subjective health over time. Data from the 1994, 1998, 2002 and 2006 Health Behaviour in School-aged Children surveys were analysed using Multilevel Binomial modelling. Boys and younger adolescents scored more favourably on measures of confidence, happiness, helplessness and feeling left out than girls and older adolescents. Multiple health complaints (MHC) were also more prevalent among girls than boys. Significant increases over time were observed for all mental well-being measures among girls and for all but confidence among boys. Similarly, there was a significant decrease in odds of MHC over time for both boys and girls. There were no socioeconomic inequalities in any of the five outcomes in 1998. However by 2006, socioeconomic inequalities in young people's happiness, confidence and MHC emerged, while inequalities in girls' helplessness also approached significance. Between 1998 and 2006 significant increases in socioeconomic inequalities in happiness and MHC were observed and increases in feeling left out also approached significance. Adolescent mental well-being and subjective health in Scotland is improving. However, gender differences persist and socioeconomic inequalities are emerging for some measures, suggesting that a longer term monitoring of mental well-being and subjective health in Scotland is required.
Prevalence of smoking at each time point by gender and smoking method in a school-based sample of adolescents in Irbid, Jordan, 2008-11 
Background: Coordinated high-impact interventions and community-level changes in smoking behaviour norms effectively reduced prevalence of smoking among youth in many developed countries. Smoking trends among Jordanian adolescents are likely different than their Western counterparts and must be understood in the context of their daily lives to tailor interventions specifically for adolescents in this setting. Methods: Between 2008 and 2011, a school-based longitudinal study was conducted in Irbid, Jordan. All seventh-grade students in 19 randomly selected schools (of 60) were surveyed annually for 4 years. Outcomes of interest were time trends in smoking behaviour, age at initiation and change in frequency of smoking. Results: Among 1781 participants, baseline prevalence of current smoking (cigarettes or waterpipe) for boys was 22.9% and 8.7% for girls. Prevalence of ever-smoking and current any smoking, cigarette smoking, waterpipe smoking and dual cigarette/waterpipe smoking was significantly higher in boys than girls each year (P < 0.001). Smoking prevalence increased every year after year 2 for current smoking (P < 0.05) across all methods (any, cigarette, waterpipe and dual). At all time points for both boys and girls, prevalence of waterpipe smoking was higher than that of cigarette smoking (P < 0.001). Conclusion: This study shows intensive smoking patterns at early ages among Jordanian youth in Irbid, characterized by a predominance of waterpipe smoking and steeper age-related increase in cigarette smoking. It also points to the possibility of waterpipe being the favourite method for introducing youth to tobacco, as well as being a vehicle for tobacco dependence and cigarette smoking.
in prevalence of being bullied once or more at school in the past couple of months by gender, country and survey year a 
in prevalence of being bullied at least two or three times at school in the past couple of months by gender, country and survey year a 
Bullying among children and adolescents is a public health concern; victimization is associated with psychological and physical health problems. The purpose of this study is to examine temporal trends in bullying victimization among school-aged children in Europe and North America. Data were obtained from cross-sectional self-report surveys collected as part of the Health Behaviour in School-aged Children (HBSC) study from nationally representative samples of 11-, 13- and 15-year-olds, from 33 countries and regions which participated in the 2001-02, 2005-06 and 2009-10 surveys. Responses from 581 838 children were included in the analyses. Binary logistic regression was used for the data analyses. The binary logistic regression models showed significant decreasing trends in occasional and chronic victimization between 2001-02 and 2009-10 across both genders in a third of participating countries. One country reported significant increasing trends for both occasional and chronic victimization. Gender differences in trends were evident across many countries. Overall, while still common in many countries, bullying victimization is decreasing. The differences between countries highlight the need to further investigate measures undertaken in countries demonstrating a downward trend. © The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
Age-adjusted prevalence of overweight in boys from 2002 to 2010 by country 
Age-adjusted prevalence of overweight in girls from 2002 to 2010 by country 
The purpose of this study was to assess recent changes in the prevalence of overweight (including obesity) among 11-, 13- and 15-year-olds in 33 countries from 2002 to 2010. Data from 25 countries from three consecutive survey cycles (2002, 2006 and 2010) that had at least 80% response rate for self-reported height, weight and age were analysed using logistic regression analysis. Overweight prevalence increased among boys in 13 countries and among girls in 12 countries; in 10 countries, predominantly in Eastern Europe, an increase was observed for both boys and girls. Stabilization in overweight rates was noted in the remaining countries; none of the countries exhibited a decrease over the 8-year period examined. In the majority of countries (20/25) there were no age differences in trends in overweight prevalence. In over half of the countries examined overweight prevalence did not change during 2002-2010. However, increasing overweight prevalence was noted in many Eastern European countries over this time period. Overweight prevalence remained high in several countries in Europe and North America. These patterns call for continued research in youth overweight and highlight the need to understand cross-national differences by examining macro-level indicators. Such research should feed into developing sound translations and practices to prevent and reduce overweight in youth. © The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
Background: Evidence of inequalities in obesity and overweight is available mostly from national studies. This article provides a broad international comparison of inequalities by education level and socio-economic status, in men and women and over time. Methods: Data from national health surveys of 11 OECD countries were used. The size of inequalities was assessed on the basis of absolute and relative inequality indexes. A regression-analysis approach was used to assess differences between social groups in trends over time. Results: Of the countries examined, USA and England had the highest rates of obesity and overweight. Large social inequalities were consistently detected in all countries, especially in women. Absolute inequalities were largest in Hungary and Spain with a difference of 11.6 and 10% in obesity rates in men, and 18.3 and 18.9% in women, respectively, across the education spectrum. Relative inequalities were largest in France and Sweden with poorly educated men 3.2 and 2.8 times as likely to be obese as men with the highest education (18 and 17 times for women in Spain and Korea, respectively). Pro-poor inequalities in overweight were observed for men in USA, Canada, Korea, Hungary, Australia and England. Inequalities remained virtually stable during the last 15 years, with only small variations in England, Korea, Italy and France. Conclusion: Large and persistent social inequalities in obesity and overweight by education level and socio-economic status exist in OECD countries. These are consistently larger in women than in men.
