The European Journal of Public Health - Advance Access

Do medical services personnel who deployed to the Iraq war have worse mental health than other deployed personnel?

2008-05-08

Aim: There is evidence of increased health care utilization by medical personnel (medics) compared to other trades in the UK Armed Forces. The aim of this study was to compare the burden of mental ill health in deployed medics with all other trades during the Iraq war. Methods: Participants’ main duty during deployment was identified from responses to a questionnaire and verified from Service databases. Psychological health outcomes included psychological distress, post-traumatic stress disorder, multiple physical symptoms, fatigue and heavy drinking. Results: A total of 479 out of 5824 participants had a medical role. Medics were more likely to report psychological distress (OR 1.30, 95% CI 1.00–1.70), multiple physical symptoms (OR 1.65, 95% CI 1.20–2.27) and, if men, fatigue (1.38, 95% CI 1.05–1.81) than other personnel. Female medics were less likely to report fatigue (0.57 95% CI 0.35–0.92). Neither post-traumatic stress disorder nor heavy drinking symptoms were associated with a medical role. Traumatic medical experiences, lower group cohesion and preparedness, and post-deployment experiences explained the positive associations with psychological ill health. Medics made greater use of medical facilities than other trades. Conclusions: There is a small excess of psychological ill health in medics, which can be explained by poorer group cohesion, traumatic medical and post-deployment experiences. The association of mental ill health with a medical role was not the consequence of a larger proportion of reservists in this group.

Health, alcohol and EU law: understanding the impact of European single market law on alcohol policies

Baumberg, B., Anderson, P. — 2008-05-08

Background: many professionals in the alcohol field see the role of the the European Court of Justice (ECJ) as negative for health. This review examines ECJ and European Free Trade Association (EFTA) case law in the context of two broader debates: firstly the extension of European Union (EU) law into alcohol policy (the ‘juridification’ of alcohol policy), and secondly the extent to which alcohol policy is an example of the dominance of ‘negative integration’ (the removal of trade-distorting policy) over ‘positive integration’ (the creation of European alcohol policies). Methods: a comprehensive review of all ECJ/EFTA Court cases on alcohol, with interpretation aided by a secondary review on alcohol and EU law and the broader health and trade field. Results: from looking at taxation, minimum pricing, advertising and monopoly policies, the extension of the scope of the these courts over alcohol policy is unquestionable. However, the ECJ and EFTA Court have been prepared to prioritise health over trade concerns when considering alcohol policies, providing certain conditions have been met. Conclusion: while a partial juridification of alcohol policy has led to the negative integration of alcohol policies, this effect is not as strong as sometimes thought; EU law is more health friendly than it is perceived to be, and its impact on levels of alcohol-related harm appears low. Nevertheless, lessons emerge for policymakers concerned about the legality of alcohol policies under EU law. More generally, those concerned with alcohol and health should pay close attention to developments in EU law given their importance for public health policy on alcohol.

Delivering a cardiovascular disease prevention programme in the United Kingdom: translating theory into practice

Lloyd-Williams, F., Capewell, S., Ireland, R., Birt, C. — 2008-05-01

In response to, and support of the Editorial by Pekka Puska in the August 2007 edition of the Journal (Health in all Policies. European Journal of Public Health 2007;17(4):328), this article describes the Heart of Mersey (HoM) cardiovascular disease (CVD) prevention programme, which aims to improve the health of the local population by tackling inequalities via structural changes at regional, national and European level. Principally, the programme advocates that health improvement will be achieved primarily through healthy public policy, effective partnership and community integration.

Decentralization, re-centralization and future health policy

Bohigas, L. — 2008-05-01

Actual incidences of road casualties, and their injury severity, modelled from police and hospital data, France

Amoros, E., Martin, J.-L., Lafont, S., Laumon, B. — 2008-05-01

Background: Nation-wide road casualty figures usually come from police data. In France, as in many developed countries, the reporting of fatalities is almost complete but the reporting of non-fatal casualties is rather low. It is moreover strongly biased. Valid estimates are needed. Methods: Using the capture–recapture method on police data and on a road trauma registry covering a large county of 1.6 million inhabitants, we estimate police under-reporting correction factors that account for unregistered casualties. These correction factors are then applied to the nation-wide police data, with standardization on under-reporting bias factors. Results: In 2004, whereas the police report 108 727 non-fatally injured, the estimation yields 400 200. Over the 1996–2004 study period, the average annual estimated incidence is 871/100 000 for all injured (3.4 times the police incidence), 232/100 000 for hospitalized, 103/100 000 for seriously injured (2.2 times the police incidence) and 12.6/100 000 for casualties with long-term major impairment. The incidence of seriously injured (NISS 9+) is 11.3/100 000 for pedestrians, 9.5/100 000 for cyclists, 36.3/100 000 for motorized two-wheel users and 42.5/100 000 for car users. Conclusions: The estimated incidences are much higher than the police-based ones. This changes the scale of the road injuries issue. The risk of suffering a major impairment from a road crash is equal to the risk of being killed. Motorized two-wheel users experience a large burden of traffic casualties, much larger than that indicated by police data. The approach used can be reproduced in other countries, if an additional medical registration exists.

The health effects of education: a meta-analysis

Furnee, C. A., Groot, W., Brink, H. M. v. d. — 2008-04-23

Background: There is an abundance of empirical evidence, mainly from the epidemiological and social science literature, on the relation between education and health. Until now a meta-analysis of the relation between education and health was not available. This article presents a meta-analysis of studies that use self- reported health as an outcome variable to quantify the effect of education on health. Methods: Meta-analysis using a random and a fixed-effects model to quantify the marginal effect of education on self-reported health. Results: The results of the meta-analysis show that the quality adjusted life years weight (QALYweight) of a year of education is ~0.036. Some tentative calculations suggest that the cost-benefit ratio of investments in education on health is highly positive. Conclusion: For public policy this implies that a more integrated approach to education and health policies should be taken.

