The European Journal of Public Health - Advance Access

Thomas B Newman, Michael A Kohn. Evidence-based Diagnosis.

Bodin, L. — Mon, 16 Nov 2009 00:36:47 PST

A cost-utility analysis of adding a bivalent or quadrivalent HPV vaccine to the Irish cervical screening programme

Dee, A., Howell, F. — Wed, 11 Nov 2009 07:18:45 PST

Background: Cervical cancer is a leading cause of death worldwide, and in Ireland it is the ninth most commonly diagnosed cancer in women. Almost 100% of these cancers are caused by human papillomavirus (HPV) infection. Two newly developed vaccines against HPV infection have become available. This study is a cost–utility analysis of the HPV vaccine in Ireland, and it compares the cost–effectiveness profiles of the two vaccines. Methods: A cost–utility analysis of the HPV vaccine in Ireland was performed using a Markov model. A cohort of screened and vaccinated women was compared with an unvaccinated screened cohort, and both cohorts were followed over their lifetimes. The model looked at uptake of services related to HPV disease in both cohorts. Outcomes were measured in quality adjusted life years (QALYs). Extensive sensitivity analysis was done. Results: For the base case analysis, the model showed that the incremental cost–effectiveness ratio (ICER) for quadrivalent HPV vaccination would be 25 349/QALY and 30 460/QALY for the bivalent vaccine. The ICER for the quadrivalent vaccine ranged from 2877 to 36 548, and for the bivalent from 3399 to 45 237. At current prices, the bivalent vaccine would need to be 22% cheaper than the quadrivalent vaccine in order to have equivalent cost effectiveness. Conclusion: HPV vaccination has the potential to be very cost effective in Ireland. The quadrivalent vaccine is more cost effective than the bivalent vaccine.

Changes in the prevalence of overweight and obesity: some evidence from the Swiss Health Surveys 1992/93 and 2002

Heeb, J.-L. — Wed, 11 Nov 2009 07:18:44 PST

Background: This study examines changes in the prevalence of overweight and obesity in the Swiss general population from 1992/93 to 2002 and their relationship with changes in the distribution and effect of socioeconomic and health behavioural risk factors. Methods: Cross-sectional data from telephone interviews of the non-institutionalized Swiss population aged 19 years and more were obtained from the Swiss Health Study 1992/93 (n = 13798) and 2002 (n = 17677). Binary logistic regression was used to address changes in overweight and obesity, defined as body mass index 25.0 kg/m² or more. The expected prevalence of overweight and obesity under adjusted models was computed to demonstrate the influence of changes in risk factors. Results: The prevalence of overweight and obesity rose from 22.8% in 1992/93 to 30.9% in 2002 among women and from 41.1% to 48.1% among men. In international comparison, the increase in the overall prevalence of overweight and obesity in Switzerland was lower. Contrary to similar studies from other countries, the increase in prevalence was lower among men than that among women, possibly because of an increased protective effect of the observed health behavioural factors among men and unobserved behavioural factors among middle-aged men. Conclusion: Public health action should consider the potential of changing health behavioural factors in subgroups with a higher prevalence of overweight and obesity. Measures that stimulate, for instance, light physical activity or healthy diet, to be supported by changes in the obesogenic environment, should be encouraged. More evidence is needed for gender-specific approaches.

Lead poisoning among internally displaced Roma, Ashkali and Egyptian children in the United Nations-Administered Province of Kosovo

Fri, 06 Nov 2009 06:45:30 PST

Background: This study assessed the association between lead poisoning prevention activities and blood lead levels (BLLs) among children living in lead-contaminated camps for internally displaced persons in the United Nations-Administered Province of Kosovo. Methods: We conducted a population-based study to examine the relationship among geometric mean BLLs in children (i) born before any lead poisoning prevention activities were instituted, (ii) born when specific interim interventions were instituted and (iii) born after relocation and medical therapy were available. The study population consisted of 145 of the 186 children born in the camps between December 1999 and July 2007. Results: Lower mean BLLs were found in children born following implementation of the interventions as compared with the children born before the interventions. However, this decrease in mean BLLs was attenuated in children born into families suspected of informal lead smelting. Conclusion: Despite lower BLLs following interventions, children living in these camps have BLLs that remain unacceptably high. Further efforts are urgently needed to control or eliminate lead exposure in this population. Continued blood lead monitoring of the population is also warranted.

Professional quality improvement project in vaccination services: results of a 5-year survey

Thu, 05 Nov 2009 07:51:35 PST

A voluntary professional quality improvement project involving preventive departments and vaccination centres of an Italian region was carried out through two surveys (in 2001 and in 2006) performed using a quality assessment manual including 12 standards and 157 criteria. After the first survey, a feedback was sent to all participating centres. All six local health authorities participated, as well as all regional vaccination centres, 48 in 2001 and 41 in 2006. The overall adherence rate to the criteria was 56.0% (3258/5820) in 2001 and 74.4% (3784/5085) in 2006. The improvement was obtained without mandatory interventions from regional authorities.

Prevalence and determinants of oral impacts on daily performance: results from a survey among school children in Italy

Bianco, A., Fortunato, L., Nobile, C. G. A., Pavia, M. — Thu, 05 Nov 2009 07:51:35 PST

Background: The use of health status measures to assess health-related quality of life is not widespread. The objectives of this study were to assess the prevalence, characteristics and severity of oral impacts on health using the Child-Oral Impact on Daily Performance (Child-OIDP). Methods: The survey was conducted on 11–16 years old randomly selected students in Catanzaro. Data were collected through a self-administered questionnaire, an interview for the calculation of Child-OIDP and the Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN) and an oral examination. Results: Only 5.5% out of 530 children did not report any dental problem in the previous 3 months and 66.8% had experienced dental impacts according to the Child-OIDP. Sex, fruit intake frequency, mouthwash habits and IOTN AC score assessed by dentist were significant risk factors for dental impacts. Conclusion: Our findings suggest that the measurement of Oral Health-Related Quality of Life (OHRQoL) should be an essential component of oral health surveys.

Knowledge, attitudes and risk of HIV, HBV and HCV infections in hairdressers of Palermo city (South Italy)

Amodio, E., Di Benedetto, M. A., Gennaro, L., Maida, C. M., Romano, N. — Thu, 05 Nov 2009 07:51:34 PST

Background: The hairdressing trade may potentially expose its practitioners and their customers to blood-borne infections. Methods: Knowledge, attitudes and behaviours towards occupational risk of HIV, HBV and HCV infections were evaluated in a cross-sectional survey, conducted during spring 2008, in 105 out of 112 randomly selected hairdressers of Palermo. Participants were queried by answering to an anonymous questionnaire. Results: Most of hairdressers (93.3%) knew that HIV and hepatitis are transmitted through parenteral route and could also be transmitted by razors. The availability of gloves was inadequate, up to 30% of the participants never used them and up to 50% usually reused them. In total, 90 respondents stated to perform a sterilization process of the cutting instruments by ultraviolet light, but only 70 sterilized the articles between two customers and only 34.3% executed a daily disinfection of the hair brushes. Statistical analysis showed that younger age and post-primary school instruction were significantly associated with knowledge and procedures that could prevent transmission of blood-borne virus (P = 0.01 and P < 0.01, respectively). Moreover, only 32 hairdressers agreed to participate to a free specific course on occupational risk offered by the University of Palermo. Conclusion: Although the level of awareness among hairdressers about HIV, hepatitis and risk of transmission was good, there were some unsafe practices that may lead to infections due to blood-borne viruses. The present article highlights the need to improve specific health messages in media campaigns carried out to general population, diffusing more appropriate educational materials for salons and organizing obligatory refresher courses for the hairdressing sector.

Disordered gambling, type of gambling and gambling involvement in the British Gambling Prevalence Survey 2007

LaPlante, D. A., Nelson, S. E., LaBrie, R. A., Shaffer, H. J. — Thu, 05 Nov 2009 07:51:34 PST

Background: The purpose of this study was to examine the relationships between types of gambling and disordered gambling, with and without controlling for gambling involvement (i.e. the number of types of games with which respondents were involved during the past 12 months). Methods: We completed a secondary data analysis of the 2007 British Gambling Prevalence Survey (BGPS), which collected data in England, Scotland and Wales between September 2006 and March 2007. The sample included 9003 residents, aged 16 or older, recruited from 10 144 randomly selected addresses. 5832 households contributed at least one participant. Post-facto weighting to produce a nationally representative sample yielded 8968 observations. The BGPS included four primary types of measures: participation in gambling (during the past 12 months and during the past 7 days), disordered gambling assessments, attitudes toward gambling and descriptive information. Results: Statistically controlling for gambling involvement substantially reduced or eliminated all statistically significant relationships between types of gambling and disordered gambling. Conclusions: Gambling involvement is an important predictor of disordered gambling status. Our analysis indicates that greater gambling involvement better characterizes disordered gambling than does any specific type of gambling.

Are women getting relevant information about mammography screening for an informed consent: a critical appraisal of information brochures used for screening invitation in Germany, Italy, Spain and France

Thu, 05 Nov 2009 07:51:33 PST

Background: The aim was to find out if information brochures on mammography screening in Germany, Italy, Spain and France contain more information to facilitate informed consent than in similar studies carried out over the last few years in Sweden, Canada, USA and the UK, countries with different medical cultures. Methods: We generated a list of essential information items on mammography screening for the purpose of informed consent. We mostly used the same items of information as had been used in previous studies and analysed the information brochures of major national initiatives in Germany and France, and three brochures each from regionalized programmes in Italy and Spain. We cross-checked which of our items were covered in the brochures and if correct numbers were given. Results: We found that the information brochures contained only about half of the information items we defined. Six of the eight brochures mentioned the reduction in breast-cancer fatalities. Four of the eight provided information on false positives, and four of the brochures highlighted the side-effects of radiation. The information on side-effects and risks provided by the brochures was generally of poor quality, and none of them referred to over diagnosis. When numbers were given, they were only indicated in terms of relative numbers. Conclusion: The information brochures currently being used in Germany, Italy, Spain and France are no better than the brochures analysed some years ago. Our results suggest that the providers of mammography screening programmes continue to conceal information from women that is essential when making an informed decision.

Impact of hearing impairment on spousal mental health: the Nord-Trondelag Health Study

Ask, H., Krog, N. H., Tambs, K. — Tue, 03 Nov 2009 05:28:52 PST

Background: Previous studies indicate that hearing loss have negative emotional implications also on spouses of the hearing impaired persons. We sought to assess the relationship between hearing impairment and spousal mental health in the general population. Methods: Pure tone audiometry and questionnaires were administered to the adult population of Nord–Trøndelag County, Norway (1996–97). In the age group between 20 and 44 years, the number of cases with hearing impairment was very low; thus, this age group was excluded from analyses. In total, 8607 couples with women over 44 years and 9530 couples with men over 44 years were identified. Associations between measured and self-reported hearing impairment and spousal self-reported symptoms of anxiety and depression, and subjective well-being were estimated. Stratified by sex and adjusting for several covariates, mental health in spouses of persons with hearing impairment was compared with that of spouses of persons with normal hearing using the general linear model. Results: Audiometrically measured hearing was not significantly associated with spousal mental health. Moderate relations between self-reported hearing and spousal mental health were observed. Conclusion: Contrary to previous results based on self-reported hearing loss, our results based on audiometry did not indicate severe loss of mental health among spouses of persons with impaired hearing.