Hierarchical logistic regression model for easy talk to opposite sex by region 
Electronic media has become a central part of the lives of adolescents. Therefore, this study examines trends in adolescent electronic media communication (EMC) and its relationship with ease of communication with friends of the opposite sex, from 2002 to 10 in 30 European and North American regions. Data from the HBSC study were collected using self-report questionnaires from 11-, 13- and 15-year-old participants (N = 404 523). EMC use has grown over the years in most of these regions and increases with age. Even though Internet usage is often blamed for its negative effects on teenagers' social interactions in the physical world, in this study EMC was found to predict ease of communication with friends. Especially, the more they use EMC, the easier they find it to talk with friends of the opposite sex. Although these findings suggest that EMC reinforces communication, the interaction between year (2002-2006-2010) and EMC usage was not significant. This finding contradicts research that suggests that EMC contributes to loneliness and isolation, and supports other studies that present electronic media as a powerful tool for helping to connect people. © The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
Prevalence of influenza vaccination and corresponding 95% confidence intervals by country and high-risk group  
Multivariable odds ratios (ORs) and 95% confidence intervals for the association between high-risk group membership and influenza vaccination, by country. (A) Older age (!65 years vs 50–64 years) and vaccination; (B) Vascular disease (yes vs no) and vaccination; (C) Chronic lung disease (yes vs no) and vaccination; (D) Diabetes (yes vs no) and vaccination. ORs are adjusted for high-risk group membership, sex, income, education and the number of annual contacts with physicians  
National vaccination coverage rates for individuals at increased risk of influenza-related complications represent a useful public health indicator of preparedness. We compared European countries regarding (i) vaccination coverage among high-risk groups and (ii) the likelihood that high-risk individuals reported influenza vaccination compared with those at lower risk. We used data from the Survey of Health, Ageing and Retirement in Europe (SHARE) collected in 2004-05. Adults aged ≥ 50 years from 11 countries provided self-reports of an influenza vaccination in the previous year (n = 16,913). We defined four high-risk groups (age ≥ 65 years, presence of vascular disease, chronic lung disease or diabetes) and calculated vaccination coverage with 95% confidence intervals for each country. Country-specific multivariable logistic regression was used to estimate odds ratios (ORs) for membership in a high-risk group and vaccination. The Netherlands had the highest influenza vaccination coverage in high-risk groups (≥ 75% in any group) while Greece had the lowest (<27% in any group). Older age was positively associated with report of vaccination in all countries, but the strength of this association varied from an OR of <2 (Germany) to >13 (The Netherlands). The ORs for the chronic disease groups was ≥ 4 for The Netherlands and were considerably lower (and often not statistically significant) for the other countries. Influenza vaccination coverage among high-risk groups varies considerably between European countries. Our findings highlight potential opportunities for reducing influenza-related complications through support for vaccination programs that target high-risk individuals more effectively.
Unlabelled: The plurality of definition of faecal incontinence (FI) complicates the cross-national comparisons between studies conducted in the area. The aim of the study was to investigate work-load and subjective care-giver burden associated with FI, among home-care patients, in Europe. Design and methods: In this cross-sectional retrospective study, a random sample of 4010 RAI-HC assessments were collected during 2001-02 from home care patients aged 65 years and over (74% females; age 82.8 +/- 7.2 years) in Czech Republic, Denmark, Finland, France, Germany, Iceland, Italy, The Netherlands, Norway, Sweden and United Kingdom. Results: Of the 4010 individuals, 411 (10.3%) suffered from FI (range 1.1-30.8% from site to site). The factors significantly associated with faecal incontinence were diarrhoea [odds ratio (OR) 10.3, 95% confidence interval (CI) 6.590-15.96], urinary incontinence (OR 3.99, 95% CI 2.991-5.309) and pressure ulcers (OR 3.15, 95% CI 2.196-4.512) together with severe impairments in physical (OR 4.25, 95% CI 2.872-6.295) and cognitive (OR 3.76, 95% CI 2.663-5.304) functions. High use of working hours of the visiting nurses (OR 2.04, 95% CI 1.221-3.414) and home health carers (OR 2.40, 95% CI 1.289-4.470) were additionally associated with faecal incontinence. Use of five or more medications was an inversely associated with FI (OR 0.62, 95% CI 0.473-0.820). Conclusions: The additional work load associated with faecal incontinence comprises considerable numbers of formal health care hours and should be taken into account when planning home health services for the older in home care patients.
Valid parental responses for BMI of child, by country and total response 
Mean Z-scores with standard deviations for height, weight and BMI by gender and country 
Prevalence of stunting, underweight, overweight and obese children by CDC-2000 and IOTF criteria with 95% confidence intervals (CI) 
To assess country differences in prevalence of overweight, obesity, underweight and stunting in the Pro Children Survey. A cross-sectional study conducted in a random sample of schools in nine European countries in 2003. The subjects were 8317 11-year-old children from Austria, Belgium, Denmark, Iceland, The Netherlands, Norway, Portugal, Spain and Sweden. Parents reported height and weight of the children, and BMI values were analysed using the US Centers of Disease Control and Prevention and the International Obesity Task Force reference populations. Continuous variables were compared with one-way analysis of variance (ANOVA) with Games-Howell post hoc tests. Categorical variables were analysed using chi-square tests. The prevalence of overweight + obesity varied between the countries from 8.6% to 30.6% and 5.9% to 26.5%, respectively, depending on the reference population, with the lowest prevalence in Dutch girls, the highest in Portuguese boys. Obesity prevalence varied from 1.1% (Dutch and Danish girls) to 10.7% (Portuguese boys) and from 0.3% (Dutch girls) to 6.2% (Portuguese boys), respectively. Portugal and Spain had the highest prevalence of overweight and obesity for both genders. The ranking of the countries according to overweight and obesity prevalence was roughly the same, independent of reference population. The prevalence of underweight varied from 2.3% (Swedish boys) to 12.3% (Belgian boys), using the American reference population. The proportion of stunted children was highest in Portugal, Spain and Belgium. The highest levels of overweight, obesity and stunting in the pro children material are found in Portugal and Spain.