Inside the virtual casino: a prospective longitudinal study of actual Internet casino gambling

LaBrie, R. A., Kaplan, S. A., LaPlante, D. A., Nelson, S. E., Shaffer, H. J. — 2008-04-23

Background: Participation in Internet gambling is growing rapidly, as is concern about its possible effects on the public's health. This article reports the results of the first prospective longitudinal study of actual Internet casino gambling behaviour. Methods: Data include 2 years of recorded Internet betting activity by a cohort of gamblers who subscribed to an Internet gambling service during February 2005. We examined computer records of each transaction and transformed them into measures of gambling involvement. The sample included 4222 gamblers who played casino games. Results: The median betting behaviour was to play casino games once every 2 weeks during a period of 9 months. Subscribers placed a median of 49 bets of 4 each playing day. Subscribers lost a median of 5.5% of total monies wagered. We determined a group of heavily involved bettors whose activity exceeded that of 95% of the sample; these players bet every fifth day during 17.5 months. On each playing day, these most involved bettors placed a median of 188 bets of 25. Their median percent of wagers lost, 2.5%, was smaller than that lost by the total sample. Conclusion: Our findings suggest that Internet casino betting behaviour results in modest costs for most players, while some, roughly 5%, have larger losses. The findings also show the need to consider time spent as a marker of disordered gambling. These findings provide the evidence to steer public health debates away from speculation and toward the creation of empirically-based strategies to protect the public health.

Surveillance for Rare Infectious Diseases: is one passive data source enough for Haemophilus influenzae?

2008-04-18

Background: The completeness of a compulsory reporting system of systemic Haemophilus influenzae infections in children in Germany is studied by means of cross-linking registry data from three sources and applying capture-recapture methods. Methods: Cases were collected for the years 2001–05 by three national data sources: a passive administration registry (SurvNet7commat;RKI), an active hospital surveillance system and an active laboratory surveillance system. The case definition required cultural detection of H. influenzae in blood or cerebrospinal fluid. Linkage was carried out by month and year of birth, sex, geographical region and date of disease onset. Capture-recapture models were used to estimate the incidence of invasive H. influenzae infections. Results: SurvNet7commat;RKI reported 113 H. influenzae and 38 H. influenzae type b (Hib) cases, compared to a total of 231 and 68 cases, respectively, reported by all three sources combined. Best-fitting 3-source capture-recapture estimations amounts to 258 (95% confidence interval: 247–276) H. influenzae and 71 (69–74) Hib cases. SurvNet7commat;RKI data depicted a similar decrease in annual H. influenzae cases as the capture-recapture estimates but failed to detect the underlying decrease in Hib cases which was observed in the capture-recapture estimates due to a considerable annual variability of ascertainment of serotyped cases in SurvNet7commat;RKI ranging from 14% to 69%. Conclusions: Because of small variability of ascertainment, the compulsory passive reporting system depicted trends in H. influenzae incidence, although less than half of the cases were ascertained. However, time trend in Hib cases could not be depicted, because of highly variable serotyping proportions.

Patient survival for all cancers combined as indicator of cancer control in Europe

2008-04-15

Background: EUROCARE found marked differences in cancer survival across European populations, provoking extensive discussion as to the cause. We investigated the influence of socioeconomic indicators on survival, making use of the indicator population-based age-standardized and cancer site-standardized relative survival for all cancers combined (all cancer survival). Methods: Bivariate correlation and multivariate regression analyses investigated relations between 1995 socioeconomic variables and all cancer survival in EUROCARE-3 patients from 19 European countries diagnosed 1990–94 and followed to 1999. Results: Gross domestic product (GDP) and total national expenditure on health (TNEH) correlated highly with all cancer survival. Wealthy northern and western European countries had high survival; eastern European countries had low all cancer survival. GDP, TNEH, and number of computed tomography scanners per million—proxy of technological investment in cancer care—explained most survival differences. Low all cancer survival in the UK and Denmark compared to countries of similar wealth was closely related to fewer computed tomography scanners. Low all cancer survival in Poland compared to countries of similar wealth was also related to low TNEH. Conclusions: All cancer survival appears a useful and important indicator for monitoring countries’ performance in cancer control. The most direct way for poorer European countries to improve all cancer survival would be to get richer; for richer countries more investment in health technology is important. However the sharply increasing costs of cancer care may render this impossible suggesting the need to radically rethink cancer control strategies.

Low HIV-testing rates and awareness of HIV infection among high-risk heterosexual STI clinic attendees in The Netherlands

Van der Bij, A. K., Dukers, N. H. T. M., Coutinho, R. A., Fennema, H. S. A — 2008-03-31

Objectives: Since 1999, HIV testing is routinely offered to all attendees of the sexually transmitted infections (STI) outpatient clinic in Amsterdam, the Netherlands. This study evaluates whether this more active HIV-testing policy increased uptake of HIV testing and awareness of an HIV-positive serostatus among heterosexual attendees. Methods: In addition to routine data collected at each STI consultation, data from half-yearly HIV surveys were used from 1994 to 2004. During each survey period, 1000 consecutive attendees are enrolled voluntary and anonymously for HIV testing and are interviewed on previous HIV testing and outcome. Trends in and predictors for uptake of HIV testing as offered during routine STI consultation were analysed by logistic regression. Trends in awareness of an HIV-positive serostatus as obtained from the anonymous HIV surveys were likewise analysed. Results: The percentage of heterosexual attendees opting for an HIV test during consultation increased from 13% in 1996 to 56% in 2004. However, the proportion of individuals aware of their HIV infection did not change over time and only a minority (19%) of the 108 attendees found HIV-positive in the anonymous surveys were aware of their HIV infection. Persons being or visiting a commercial sex worker, having a non-Dutch ethnicity, lacking health insurance and having an STI diagnosed were less likely to opt for an HIV test. Conclusions: Although heterosexual attendees increased their uptake of HIV testing during STI consultation over time, uptake of testing by attendees at risk for HIV infection, such as those infected with an STI, remained low. As a result, the percentage of persons aware of their HIV infection remained low, posing a risk for their individual health and for ongoing HIV transmission. Current testing strategies, therefore, misses the group that most needs testing. Based on these results, ‘opt-out’ HIV testing is now the standard procedure at the Amsterdam STI clinic.