Mental health problems of Dutch adolescents: the association with adolescents' and their parents' educational level

Havas, J., Bosma, H., Spreeuwenberg, C., Feron, F. J. — Tue, 03 Nov 2009 05:28:52 PST

Background: We studied the hypothesis of socioeconomic equalization regarding adolescents’ mental health problems by examining whether a low educational level of adolescents and their parents shows independent (cumulative) or dependent (including interactive) associations with adolescents’ mental health problems, or whether equalization occurred. Methods: Cross-sectional data were obtained from the preventive Youth Health Care Centre in a relatively deprived Dutch former mining area. Participants were 1861 adolescents aged 13 or 14 years (response rate 71.7%). The self-administered Dutch version of the Strengths and Difficulties Questionnaire (SDQ) was used to identify adolescents’ mental health problems. Multiple logistic regression analyses were used to examine the associations, and linear regression models to check the robustness of the findings. Results: A low educational level of adolescents was strongly related to their mental health problems (OR = 5.37; 95% CI: 3.31–8.70). The initially high odds ratios for adolescents with low-educated parents (OR = 1.72; 95% CI: 1.14–2.59) disappeared after controlling for the adolescents’ own educational level (OR = 1.12; 95% CI: 0.73–1.74). In terms of interactions, no specifically increased odds were found, e.g. for low-educated adolescents with high-educated parents. Conclusion: There was no evidence for socioeconomic equalization regarding adolescents’ mental health problems. Lower educated adolescents had substantially higher odds of having mental health problems, regardless of their parents’ education. The odds may be affected by differences in intelligence and life events. Youth healthcare workers should collaborate closely with schools to intervene in time, particularly among low-educated adolescents. More interventions are probably needed to reduce these major inequities.

Cigarette smoking and occupational noise-induced hearing loss

Mohammadi, S., Mazhari, M. M., Mehrparvar, A. H., Attarchi, M. S. — Tue, 03 Nov 2009 05:28:51 PST

Background: Noise is the most common occupational hazard. Noise-induced hearing loss (NIHL) is a known occupational disease. The economic costs of NIHL have been estimated to be billions of dollars. Besides, cigarette smoking is a common habit worldwide. Methods: In a cross-sectional study, we surveyed the effect of smoking on NIHL in 504 workers in a large wagon manufacturing company exposed to noise >85 dBA. All required data were obtained using direct interview and questionnaires. To determine noise exposure level, we used industrial hygienist's reports of sound level measurements. A qualified audiologist assessed hearing status using standardized audiometric examination. Results: We concluded that the frequency of hearing loss in smokers was higher than non-smokers [based on Model 1: odds ratio (OR) = 9.35, 95% confidence interval (CI) = 5.74–15.22 and P-value < 0.001; and based on Model 2: OR = 9.06, 95% CI = 5.93–13.84 and P-value < 0.001]. Besides, these results were confirmed by logistic regression statistical method. Conclusions: It can be concluded that smoking may accelerate NIHL, but for confirming this opinion, further studies are warranted.

The Singh libel case and 'alternative medicine'

Bonneux, L. — Mon, 02 Nov 2009 00:39:41 PST

Neighbourhood influences on narghile smoking among youth in Beirut

Afifi, R. A., Yeretzian, J. S., Rouhana, A., Nehlawi, M. T., Mack, A. — Mon, 02 Nov 2009 00:39:41 PST

Background: Increasingly neighbourhoods are identified as influencing health. Neighbourhood characteristics have been linked to cigarette use. In Lebanon, the water pipe (narghile) use is most frequent among youth. The current study is aimed at identifying differential neighbourhood influences on smoking narghile among youth. Methods: A quantitative interview was completed with 1294 adolescents, 13–20 years, in three urban disadvantaged neighbourhoods of Beirut. Individual and social factors, suggested by the literature, were associated with smoking narghile. The neighbourhood variation in the influence of these factors was then explored. Bivariate and stratified logistic regression analysis were conducted, neighbourhood being the stratification variable. Results: About 60% of respondents had ever tried a narghile, about one-fifth continued to smoke. Several individual-level and social variables predicted narghile smoking bivariately. The influences on narghile smoking varied by neighbourhood. Neighbourhood differences persisted at the multivariate level. Consistently across neighbourhoods, the influence of friends was the predominant predictor of narghile smoking. In one neighbourhood, maternal smoking was a risk factor for narghile smoking of youth, in another paternal smoking. Being female seems to be protective in two of the three neighbourhoods. Other factors also differentially influence narghile use by neighbourhood. Conclusions: The mechanisms of influence of neighbourhoods on health are not clearly understood, but a transactional paradigm seems most fitting with the results found in this research. Interventions to prevent the narghile smoking should address multiple levels of influence; and must be tailored to the particular aspects of neighbourhoods which are influential in the uptake of this behaviour.

Lifecourse influences on maternal smoking before pregnancy and postpartum among women from ethnic minority groups

Hawkins, S. S., Law, C., Graham, H. — Mon, 02 Nov 2009 00:39:40 PST

Background: Studies using a lifecourse framework to examine women's smoking behaviour have focused on samples of predominantly white women. We examined the contributions of conventional lifecourse factors and women's domestic trajectories to smoking behaviour before pregnancy and postpartum among women from ethnic minority groups. Methods: We analysed data from 2140 mothers from ethnic minority groups in the UK Millennium Cohort Study. Mothers reported their smoking habits (smoking ≥1 cigarette/day) before pregnancy, at 9 months, and 3 years postpartum, along with information used to characterise their social and domestic lifecourse trajectories. Results: In a mutually adjusted model, women were more likely to smoke before pregnancy if, when they were children, their father held a routine/manual occupation [adjusted odds ratio (aOR) 1.67, 95% confidence interval 1.00–2.80] (compared with managerial/professional), they left education at age ≤18 (aOR 2.10, 1.18–3.73) (compared with ≥22), or they were currently in a routine/manual occupation (aOR 1.53, 0.84–2.76) (compared with managerial/professional). Women were also more likely to smoke before pregnancy if they were age 14–19 years at their first birth (aOR 1.92, 1.05–3.50) (compared with age ≥30) or a lone parent (aOR 3.39, 2.18–5.28) (compared with non-lone parents). Similar relationships were apparent for smoking at 9 months and 3 years postpartum. Conclusions: Among women from ethnic minority groups, those on more disadvantaged social and domestic lifecourse trajectories were more likely to smoke before pregnancy and postpartum. These patterns are consistent with studies of predominantly white women, indicating the importance of disadvantage across the lifecourse in all ethnic groups.

Patterns of chronic hepatitis B in Central Italy: a cross-sectional study

Mon, 02 Nov 2009 00:39:38 PST

We investigated the patterns of chronic hepatitis B virus (HBV)-related disease in a large cohort of HBsAg-positive patients, in Central Italy, by collecting a screening form with demographic, clinical and laboratory data. Overall, 737 HBsAg-positive cases were included (70% male; median age 52 years): 30% were inactive HBsAg carriers, 51% had chronic hepatitis B (CHB) and 19% had HBV-related cirrhosis. Patients from non-European Union (EU) countries (n = 65) were significantly younger, had a higher prevalence of HBeAg-positive infection and hepatitis delta virus (HDV) co-infection than patients of Italian origin. Therefore, as immigration from non-EU countries continues to grow, we can expect a change in the landscape of HBV-related disease in our area.

Occupational blood exposure accidents in the Netherlands

Wed, 28 Oct 2009 05:24:41 PDT

Background: To make proper evaluation of prevention policies possible, data on the incidence and associated medical costs of occupational blood exposure accidents in the Netherlands are needed. Methods: Descriptive analysis of blood exposure accidents and risk estimates for occupational groups. Costs of handling accidents were calculated. Results: Each year, an estimated 13 000–15 000 blood exposure accidents are reported in the Netherlands, 95% in occupational settings. Hepatitis B (HBV) vaccination is offered free of charge only to people in risk groups, the seroprevalence of HBV, hepatitis C (HCV) and human immunodeficiency virus (HIV) is low and few infections are related to blood exposure accidents. High-risk accidents occur mainly in hospitals. In nursing homes and home care settings, the majority of the accidents are low-risk. Limited data are available about occurrence of accidents in other occupational groups. Associated medical costs from occupational blood exposure accidents are mainly determined by the initial risk management. Conclusions: Accidents must be managed effectively to prevent infection and reduce anxiety in injured employees. While strategies to reduce HCV and HIV infection should be primarily aimed at reducing the occurrence of high-risk accidents, vaccination can prevent HBV infection and cut the costs of handling low-risk accidents. The implementation of vaccination strategies, safe working policies and the proper use of safe equipment should be monitored better.

Identification and management of psychosocial problems among toddlers by preventive child health care professionals

Klein Velderman, M., Crone, M. R., Wiefferink, C. H., Reijneveld, S. A. — Sun, 25 Oct 2009 21:30:29 PDT

Background: Objective of this study was to assess the degree to which preventive child health professionals (CHPs) identify and act upon psychosocial problems among young toddlers in the general population and to determine the concordance with parent-reported behavioural and emotional problems. Also, associations of psychosocial problems with socio-demographic factors, and (mental) health history of the toddlers were studied. Methods: CHPs examined a national sample of children aged 14 months and interviewed their parents during the routine health assessments. Identification of and action upon psychosocial problems by CHPs were registered. The Infant-Toddler Social and Emotional Assessment (ITSEA) was completed by the parents. Data were available on 701 Dutch 14-month-old toddlers. Results: In 7.6% of all toddlers, CHPs identified one or more psychosocial problems. Forty-seven percent of identified children were referred to another professional or received follow-up. Identification of psychosocial problems and subsequent action were 3–16 times more likely in children with clinical parent-reported problem behaviour according to the Dutch adapted version of the ITSEA. Also, past or current professional care for psychosocial problems was associated with the CHPs’ identification or action. Associations with socio-demographic variables were weak. Conclusion: The CHPs frequently identify psychosocial problems in 14-month-old toddlers, but they miss many cases of parent-reported problems as measured by a clinical ITSEA score. This general population study shows substantial room for improvement in the early identification of psychosocial problems in young toddlers.

Prevention and social constructivism

Vlassov, V. V. — Sun, 25 Oct 2009 21:30:28 PDT

Employment trajectories and changes in sense of coherence

Thu, 22 Oct 2009 07:53:51 PDT

Background: Knowledge of the associations between labour market position and sense of coherence (SOC) comes mainly from cross-sectional studies. We investigated whether change in employment status is associated with change in SOC and whether such an association varies when young (<30 years) and older employees are compared. Methods: Data were derived from two studies: a cohort of initially non-permanent employees (n = 1898) was followed up for four years, and a cohort representing the national workforce (n = 9623) was followed up for five years. Labour market position at baseline and at follow-up (permanent/fixed-term job/unemployed) was used to locate the participants into six or nine different employment trajectories depending on the cohort. SOC was measured with a 13-item questionnaire. Associations of the employment trajectories with changes in SOC were analysed with general linear models. Results: In both cohorts the change of SOC was significantly associated with type of employment trajectory. The results supported the hypothesis of more favourable development of SOC among those whose trajectories were directed upward: the associations of poor SOC with unemployment are indisputable, whereas the effects of fixed-term employment seem to be neutral or even positive. The analysis by age revealed that the effects of employment trajectory on SOC are particularly strong among individuals aged below 30 years. Conclusion: This longitudinal study provided evidence for the interpretation that stabilisation of SOC associates with stabilisation of the labour market position. Moreover, the fluctuations of SOC seem to depend on the type of trajectory throughout adult life.

The impact of widowhood on Irish mortality due to suicide and accidents

Corcoran, P. — Tue, 20 Oct 2009 07:01:08 PDT

The impact of widowhood on suicide and accident mortality in Ireland was investigated using Poisson regression analysis applied to routine data relating to all 10 561 suicidal and accidental deaths of married or widowed persons aged at least 35 years in Ireland during 1986–2005. Mortality rates were almost always higher among the widowed and often by a 2-fold, statistically significant difference. The excess mortality was equivalent to 2083 or 57.6% of all suicidal or accidental deaths of widowed persons in 1986–2005. Routine contact with recently widowed persons by public health professionals may be warranted with a view to reducing their excess mortality.

The epidemiology of domestic injurious falls in a community dwelling elderly population: an outgrowing economic burden

Tue, 20 Oct 2009 07:01:07 PDT

In Italy, more than 3 million people annually sustain a domestic injury; the elderly experience it the most. From a healthcare perspective, elderly falls are a major clinical issue with an outgrowing socioeconomic burden. The aim of the study was to evaluate the epidemiology of injurious falls in a community dwelling population, admitted to the emergency room (ER) because of a domestic injury, to assess the socioeconomic burden. Seventy-four hospitalized patients among 227 were examined. Falls represented the main cause of admittance to the ER; the average cost for fall-related hospitalization was of 5479.09.