Most adolescent smokers start smoking before the age of twelve. Little is known about the behavioural smoking determinants of Dutch primary school children. A cross-sectional study was carried out on a sample of students from the final year of 143 Dutch primary schools. A total of 3700 students (mean age = 11.6 years) completed a questionnaire based on the ASE model, measuring the attitude, social influences and self-efficacy expectations concerning smoking. Students were categorized as never smokers (64.3%), experimental smokers (28.0%), and regular smokers (7.8%). Multinomial logistic regression analyses showed that never smokers were younger, and were more often female, religious and from two-parent families than experimental smokers. Never smokers perceived more disadvantages, long-term physical consequences, more negative social norms and less pressure regarding smoking, higher self-efficacy expectations towards non-smoking, and had fewer parents, siblings or best friends who smoked. Looking at differences between experimental and regular smokers showed that experimental smokers received less pocket money. They also perceived more disadvantages, fewer advantages, more negative social norms and less pressure towards smoking, higher self-efficacy expectations towards non-smoking, and were less likely to be surrounded by friends, peers, family or teachers who smoked. Generally, the low scores for physical consequences and risk perception regarding addiction were striking. Smoking prevention aimed at primary schoolchildren should consider the different smoking categories, with their specific motives and influences. For instance, the influences on smoking initiation of parents, siblings and best friends suggest more comprehensive programmes aimed at the entire family. Youngsters' ignorance of addiction needs more attention.
We examined how acceptance of euthanasia among the general public has changed between 1981 and 2008 in western and central and eastern European (CEE) countries using data of the European Values Surveys. Data were collected in 1981, 1990, 1999 and 2008 for 13 western European countries and in 1990, 1999 and 2008 for 10 CEE countries. Euthanasia acceptance increased each decade up until 2008 in 11 of 13 western European countries; in CEE countries, it decreased or did not increase between 1999-2008 in 8 of 10 countries. A number of explanations for and implications of this apparent east-west polarization are suggested.
This first European Public Health News of 2013 is closely related to the theme of the 2013 European Public Health Conference: ‘Health in Europe: are we there yet? Learning from the past, building the future’. Chaze and Adam show that more needs to be done in patient safety; Jakab shows how WHO Europe helps build the future with the Health 2020 initiative; Zeegers Paget explains that building the future of EUPHA is based on the successes from the past; and Ricciardi reflects on the importance of European Public Health Conferences by summarizing the Malta 2012 conference. Ms Jakab describes the new year of European public health wonderfully in her column: ‘I believe that Health 2020 can add significant value to all our work and serve as unique resource to renew, enhance and enrich our efforts to work together for the benefit of the people of our Region, even in these difficult economic times’. # President’s column {#article-title-2} Taking advantage of the notes of our dear colleague and friend Natasha Muscat Azzopardi, Chief Medical Officer of Malta, I would like to underline the importance and success of the 5th European Public Health Conference. This conference was an important landmark, and it marked the 20th anniversary of EUPHA, a small project starting out from a noble idea of public health researchers who believed they had to go beyond the mere confines of the traditional researcher role and do something for public health at a European level. It was also the 5th anniversary of the European Public Health Conference, which has brought together the leading organizations in public health in Europe and has taken this conference altogether to a different scope and dimension. The conference got off to a fantastic start with Louise Gunning-Schepers putting forward the challenge that we do reasonably well on knowledge generation but …
Differences in the UFS children's CVD biomarkers (outcomes) by parental socio-economic position (occupational and educational group), adjusted for child's age, gender, pubertal stage and family clustering 
Differences in the USF children's CVD biomarker (outcomes) by parental lifestyle habits (smoking, alcohol consumption and PA), adjusted for child's age, gender, pubertal stage, family clustering and parental socio-economic group (education and occupation) 
Background: Precursors of cardiovascular diseases (CVD) originate in childhood. We investigated relationships of children's CVD risk factors with parent's socio-economic position (SEP) and lifestyle and how CVD risk factors correlate within families. Methods: We studied 602 families with 2141 individuals comprising two full sibs; aged 5-14 years, and their biological parents (Uppsala Family Study). Parental SEP (occupational class and education) and lifestyle habits [smoking, physical activity (PA), alcohol consumption] were taken from questionnaires. Associations with cholesterol, ApoB/ApoA1, leptin, adiponectin, blood pressure, body mass index (BMI) and overweight/obesity (OW/OB) were analysed by linear/logistic regression. Results were adjusted for child's age, gender, pubertal stage and family clustering. Results: We observed no consistent associations between parental SEP and children's CVD risk factors. Parental lifestyle had stronger effects, independent of parental SEP. Children of smoking fathers had higher BMI (4%, 95% CI 1-7%) and leptin levels (27%, 95% CI 1.00-61.60%). Children of mothers reporting vigorous PA had lower BMI, cholesterol and decreased odds for OW/OB with a possible dose effect. Compared with mothers reporting no vigorous activity, mothers with ≤75 min and 76-150 min/week of vigorous activity had 43% (OR 0.57, 95% CI 0.22-0.89) and 72% (OR 0.28, 95% CI 0.14-0.60) lower risk of having an OW/OB child, respectively, after adjustment for confounders. Independent, consistently stronger and significant associations were found between all studied parents' and children's CVD risk factors. Conclusion: Parental behaviours: smoking, alcohol consumption, low PA are associated with higher levels of CVD risk factors (BMI, OW/OB, cholesterol) in children. Strong correlations in CVD risk factors within families not related to parental SEP/lifestyle suggest a role of genetics in influencing children's CVD risk factors. Public health policies should target families with unhealthy lifestyles.