Home warmth and health status of COPD patients

Osman, L. M., Ayres, J. G., Garden, C., Reglitz, K., Lyon, J., Douglas, J. G. — 2008-03-26

Background: Home Energy Efficiency guidelines recommend domestic indoor temperatures of 21°C for at least 9 h per day in living areas. Is health status of patients with Chronic Obstructive Pulmonary Disease (COPD) associated with maintaining this level of warmth in their homes? Methods: In a cross-sectional observational study of patients, living in their own homes, living room (LR) and bedroom (BR) temperatures were measured at 30 min intervals over 1 week using electronic dataloggers. Health status was measured with the St George's Respiratory Questionnaire (SGRQ) and EuroQol: EQ VAS. Outdoor temperatures were provided by Met Office. Results: One hundred and forty eight patients consented to temperature monitoring. Patients’ mean age was 69 (SD 8.5) years, 67 (45%) male, mean percentage of predicted Forced Expiratory Volume in one second (FEV₁) 41.7 (SD 17.4). Fifty-eight (39%) were current smokers. Independent of age, lung function, smoking and outdoor temperatures, poorer respiratory health status was significantly associated (P = 0.01) with fewer days with 9 h of warmth at 21°C in the LR. A sub analysis showed that patients who smoked experienced more health effects than non-smokers (P < 0.01). Conclusion: Maintaining the warmth guideline of 21°C in living areas for at least 9 h per day was associated with better health status for COPD patients. Patients who were continuing smokers were more vulnerable to reduction in warmth.

Tobacco marketing awareness on youth smoking susceptibility and perceived prevalence before and after an advertising ban

Moodie, C., MacKintosh, A. M., Brown, A., Hastings, G. B. — 2008-03-24

Background: The Tobacco Advertising and Promotion Act (TAPA) was implemented in the United Kingdom in 2003. This study is the first to assess its impact on young people, examining smoking susceptibility (intention to smoke among never smokers) and perceived prevalence across three British cross-sectional samples (aged 11–16) before and after the introduction of the ban. Methods: Three in-home surveys (n = 1078, 1121 and 1121) were conducted before (1999 and 2002) and after (2004) the implementation of the TAPA. Results: Significant declines in awareness of tobacco marketing and perceived prevalence occurred across the three waves. Higher levels of awareness and perceived prevalence were associated with increased susceptibility, but direct measures of susceptibility remained stable. Conclusions: The TAPA is protecting young people in United Kingdom from tobacco marketing and reducing perceived prevalence, both of which are linked to susceptibility. The stability of susceptibility across the three waves is probably best explained by both the partial implementation of TAPA at the final survey point and the time such effects take to emerge. The evidence from this and previous studies is, however, that, ultimately, they will appear.

Mortality after long-term sickness absence: prospective cohort study

2008-03-09

Background: The study estimated the excess mortality after long-term sickness absence (LTSA), and identified socio-demographic and diagnostic risk factors of death. Methods: Prospective cohort study during 1994–2003 in a Norwegian county with 256 654 inhabitants aged 16–62 years. A representative sample of 3386 persons with a spell of sickness absence >8 weeks was compared with the total county population with respect to all cause mortality. Comparative mortality figures (CMF) for the total sample and standardized mortality rates for diagnostic groups were calculated. Results: The CMFs were 1.5 (95% CI 1.1–1.9) for the female and 2.0 (95% CI 1.7–2.4) for the male sample. Among women, persons’ sickness certified with cancer contributed with 43% of all deaths and standardized mortality ratios (SMR) was 16.1 (11.2–23.2). The respective figure for the men was 27% and SMR was 8.0 (5.7–11.1). SMR for men with mental diagnoses was 1.7 (95% CI 1.1–2.9) and for ‘other’ (respiratory, neurological, digestive) 1.8 (95% CI 1.3–2.7). Musculoskeletal cases had not elevated SMRs. Cox proportional hazard analysis with musculoskeletal cases as reference adjusted for age and income showed very high hazard ratios (HR) for cases with cancer diagnoses. Among the men, mental and ‘other’ diagnoses had also HR above unity. Conclusion: The study verified findings from Finland and the UK of excess mortality after LTSA, also when compared with the total population of the same age. Among women, cancer cases explained all the excess mortality, whereas other cases outside the musculoskeletal group also contributed among men.

Pan American Health Organization (PAHO), Health in the Americas, 2007.

Allebeck, P. — 2008-02-26

The same factors influence job turnover and long spells of sick leave--a 3-year follow-up of Swedish nurses

Josephson, M., Lindberg, P., Voss, M., Alfredsson, L., Vingard, E. — 2008-02-21

Background: In many countries, a general shortage of nurses is a public health problem, and retention of nurses in active work is a challenge. The aim of this study was to ascertain whether the same individual factors, working conditions and health problems had led to increased probability of both leaving jobs and prolonged sickness absence in a cohort of Swedish nurses over a period of 3 years. Methods: A baseline questionnaire was answered by 2293 nurses, representing a response rate of 86%. Exposed and unexposed nurses were compared with regard to two outcomes. During the 3-year follow-up, exposed and unexposed nurses were compared with regard to two outcomes: resigning and having at least one sick leave spell that lasted 28 days or longer. Results: We found that 18% of the nurses left their employment, and 16% had sick leave spells ≥28 days. Work in geriatric care, being socially excluded by superiors and/or workmates, negative effects of organizational changes and poor self-rated general health were factors that increased the likelihood of both leaving jobs and long-term sick leave. Conclusions: The present results underline the importance of improving working conditions and supporting sustainable health in order to prevent high turnover and prolonged sick leave among nurses. Resigning and moving to another institution can be interpreted as a way to actively cope with an unhealthy work environment.