Interrelationships between education, occupational class, income and sickness absence

Piha, K., Laaksonen, M., Martikainen, P., Rahkonen, O., Lahelma, E. — Tue, 20 Oct 2009 07:01:05 PDT

Background: Socio-economic position measures, such as education, occupational class and income, are well-known determinants of health. However, previous studies have not paid attention to mutual interrelationships between these socio-economic position measures and medically confirmed sickness absence. Methods: The study is a register-based study. The participants were municipal employees of the City of Helsinki aged 25–59 years in 2003. There were 21 599 women and 5841 men participants. Three socio-economic position measures were used, namely three-level education, four-level occupational class and gross individual income quartiles. Main outcome measure was medically confirmed sickness absence spells of 4 days or longer. Inequality indices were calculated using Poisson regression analysis. Results: High education, occupational class and individual income were all consistently associated with lower sickness absence rates among both women and men. After mutual adjustment, education and occupational class remained independent determinants of sickness absence. The association of individual income with sickness absence was practically explained by temporally preceding education and occupational class. Conclusions: Our results indicate that education and occupational class—rather than income—are strong determinants of sickness absence. Education, occupational class and income are complementary socio-economic position measures. To better inform sickness absence policy, future studies should aim to establish whether the observed socio-economic differences reflect broader differences in ill-health, lifestyle and working conditions.

Organizational capacity for chronic disease prevention: A survey of Canadian public health organizations

Hanusaik, N., O'Loughlin, J. L, Kishchuk, N., Paradis, G., Cameron, R. — Tue, 20 Oct 2009 07:01:03 PDT

Background: There are no national data on levels of organizational capacity within the Canadian public health system to reduce the burden of chronic disease. Methods: Cross-sectional data were collected in a national survey (October 2004 to April 2005) of all 216 national, provincial and regional-level organizations engaged in chronic disease prevention through primary prevention or healthy lifestyle promotion. Levels of organizational capacity (defined as skills and resources to implement chronic disease prevention programmes), potential determinants of organizational capacity and involvement in chronic disease prevention programming were compared in western, central and eastern Canada and across three types of organizations (formal public health organizations, non-governmental organizations and grouped organizations). Results: Forty percent of organizations were located in Central Canada. Approximately 50% were formal public health organizations. Levels of skill and involvement were highest for activities that addressed tobacco control and healthy eating; lowest for stress management, social determinants of health and programme evaluation. The few notable differences in skill levels by provincial grouping favoured Central Canada. Resource adequacy was rated low across the country; but was lowest in eastern Canada and among formal public health organizations. Determinants of organizational capacity (organizational supports and partnerships) were highest in central Canada and among grouped organizations. Conclusion: These data provide an evidence base to identify strengths and gaps in organizational capacity and involvement in chronic disease prevention programming in the organizations that comprise the Canadian public health system.

Do academic competencies relate to 'real life' public health practice? A report from two exploratory workshops

Whittaker, P. J., Pegorie, M., Read, D., Birt, C. A., Foldspang, A. — Mon, 12 Oct 2009 00:32:58 PDT

Comparing salivary cotinine concentration in non-smokers from the general population and hospitality workers in Spain

Mon, 12 Oct 2009 00:32:58 PDT

Background: The objective was to compare the pattern of exposure to second-hand smoke (SHS) among non-smokers in the general population and in hospitality workers. Methods: We used the adult (16–64 years) non-smokers of two independent studies (general population and hospitality workers) in Spain. We assessed the exposure to SHS by means of questionnaire and salivary cotinine concentration. Results: The salivary cotinine concentration by sex, age, educational level, day of week of saliva collection, and exposure to SHS were always higher in hospitality workers than in the general population. Conclusion: Our results indicated that non-smoker hospitality workers have higher levels of exposure to SHS than general population.

Individual health services and the denial of health services in German medical practices: prevalence, regional differences and socio-demographic determinants

Richter, S., Rehder, H., Raspe, H. — Mon, 12 Oct 2009 00:32:57 PDT

Background: Internationally, in many healthcare systems financial pressure has led to the implementation of co-payments, private medical (extra) services and rationing. In Germany, members of statutory health insurances (SHIs) increasingly report the denial of medical services and the offer/demand of privately financed supplementary health services individual health services, (IHSs) in medical practices. The public discussion on both denial and IHSs is chequered, mainly critical, partly polemic. The present study aims to operationalize IHSs and denial and investigates their occurrence, socio-demographic determinants within two regional populations. Methods: Two postal surveys were conducted in 4898 German inhabitants of Lübeck (Northern Germany) and Freiburg (Southern Germany), aged 20–79 years. The survey focused on experiences with IHSs and denial of health services in medical practices among members of SHIs. Results: In all members of SHIs that had consulted a physician during the past 12 months (n =1899), the one-year-prevalence of IHSs and denial of medical services were 41.7 and 20.5%. About 40% were offered a denied medical service as an IHS later. Conclusion: The study presents population-based, quantitative data on IHSs and denial of medical services in German practices. The results partly confirm former findings on the occurrence of IHSs. Contrary to other studies, socio-demographics seemed to play a minor role in the offer/demand of IHSs.

Living longer, working longer? The impact of subjective life expectancy on retirement intentions and behaviour

van Solinge, H., Henkens, K. — Mon, 12 Oct 2009 00:32:56 PDT

Background: Virtually all Western countries are seeking to bring retirement ages more in line with increases in longevity. The central question in this article is whether individuals choose a retirement age that fits their life expectancy. This would be ideal from a public policy perspective. The present study aims to test empirically whether retirement planning varies with expectations of survival among a sample of older employees in the Netherlands. Two questions are addressed: (i) what are older employees’ expectations of their remaining lifetime, and what factors influence this subjective life expectancy? (ii) Are individuals who perceive longer life horizons (high subjective life expectancy) more inclined to retire later than people who expect to live shorter? Methods: Using data from a panel study on retirement behaviour in the Netherlands (N = 1621 older employees aged 50–60 years), regression and survival models are estimated to examine the effect of subjective life expectancy on retirement planning and behaviour. Results: The results indicate that subjective life expectancy is a factor that is taken into account in retirement decision making, at least as far as retirement intentions are concerned. Older employees with longer time horizons have a preference for later retirement. When it comes to actual behaviour, however, time horizon does not appear to play a role. Conclusion: The results suggest that particularly employees with a high perceived life expectancy and an intention to work longer do not succeed in carrying their intentions into effect.

Dawson A (ed.). The philosophy of public health.: Does a discipline of philosophy of public health exist?

Foldspang, A. — Wed, 07 Oct 2009 06:59:33 PDT

Soft drink consumption in adolescence: associations with food-related lifestyles and family rules in Belgium Flanders and the Veneto Region of Italy

Verzeletti, C., Maes, L., Santinello, M., Vereecken, C. A. — Mon, 05 Oct 2009 08:47:11 PDT

Background: The number of studies among adolescents that focus on several lifestyle behaviours and family rules as determinant of soft drink consumption are limited. The aim of this study is to investigate the associations between daily soft drink consumption, food-related lifestyles and family rules in adolescence. Methods: The data are part of the Health Behavior in School-aged Children (HBSC) cross-sectional survey. Adolescents between 11 and 16 years of age were included, resulting in a final sample of 14 407 adolescents representative of Belgium Flanders (N = 7904) and the Veneto Region of Italy (N = 6503). Binary logistic regression was used to test the association between soft drink consumption and food-related lifestyle (breakfast habits, family meals, snacking, meals in fast food restaurants and television viewing) and family rules (restriction and obligation rules) by region and gender. Results: Each independent variable is significantly associated with daily soft drink consumption, despite some sub-groups exceptions. When we entered all the variables into the same statistical model, the positive association with daily soft drink consumption remained significant for frequent meals in fast food restaurants, television variables and low restriction rules. Breakfast during weekdays, evening meal with parents and obligation rules remained significant only in specific sub-groups and not the entire sample. Finally, the association with breakfast with parents and during the weekend disappeared. Conclusion: These findings suggest that considering gender and cultural differences, involving parents and limiting adolescents’ exposure to television would increase the effectiveness of interventions aimed to reduce soft drink consumption in adolescence.

Influence of cannabis use trajectories, grade repetition and family background on the school-dropout rate at the age of 17 years in France

Legleye, S., Obradovic, I., Janssen, E., Spilka, S., Le Nezet, O., Beck, F. — Mon, 05 Oct 2009 08:47:10 PDT

Background: 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. Methods: 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. Results: The main factors associated with dropout were a low family socio-economic status, early grade repetition, single-parent families and daily tobacco smoking (ORa ≥ 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 ≥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. Conclusion: 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.

Cigarette pack design and perceptions of risk among UK adults and youth

Hammond, D., Dockrell, M., Arnott, D., Lee, A., McNeill, A. — Mon, 05 Oct 2009 08:47:09 PDT

Background: It is illegal in the EU for tobacco packaging to suggest that some cigarettes are safer than others. This study examined consumer perceptions of cigarette packs in the UK, including perceptions of ‘plain packaging’, in which colour and other design elements are removed, whilst retaining the brand name. Methods: 516 adult smokers and 806 youth aged 11–17 participated in an online survey. Participants were asked to compare pairs of cigarette packs on five measures: taste, tar delivery, health risk, attractiveness and either ease of quitting (adult smokers) or brand they would choose if trying smoking (youth). Results: Adults and youth were significantly more likely to rate packs with the terms ‘smooth’, ‘silver’ and ‘gold’ as lower tar, lower health risk and either easier to quit smoking (adults) or their choice of pack if trying smoking (youth). For example, more than half of adults and youth reported that brands labelled as ‘smooth’ were less harmful compared with the ‘regular’ variety. The colour of packs was also associated with perceptions of risk and brand appeal: compared with Marlboro packs with a red logo, Marlboro packs with a gold logo were rated as lower health risk by 53% and easier to quit by 31% of adult smokers. Plain packs significantly reduced false beliefs about health risk and ease of quitting, and were rated as significantly less attractive and appealing to youth for trying smoking. Conclusions: Current regulations have failed to remove potentially misleading information from tobacco packaging. Removing colours from packs (plain packaging), as well as terms such as ‘smooth’ ‘gold’ and ‘silver’ would significantly reduce false beliefs and increase compliance with existing legislation.

Swine-origin influenza virus A(H1N1)v: lessons learnt from the early phase of the epidemic

Rezza, G. — Wed, 30 Sep 2009 06:35:39 PDT

Influence of smoking and alcohol consumption on admissions and duration of hospitalization

Hvidtfeldt, U. A., Rasmussen, S., Gronbaek, M., Becker, U., Tolstrup, J. S. — Wed, 30 Sep 2009 06:35:38 PDT

Background: Previous studies have linked smoking and alcohol consumption to a considerable disease burden and large healthcare expenditures. However, findings from studies based on individual level data are sparse and inconclusive. Our objective was to assess the association between alcohol consumption, smoking and patterns of hospitalization, defined as admission and duration of hospitalization. Methods: The study was based on 12 698 men and women, aged 20 years or more, enrolled in the Copenhagen City Heart Study. We related smoking and alcohol to hospital admission from any cause, smoking- and alcohol-related diseases and duration of hospitalization in a two-part random effects model. Results: Smoking status was strongly associated with admission and duration of hospitalization. For smoking-related admissions, odds ratios (OR) of 2.77 (95% CI 2.13–3.59) in men and 6.30 (95% CI 4.80–8.26) in women were observed among smokers of >20 g/day compared to never-smokers. For any admission (excl. smoking-related causes), corresponding ORs were 1.32 (95% CI 1.15–1.51) and 1.80 (95% CI 1.58–2.06), respectively. In men, a U-shaped association between alcohol consumption and risk of admission was found, both regarding any admission and admissions due to alcohol-related diseases. Alcohol was associated with alcohol-related admissions in women but not with duration of hospitalization. Conclusions: Smoking was associated with increased risk of hospital admission and duration of hospitalization. A U-shaped relation was observed for alcohol consumption and risk of hospitalization in men, but no effect on duration was observed. In women, however, alcohol consumption was only vaguely associated with admission and duration of hospitalization.