To analyse the impact of labour market trajectory indicators on early retirement, measured by age at onset of permanent disability (PD). Four labour market trajectory indicators were reconstructed in 14 972 new cases of PD recognized between 2004 and 2010: (1) number of employment contracts, (2) number of unemployment periods, (3) number of periods without social security affiliation and (4) percentage of time spent in inactivity. The outcome was measured as the age at onset of PD. Median differences and 95% confidence intervals (95%CI) were compared using a median regression. Analyses were stratified by sex and adjusted for occupational category and total time elapsed between the beginning of working life and the age at onset of PD: separately for each labour market indicator, and adjusted for each other. In men, the age at the onset of PD for workers with 15 or more employment contracts decreased by 4.8 years; and for workers with five or more periods without affiliation it decreased by 4.6 years. In women, the corresponding decreases were 5.8 years for 15 or more contracts and 7.2 years for five or more unaffiliated periods. The results for four indicators slightly changed when they were mutually adjusted. Poor employment conditions, such as having a high number of periods without affiliation, a high number of contracts (in men) and a higher percentage of inactive time (in women) are associated with early retirement due to PD. © The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
Variations in early sexual debut among 16 year olds were investigated by social level variables, parental occupation, gender, ethnicity, family structure, family functioning, and individual level variables, future aspirations, academic and social self-perception, and depressed moods. The variations in sexual debut were investigated by examining proportions of 16 year olds reporting their first intercourse before age 16. The data were collected by self-reporting questionnaires administered to in-school-youth, in Oslo. Multivariate logistic regression analyses were used to test for associations. Gender interactions with all variables were tested. Overall, 25% reported early debut. Independent effect of social class on differences in proportions in early sexual debut were found. Gender interaction with social class, ethnicity and academic self-perception as they associate to proportions having had early sexual debut, were found. For girls the pattern of social class differences was linear and the highest proportions were found among working classes. For boys the pattern was U-shaped and upper managerial and manual working class youth had similar, higher proportions of early debutants. High scores of parental monitoring, future aspirations and academic self-concept and low scores of depressed moods, are protective factors. While high social self-perception is positively associated with early debut for both genders. Early sexual debut varies according to social class, following gender-specific patterns, among 16 year olds in Oslo. The negative association between early debut and academic self-perception are for boys less influenced by other social and individual level factors, than for girls.
The number of offspring and deaths according to offspring age and maternal educational level 
Adjusted excess mortality rate (OR minus 1) of offspring according to maternal education. Reference group: offspring of mothers with university/college education 
The associations of maternal educational level with fetal death in different pregnancy weeks 
The associations of maternal educational level with infant death in different infant age groups 
Background: The social disparity in perinatal mortality may vary by the age of the offspring. We studied offspring mortality from pregnancy week 16 until 1 year after birth by maternal educational level. Methods: We included all births in Norwegian women during the years 1999-2004 (n = 297 663). The Medical Birth Registry of Norway was linked to the Norwegian Education Registry to obtain individual information on maternal education at the time of delivery. Information on infant mortality was obtained by linkage to the Norwegian Central Person Registry. Results: In pregnancy weeks 37 through 43 and in the first week after birth, there was little difference in offspring mortality by maternal education. Before pregnancy week 37, the excess offspring mortality associated with compulsory school only was >60% using university/college education as the reference. During the 2nd through 12th month after birth, the excess mortality was 132% in offspring of mothers with compulsory school only. Conclusion: The social disparity in offspring mortality was lowest in pregnancies at term and in the first week after birth. In this period, all women living in Norway and their infants use the public health care service extensively. Our results may suggest that health care that is equally available to all citizens, reduces social disparities in mortality.
Location of fatal injuries by age, average annual number and percent, 16 European countries a , 3-year average, 2002-04 
Child injury mortality and morbidity are a public health concern in European countries and data are scarce. Cross-national efforts are needed to identify high-risk groups, follow trends and assist in establishing European-wide safety legislation. This study investigates fatal child injuries in the home, as compared to those in transport in European countries. Injury mortality was extracted from the World Health Organization Mortality Database for the years 2002-04. The mortality rate per 100 000 population was calculated by age group for 16 contributing countries, grouped by their economic level of development. Fatal home injuries were highest in children under 5 years of age and then sharply decreased, as opposed to road traffic injuries, which increased with age. The majority of the upper-middle-economy countries tended to have higher home injury incidence rates compared to the high-income countries. The top five injury causes all countries aggregated were drowning/submersion, thermal injuries, poisoning, falls and homicide, all of which account for almost 90% of home injury deaths. Home injuries were the leading cause of injury death in children under 5 years of age in the countries under study and the inequalities found among the countries indicate potential for improvement. Evidence-based interventions exist to prevent these injuries and the barriers to their implementation ought to be determined and addressed.
Relationships between smoking behaviours and demographics, drinking behaviours and parental smoking 
Percentage of smokers who access cigarettes through various sources 
Logistic regression analysis of predictors of smoking, smoking heavier, buying fake or foreign cigarettes and buying single cigarettes 
Adolescent smoking is a significant public health concern in the UK and across Europe. This study examines smoking behaviours, methods of accessing cigarettes and use of non-commercial (fake, foreign and single) cigarettes across a sample of schoolchildren. Relationships with alcohol consumption, deprivation, personal income and extra-curricular activities are also explored. A cross-sectional survey of 9833 15- and 16-year-old schoolchildren in the North West of England. Cigarettes were most commonly accessed from off-licences and newsagents, but pupils also reported non-commercial access through friends, family and street sellers/neighbours. A high percentage of smokers had bought foreign (57%), fake (28%) and single (54%) cigarettes. Frequent binge drinking, not participating in extra-curricular activities, receiving greater personal income, and having parents that smoked were significantly associated with being a regular and heavier smoker. Frequent binge drinking was also significantly associated with buying foreign/fake or single cigarettes. A higher percentage of those living in deprived areas were current smokers, although deprivation was not an independent predictor of cigarette use. Strategies that restrict commercial access to cigarettes among adolescents may increase their reliance on social methods of access, and use of fake, foreign and single cigarettes. Interventions to reduce adolescent smoking must recognize the critical role of parents and communities in discouraging smoking and preventing social access to cigarettes in children. A joint approach to prevention is required that targets children at risk of smoking, heavy alcohol use and associated health-damaging behaviours.