Alcohol-related adverse consequences: cross-cultural variations in attribution process among young adults

Kuendig, H., Plant, M. A., Plant, M. L., Miller, P., Kuntsche, S., Gmel, G. — 2008-02-19

Background: Social norms around what is culturally accepted in terms of alcohol consumption and drunken comportment appear important regarding the acceptance of alcohol-related adverse consequences; however, investigations often neglect to consider differences in terms of attribution. This study aims at assessing cross-cultural differences in the reporting of alcohol-related adverse consequences. It also considers differences across consequences that might explain which type of consequences (mainly acute or mainly chronic) are most affected by an attribution process. Methods: Conditional regression models were estimated based on data from eight European countries participating in the Gender, Alcohol and Culture—An International Study (GENACIS) project. Cases were matched to controls based on usual drinking patterns in order to control for average volume of alcohol and frequency of ‘risky single occasion drinking’ (RSOD). Results: Differences among the patterns of associations between countries and consequences were evident. The distinction between Nordic and other European countries was persistent. A higher variability of associations was observed for some consequences, namely the mainly acute instances. Finally, the Isle of Man and Switzerland showed specific trends with associations across consequences. Conclusion: Reporting of alcohol-related adverse consequences seemed strongly affected by cultural norms. The latter may be exemplified by viewing drinking as ‘time-out’ behaviour. Respondents in countries with a stereotypical history of being ‘dry’ or with a stereotyped ‘binge’ drinking culture were more likely to attribute consequences to their alcohol consumption than people in ‘wet’ countries. This was particularly true for consequences that related to episodic ‘time-out’ heavy drinking.

Trends in physical activity and participation in sports clubs among Icelandic adolescents

Eithsdottir, S. Th., Kristjansson, A. L., Sigfusdottir, I. D., Allegrante, J. P. — 2008-02-19

Background: Physical activity among adolescents and its implications for health status is of increasing concern. We examined trends in physical activity and participation in sports clubs among Icelandic adolescents. Methods: Cross-sectional survey data were used to determine levels of vigorous physical activity and participation in sports clubs (defined as engaging in moderately intensive activity four times or more a week) for cohorts of Icelandic adolescents in 1992, 1997, 2000 and 2006. Results: There was a 6% increase in the rate of vigorous physical activity and a 15% increase in active sports club participation among 14- and 15-year old Icelandic adolescents from 1992 to 2006. The trends were consistent across genders; however, only 53% of boys actually achieved the recommended criterion for vigorous physical activity, with the percentage of girls averaging 16% lower than that for boys. Additionally, there was an overall increase in the proportion of inactive adolescents, with girls consistently reporting higher levels of inactivity than boys even though the net increase in inactivity was higher for boys. Conclusion: Although our results show an overall increase in vigorous physical activity and participation in sports clubs over the past decade among both genders, our data also indicate that over half of all Icelandic adolescents are not achieving the recommended level of participation in physical activity. Furthermore, less than one third of the population studied is achieving the recommended level of activity through organized clubs. Initiatives to increase physical activity among the least active of adolescents should receive high priority in public health.

Religious affiliation and acute coronary syndrome: a population-based case-control study in Tirana, Albania

Burazeri, G., Goda, A., Roshi, E., Kark, J. D. — 2008-02-07

Background: Our aim was to assess the association of religious affiliation (Muslim versus Christian) with acute coronary syndrome (ACS) in Albania, a predominantly Muslim country in Southeast Europe. Methods: A population-based case-control study was conducted in Tirana, the Albanian capital, in 2003–2006. Of non-fatal consecutive ACS patients, 467 were recruited (370 men aged 59.1 ± 8.7 years and 97 women 63.3 ± 7.1 years, 88% response). The coronary heart disease-free control group comprised 469 men (53.1 ± 10.4 years) and 268 women (54.0 ± 10.9 years) (69% response), 452 and 237 of whom were fully examined. Information collected included sociodemographic, psychosocial and behavioural characteristics by structured interview and anthropometric measurements. Furthermore, data on religious affiliation was available for all but 20 of the non-respondents. Multivariable-adjusted logistic regression was used to assess the association of religious affiliation (Muslim versus Christian) with ACS. Results: Of ACS patients, 77.1% were Muslims compared with 65.8% of the entire control group. Muslims in both sexes were at higher risk of ACS than Christians (age- and sex-adjusted OR = 1.8, 95% CI = 1.4–2.3, P < 0.01). The association persisted (OR = 1.6, 95%CI = 1.1–2.3, P = 0.02) upon further adjustment for marital status, family size, education, income, employment status, social position, emigration of close relatives, financial loss and coronary risk factors. Conclusions: In this transitional country, we found a higher risk of ACS in Muslims than Christians, independent of the socioeconomic circumstances and conventional coronary risk factors assessed. This finding requires replication and the determinants of the excess risk sought.

An international scoring system for self-reported health complaints in adolescents

2008-02-05

Background: Aimed to develop a unitary scoring system for the ‘Health Behaviour in school-aged Children’ (HBSC) symptom checklist that would facilitate cross-national comparisons and interpretation. Rasch measurement analysis and investigation of differential item functioning (DIF) were conducted. Methods: Data were obtained from the ‘WHO collaborative study HBSC 2001/2002’. A total of 162 305 students aged 11, 13 and 15 years from 35 European and North American Countries were surveyed. Unidimensionality of the items and local independence were tested using means of confirmatory factor analysis. DIF across countries, age groups and gender was investigated using a logistic regression procedure. Item and person parameters were estimated according to the Rating Scale Model (RSM). Results: All items proved to be unidimensional. One item displayed noticeable DIF across countries and was discarded. The remaining items were functioning equally across subgroups. The RSM analysis resulted in Rasch model conform item parameter estimation. Infit mean square values between 0.84 and 1.35 revealed acceptable item fit. Conclusion: The control of DIF enables comparable and unbiased assessment of subjective health complaints across countries, age groups and gender. A scoring algorithm could be developed which enables a cross-cultural comparable and interval-scaled assessment of subjective health complaints.