Prevalence of tobacco smoking in teachers following anti-smoking policies: results from two French surveys (1999 and 2005)

Wed, 30 Sep 2009 06:35:35 PDT

Background: French public health policies aimed at reducing smoking were reinforced in France between 1999 and 2004 to decrease tobacco consumption. The consequences of these policies are of particular interest to teachers who play a role model for young people. Depression and alcohol problems were particularly studied as they may influence smoking behaviour. Methods: Two large cross-sectional health surveys conducted in 1999 (N = 2931) and 2005 (N = 3702) included teachers, aged 20–59 years. Smoking status, socio-demographic characteristics, history of depressive episode in the previous year and problems with alcohol were collected using self-administered postal questionnaires. Results: From 1999 to 2005, the prevalence of smoking decreased significantly from 25.7 to 18.2% for men (P < 0.001), from 20.0 to 16.5% (P < 0.001) for women; and the proportion of never-smokers increased. In smokers, the number of cigarettes consumed per day decreased significantly. Multivariate analysis revealed a significant decrease of the risk of being a smoker in 2005 compared with 1999 [odds ratio (OR) = 0.68 for men; OR = 0.78 for women]. Risk factors of smoking were: men aged 20–34 years (OR = 1.81), CAGE score ≥2, (OR = 1.95 for men, 2.12 for women) history of a major depressive episode in the previous 12 months (OR = 1.46 for men, 1.44 for women). Conclusion: Anti-smoking policies resulted in a decrease of teachers’ tobacco consumption between 1999 and 2005. However, people with more difficulties in quitting smoking, in particular people with depressive episodes or problems with alcohol, might benefit from comprehensive programmes, including training of health professionals.

Media running amok after school shooting in Winnenden, Germany!

Neuner, T., Hubner-Liebermann, B., Hajak, G., Hausner, H. — Fri, 18 Sep 2009 08:33:32 PDT

Intimate partner violence: last year prevalence and association with socio-economic factors among women in Madrid, Spain

Fri, 18 Sep 2009 08:33:32 PDT

Background: Intimate partner violence (IPV) is a public health problem with significant consequences on women's health. This study estimates the prevalence of intimate partner violence by type among Madrid's female population and assesses the association with socio-economic variables. Methods: We conducted a cross-sectional study in 2004, 2136 women aged 18–70 years, living in the Madrid region with a partner or who had been in contact with an ex-partner in the previous year, were interviewed by telephone. The questionnaire used to measure past-year intimate partner violence, consisted of a Spanish translation of the psychological and sexual violence module of the French National Survey on Violence against Women, and the physical violence module of the Conflict Tactics Scale-1. To assess the association with socio-economic factors, logistic regression models were fitted. Results: About 10.1% [confidence interval (CI) 8.9–11.5] of the women had suffered some type of IPV in the previous year. 8.6% (CI 7.4–9.8) experienced psychological violence, 2.4% (CI 1.8–3.1) physical violence and 1.1% (CI 0.68–1.6) sexual violence; the prevalence of psychological-only violence (non-physical/non-sexual) was 6.9% (CI 5.8–8.0). Factors associated with psychological-only violence were divorced or separated status and Group III (clerical workers; supervisors of manual workers) or V (unskilled manual workers) occupation. Unemployment and divorced or separated status were associated with physical violence. Conclusions: Spanish women in our study, experienced past year partner violence at a similar level as in other industrialized countries. Unemployment and low occupational status are associated with physical and psychological-only violence, respectively.

Increased sexually transmitted infection incidence in a low risk population: Identifying the risk factors

Shiely, F., Horgan, M., Hayes, K. — Fri, 18 Sep 2009 08:33:31 PDT

Background: Between 1994 and 2006, the incidence of sexually transmitted infections (STIs) in Ireland has increased by over 300%. Recent literature would suggest that this figure is an underestimation of the true scale of infection. Our objective was to determine the risk factors associated with STI diagnosis in a population with a rapidly increasing STI incidence. Methods: Using diagnostic, demographic and behavioural information from three STI clinics (January 1999 to December 2006), multivariable logistic regression models were used to identify risk factors associated with STI diagnosis. Results: Age, smoking and inconsistent condom use are the dominant risk factors. Males aged 20–24 years and females aged <20 years being at greatest risk of STI acquisition. Having three or more partners was not associated with an elevated risk of STI diagnosis. At univariate level, homosexuals and bisexuals have a decreased risk of STI acquisition compared with heterosexuals. Rate of consistent condom use was low ≤13.3%. Conclusions: Age, condom use and number of sexual partners are important risk factors for STI diagnosis. Contrary to international STI literature, having multiple sexual partners does not increase STI incidence. Age specific behavioural interventions that target increased condom use may be effective in reducing STIs in Ireland. At policy level, a reduction in the taxation on condoms from 13.5 to 5% is needed to lower the prohibitive cost and increase their use.

Adolescents' health-related dietary patterns by parental socio-economic position, The Nord-Trondelag Health Study (HUNT)

Nilsen, S. M., Krokstad, S., Holmen, T. L., Westin, S. — Fri, 18 Sep 2009 08:33:31 PDT

Background: Nutrition is among the important determinants of diseases, and the social patterning of early eating habits may offer keys to prevention. We studied associations between selected indicators of adolescents’ health-related dietary habits (daily intake of candy, soft drinks, fruit and vegetables) and parental socio-economic position (education, social class and income). Methods: The material consisted of participants in the adolescent part (Young-HUNT) of the Nord-Trøndelag Health Study during the period 1995–97, 8817 girls and boys aged 13–19 years (89% of all students in junior high schools and high schools in a Norwegian county). Data on parental socio-economic position was available from the adult part of HUNT and Statistics Norway. Cross-sectional data analyses were performed using cross-tables and binary logistic regression. Results: Of the indicators of socio-economic position used, the parent's educational level, in particular the mother's education, showed the highest impact on adolescents’ health-related dietary habits. Girls with the least educated mothers had a prevalence odds ratio of 2.5 (1.8–3.3) for drinking soft drinks daily and 0.6 (0.5–0.8) for eating vegetables daily as compared to girls with the most educated mothers. The corresponding numbers for boys were 1.9 (1.5–2.4) and 0.6 (0.5–0.8). Parental social class also showed gradients in adolescents’ health-related dietary habits, but there was virtually no gradient by income. Conclusion: Higher levels of parental education, in particular the mother's education, are clearly associated with healthier dietary habits among adolescents. This social patterning should be recognized in public health interventions.

Living longer and feeling better: healthy lifestyle, self-rated health, obesity and depression in Ireland

Fri, 18 Sep 2009 08:33:30 PDT

Background: The combination of four protective lifestyle behaviours (being physically active, a non-smoker, a moderate alcohol consumer and having adequate fruit and vegetable intake) has been estimated to increase life expectancy by 14 years. However, the effect of adopting these lifestyle behaviours on general health, obesity and mental health is less defined. We examined the combined effect of these behaviours on self-rated health, overweight/obesity and depression. Methods: Using data from the Survey of Lifestyle Attitudes and Nutrition (SLÁN) 2007 (), a protective lifestyle behaviour (PLB) score was constructed for 10 364 men and women (>18 years), and representative of the Republic of Ireland adult population (response rate 62%). Respondents scored a maximum of four points, one point each for being physically active, consuming five or more fruit and vegetable servings daily, a non-smoker and a moderate drinker. Results: One-fifth of respondents (20%) adopted four PLBs, 35% adopted three, 29% two, 13% one and 2% adopted none. Compared to those with zero PLBs, those with four were seven times more likely to rate their general health as excellent/very good [OR 6.8 95% CI (3.64–12.82)] and four times more likely to have better mental health [OR 4.4 95% CI (2.34–8.22)]. Conclusions: Adoption of core protective lifestyle factors known to increase life expectancy is associated with positive self-rated health, healthier weight and better mental health. These lifestyles have the potential to add quality and quantity to life.

Response to 'too early to stop immigrant vaccination programmes'

Mon, 14 Sep 2009 08:23:36 PDT

Issues in estimating smoking attributable mortality in Israel

Ginsberg, G. M., Rosenberg, E., Rosen, L. — Thu, 10 Sep 2009 08:24:32 PDT

Background: The US Centres for Disease Control provides a widely used online user-friendly computational program, called SAMMEC (Smoking Attributable Mortality, Morbidity and Economic Costs) to produce estimates of tobacco-related mortality. However, the SAMMEC tool loses accuracy because it lacks flexibility in deciding which diseases enter into the calculations, has estimates of relative risk (RR) attributable to smoking based on old studies, and does not allow for the latency period that occurs between initial exposure and mortality. Methods: Smoking attributable mortality (SAM) due to active smoking in Israel was estimated with the approach used by SAMMEC taking into account past and present smoking prevalence (lag-times) as well as using new and expanded disease categories. Results: Around 50.3% of the increase from the un-lagged SAM estimate of 3859 deaths to the final SAM estimate of 8664 deaths in 2003 is attributable to the introduction of lag times. More robust estimates of risk accounted for a further 29.6% of the increase. While 21.2% is attributable to the inclusion of additional disease categories, only 1.5% was attributable to the widening of existing diseases categories. Conclusion: This difference in estimates is attributable to expansion of the list of diseases included, updating the estimates of RR for smoking-attributable death, and the use of smoking prevalence from previous years to more accurately reflect the effect of tobacco use on disease occurrence. There is a need to establish an ‘authority’ to implement a multi-faceted intervention strategy to decrease the considerable burden from smoking in Israel.

HIV transmission risk behaviours among HIV seropositive sexually transmitted infection clinic patients in Cape Town, South Africa

Kalichman, S. C., Simbayi, L. C., Cain, D. — Wed, 02 Sep 2009 08:43:53 PDT

Background: South Africa has one of the fastest growing HIV epidemics in the world and new infections may often result from people who have tested HIV positive. This study examined the sexual practices and risk behaviours of men and women living with HIV/AIDS being treated for a co-occurring sexually transmitted infection (STI). Methods: A sample of men and women receiving services at three South African STI clinics completed a computer administered behavioural assessment. Results: Among the 218 HIV positive STI clinic patients, 34 (16%) had engaged in unprotected vaginal or anal intercourse with uninfected or unknown HIV status sex partners in the previous month. A multivariate logistic regression indicated that unprotected sex with uninfected or unknown HIV status partners was independently associated with older age, female gender, alcohol use, and other drug use, and drug use in sexual contexts. Conclusions: People living with HIV/AIDS who contract co-occurring STI are at significant risk for transmitting HIV to uninfected partners. Positive prevention interventions are urgently needed for South Africa.

Nursing home policies regarding advance care planning in Flanders, Belgium

De Gendt, C., Bilsen, J., Vander Stichele, R., Deliens, L. — Wed, 02 Sep 2009 08:43:52 PDT

Background: The aim of this study is to discover how many nursing homes (NHs) in Flanders (Belgium) have policies on advance care planning (ACP) and their content regarding different medical end-of-life decisions. Methods: A structured mail questionnaire was sent to the NH administrators of all 594 NHs in Flanders (Belgium) at the end of 2006. The questionnaire asked about the existence, timing of implementation and content of ACP policy documents (guidelines and patient-specific planning forms), and on NH characteristics related to end-of-life care. Results: The response rate was 58.1%. The development of ACP policy documents began in 1989 with major increases in implementation taking place from 2000. In 2006, ACP policy documents were available in 95.1% of NHs. Most of these NHs had ACP guidelines as well as ACP patient-specific planning forms. Almost all patient-specific planning forms included anticipatory do-not-hospitalize (90.0%) and do-not-resuscitate decisions (83.2%). Anticipatory decisions about terminal sedation (29.2%) and euthanasia (19.7%) were mentioned less often and these decisions were not permitted to be made in all NHs. One out of three NHs had policies on the appointment of a patient's representative. Conclusion: By the end of 2006, almost all NHs in Flanders (Belgium) had an ACP policy. The implementation of ACP policies in Flemish NHs lagged behind other countries, but has developed rapidly since 2000. However, some NHs appear to ban some end-of-life options which are actually legal in Belgium. Further research is needed to investigate whether ACP policies have much impact on the quality of end-of-life care in NHs.