IPV during the last 12 months grouped according to type of violence 
method during the most recent sexual intercourse by IPV exposure during the last 12 months a 
and adjusted OR for selected sexual health outcomes associated with IPV exposure during the last 12 months a 
Background: Violence against women as a public issue and health burden has only recently been acknowledged in Estonia. The aim of this study was to outline the prevalence and to explore the associations of intimate partner violence (IPV) and selected sexual health outcomes. Methods: Data from the population based cross-sectional survey among representative sample of 16-44-year-old non-pregnant women (n = 1966) were analysed using multivariate logistic regression. Results: Of 1966 respondents, 362 (18.4%) reported IPV during 12 months preceding the survey. Physical IPV was reported by 339 (17.2%), sexual by 80 (4.1%) and both physical and sexual by 35 (1.8%) of respondents. After controlling for significant confounding socio-demographic factors, exposure to IPV was found to be associated with contraception non-use [adjusted odds ratio (AOR) = 2.02, 95% confidence interval (CI) 1.44-2.82] or the use of unreliable contraceptive methods (AOR = 1.54, CI 1.16-2.04) during the most recent sexual intercourse, having never used a condom (AOR = 1.53, CI 1.12-2.10), repeat induced abortion (AOR = 1.72, CI 1.24-2.37), lifetime sexually transmitted infections (AOR = 2.05, CI 1.56-2.68) and dyspareunia (AOR = 2.14, CI 1.65-2.77). Conclusion: The exposure of IPV was an important contributor to sexual risk behaviour and adverse sexual health outcomes among women of reproductive age in Estonia. Any strategy to promote sexual health should include prevention of IPV and other forms of violence against women with the strengthening of women's sexual and reproductive rights.
Calibration results 
Human papillomavirus (HPV) epidemiology and screening practices vary considerably between countries and specific analyses are required to estimate the impact of HPV vaccination. This study aimed to predict the clinical benefits of introducing a bivalent HPV16/18 vaccine in Spain, where the cervical cancer (CC) incidence is 10.3 per 100 000. A Markov model based upon the natural history of HPV and CC was developed to simulate transitions between health states, in the presence of specific screening programmes. Published data were used to reflect the Spanish situation in terms of epidemiological characteristics, screening and treatment practices. Calibration consisted of varying disease progression rates within established ranges until model predictions matched observed epidemiological data. The clinical impact of vaccinating a cohort of 12-year-old girls against HPV was assessed over their lifetime using the calibrated model. Vaccination of all 12-year-old girls would result in a reduction of 75% (from 0.32% to 0.08%) in the prevalence of high-grade precancerous lesions due to oncogenic HPV, and a 79% reduction in both CC cases (from 1745 to 365) and CC deaths (from 417 to 86). Assuming a vaccine coverage of 80%, the number of CC cases and deaths would decrease by 63%. Vaccination could also substantially reduce the number of screening tests and treatments required for cervical dysplasia. Our model was successfully adapted to the Spanish epidemiological environment, screening and treatment practices and predicted a substantial long-term benefit of HPV vaccination despite a low HPV prevalence in Spain.
A general quality of life model, life spheres and 
Respondents by country, age and gender in 1984 and 1996 
The aim of the study was to analyse children's quality of life (QoL) in the five Nordic countries from 1984 to 1996, a period in which major economic recessions occurred. The study design was cross-sectional based on a random sample of 3000 children in each country, aged 2 to 17 years, totalling 15,000 in 1984 and 15,000 in 1996. The data were collected by mailed questionnaires. QoL was analysed for three spheres of life: external, interpersonal, personal including both factual and perceived variables. The external sphere represented the socio-economic conditions for the child's family, the interpersonal sphere the structure and the function of the child's social networks and the personal sphere the psychological well-being of the child. The total QoL for Nordic children from 1984 to 1996 increased, but there were differences in the development of QoL between the countries. The objective QoL became better, at the same time the subjective QoL worsened, except in Denmark and Iceland. The external QoL became better, whereas the interpersonal QoL was nearly unchanged but there were differences in the development between countries. The personal QoL worsened slightly except for children in Iceland. The ranking between countries changed. Danish children had the highest subjective and Norwegian children the highest objective and external QoL. Swedish children had the highest personal QoL. Children 7-12 years had the highest QoL. Girls had a tendency to higher QoL in all ages. Nordic children still enjoy a high standard of living in spite of economic constraints, and the prerequisites for a high QoL are fulfilled. Further research is suggested for clarifying the complex background of these results.
School-dropout rates at the age of 17 years according to subject characteristics 
Research has shown that cannabis use contributes to school dropout, but few studies have distinguished the age at onset of use from the age at progression to daily use neither their interaction with grade repetition. This study is based on a French representative cross-sectional survey (N = 29,393 teenagers aged 17 years) and uses retrospective data. The influence of drug-use patterns <16 years of age on school-dropout rates (5.3%) are modelled with logistic regressions among boys and girls. The main factors associated with dropout were a low family socio-economic status, early grade repetition, single-parent families and daily tobacco smoking (ORa > or = 2.6). The link with the move to daily cannabis use was more evident when it occurred <14 years of age (ORa = 2.05 for boys and 3.41 for girls) rather than at > or =15 years (ORa = 1.45 for both sexes). The onset of cannabis use was not significant when occurring <14 years of age, but was linked to school attainment when occurring at age 15-16 years (ORa = 0.80 for boys and 0.64 for girls). Results are similar for alcohol use. Repeating a grade before beginning to use cannabis increased the dropout rates compared with the opposite sequence. Girls were more affected by early grade repetition and by early and daily cannabis use. Cannabis use is rarely a trigger for grade repetition but can have either damaging or positive effects on school attainment depending of the level of use. Positive social competence reflected by peer initiation should be investigated to understand this paradoxical effect.