Risk factors for disability pension in a population-based cohort of men and women on long-term sick leave in Sweden

Karlsson, N. E., Carstensen, J. M., Gjesdal, S., Alexanderson, K. A. E. — 2008-02-01

Background: Knowledge on predictors of disability pension is very limited. The aim was to assess the importance of sick-leave diagnosis and socio-demographic variables as risk factors for disability pension among individuals on long-term sickness absence and to compare these factors by gender and over time. Methods: A prospective population-based cohort study in Östergötland County, Sweden, included 19 379 individuals who, in 1985–87, were aged 16–60 years and had a new spell of long-term sickness absence lasting ≥56 days. Follow-up was done in two time frames: 0–5 and 6–10 years after inclusion. The risk of disability pension in relation to sick-leave diagnosis and socio-demographic factors was assessed by Cox proportional hazard regression analysis. Results: In 5 years, after inclusion, 28% of the cohort had been granted disability pension. Those with higher age, low income, previous sick leave, no employment and non-Swedish origin had higher risk of disability pension, while those with young children had lower risk. Considering the inclusion diagnosis, the pattern differed between men and women (P < 0.001). Among men, those with mental disorders had the highest risk and among women those with musculoskeletal disorders. Except for income, the effect of which was reversed over time, the overall pattern of disability pension predictors remained 6–10 years after inclusion but was attenuated. Conclusion: Besides socio-demographic risk factors, the sick-leave diagnoses constitute an important both medium and long-term predictor of disability pension among both men and women on long-term sickness absence.

Economic evaluation of folic acid food fortification in The Netherlands

2008-01-31

Background: Folic acid intake before and during pregnancy reduces neural tube defects (NTD). Therefore, several countries have enriched bulk food with folic acid resulting in a 26–48% decrease in the prevalence of NTDs. In 2000, the Dutch Health Council advised against folic acid enrichment based on literature research; yet formal cost-effectiveness information was absent. We designed our study to estimate cost-effectiveness of folic acid food fortification in the Netherlands. Method: Prevalence of NTD at birth, life-time costs of care, and folic acid fortification costs were estimated using Dutch registrations, Dutch guidelines for costing, (inter)national literature and expert opinions. Both net cost per discounted life year gained and net cost per discounted quality adjusted life year (QALY) gained were estimated for the base case and sensitivity analyses. Results: In the base case and most sensitivity analyses, folic acid enrichment was estimated to be cost-saving. Bulk food fortification with folic acid remains cost-effective as long as enrichment costs do not exceed 5.5 million (threshold at 20 000 per QALY). Conclusion: Our model suggests that folic acid fortification of bulk food to prevent cases of NTD in newborns might be a cost-saving intervention in the Netherlands. Additionally, besides the evidence that folic acid reduces the number of NTDs, there are indications that folic acid is associated with the prevention of other birth defects, cardiovascular diseases and cancer. Our model did not yet include these possibly beneficial effects.

Evidence synthesis, upstream determinants and health inequalities: the role of a proposed new Cochrane Public Health Review Group

Waters, E., Petticrew, M., Priest, N., Weightman, A., Harden, A., Doyle, J. — 2008-01-27

Severe depressive symptoms as predictor of disability pension: a 10-year follow-up study in Denmark

Bultmann, U., Christensen, K. B., Burr, H., Lund, T., Rugulies, R. — 2008-01-17

Are severe depressive symptoms prospectively associated with disability pension? To answer that question, we linked data from a representative sample of the Danish workforce with disability pension (DP) award data from the National Registry on Public Transfer Payments. Of the 5106 study participants, 111 employees (2.2%) received DP during the 10-year follow-up. Severe depressive symptoms, reported in 1995, predicted DP award during follow-up (adjusted hazard ratio = 2.38, 95% confidence interval 1.22–4.66). Further research is needed to understand more fully the pathway(s) from severe depressive symptoms to DP.

Parenting and health in mid-childhood: a longitudinal study

Waylen, A., Stallard, N., Stewart-Brown, S. — 2008-01-17

Background: Parenting and parent–child relationships influence children's emotional and social development and evidence exists that they may be life-course determinants of health. This study tests the hypothesis that adverse parenting in the early years predicts poor health in mid-childhood. Methods: A prospective study using data from the Avon Longitudinal Study of Parents and Children cohort. Health data on over 8000 children (60% of those recruited) were available for analysis at 6.9 and 7.7 years. Exposures: self-reported maternal hostility, resentment and hitting/shouting in early childhood. Outcomes: maternal report of child's health in general and number of health problems when the child was 6.9 and 7.7 years, adjusting for socioeconomic factors. Results: Sub-optimal parenting, as measured here, was observed among 62, 80 and 83% of families for hostility, resentment and hitting/shouting, respectively. Resentment was more common among older mothers in owner-occupied housing. Resentment and hostility predicted health at both ages independently of socioeconomic circumstances. ‘Hitting/shouting’ was weakly predictive of number of health problems. A greater proportion of variance was explained by parenting variables than by socio-economic variables. Conclusions: Parenting and parent–child relationships in the early years predict health in mid-childhood in a way consistent with a causal role. If further studies replicate this finding, policies to improve parenting could be expected to have a modest beneficial impact on health as well as emotional and social development. As some aspects of sub-optimal parenting show reverse social class distribution, initiatives targeted at those living in social deprivation may not achieve the optimum impact on health.

The impact of psychosocial work environment factors on the risk of disability pension in Denmark

Christensen, K. B., Feveile, H., Labriola, M., Lund, T. — 2008-01-17

This study quantifies the impact of psychosocial work environment factors on the risk of disability pension. Differences in risk of disability pension were estimated in a representative sample of Danish employees followed for a total of 118 117 person-years of risk time. After control for smoking, BMI and ergonomic work environment, low decision authority and low variation in work showed a statistically significant association with disability pension. Adverse psychosocial work environment factors accounted for 10–15% of disability pension cases.