Use of dietary supplements and anabolic-androgenic steroids among Finnish adolescents in 1991-2005

Mattila, V. M., Parkkari, J., Laakso, L., Pihlajamaki, H., Rimpela, A. — Wed, 26 Aug 2009 07:59:13 PDT

Background: The aim of the study was to describe the prevalence, trends and associated factors of dietary supplements (DS) and anabolic-androgenic steroids (AAS) use among Finnish adolescents. Methods: The sample comprised 30 511 adolescents aged 12–18 years, of which 22 519 (74%) answered a questionnaire. We also studied associations between 14 socioeconomic, health and health behavioural variables and DS and AAS use by logistic regression. Results: The proportion of respondents using DS was 45% during the past year and it increased linearly by age. Vitamins (37%) and herbal products (13%) were the most common DSs. In 1991, 9% of the boys aged 16–18 years reported protein use, while the frequency in 2005 was 17% (P < 0.001). AAS use was uncommon; only 53 boys (0.5%) and 20 girls (0.2%) reported AAS use. The strongest factors associated with DS use in multivariate model were physical exercise outside sports clubs (OR 1.9; 95% CI: 1.6–2.2), and in sports clubs (OR 1.7; 95% CI: 1.5–1.9). Recurrent drunkenness (OR 5.8; 95% CI: 1.5–21.6) and peer drug use in boys (OR 2.1; 95% CI: 1.2–3.7) were the risk factors for AAS use, whereas physical exercise outside sports clubs (OR 0.3; 95% CI: 0.1–0.5) was a protecting factor. Conclusions: Although the overall use of DS remained at the same level during the study period, there was a slight trend towards increasing use of vitamin and protein supplements. DS use is associated with frequent sports participation and poorer than average health, while AAS use is associated with health-compromising behaviours.

Reduction of smoking in Dutch adolescents over the past decade and its health gains: a repeated cross-sectional study

Tue, 25 Aug 2009 06:16:45 PDT

Background: Smoking is the main preventable lifestyle-related risk factor threatening human health. In this study, time trends in smoking behaviour between 1996 and 2005 among adolescents enrolled in secondary school were assessed. Methods: In 1996, 2001 and 2005, a survey was conducted in the south-eastern region of the Netherlands. All students in second and fourth year of secondary education (1996: n = 20 000; 2001: n = 27 500; 2005: n = 24 000) were asked to complete a questionnaire about their smoking behaviour. A simulation model was used to estimate lifetime health gains related to the observed trends. Results: In 1996, 2001 and 2005, the number of questionnaires analysed were 13 554 (68%), 20 767 (76%) and 17 896 (75%), respectively. The results show a decrease in ‘ever smoking’ as well as ‘current smoking’ between 1996 and 2005. Among second year high school students, current smoking prevalence decreased from 22.2% in 1996 to 8.0% in 2005 (P_trend < 0.001). Among fourth year students, current smoking declined from 37.5% in 1996 to 22c0% in 2005 (P_trend < 0.001). Time trends were not influenced by gender or educational level. Model projections show that if these students not take up smoking later in life, 11 500 new cases of COPD, 3400 new cases of lung cancer and 1800 new cases of myocardial infarction could be prevented for the Dutch 13-year-olds. Conclusion: This study found that, in the past decade, smoking prevalence among adolescents has declined by almost 50%, potentially resulting in a considerable reduction in new cases of COPD or lung cancer.

Fatigue and chronic fatigue syndrome-like complaints in the general population

Tue, 18 Aug 2009 09:22:21 PDT

Background: Most knowledge on chronic fatigue (CF) and chronic fatigue syndrome (CFS) is based on clinical studies, not representative of the general population. This study aimed to assess the prevalence of fatigue in an adult general population and to identify associations with lifestyle factors. Methods: Total 22 500 residents of Nijmegen were selected at random and interviewed by questionnaire. Data on 9062 respondents (43% response) were analysed, taken into account age, gender and concomitant disease. Subjects were classified into four groups: not fatigued (NF, reference group), short-term fatigue (SF, <6 months), chronic fatigue (CF, ≥6 months) and CFS-like fatigue (in accordance with the Center for Disease Control criteria for CFS, without clinical confirmation). Results: Our study population showed the following breakdown: NF 64.4% (95% CI 63.6–65.6%), SF 4.9% (95% CI 4.5–5.4%), CF 30.5% (95% CI 29.5–31.4%) and CFS-like fatigue 1.0% (95% CI 0.8–1.2%). Compared with the NF group, more of the CFS respondents were female [odds ratio (OR) = 1.9], obese (OR = 4.1), using analgesics (OR = 7.8), had a low alcohol intake (OR = 0.4), were eating less healthy food (OR = 0.5) and were physically less active (OR = 0.1). These associations largely applied to the SF and CF group. The fatigue could have been due to a concomitant disease in 34 and 55.5% of the SF and CF cases, respectively. Conclusion: The prevalence of CF in the general population appears to be much higher than previously indicated. Even with strict criteria for CFS, it is estimated that ~1% of the adult population experiences this condition. Interestingly, a large part of this group remains unrecognized by the general practitioner. A striking similarity in lifestyle pattern between SF, CF and CFS calls for further research.

Annual variations in indoor climate in the homes of elderly persons living in Dublin, Ireland and Tromso, Norway

Bokenes, L., Mercer, J. B., MacEvilly, S., Andrews, J. F., Bolle, R. — Tue, 18 Aug 2009 09:22:20 PDT

School health promotion: organization of services and roles of health professionals in seven European countries

Mon, 17 Aug 2009 23:15:26 PDT

Background: This comparative study is intended to provide a better understanding of how health promotion services are organized in school settings in Europe and to show how health professionals involved outside or within the school setting help to improve young people's health. Methods: This study was based on an analysis of school health policies and the organization of school health services, where these existed, as well as on interviews with health and education professionals. The countries concerned were Belgium (French-speaking community), Denmark, France, Spain (Catalonia), Switzerland (Jura), Poland and Portugal. Results: Although the provision of health services for children and adolescents varied considerably, the health services available were very similar in each of the countries. The emphasis put on particular aspects of these services varied depending on the political and institutional culture in each country. Three different types of school health service provision were identified: community-based, school-based or health needs-focused. Conclusion: All countries had health education and health promotion services but the provision of these services varied considerably from country to country. They were provided either by a specific category of professionals (health personnel or teachers) or considered to be the responsibility of the educational community as a whole.

Indices of Multiple Deprivation predict breastfeeding duration in England and Wales

Brown, A. E., Raynor, P., Benton, D., Lee, M. D. — Mon, 17 Aug 2009 23:15:25 PDT

Background: To investigate the association between breastfeeding duration and socio-economic status as measured by the English and Welsh Indices of Multiple Deprivation (IMD). Methods: Total 216 multiparous women whose youngest or only child was between 6 and 24 months completed a retrospective questionnaire study of infant feeding between birth and 26 weeks. Measurements included breast-feeding history; socio-economic demography and IMD. Results: Breastfeeding duration was associated with levels of multiple deprivation in both English and Welsh samples. Deprivation level and breastfeeding duration were associated with traditional indicators of socio-economic status. When considered in combination with other socio-economic indicators of breastfeeding duration, the deprivation level remained a strong predictor of breastfeeding duration over and above other socio-economic measures. Conclusions: Deprivation, as assessed by the IMD is predictive of breastfeeding duration. Postcode and thus deprivation level can be used as a non-intrusive way to identify women most at risk of low breastfeeding rates. Service provision can be targeted directly at women in areas recognized at being high in deprivation.

Just add a pinch of salt!--current directions for the use of salt in recipes in Australian magazines

Webster, J., Dunford, E., Barzi, F., Neal, B. — Fri, 07 Aug 2009 06:59:08 PDT

Background: Australians currently consume too much salt causing adverse consequences for health. The media play an important role in the provision of nutrition advice to consumers. Previous research shows that many foods advertized in consumer magazines are high in salt, but little research has examined magazine recipes in this context. The aim of this project was to summarize directions for salt use in recipes in leading Australian magazines. Methods: In August 2007 and 2008, the top 10 magazines by circulation that included at least five recipes, were examined. Standardized information was collected about directions for salt use in recipes. Results: Three hundred and thirty recipes were identified in 2007 and 417 in 2008. About 68% of recipes included high-salt ingredients, 37% instructed to season with salt, 10% instructed to add a specific quantity of salt and 15% recommended selection of low-salt ingredients. There was substantial variability in directions for salt use in recipes between magazines, but no clear differences between 2007 and 2008. Conclusion: Many recipes advised to add salt in direct contradiction to national dietary guidelines. There is clear potential for editorial guidelines on salt use in recipes to play a role in advancing public health efforts in Australia and other such nations.

The hidden figure: sexual intimate partner violence among Pakistani women

Kapadia, M. Z., Saleem, S., Karim, M. S. — Fri, 07 Aug 2009 06:59:07 PDT

Background: The objectives of the present study were to determine the magnitude and factors associated with sexual intimate partner violence (SIPV) in women presenting to tertiary-care hospitals of Karachi, Pakistan. Methods: Five hundred women who presented to four tertiary-care hospitals to deliver were interviewed from September to December 2005. SIPV was assessed by using questions on sexual abuse in WHO Domestic Violence Module designed to determine intimate partner violence. Multiple logistic regression analysis was applied to determine factors associated with SIPV. Results: Twenty-one percent of women reported experiencing sexual violence in their married life. Gravida with five or more pregnancies [adjusted odds ratio (AOR) = 2.78; 95% confidence interval (CI) 1.12–6.96], index pregnancy as unwanted (AOR = 2.64; CI 1.16–6.02) and conflict with in-laws (AOR 1.9 CI 1.14–3.16) were independently associated with sexual abuse. Women who had social support were less likely to be abused by their intimate partners (AOR 0.76; CI 0.58–0.98). Conclusion: One in five women reported spousal sexual abuse in their married life. Women having more than five children, unwanted pregnancies or reporting differences with in-laws are more likely to be subjected to such abuse. Social support protects women from sexual abuse by intimate partner.

Environmental survey of segregated habitats of Roma in Hungary: a way to be empowering and reliable in minority research

Kosa, K., Darago, L., Adany, R. — Fri, 17 Jul 2009 08:44:49 PDT

Background: Roma people, the largest minority in Europe live in segregated communites in several countries. The size of the Roma population is based on estimations deriving from various sources, whereas only narrative accounts of their living conditions have been available. Methods: A comprehensive environmental survey of all settlements in Hungary (n = 3145) was carried out employing Roma field workers in order to locate and characterize segregated parts (colonies) of human habitats. Based on the collected data on environmental conditions and aggregate population numbers of the colonies, ranking of colonies and maps on their characteristics were prepared for all counties of Hungary. Results: Seven hundred fifty-eight colonies were identified with approximately 134 000 inhabitants. Ninety-four percent of all colonies are populated dominantly by Roma. Most frequent environmental problems in the colonies were found to be lack of sewage and gas mains, garbage deposits, waterlogged soil and lack of water mains. Conclusion: Census data cannot be used for policy design aiming at those Roma who are in greatest need of help; that is, living in segregated settlements (colonies). Colonies constitute disadvantaged living conditions of varying severity which can be quantified by a composite score based on indicators of access to services and presence of environmental dangers. The proportion of colony-dwelling Roma is approximately one-fifth to one-quarter of the estimated number of Roma people in Hungary.

Response of mass media, tobacco industry and smokers to the introduction of graphic cigarette pack warnings in Australia

Miller, C. L., Hill, D. J., Quester, P. G., Hiller, J. E. — Thu, 09 Jul 2009 05:29:16 PDT

Background: In the year 2006, Australia introduced graphic cigarette packet warnings. Previous warnings were text only. New warnings include one of 14 pictures, many depicting tobacco-related pathology. Methods: This study monitored the roll-out of the health policy initiative using multiple methodologies. Print media coverage of new pack warnings was observed over 3 years. Story content was coded as positive (supportive of pack warnings), neutral or negative. An observational study of small random sample of metropolitan stores (n = 16) over 7 months measured the pace of the roll-out in shops. Once new packs were readily available in stores, smokers (n = 152) were intercepted in city streets and asked about their reactions. Results: Of the 67 media stories, 85% were positive or neutral about the new warnings and 15% were negative. Supportive content presented health benefits. Unsupportive content presented industry arguments. After the legislative change, it took 2 months before any new packs appeared in stores. After 6 months, the majority carried them. Newest images had highest recall among smokers. About 60% said new warnings detracted from the look of their brand. About 51% felt the increased risk of dying from smoking-related illness. About 38% felt motivated to quit. Conclusion: Plans by government to introduce graphic warnings were delayed up to 2 years, apparently by heavy industry lobbying. Actual widespread appearance in shops occurred several months after the implementation date. While media coverage of the new warnings reported the industry arguments against them, the balance of coverage was overwhelmingly positive. Smokers’ initial reactions were in line with tobacco control objectives.