Background: Human Papillomavirus (HPV) is a common sexually transmitted infection and is aetiologically linked with a number of health problems. In Germany, HPV vaccination for cervical cancer prevention is recommended for girls aged 12-17 years since 2007; however, a coordinated national immunization programme does not exist. We assessed whether socio-demographic factors and sexual history are associated with awareness of HPV and the HPV vaccine, vaccine uptake and HPV-related knowledge among young women and men. Methods: In 2010, a survey was conducted with 18- to 25-year-old students from six vocational schools in Berlin. A total of 259 women and 245 men completed the questionnaire that included socio-demographic and sexual behaviour characteristics, questions about HPV awareness, vaccine status, reasons for not wanting to get vaccinated and HPV-related knowledge. Results: Among women aged 18-20 years (those eligible for reimbursed vaccination), 67% were vaccinated. At trend level, women with low education and those without past sexual intercourse were less likely to be vaccinated. Ninety-five per cent of the women and 80% of the men were aware of the 'vaccine against cervical cancer', but only half of the women and 25% of the men had heard of HPV. Knowledge was poor (M = 2.8; SD = 2.10 for women and M = 1.5; SD = 1.49 for men; possible range 0-11). Fifty-one per cent of the women and 42% of the men thought that only women can be infected with HPV and the majority did not know that HPV is sexually transmitted. Conclusion: Results indicate a need for better education about HPV that should extend beyond its link with cervical cancer.
Correlation between combined LIC assessment scores and mortality rates for children 0–19 years in 18 countries in Europe (Rankings based on average 5-year unintentional mortality rate per 100 000 population 0–19 years for 1998– 2003 or most recent 5 years of data; given the decentralization of health-related policy to constituent countries, N. Ireland and Scotland are considered as individual countries of the United Kingdom within this analysis.) 
Indicators of national-level infrastructure as it relates to child injury prevention in 18 countries a in Europe and infrastructure score out of 12 b Measure of infrastructure DK SE CZ PL AU NL NO GR GE IT HU NI PT SC EE FR BE ES
Mortality and morbidity rates, traditionally used indicators for child injury, are limited in their ability to explain differences in child injury between countries, are inadequate in capturing actions to address the problem of child injury and do not adequately identify progress made within countries. There is a need for a broader set of indicators to help better understand the success of countries with low rates of child injury, provide guidance and benchmarks for policy makers looking to make investments to reduce their rates of fatal and non-fatal child injury and allow monitoring of progress towards achieving these goals. This article describes an assessment of national leadership, infrastructure and capacity in the context of child injury prevention in 18 countries in Europe and explores the potential of these to be used as additional indicators to support child injury prevention practice. Partners in 18 countries coordinated data collection on 21 items relating to leadership, infrastructure and capacity. Responses were coded into an overall score and scores for each of the three areas and were compared with child injury mortality rankings using Spearman's rank correlation. Overall score and scores for leadership and capacity were significantly negatively correlated to child injury mortality ranking. Findings of this preliminary work suggest that these three policy areas may provide important guidance for the types of commitments that are needed in the policy arena to support advances in child safety and their assessment a way to measure progress.
We examined mortality among working-age Russian men whose identity could not be determined, focusing on where and how they died. Employing micro-data from deaths that occurred in Izhevsk (Ural region) between June 2004 and September 2005, we analysed the characteristics of decedent men aged 25-54 (n = 2158). Differences between completely identified (n = 1699) and unidentified deaths (n = 282) were compared via logistic regression. Data on all deaths in Russia in 2002 were used for supplemental comparisons. We found that relative to identified men, unidentified men were at a higher risk of death from exposure to natural cold, violence, alcoholic cardiomyopathy, acute respiratory infections and poisonings. Our results also revealed that alcohol played an important role in the mortality of unidentified men. The places and causes of death among these unidentified men provide substantial evidence of their homelessness and social isolation. The increase in deaths among unidentified men of working-age indicates the emergence of a health threat associated with homelessness and social marginalization. This vulnerable group is exposed to different levels and causes of mortality compared with the larger population and represent a new challenge that requires serious and immediate scholarly attention and policy responses.
Distribution of adolescents reporting violent events during the preceding month in 1999 and 2009 by number of events, age and sex 
We examined whether the occurrence of violence changed among Finnish adolescents between 1999 and 2009. The study was based on the nationwide Adolescent Health and Lifestyle Survey from samples of 12- to 18-year-olds. The number of respondents was 8136 in 1999 and 5516 in 2009. The proportion of adolescents reporting violence was 7.9% in 1999 and 6.2% in 2009 (P < 0.000). In both of the study years, the violence occurrence rate varied by age and sex, with boys reporting higher rates in all age groups. The results did not support our hypothesis of a general increase in violence among adolescents.