Cost effectiveness of hepatitis B vaccination strategies in Ireland: an economic evaluation

Tilson, L., Thornton, L., O'Flanagan, D., Johnson, H., Barry, M. — 2008-01-03

Background: In accordance with World Health Organization recommendations, many European countries have introduced universal hepatitis B vaccination policies. The UK and Ireland are exceptions. In this study, we conducted an economic evaluation of a universal infant hepatitis B vaccination programme, using a six-component vaccine, compared with the current selective strategy of vaccinating high-risk infants with a monovalent hepatitis B vaccine. Methods: A cost effectiveness analysis was conducted using a Markov model. The perspective of the analysis was the Irish Health Service Executive. Unit cost and resource utilization data were derived from expert clinical opinion, published sources, diagnosis-related group costs for hospital admissions and local cost estimates for medical fees and laboratory investigations. A full probabilistic sensitivity analysis was undertaken. Both costs and outcomes were modelled over a period of 80 years and discounted at 3.5%. Results: Assuming an incidence of acute hepatitis B virus (HBV) infection in Ireland of 8.4 per 100 000 population, the incremental cost effectiveness ratio ranged from 10 992/life years gained (LYG) to 67 200/LYG, at the lowest and highest price estimates for the six-component vaccine, respectively. The cost effectiveness of universal versus selective hepatitis B vaccination was sensitive to the risk of acute HBV infection, the cost of the universal infant vaccination programme and the discount rate. Conclusion: At a cost of 29.00 per dose of the six-component vaccine, universal infant hepatitis B vaccination is cost effective at 37 018/LYG. This compares favourably with other preventive programmes in Ireland.

Neonatal and postneonatal mortality by maternal education a population-based study of trends in the Nordic countries, 1981 2000

2007-12-26

Background: This study examined changes in the educational gradients in neonatal and postneonatal mortality over a 20-year period in the four largest Nordic countries. Methods: The study populations were all live-born singleton infants with gestational age of at least 22 weeks from 1981 to 2000 (Finland 1987–2000). Information on births and infant deaths from the Medical Birth Registries was linked to information from census statistics. Numbers of eligible live-births were: Denmark 1 179 831, Finland 834 299 (1987–2000), Norway 1 017 168 and Sweden 1 971 645. Differences in mortality between education groups were estimated as risk differences (RD), relative risks (RR) and index of inequality ratio (RII). Results: Overall, rates of infant mortality were in Denmark 5.9 per 1000 live-births, in Finland 4.2 (1987–2000), in Norway 5.3 and in Sweden 4.7. Overall the mortality decreased in all educational groups, and the educational level increased in the study period. The time-trends differed between neonatal and postneonatal death. For neonatal death, both the absolute and relative educational differences decreased in Finland and Sweden, increased in Denmark, whereas in Norway a decrease in absolute differences and a slight increase in relative differences occurred. For postneonatal death, the relative educational differences increased in all countries, whereas the absolute differences decreased. Conclusions: All educational groups experienced a decline in infant mortality during the period under study. Still, the inverse association between maternal education and RR of postneonatal death has become more pronounced in all Nordic countries.

An investigation of the growing number of deaths of unidentified people in Russia

Andreev, E., Pridemore, W. A., Shkolnikov, V. M., Antonova, O. I. — 2007-12-26

Background: We examined mortality among working-age Russian men whose identity could not be determined, focusing on where and how they died. Methods: Employing micro-data from deaths that occurred in Izhevsk (Ural region) between June 2004 and September 2005, we analysed the characteristics of decedent men aged 25–54 (n = 2158). Differences between completely identified (n = 1699) and unidentified deaths (n = 282) were compared via logistic regression. Data on all deaths in Russia in 2002 were used for supplemental comparisons. Results: We found that relative to identified men, unidentified men were at a higher risk of death from exposure to natural cold, violence, alcoholic cardiomyopathy, acute respiratory infections and poisonings. Our results also revealed that alcohol played an important role in the mortality of unidentified men. The places and causes of death among these unidentified men provide substantial evidence of their homelessness and social isolation. Conclusion: The increase in deaths among unidentified men of working-age indicates the emergence of a health threat associated with homelessness and social marginalization. This vulnerable group is exposed to different levels and causes of mortality compared with the larger population and represent a new challenge that requires serious and immediate scholarly attention and policy responses.

Health visitors and breastfeeding support: influence of knowledge and self-efficacy

Kronborg, H., Vaeth, M., Olsen, J., Harder, I. — 2007-12-26

Background: Little is known about what influences health visitors’ breastfeeding support. The objective was to describe health visitors’ breastfeeding experiences, beliefs, knowledge and self-efficacy in breastfeeding guidance and determine the impact of a training course on these factors, and how they were reflected in practice. Methods: A randomized intervention study enrolled 52 health visitors in the intervention group and 57 in the comparison group. The intervention group participated in an 18-hour pre-study training course that focused on knowledge about lactation and how to guide the mother to learn the mechanisms of breastfeeding. Data were collected through self-administered questionnaires before the intervention and after the follow-up period. One hundred and six (97%) health visitors and 1302 (82%) mothers responded. Results: At baseline no substantial differences were seen between the two groups on years since education, own breastfeeding experiences, beliefs or self-efficacy in breastfeeding guidance except that health visitors in the intervention group, who had completed the course, demonstrated significantly higher scores on knowledge questions (P < 0.01). After the intervention health visitors in the intervention group reported significantly higher self-efficacy in guidance on three of five breastfeeding problems (P < 0.01). Mothers in the intervention group reported having received more support than mothers in the comparison group. Conclusion: An interactive course increased the health visitors’ knowledge of breastfeeding practice. After the intervention period the health visitors in the intervention group had increased their self-efficacy in helping mothers with common breastfeeding problems. The mothers in the intervention group reported more informational and instrumental breastfeeding support.

Material deprivation and health-related dysfunction in older Dutch people: findings from the SMILE study

2007-12-26

Background: Even in generally wealthy Western countries material deprivation and poverty are not uncommon. There is, however, little data on the prevalence of material deprivation and its associations with health-related dysfunction in older people. Methods: Cross-sectional data from the SMILE study were used to examine the prevalence of material deprivation and the associations between material deprivation and health-related dysfunction in persons aged 55 years and older (n > 4000). Material deprivation was measured with a comprehensive questionnaire assessing seven subdomains referring to current and anticipated financial problems and poverty in childhood. Health-related dysfunction was measured using the SF36-based physical and mental components. In addition, self-reported heart disease was examined as an indicator of health-related dysfunction as well. Results: Almost 29% of subjects experienced at least one financial problem. Those reporting material deprivation had more than twice the risk of physical (OR = 2.22; 95% CI: 1.72–2.86) and mental (OR = 2.34; 95% CI: 1.84–2.97) dysfunction compared with non-deprived persons. A slightly weaker association was found when self-reported heart disease was used as an outcome variable (OR = 1.74; 95% CI: 1.40–2.15). Although odds ratios were generally higher for diseased older persons, no significant interaction effect between chronic disease and material deprivation subscales was found. Conclusions: Material deprivation in the Netherlands is not uncommon and is strongly related to both mental and physical dysfunction, and therefore needs further attention in public health policy. Longitudinal research is necessary to clarify the causal nature of our results and to develop appropriate interventions.