Belief in complementary and alternative medicine is related to age and paranormal beliefs in adults

Van den Bulck, J., Custers, K. — Wed, 08 Jul 2009 09:54:45 PDT

Background: The use of complementary and alternative medicine (CAM) is widespread, even among people who use conventional medicine. Positive beliefs about CAM are common among physicians and medical students. Little is known about the beliefs regarding CAM among the general public. Among science students, belief in CAM was predicted by belief in the paranormal. Methods: In a cross-sectional study, 712 randomly selected adults (>18 years old) responded to the CAM Health Belief Questionnaire (CHBQ) and a paranormal beliefs scale. Results: CAM beliefs were very prevalent in this sample of adult Flemish men and women. Zero-order correlations indicated that belief in CAM was associated with age (r = 0.173 P < 0.001) level of education (r = –0.079 P = 0.039) social desirability (r = –0.119 P = 0.002) and paranormal belief (r = 0.365 P < 0.001). In a multivariate model, two variables predicted CAM beliefs. Support for CAM increased with age (regression coefficient: 0.01; 95% confidence interval (CI): 0.006 to 0.014), but the strongest relationship existed between support for CAM and beliefs in the paranormal. Paranormal beliefs accounted for 14% of the variance of the CAM beliefs (regression coefficient: 0.376; 95%: CI 0.30–0.44). The level of education (regression coefficient: 0.06; 95% CI: –0.014–0.129) and social desirability (regression coefficient: –0.023; 95% CI: –0.048–0.026) did not make a significant contribution to the explained variance (<0.1%, P = 0.867). Conclusion: Support of CAM was very prevalent in this Flemish adult population. CAM beliefs were strongly associated with paranormal beliefs.

The prevalence of sedentary behaviours and physical activity in Hungarian youth

Hamar, P., Biddle, S., Soos, I., Takacs, B., Huszar, A. — Wed, 08 Jul 2009 09:54:43 PDT

Background: The study of sedentary behaviour is becoming much more visible, alongside research on physical activity. Few published studies, however, originate from Eastern or Central Europe. Method: Prevalence and point estimate data of key leisure time sedentary and active behaviours are reported from Hungary, a country that has been through an important political transition in the past two decades. Participants (n = 301) aged 13–18 years completed time-use diaries over 4 days for time outside of school. Sedentary and active behaviours were coded and analysed. Results: TV viewing reflected trends found elsewhere and was the most prevalent sedentary behaviour. Physical activity levels were low. The next most time-consuming sedentary weekday activities were homework, motorized transport, sitting and talking and playing computer/video games. Gender differences were different to some other countries, with girls reporting more computer game use and boys more sitting and talking, but these may reflect cultural and reporting differences. Conclusion: This study provides the first comprehensive description of sedentary behavioural prevalence in Hungarian youth.

Impact of the most frequent chronic health conditions on the quality of life among people aged >15 years in Madrid

Wed, 08 Jul 2009 09:54:43 PDT

Background: This study sought to ascertain to what degree health-related quality of life (HRQL) in the City of Madrid was affected by each of the most frequent chronic health conditions, and the specific quality-of-life (QL) domains on which such health conditions had the greatest impact, taking co-morbidity and socio-demographic variables into account. Methods: A descriptive, analytical, cross-sectional study was conducted covering 7341 subjects aged ≥16 years in the City of Madrid. Data were collected on self-reported diagnosed morbidity, including hypertension, hypercholesterolaemia, varicose veins, diabetes, chronic asthma/bronchitis, myocardial infarction/angina pectoris, stomach problems, allergy, arthrosis/arthritis or rheumatism, depression/anxiety, cataracts, cerebrovascular accidents (CVACs), chronic constipation, osteoporosis and Alzheimer's disease or dementia. HRQL was measured using the COOP/WONCA questionnaire. The effects of diagnosis, age, social class, gender and the co-morbidity were analysed using a multivariate analysis of covariance (ANCOVA). Results: The chronic health conditions that registered the worst overall mean scores on the COOP/WONCA questionnaire were Alzheimer's disease or dementia, Parkinson's disease, fibromyalgia, CVACs and depression, with scores of over 26 points in all cases. After the introduction of socio-demographic variables in the model, the highest values of Snedecor's F-test corresponds to depression (F = 461.63), ‘arthrosis/arthritis or rheumatism’ (F = 175.41), Alzheimer's disease or dementia (F = 65.70), gastric disorders (F = 65.17), cancer (F = 43.08) and CVACs (F = 41.65). Conclusions: Depression and ‘arthrosis/arthritis or rheumatism’ are the two chronic health conditions, which have the greatest impact on HRQL in Madrid's citizens, therefore is mandatory to propose and implement public health strategies that would reduce the prevalence and morbidity of such disorders.

Value for money or making the healthy choice: the impact of proportional pricing on consumers' portion size choices

Vermeer, W. M., Alting, E., Steenhuis, I. H. M., Seidell, J. C. — Wed, 08 Jul 2009 09:54:41 PDT

Background: Large food portion sizes are determinants of a high caloric intake, especially if they have been made attractive through value size pricing (i.e. lower unit prices for large than for small portion sizes). The purpose of the two questionnaire studies that are reported in this article was to assess the impact of proportional pricing (i.e. removing beneficial prices for large sizes) on people's portion size choices of high caloric food and drink items. Methods: Both studies employed an experimental design with a proportional pricing condition and a value size pricing condition. Study 1 was conducted in a fast food restaurant (N = 150) and study 2 in a worksite cafeteria (N = 141). Three different food products (i.e. soft drink, chicken nuggets in study 1 and a hot meal in study 2) with corresponding prices were displayed on pictures in the questionnaire. Outcome measures were consumers’ intended portion size choices. Results: No main effects of pricing were found. However, confronted with proportional pricing a trend was found for overweight fast food restaurant visitors being more likely to choose small portion sizes of chicken nuggets (OR = 4.31, P = 0.07) and less likely to choose large soft drink sizes (OR = 0.07, P = 0.04). Conclusion: Among a general public, proportional pricing did not reduce consumers’ size choices. However, pricing strategies can help overweight and obese consumers selecting appropriate portion sizes of soft drink and high caloric snacks. More research in realistic settings with actual behaviour as outcome measure is required.

Trends in the incidence of sickness absence due to common mental disorders between 2001 and 2007 in the Netherlands

Mon, 06 Jul 2009 08:17:10 PDT

Background: Mental disorders are an important public health problem because of their prevalence and the probability of long-term work disability. The incidence of sickness absence with mental disorders has increased between 1985 and 2000, but little is known about trends in recent years. This study investigated the incidence of sickness absence due to common mental disorders in the Netherlands from 2001 to 2007. Methods: Observational study in about 1 million employees, working in various economic sectors, representative for the Dutch workforce. Sickness absence episodes were medically certified by an occupational physician utmost in the fifth week of absence. The 12-month incidence of medically certified sickness absence was calculated for each year by dividing incident episodes by the number of employees. Sick days due to common mental disorders were computed as percentage of the total number of medically certified sick days. Results: The 12-month incidence of sickness absence due to common mental disorders was 2.2% in 2001, increased to 2.7% in 2004 and decreased thereafter to 2.0% in 2007. The percentage of sick days due to common mental disorders was highest in the education sector (39%) followed by financial services (31%) and health care (30%). Conclusions: In the Netherlands, the incidence of sickness absence with common mental disorders was highest in 2004 and has decreased since then probably because of changes in sick leave compensation, economic market position and company policies.

Greater gains from smoke-free legislation for non-smoking bar staff in Belfast

Bannon, F., Devlin, A., McElwee, G., Gavin, A. — Tue, 30 Jun 2009 09:20:25 PDT

Background: In April 2007, smoke-free legislation was enacted in workplaces throughout N. Ireland. The effects of this legislation on bar workers’ health and their exposure to second-hand smoke at home, work and social environment, and their attitudes to the legislation before and after its implementation remain to be documented. Methods: A self-completed questionnaire of bar staff in 35 Belfast bars, before (March 2007, n = 110) and after the legislation (July 2007, n = 110). Results: Smokers (excluding ‘social smokers’) made up 41.6% of respondents. After the introduction of the smoke-free legislation, the reductions in the proportion of bar workers reporting various respiratory symptoms ranged from 1.3% to 18.6% for smokers and from 21.9% to 33.2% for non-smokers. Likewise, the reductions for various sensory symptoms ranged from 7.3% to 17.7% for smokers and from 29.6% to 46.8% for non-smokers. Reduction in wheeze, cough and throat symptoms after the legislation were much greater for non-smokers than smokers. The proportion of bar staff who reported satisfaction with the legislation remained unchanged across the surveys. Decreases in perceived exposure to second-hand smoke occurred at work, home and in social settings. After the legislation's enactment, a majority of bar workers felt the workplace was healthier (98%). Conclusion: These first findings show reduced reported symptoms among bar workers, both smokers and non-smokers, after the introduction of smoke-free legislation in N. Ireland, though greater among non-smokers. There was also a reported fall in the hours of second-hand smoke exposure in the home for this group of workers which has a high prevalence of smokers.

Correlates of intensive alcohol and drug use in men who have sex with men in Catalonia, Spain

Folch, C., Esteve, A., Zaragoza, K., Munoz, R., Casabona, J. — Mon, 29 Jun 2009 06:14:45 PDT

Background: The objectives of the study were to determine the prevalence of alcohol and drug use before or during sex among men who have sex with men (MSM) in Catalonia during 2006, and to identify factors associated with variables of intensive alcohol and drug use. Methods: Cross-sectional study using self-administered questionnaires. Men were recruited in saunas, sex shops, bars and a public park and by mail to all the members of the Catalonia Gay Federation. Results: 19.6% of men said they were frequent users of alcohol, some type of drug (21.7%), or that they were multidrug users (18%) in the last 12 months. The multivariate analysis showed an association between having suffered discrimination and frequent alcohol and multidrug use. Being human immunodeficiency virus (HIV)-positive was associated with frequent use of drugs and multidrug use. Associations between substance use and sexual risk behaviour also emerged. Conclusion: The high percentage of MSM who use alcohol and drugs before and during sex and association between these substances and sexual risk behaviours reveals the need to intensify interventions to reduce their levels of use and/or to reduce the associated damage and risks. These programs must try to cover MSM-specific psychosocial aspects and include prevention for HIV-positive men.

The contribution of qualitative research to the development of tailor-made community-based interventions in primary care: a review

Jansen, Y. J. F. M., Foets, M. M. E., Bont, A. A. d. — Fri, 26 Jun 2009 09:48:09 PDT

Background: In recent years, a trend in the use of tailor-made approaches and pragmatic trial methodology for evaluating effectiveness has been visible in programs ranging from large-scale national health prevention campaigns to community-based initiatives. Qualitative research is used more often for tailoring interventions towards communities and/or local care practices. This article systematically reviews the contribution of qualitative research in developing tailor-made community-based interventions in primary care evaluated by means of the pragmatic trial methodology. Methods: A systematic search of Pubmed/Medline and Embase revealed 33 articles. Using a literature mapping process, the articles were arranged according to the development phases identified in the MRC framework for the development of complex interventions to improve health. Results: The review showed qualitative research is mainly used to provide insight into the contextual circumstances of the interventions’ implementation, delivery and evaluation. To a lesser extent, qualitative research findings are used for tailoring and improving the design of the interventions for a better fit with daily primary care practice. Moreover, most qualitative findings are used for tailoring the interventions’ contextual circumstances so that the interventions are performed in practice as planned, rather than adjusted to local circumstances. Conclusions: Pragmatic trials seem to be oxymoronic. Although the pragmatic trial methodology establishes the effectiveness of interventions under natural, non-experimental conditions, no pragmatic fit is allowed. Qualitative research's contribution to the development of tailor-made community-based interventions lies in providing ongoing evaluations of the dilemmas faced in pragmatic trials and allowing for the development of true tailor-made interventions.