Background: Scotland has been dubbed 'the sick man of Europe' on account of its higher mortality rates compared with other western European countries. It is not clear the length of time for which Scotland has had higher mortality rates. The root causes of the higher mortality in Scotland remain elusive. Methods: Life expectancy data from the Human Mortality Database were tabulated and graphed for a selection of wealthy, mainly European countries from around 1850 onwards. Results: Scotland had a life expectancy in the mid-range of countries included in the Human Mortality Database from the mid-19th century until around 1950. After 1950, Scottish life expectancy improved at a slower rate than in comparably wealthy nations before further faltering during the last 30 years. Scottish life expectancy now lies between that of western European and eastern European nations. The USA also displays a marked faltering in its life expectancy trend after 1981. There is an inverse association between life expectancy and the Index of Economic Freedom such that greater neoliberalism is associated with a smaller increase, or a decrease, in life expectancy. Conclusion: Life expectancy in Scotland has only been relatively low since around 1950. From 1980, life expectancy in Scotland, the USA and, to a greater extent, the former USSR displays a further relative faltering. It has been suggested that Scotland suffered disproportionately from the adoption of neoliberalism across the nations of the UK, and the evidence here both supports this suggestion and highlights other countries which may have suffered similarly.
It has been suggested that diabetes is under-recorded on death certificates. We examined the death certificates of 1,872 people with type 2 diabetes in Tayside, Scotland, to determine how frequently diabetes was recorded. Diabetes was mentioned on the certificates of 42.8% and was the underlying cause of death for 6.4%. There was mention of diabetes for 51.3% of the 811 people for whom cardiovascular disease was the underlying cause of death. Being male was associated with less frequent mention of diabetes, with more frequent mention associated with increasing duration of diabetes, increasing age and underlying cardiovascular cause of death. This study highlights the limitations of using routine mortality data for monitoring the burden of diabetes in populations.
At the end of the 19th century, infant mortality was high in urban and rural areas in Sweden. In Stockholm, the mortality rate was particularly high among foster children. This study addresses the importance for health of targeted public policies and their local implementation in the reduction of excess mortality among foster children in Stockholm at the turn of the 19th century. In response to public concern, a law was passed in 1902 on inspections of foster homes. Stockholm city employed a handful of inspectors who visited foster homes and advised parents on child care and feeding. Analysis of historical records from the City of Stockholm was combined with epidemiological analysis of mortality rates and hazard ratios on individual-level data for 112, 746 children aged <1 year residing in one part of Stockholm between 1878 and 1925. Hazard ratios of mortality were calculated using Cox' regression analysis. Mortality rates of foster infants exceeded 300/1000 before 1903. Ten years later the mortality rates among foster children had declined and were similar to other children born in and out of wedlock. Historical accounts and epidemiological analysis of individual-level data over a longer time period showed similar results. Targeted policy measures to foster children may have potentiated the positive health effects of other universal policies, such as improved living conditions, clean water and sanitation for the whole population in the city, contributing to an equalization of mortality rates between different groups.
Since the economic recession in Sweden in the 1990s alarming reports about deteriorating mental and psychosomatic health among young people have repeatedly been published but reliable survey data are rare. The purpose of the study is to describe the trends in psychosomatic health problems among adolescents, focusing on gender differences. The analysis is based on repeated cross-sectional data collected 1988-2005 among about 15,000 adolescents (15- to 16-years old) within a county in Sweden. The data were collected in schools using a questionnaire that was completed anonymously. A composite measure of psychosomatic health problems based on eight items was used. Psychosomatic health complaints among boys increased mainly during the in-recession time period, while the health problems among girls increased only slightly during the crisis, but increased dramatically in the post-recession time period. Only among boys did the variance in psychosomatic health increase successively across years of investigation, implying that the psychosomatic health among boys on average did not change over time. In showing different trend patterns across genders, the present study nuances and qualifies previous reports on deteriorating mental and psychosomatic health among adolescents. Whether the gender-related trend patterns are due to differences in the relative influence of economic and social stress factors or if they reflect other factors such as changes in the educational systems should be addressed in future studies.
Characteristics of study population 
Background: The present study examines (i) if the level of vigorous physical activity (VPA) at age 15 predicts low VPA at ages 19 and 27 and (ii) whether the observed prediction pattern differs by childhood socio-economic position (SEP). In this way, prediction analyses are applied to study tracking behaviour. Methods: Data are from The Danish Longitudinal Health Behaviour Study. The baseline survey was conducted in 1990 at age 15, the first follow-up in 1994 at age 19, and the second follow-up in 2002 at age 27, n = 561. The study population was a random sample of the Danish population selected from the National Civic Registration System, and data were collected by anonymous postal questionnaires. The indicator of childhood SEP was family occupational social class. Prediction analyses are conducted by stratified logistic regression analyses. Results: There was a significant and marked predictive power of low levels of VPA in mid adolescence (aged 15) for low VPA in late adolescence (age 19) [odds ratio (OR)=4.95 (2.83-8.66)], from late adolescence (age 19) into early adulthood (age 27) [OR = 2.71 (1.61-4.55)] and also over the full study period from age 15 to age 27 [2.91 (1.72-4.94)]. Analyses stratified by SEP revealed that the predictive power of VPA at age 19 for low VPA at age 27 was only significant among participants from low SEP. Conclusion: These findings suggest that low VPA tracks through adolescence while tracking into adulthood only occurs among individuals with low childhood SEP.
Results of the multinomial logistic regression for sociodemographic characteristics 
Many prevention and intervention measures are still targeting isolated behaviours such as tobacco use or physical inactivity. Cluster analysis enables the aggregation of single health behaviours in order to identify distinctive behaviour patterns. The purpose of this study was to group a sample of the over-50 population into clusters that exhibit specific health behaviour patterns regarding regular tobacco use, excessive alcohol consumption, unhealthy diet and physical inactivity. From the total population of the federal state of Baden-Wuerttemberg, Germany, 982 men and 1020 women aged 50-70 were randomly selected. Subjects were asked by trained interviewers in computer-assisted telephone interviews (CATI) about health behaviour and sociodemographic characteristics. Cluster analysis was conducted to identify distinct health behaviour patterns. Multinomial logistic regression was used to characterize clusters by specific social attributes. Five homogeneous health behaviour clusters were identified: 'No Risk Behaviours' (25.3%), 'Physically Inactives' (21.1%), 'Fruit and Vegetable Avoiders' (18.2%), 'Smokers with Risk Behaviours' (12.7%) and 'Drinkers with Risk Behaviours' (22.7%). Whereas the first cluster is the ideal in terms of risk and prevention, the latter two groups include regular users of tobacco and excessive consumers of alcohol, who also engage in other risk behaviours like inactivity and maintaining an unhealthy diet. These two risk groups also exhibit specific sociodemographic attributes (male, living alone, social class affiliation). Unhealthy behaviours evidently occur in typical combinations. An awareness of this clustering enables prevention and intervention measures to be planned so that multiple behaviours can be modified simultaneously.