Prescribing patterns for upper respiratory tract infections in general practice in France and in the Netherlands

2007-12-26

Background: France and the Netherlands are often presented as two contrasting countries with regard to drug prescriptions and consumption. This study aimed to analyse general practitioners’ (GP's) prescription patterns for upper respiratory tract infections (URTI). Methods: Data on diagnoses and prescriptions were derived from two databases recording daily electronic medical patient files: the ‘Société Française de Médecine Générale’ database (SFMG-DB) and the Dutch Landelijk Informatie Netwerk Huisatsenzorg database (LINH-DB). Logit regression models were developed to estimate and compare prescription patterns in both countries. We carried out a study including all the patients consulting for URTI in 2003. Results: French GPs had more URTI patients than their Dutch counterparts (372.1 URTI patients/GP versus 181.3). They prescribed higher volumes of URTI medications (3.55 per patient/year versus 0.82). Striking differences were observed in analgesic and symptomatic prescriptions (0.84 per patient/year versus 0.12 and 1.01 per patient/year versus 0.21, respectively). We did not observe important discrepancies in volume of antibiotic prescriptions (0.29 per patient/year in France versus 0.32). After adjustment for patient characteristics, the logit model showed that prescription patterns for antibiotic were quite similar and associated with a diagnosis of acute tonsillitis. Conclusion: The analysis per consultation in this study did not highlight important differences in antibiotic prescribing volumes and patterns. But symptomatic and analgesic prescriptions were significantly higher in the French database. This can be explained by differences in help-seeking behaviour, medication perception, status of OTC medications and remuneration system.

Characteristics trends, mortality and morbidity in persons newly diagnosed HIV positive during the last decade: the profile of new HIV diagnosed people

2007-12-10

We analysed mortality, morbidity and trends in the characteristics, including risk factors of late testing, in 6805 the patients newly diagnosed for HIV infection between 1 January 1996 and 1 July 2006. The proportion of individuals in high risk groups of infection, as MSM, has decreased over time whereas the proportion of those in low risk of infection, as heterosexual persons in couple with children, has increased. This population is mainly diagnosed late with major consequences on morbidity and mortality.

Impact of high temperatures on hospital admissions: comparative analysis with previous studies about mortality (Madrid)

Linares, C., Diaz, J. — 2007-11-28

Background: Heat wave prevention plans are traditionally implemented according to a temperature limit above which mortality begins to rise. Although these prevention plans are obviously designed to avoid deaths, it is also necessary to establish the impact of extreme temperatures on hospital admissions in order to put hospital alert plans into action for dealing with people affected by heat wave victims.

Methods: We used data on daily emergency admissions between May and September, from 1995 to 2000, in the Hospital General Universitario Gregorio Marañón in Madrid. The causes for admission were considered as ‘organic’ (International Classification of Diseases, ICD-9: 1–799), circulatory (ICD-9: 390–459) and respiratory (ICD-9: 460–519). We stratified them according to the following age groups: all ages, from 0 to 10, 18 to 44, 45 to 64, 65 to 74 and above 75 years. The methodology used was Autorregresive Integrated Moving Average (ARIMA) modelling, including variables related to atmospheric pollution, seasonality and trends.

Results: The results show that the temperature above which hospital admissions soar coincides with the temperature limit above which mortality sharply rises, which, in turn, coincides with percentile 95 of the maximum daily temperature series for summer months. The pattern of hospital admissions is completely different from that of mortality. The rise in hospital admissions due to all causes and age groups is clearly smaller than that detected for mortality.

Discussion: These results suggest that people die rapidly from circulatory diseases before they can be admitted to hospital. This datum is vital with regard to implementing prevention plans prior to the arrival of the heat wave, if they are to effectively reduce mortality.

Length of life and the pensions of five million retired German men

Shkolnikov, V. M., Scholz, R., Jdanov, D. A., Stegmann, M., von Gaudecker, H. M. — 2007-11-05

Background: Socioeconomic differences in old-age mortality have not been studied in Germany. This study fills in the gap, evaluating mortality and life expectancy differentials among retired German men aged 65+ in 2003. Methods: Mortality rates are calculated from the administrative database on all public pensions and deaths of pensioners in 2003. Relative mortality rates and life expectancies are estimated for population subgroups according to the quintiles of lifetime earnings, type of medical insurance, broad occupational group, and residence in eastern or western Germany. Results: Among pension income quintiles, mortality varies by 60% and life expectancy at age 65 ranges from 14.9 to 18.5 years. Quintile-specific mortality and life-expectancy values are only slightly more favorable in western compared to eastern Germany. The mortality of manual workers is by 35% greater than that of salaried employees, while the mortality of those with mandatory public health insurance is 44% greater than the mortality of those with private or voluntary public health insurance. When all four characteristics are taken into account, relative mortality in the group with the highest mortality is three times higher than at the opposite end of the distribution, and corresponding life expectancies are 12.5 and 20 years. Half of all male deaths at ages 65+ are attributable to this variation. The mortality differentials remain significant at ages 80+. Conclusions: Socioeconomic mortality differentials persist into old age. They are similar in both regions and their magnitude is much greater than the diminishing mortality gap between the two parts of the country.