Changes in alcohol consumption and drinking patterns during 11 years of follow-up among ageing men: the FinDrink study

Fri, 26 Jun 2009 09:48:09 PDT

Background: 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. Methods: 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. Results: 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). Conclusion: 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.

Underappreciated role of binge drinking in the risk of lung cancer

Thu, 25 Jun 2009 08:10:34 PDT

Children's physical activity, TV watching and obesity in Cyprus: the CYKIDS study

Lazarou, C., Soteriades, E. S. — Thu, 25 Jun 2009 08:10:34 PDT

Background: Even though there is a severe obesity problem in Cyprus, information about the contribution of predisposing lifestyle factors is limited. Our aim was to investigate the relationship between physical activity (PA), sedentary behaviour and various obesity indices [i.e. body mass index (BMI), waist circumference (WC), percentage of body fat (BF%) and ‘total & abdominal obesity’ (TAO)]. Methods: A national cross-sectional study of 1140 children (mean age = 10.7 ± 0.98 years) selected by multistage sampling in Cyprus was conducted during 2004–05. Children completed a 32-item, semi-quantitative PA questionnaire, which assessed organized and free-time PA and sedentary behaviours. Weight, height and WC were collected from a random sub-sample of 622 children and obesity was defined by IOTF criteria. Body fat percentage was calculated, and TAO status was computed based on obesity status and WC [i.e. (i) both BMI/WC, (ii) either BMI/WC abnormal and (iii) both BMI/WC abnormal]. Linear and logistic regression analyses with obesity indices as dependent variables were applied after adjusting for several potential confounders. Results: Only variables describing sedentary behaviours were retained in the final regression models in both boys and girls. Girls who spent ≥4 h/day on TV and DVD watching were almost three times more likely to be overweight or obese [OR = 2.84 (95% CI 1.08–7.47)], three times more likely to have WC ≥75th percentile [OR = 3.25 (95% CI 1.06–9.98)] and 3.5 times more likely to have ≥30% body fat [OR = 3.63 (95% CI 1.01–12.98)], while in boys, even though the same variable was retained in almost all final models, it did not reach statistical significance. Conclusion: Sedentary behaviours such as TV watching may be more important predictors of children's various obesity indices than PA behaviours. Interventions targeting sedentary behaviours, such as TV watching, may help in the prevention and treatment of obesity among Cypriot children.

Deaths in German police custody

Heide, S., Kleiber, M., Hanke, S., Stiller, D. — Thu, 25 Jun 2009 08:10:33 PDT

Background: According to the ministries of the interior of all German federal states, a total of 128 persons died in police custody between 1993 and 2003. Methods: An inquiry to the forensic university institutes and regional court doctors showed that, within this period, post mortems were conducted in 75 of these cases. We were able to include 60 of these 75 cases in our evaluation and deficiency analysis, which were carried out under assessment of the post mortem records and partly by making use of the subsequent medical expert reports and the results of criminal investigation. Results: The most frequent cause of death was acute alcoholic intoxication, followed by cerebrocranial traumata, internal diseases and fatal poisonings with medical or illegal drugs. In 23 cases, the person taken into custody had been seen by a physician in order to determine the person's fitness for detention in custody. Of these 23 cases, 15 (65.2%) revealed deficiencies in various areas of medical activity. Police officers had made mistakes in 33 of the 60 cases (55.0%), mainly because they failed to seek medical assistance or did not monitor the person with sufficient frequency. Our retrospective study however showed that in 16 cases (26.6%) death was very probably not preventable even if the person had received all necessary care. Conclusions: Our study gives recommendations on how to improve various measures to increase the quality of medical attention given to persons taken into police custody.

The effect of television news items on intimate partner violence murders

Vives-Cases, C., Torrubiano-Dominguez, J., Alvarez-Dardet, C. — Tue, 23 Jun 2009 09:53:05 PDT

Background: This study has been carried out in order to explore the effect of the growing appearance of IPV in television news items on deaths by this cause. Methods: Ecological study based on 340 deaths by intimate partner violence (IPV) and 3733 television news items covering this topic on Spanish television channels (2003 and 2007). Logistic regression analysis was carried out. Dependent variable: the difference between the number of IPV deaths in the 7 days following a news item broadcast and the number of IPV deaths in the 7 days before a media item. This outcome variable was conceptualised as a binary variable: increase vs. no increase. Independent variables: days with IPV news items—in general, concerning deaths, measures or other IPV crimes. Adjusted variables: day of the week, month, year and public holidays. Results: A small copycat effect was observed in the IPV murder rate (RR = 1.32, CI_95% = 1.07 – 1.62) for IPV-related news item days compared with days without such news. This effect continued when information about deaths was broadcast (RR = 1.28, CI_95% = 1.01 – 1.62). News items concerning measures (RR = 0.90, CI_95% = 0.82 – 0.98) or other IPV crimes (0.84, CI_95% = 0.82 – 0.98) were related to a lower possibility of an increase in deaths compared with days with death-related news. Conclusion: Given the results observed in the case of IPV-related news, there is an evident need to develop a journalistic style guide in order to determine what type of information is recommended due to the potential positive or negative effects.

Is health recognized in the EU's policy process? An analysis of the European Commission's impact assessments

Stahl, T. P. — Tue, 23 Jun 2009 09:53:03 PDT

Background: The European Commission has an Impact Assessment (IA) procedure that aims to inform decision-makers of the all important impacts that decisions may have. This article studies how health is considered in the IA procedure and how it is reflected in the reports: what aspects, whose and simply in what context health is mentioned in the IA reports. Methods: Half of the Commissions IAs from 2006 were studied. The analysis was text based and informed by content analysis. In total, 48 reports by 17 DGs were analysed. Results: Five DGs (29%) and 10 reports (21%) made no reference to human health, public health or health systems. Five DGs were clearly considering health impacts more often than others; DG EMPL, SANCO, AGRI, ELARG and ENV. Health systems/services were most often and human health next most common referred to (39% and 29% of all, respectively). Health impacts were usually referred to in the sections on the definition of problems and the analysis of impacts. Seldom were they reported on in the sections on policy options, comparing options, or in the monitoring and evaluation sections. Conclusion: The results partly support concerns about the potential neglect of health impacts. The results also suggest that health is not considered an important factor when discussing alternative policy choices, and neither does it seem to be an important objective. There is a clear need for further exploration on ways in which health could be more appropriately considered when impacts of other policies are considered by the various DGs.

Income inequality and male homicide rates: Sao Paulo, Brazil, 1996-2007

Lotufo, P. A., Bensenor, I. M. — Wed, 17 Jun 2009 10:14:54 PDT

In Sao Paulo, Brazil, homicides to men aged 15–44 years increased with an annual percentage change (APC) of 4.7% from 1996 to 2001, and then decreased from 2001 to 2007 with an APC of –14.6%. Analyzing the intra-urban distribution according to family income, the increase in the homicide rate was restricted to men living in the poorest neighbourhoods. In contrast, the decline in homicide rates was observed to men living in all districts. The reasons for this ‘up and down’ trend are not clear.

The aftershock of deindustrialization--trends in mortality in Scotland and other parts of post-industrial Europe

Walsh, D., Taulbut, M., Hanlon, P. — Mon, 15 Jun 2009 05:45:02 PDT

Background: Post-industrial decline is frequently cited as one of the major underlying reasons behind the poor health profile of Scotland and, especially, West Central Scotland (WCS). This begs the question: to what extent is poor health a common outcome in other post-industrial regions and how does Scotland's experience compare to these other comparable regions? Methods: Regions were identified by means of an expert-based consultation, backed up by analysis of regional industrial employment loss over the past 30 years. Mortality rates and related statistics were calculated from data obtained from national and regional statistical agencies. Results: Twenty candidate regions (in: Belgium; France; Germany; Netherlands; UK; Poland; Czech Republic) were identified, of which ten were selected for in-depth analyses. WCS mortality rates are generally higher and—crucially—appear to be improving at a slower rate than in the other post-industrial regions. This relatively poor rate of improvement is largely driven by mortality among the younger working age (especially male) and middle-aged female populations. Conclusion: WCS mortality trends compare badly with other, similar, post-industrial regions of Europe, including regions in Eastern Europe which tend to be characterized by higher levels of poverty. This finding challenges any simplistic explanation of WCS's poor health being caused by post-industrial decline alone, and begs the question as to what other factors may be at work.

What makes you work while you are sick? Evidence from a survey of workers

Bockerman, P., Laukkanen, E. — Fri, 12 Jun 2009 06:16:57 PDT

Background: Sickness absenteeism has been a focus of the EU Labour Force Surveys since the early 1970s. In contrast, sickness presenteeism is a newcomer. Based on surveys, this concept emerged in the empirical literature as late as the 1990s. Knowledge of the determinants of sickness presenteeism is still relatively sparse. Methods: The article examines the prevalence of sickness presenteeism in comparison with sickness absenteeism, using survey data covering 725 Finnish union members in 2008. We estimate logit models. The predictor variables capture working-time arrangements and the rules at the workplace. We include control variables such as the sector of the economy and educational attainment. Results: Controlling for worker characteristics, we find that sickness presenteeism is much more sensitive to working-time arrangements than sickness absenteeism is. Permanent full-time work, mismatch between desired and actual working hours, shift or period work and overlong working weeks increase sickness presenteeism. We also find an interesting trade-off between sickness categories: regular overtime decreases sickness absenteeism, but increases sickness presenteeism. Conclusions: Two work-related sickness categories, absenteeism and presenteeism, are counterparts. However, the explanations for their prevalence point to different factors.

National cardiovascular prevention should be based on absolute disease risks, not levels of risk factors

Powles, J., Shroufi, A., Mathers, C., Zatonski, W., Vecchia, C. L., Ezzati, M. — Mon, 08 Jun 2009 07:02:34 PDT

Background: It has been shown that the prevention of multicausal diseases such as heart attack (at an individual level) should be guided by absolute risks rather than by the level of risk factors. Here, we show that an analogous argument should form the basis of population-level prevention. Methods: Estimates of age- and sex-specific means and standard deviations for systolic blood pressures and blood cholesterol concentrations and for deaths assigned to all vascular causes in 2002 were obtained from the World Health Organization for 25 current member states of the European Union, for the ages 30–69 years. Predicted effects of 5 mmHg reductions in mean systolic blood pressures and 0.5 mmol l^–1 reductions in mean total blood cholesterol concentrations on deaths and years of life lost (YLL) per 100 000 person-years from vascular diseases were modelled using proportional risk coefficients from meta-analyses of cohort studies and randomized controlled trials. Results: Potential absolute benefits were strongly positively associated with current levels of absolute mortality risk: in the case of systolic blood pressure, predicted vascular deaths averted in the highest risk populations (Romania, Bulgaria) were over five times higher than in the lowest risk populations (Spain, France). Potential benefits were only weakly related to existing levels of the risk factor of interest. Conclusions: High-risk populations should give the highest priority to achieving favourable shifts in all modifiable risk factors. Irrespective of the level of any particular risk factor, the rewards will be greatest in these populations.

Cost-effectiveness of varenicline compared with nicotine patches for smoking cessation--results from four European countries

Tue, 02 Jun 2009 09:56:35 PDT

Background: The aim of this study was to evaluate and compare the cost-effectiveness of varenicline with nicotine replacement therapy (NRT) for smoking cessation in four European countries (Belgium, France, Sweden and the UK). Methods: Markov simulations, using the Benefits of Smoking Cessation on Outcomes (BENESCO) model, were performed. We simulated the incidence of four smoking-related morbidities: lung cancer, chronic obstructive pulmonary disease, coronary heart disease and stroke. The model computes quality-adjusted life-years gained and incremental cost-effectiveness ratios. Incremental cost-utility ratios were calculated, adopting a lifetime perspective. Efficacy data were obtained from a randomized open-label trial: Week 52 continuous abstinence rates were 26.1% for varenicline and 20.3% for NRT. Results: The analyses imply that for countries analysed, smoking cessation using varenicline versus NRT was associated with reduced smoking-related morbidity and mortality. The number of morbidities avoided, per 1000 smokers attempting to quit, ranged from 9.7 in Belgium to 6.5 in the UK. The number of quality-adjusted life-years gained, per 1000 smokers, was 23 (Belgium); 19.5 (France); 29.9 (Sweden); and 23.7 (UK). In all base-case simulations (except France), varenicline dominated (more effective and cost saving) NRT regarding costs per quality-adjusted life-year gained; for France the incremental cost-effectiveness ratio was 2803. Conclusion: This cost-effectiveness analysis demonstrated that since varenicline treatment was more effective, the result was increased healthcare cost savings in Belgium, Sweden and the UK. Our results suggest that funding varenicline as a smoking cessation aid is justifiable from a healthcare resource allocation perspective.