Number of male study subjects by smoking status and age
Number of life years and work years lost per person (male) by smoking status
To estimate the health care expenditure and productivity losses due to smoking. A retrospective cohort study of a random population sample of 5,247 men aged 25-59 years from the provinces of Kuopio and North Karelia in eastern Finland. Subjects initially surveyed in 1972 were linked to a set of national registers through their social security identification numbers and followed for 19 years. The difference in the number of life years and work years lost, the costs of drugs and hospitalization, and the value of productivity lost due to disability and premature mortality between smokers, former smokers and never-smokers was analysed. The difference in mean life expectancy between current smokers and never-smokers was 3.0 years, and the difference in mean lost work time was 2.6 years over the 19 years of follow-up. Between current smokers and former smokers, the difference in mean life expectancy was 1.8 years, and the difference in mean lost work time was 1.6 years. The mean difference between a current smoker and a never-smoker in health service costs was [symbol: see text] 2,900, and the difference in mean total costs was [symbol: see text] 69,300 (an increase of 86%). No difference in mean health care costs between current smokers and former-smokers was found, while the difference in mean total cost was [symbol: see text] 44,000. Smokers incurred excess costs in terms of both direct health care expenditure and indirect productivity losses in comparison to the never-smoking population. Most importantly, quitting smoking could save at least 60% of the losses related to excess mortality and disability of smokers.
After a steep decline in older generations, coronary heart disease mortality is stagnating in female cohorts born after the Second World War. We analysed past trends and predicted future health care needs for coronary heart disease in the Dutch population. A loglinear age-cohort model relates numbers of deaths and hospital admissions for coronary heart disease to sex, age, birth cohort and population size, and projects age-cohort changes over the future population. Population size, population forecasts and coronary heart disease mortality (period 1970-1999) are from vital statistics. Numbers of hospitalised acute coronary events are from the nationwide hospital register (period 1980-1999). Among men, the rate ratios of deaths and hospital admissions were, respectively, 0.21 (death) and 0.78 (survivors at discharge) in the cohorts born in the period 1948-1962 compared to the period 1918-1922. Among women, the same rate ratios were 0.41 and 1.89. The projection model predicts 22% less deaths from coronary heart disease and 22% more survivors of an infarction in 2015, among men. Among women, there will be 5% less deaths and 70% more survivors of an infarction, most of these being middle age members of the baby boom cohorts. Stagnating all-cause mortality is correlated with an upward trend in coronary heart disease risk in the female baby boomers. Heart health care needs among middle-aged women will increase sharply. These changes are correlated to high lung cancer mortality and high smoking rates in these cohorts.
The pattern of smoking initiation is of importance in understanding the prevalence of smoking and future trends in tobacco-related diseases. To analyse trends of cigarette smoking initiation rates by sex and educational level in Spain. Pooled data from the 1993, 1995 and 1997 Spanish National Health Interview Surveys were used (16,365 males and 17,478 females aged >15 years). The age and smoking status of each subject were reconstructed for five calendar periods (1948-1952, 1958-1962, 1968-1972, 1978-1982, 1988-1992). Age-specific (10 to 24 years old) smoking initiation rates were calculated for males and females, and according to level of education (high education: university and secondary school; low education: primary and less than primary). Among males, there was a trend towards earlier age at start of smoking and higher initiation rates between 1958 and 1982, and a subsequent decline in initiation rates, more apparent in males with a higher level of education. Smoking initiation among females was rare until the 1960s, and from the period 1968-1972 onwards a converging pattern with that of males was observed. Women with a higher level of education started smoking before women with low education, but this pattern changed over the period 1978-1982, with higher initiation rates among less educated women during the last period studied. These results help to characterize the tobacco epidemic in Spain, now at the end of stage 3. The observations are in agreement with diffusion-of-innovations theory and the social and economic changes from the 1960s onwards in Spain.
Social relations are known to influence morbidity and mortality but few have studied this association from a life-course perspective specifically targeting the importance of social relations in childhood for adult health. In childhood, a key aspect of children's relationships is the number of friendships a child has in the school class, i.e. friendship quantity. The overall aim of this study was to examine the association between childhood friendships and adult self-rated health. Data from a longitudinal study of children born in Aberdeen, Scotland, between 1950 and 1956 was used. Information on friendship quantity (1964) was derived from sociometric nominations among classmates and defined as mutual choices. The health outcome was based on self-ratings derived from a questionnaire in 2001-03. The study included various childhood and adult circumstances as possible explanatory factors. The analysis was based on ordinal logistic regression, producing odds ratios (n = 5814). The results demonstrated a gradient in women's self-rated health according to the number of friendships in the school class. A number of circumstances in childhood and adulthood were partial explanations. For men, only those without friends reported poorer self-rated health in adulthood. This finding was explained by adult socioeconomic status. It is concluded that childhood friendships are linked to health disparities in middle age, underlining the importance of such relationships and the need for a life-course perspective on health that integrates a variety of mechanisms as they interact across life.
Top-cited authors
Martin Mckee
  • London School of Hygiene and Tropical Medicine
Helmut Brand
  • Maastricht University
Stephan Van den Broucke
  • Université Catholique de Louvain - UCLouvain
Kristine Sorensen
  • Global Health Literacy Academy
Ellen Uiters
  • National Institute for Public Health and the Environment (RIVM)