Evaluating risk for cardiovascular diseases--vain or value? How do different cardiovascular risk scores act in real life

Ketola, E., Laatikainen, T., Vartiainen, E. — Fri, 29 May 2009 10:14:00 PDT

Background: Screening tools to identify persons with high cardiovascular risk exist, but less is known about their validity in different population groups. The aim of this article is to compare the sensitivity and specificity of three different cardiovascular disease risk scores and their ability to detect high-risk individuals in daily practice. Methods: The sensitivity and specificity of risk charts based on Framingham Risk Function, SCORE and cardiovascular disease (CVD) Risk Score were analysed using a large population risk factor survey database in Finland. For different cardiovascular disease end-points in 10-year follow-up true positive, false positive, true negative and false negative cases were identified using different risk charts. Subjects over 40 years (n = 25 059) of the FINRISK Study were used in analyses. Results: Risk scores differed depending on gender, age and cardiovascular outcome. Among men the sensitivity of CVD Risk Score and Framingham Risk Function at risk of ≥10% for each end point was higher than of SCORE or Framingham Risk Function at risk of 20%. The specificity of Framingham Risk Function at risk of 20% was higher than the specificity of other risk charts. Among women in all endpoints the sensitivity was highest in CVD Risk Score and lowest in Framingham Risk Function at risk of ≥20%. Specificity for all different endpoints was highest in SCORE and Framingham Risk Function at risk of 20%. Conclusions: Sensitivity and specificity varied markedly in between three cardiovascular risk evaluation tools. Practitioners should be aware of their limitations especially when estimating risk among women and younger patients.

Prevalence of family violence in adults and children: estimates using the capture-recapture method

Oosterlee, A., Vink, R. M., Smit, F. — Fri, 29 May 2009 10:14:00 PDT

Background: Reliable prevalence estimates of family violence in adults and children are difficult to obtain. Most are based on surveys or registration counts, whose research designs and methods are often questionable, making the results difficult to compare. This article presents an alternative approach. Methods: The capture–recapture method (CRC), which makes it possible to estimate unknown numbers in a partly hidden population, was applied to data from eight collaborating organizations in Haarlem, The Netherlands. Results: Uniform data registration took place over a 7-month period. The 1-year prevalence rate for adult victims of family violence was estimated to be 2.0% of the adult population (95% CI: 1.3–3.1). For victims of child abuse, it was 1.5–2.5%, and for child witnesses of spouse-abuse, it was 1.2–2.1%, though small numbers made these results more uncertain. Only ~20% of all victims in the study were known to one or more of the participating organizations. Our results accorded quite well with results obtained by general health surveys in the Netherlands. Conclusions: CRC appears to be a valid and feasible research method for estimating the prevalence of family violence and child abuse. It can be used to complement other methods, especially in young children, in whom valid results are otherwise difficult to obtain.

Smoking prevalence and tobacco exposure among adolescents in Cyprus

Karekla, M., Symeou, A., Tsangari, H., Kapsou, M., Constantinou, M. — Wed, 27 May 2009 05:20:04 PDT

Background: Smoking has been internationally recognized as an epidemic contributing to major health problems. Smoking contributes to most of the preventable deaths worldwide. Although Cyprus is considered among developed countries with high smoking prevalence (estimates of 25–35% of the population), not much has been done for the systematic scientific study of this problem, especially in adolescence. The present study aimed to investigate smoking prevalence and related factors among Cypriot adolescents. Methods: Participants were selected through stratified random sampling. The final sample included two subpopulations: middle (n = 1085) and high (n = 767) school students. Results: Six percent of middle school students reported being regular smokers. This climbed to 24% among high school students. Smoking prevalence increases with age, and appears higher in boys than in girls. Smoking is quite common in the participant's families, particularly among fathers. Cigarette and smoke exposure in the home was high, as only a fifth of the students reported smoking never being allowed in the home. Exposure to actors smoking on television was the norm (62–67%) with low reported exposure to anti-smoking messages. Having friends who smoke, exposure to others smoking and low educational aspirations were significant predictors of smoking for both groups. Additional predictors, which were different for middle and high school students, were identified. Conclusion: Further research to investigate the nature of these effects is required and to provide further insight into the psychosocial parameters affecting smoking. These results can guide possible prevention and intervention programs for adolescents, and suggest the importance of following a systemic approach.

Could recommendations about aspirin prophylaxis enhance colorectal cancer screening programmes?

Morgan, G., Elwood, P. — Mon, 18 May 2009 06:14:49 PDT

Promoting stair climbing in Barcelona: similarities and differences with interventions in English-speaking populations

Puig-Ribera, A., Eves, F. F. — Tue, 12 May 2009 06:34:16 PDT

This study evaluated the ability of three different messages to encourage stair climbing on the Barcelona underground. Two weeks of baseline were followed by three banner intervention periods with three different messages, each for a 2 week period. Follow-up data was gathered two weeks after removing the messages. Stair climbing increased overall [odds ratio (OR) = 1.45; 95% confidence intervals (CIs) = 1.25–1.68], with no statistical differences between the messages. During follow-up, stair climbing remained elevated (OR = 1.22; 95% CIs = 1.01–1.48). These preliminary data suggest stair climbing interventions, effective in the UK, may prove successful in Catalonia and Spain. Baseline differences, however, outline the magnitude of the task.

Is depression associated with health risk-related behaviour clusters in adults?

Verger, P., Lions, C., Ventelou, B. — Wed, 29 Apr 2009 09:18:02 PDT

Background: Depressive disorders have been linked to health risk-related behaviours (HRBs) considered separately. Our objective was to study whether depression is associated with the co-occurrence of HRBs in adults. Methods: A sample of 17 355 subjects aged ≥18 years, derived from the 2002–03 cross-sectional Decennial Health Survey; probable depression was assessed with the CES-D scale. A cluster analysis of various HRBs (tobacco use, alcohol use, binge drinking, physical inactivity, certain eating habits) was used to study their co-occurrence. Multiple regressions adjusted on demographic and socio-economic characteristics, Body Mass Index and chronic illnesses were performed to study associations between probable depression and the HRBs clusters obtained. Results: Five clusters were observed evidencing a gradient of cumulative exposure to HRBs: ‘healthy lifestyles (Cluster 1), ‘non-daily-consumers-fruit-and-green-vegetables’ (Cluster 2), ‘regular alcohol users’ (Cluster 3), ‘daily smokers’ (Cluster 4) and ‘cumulate risk takers’ (Cluster 5). Compared with Cluster 1, positive associations were found between probable depression and Clusters 2, 4 and 5: OR 1.49 (95% CI 1.26–1.76) for Cluster 2; OR 1.81 (95% CI 1.54–2.12) for Cluster 4; OR 2.05 (95% CI 1.68–2.51) for Cluster 5. For Cluster 3, no association was found: OR 1.01 (95% CI 0.84–1.21). Conclusions: HRBs tend to co-occur in the general population, more frequently in case of probable depression. Further research is necessary to disentangle the direction of the links between depression and HRB clusters. Nonetheless, these results question the classic design of education campaigns considering HRBs separately. Moreover, screening for depression should be systematic during prevention consultations and various HRBs should be monitored when treating depressive patients.

Relationships between work satisfaction, emotional exhaustion and mental health among Swiss primary care physicians

Bovier, P. A., Arigoni, F., Schneider, M., Gallacchi, M. B. — Wed, 29 Apr 2009 09:18:02 PDT

Background: Work-related satisfaction is an important determinant of quality of care. However, its relationship with doctors’ mental health is poorly understood. It could have an independent beneficial effect on mental health (direct association) or simply reduce the impact of work stress on mental health (moderating or ‘buffering’ role). Methods: One thousand seven hundred and thirty-two Swiss primary care physicians (824 board-certified generalists, 436 general internists, 162 paediatricians, 147 internal medicine specialists and 163 physicians without specialty qualification) completed a mailed questionnaire. Previously, validated instruments were used to measure mental health (SF-12), emotional exhaustion [Maslach Burnout Inventory (MBI)] and work-related satisfaction. Linear regression models with mental health as dependant variable were used to study the relationships between these variables. Differences in mental health scores were standardized to represent a one standard deviation (SD) difference in the other scales [standardized beta coefficients (SBC)]. Results: In multivariate analyses, higher levels of mental health were found in respondents with higher work-related satisfaction with current income and social prestige (SBC 1.04) and professional relations (SBC 0.57), and in respondents with lower emotional exhaustion (SBC –4.98) and higher personal accomplishment scores (SBC 1.72). Interaction terms between these dimensions of work-related satisfaction and emotional exhaustion were significant, supporting a ‘buffering’ role of these dimensions. Conclusion: Work-satisfaction with current income, social prestige and professional relations are important correlates of mental health among primary care physicians, as well as emotional exhaustion. Higher levels of these dimensions of work-related satisfaction seems to mitigate the relationship between emotional exhaustion and physicians’ mental health.

Mental well-being and subjective health of 11- to 15-year-old boys and girls in Scotland, 1994-2006

Levin, K. A., Currie, C., Muldoon, J. — Tue, 21 Apr 2009 09:41:52 PDT

Background: 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. Methods: Data from the 1994, 1998, 2002 and 2006 Health Behaviour in School-aged Children surveys were analysed using Multilevel Binomial modelling. Results: 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. Conclusions: 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.

Suicides in public places: findings from one English county

Owens, C., Lloyd-Tomlins, S., Emmens, T., Aitken, P. — Sun, 19 Apr 2009 23:21:50 PDT

Little is known about where suicides take place. We collected data from coroners’ files on all suicides and undetermined deaths in one large English county from 2000 to 2004. The data show that >30% of suicides occurred in public places. A quarter of these involved jumping from a height and nearly a quarter involved car exhaust poisoning. Several sites were associated with multiple methods of suicide. Identifying and managing high-risk locations should be an important part of an overall suicide prevention strategy and is best tackled at local level.

Caring, employment and health among adults of working age: evidence from Britain and Belgium

Farfan-Portet, M.-I., Popham, F., Mitchell, R., Swine, C., Lorant, V. — Thu, 16 Apr 2009 06:13:57 PDT

Background: For those of working age, results are inconclusive when exploring the health impact of providing care. Moreover, population data is lacking and the impact of welfare policies on the caregivers’ health has not been yet analysed. Methods: Associations between general health and care giving, adjusting for differences in employment and socio-economic position, were explored for working age adults using logistic regression models. Data came from the 2001 British census (n = 1 361 222, 5% sample) and from the 2001 Belgian census (n = 4 368 637). The final model was stratified by employment status, given the significant interaction between caregiving and employment status. Results: In both countries, when compared with those providing no care, men and women providing ≥20 h of care per week had an increased risk of poor health. This increased risk was attenuated after adjustment for socio-economic position and particularly after adjustment for differences in employment status. However after stratifying by employment status, a dose response relationship between time spent caring and poor health was observed for the employed and unemployed, but not for the economically inactive. Conclusions: Despite contrasting welfare systems, employment status plays an important role in the association between caring and health in both countries. For the economically active, providing more care increases the risk of poor health. Whilst formal employment may be good for general health, having to informally care whilst in formal employment may have a detrimental health impact.

A new year, a new era: Romania and Bulgaria join the European Union

McKee, M., Balabanova, D., Steriu, A. — Wed, 28 Mar 2007 00:03:10 PDT

Fri, 13 Oct 2006 22:07:23 PDT