Health behaviours in people who respond to a web-based survey advertised on regional news media

Adams, J., White, M. — 2007-10-29

Background: The internet has become a key tool in health research and is increasingly used for data collection via email and web-surveys. Whilst the demographics of those with and without access to the Internet in the UK are regularly reported, the health behaviours of those who choose to take part in web-based surveys, compared to the wider population, are not known. Methods: We compared the health behaviours of those responding to a web-based health and lifestyle survey advertised on regional TV and radio news with regional results from a large national health and lifestyle survey—the Health Survey for England 2003. Results: After exclusion of duplicates, 1116 individuals responded to the survey and provided information on age and sex as well as a postcode in the Government Office for the North East region. Those responding to the web-survey were younger and lived in less deprived areas than the regional population. After weighting survey responses for age and deprivation, respondents to the survey reported higher mean BMI, greater fruit and vegetable consumption, as well as differing patterns of physical activity, alcohol consumption and smoking, than regional respondents to the Health Survey for England. Conclusions: Conducting a web-based health and lifestyle survey advertised on regional news media was fast, cheap and relatively easy. Given the potential benefits of web-based surveys, further work is justified exploring who responds to web-based health and lifestyle surveys and whether or not more representative samples can be obtained.

Home smoking bans in Finland and the association with child smoking

Rainio, S. U., Rimpela, A. H. — 2007-10-09

Background: Few studies in Europe have investigated home smoking bans and their association with child smoking. Methods: A nationwide survey of 12 to 18-year olds in 2005 (n = 6503, response rate 66%) was used to study home smoking bans in Finland. Multinomial logistic regression analyses were used to study association of home smoking bans and child smoking. Results: Of the respondents, 58% reported a total ban, 27% a partial ban, 4% reported no ban and 10% chose the option ‘I cannot say’. The lack of total ban was strongly associated with living in non-intact families, parents’ lower educational level, parental smoking and parents’ permissive attitude towards child smoking. Moreover, partial or no ban increased the likelihood of being a daily smoker. In the multinomial logistic regression model, the odds ratios (ORs) for children's daily smoking, adjusted for sociodemographic factors, parental smoking and their permissive attitude, were OR 2.9 [95% confidence interval (CI) 2.3–3.6] for partial ban and OR 14.3 (8.6–23.7) for no ban. In families where both parents smoked, the adjusted ORs were correspondingly 1.5 (95% CI 0.7–3.0) and 2.9 (95% CI 1.1–7.8). Conclusions: Home smoking bans will contribute towards a reduced risk of child smoking even when parents smoke. Tobacco control legislation needs to be enhanced with measures promoting awareness of the benefits achievable through strict home smoking bans. Families characterized by lower socioeconomic status and smoking parents are particular target groups.

Thirty-year trends of physical activity in relation to age, calendar time and birth cohort in Finnish adults

Borodulin, K., Laatikainen, T., Juolevi, A., Jousilahti, P. — 2007-09-17

Background: The aim of this article was to investigate time trends 1972–2002 in leisure time, occupational and commuting physical activity across birth cohorts in Finnish adults. Methods: The study population comprised 59 028 men and women aged 25–64 years who participated in the FINRISK Study. The first birth cohort was born in 1913 and the last in 1977. Prevalence of physical activity was reported across birth cohorts and study years and change in the prevalence was tested using log-linear regression analysis. Results: The prevalence of leisure-time physical activity increased between 1972 and 2002 from 66% to 77% in men and from 49% to 76% in women. In each study year, the younger people were more active than the older ones. However, within the birth cohorts, physical activity tended to increase with age. The prevalence of physically demanding work decreased from 60% to 38% in men and from 47% to 25% in women and the prevalence of daily commuting activity decreased from 30% to 10% in men and from 34% to 22% in women, in the same time period. In the 1970s and the 80s, the older people had more physically demanding work than the younger ones, but within the birth cohorts, occupational activity decreased with age. Conclusion: During the past 30 years, the prevalence of leisure-time physical activity has increased, while the prevalence of occupational and commuting physical activity has decreased. The cross-sectional association of age with different types of physical activity was different from that assessed within the birth cohorts.

Increased work-load associated with faecal incontinence among home care patients in 11 European countries

Finne-Soveri, H., Sorbye, L. W., Jonsson, P. V., Carpenter, G. I., Bernabei, R. — 2007-09-01

The plurality of definition of faecal incontinence (FI) complicates the cross-national comparisons between studies conducted in the area. The aim of the study was to investigate work-load and subjective care-giver burden associated with FI, among home-care patients, in Europe. Design and methods: In this cross-sectional retrospective study, a random sample of 4010 RAI-HC assessments were collected during 2001–02 from home care patients aged 65 years and over (74% females; age 82.8 ± 7.2 years) in Czech Republic, Denmark, Finland, France, Germany, Iceland, Italy, The Netherlands, Norway, Sweden and United Kingdom. Results: Of the 4010 individuals, 411 (10.3%) suffered from FI (range 1.1–30.8% from site to site). The factors significantly associated with faecal incontinence were diarrhoea [odds ratio (OR) 10.3, 95% confidence interval (CI) 6.590–15.96], urinary incontinence (OR 3.99, 95% CI 2.991–5.309) and pressure ulcers (OR 3.15, 95% CI 2.196–4.512) together with severe impairments in physical (OR 4.25, 95% CI 2.872–6.295) and cognitive (OR 3.76, 95% CI 2.663–5.304) functions. High use of working hours of the visiting nurses (OR 2.04, 95% CI 1.221–3.414) and home health carers (OR 2.40, 95% CI 1.289–4.470) were additionally associated with faecal incontinence. Use of five or more medications was an inversely associated with FI (OR 0.62, 95% CI 0.473–0.820). Conclusions: The additional work load associated with faecal incontinence comprises considerable numbers of formal health care hours and should be taken into account when planning home health services for the older in home care patients.

Work stress and mental health in a changing society

Kopp, M. S, Stauder, A., Purebl, G., Janszky, I., Skrabski, A. — 2007-08-08

Background: The aim of this representative study in the Hungarian population was to analyse the association between work-related factors and self-reported mental and physical health after controlling for negative affect and hostility as personality traits. Methods: The effects of job related factors on Beck Depression Score, WHO well-being score and self-rated health (SRH) were analysed in a representative sample of 3153 male and 2710 female economically active Hungarians. Results: In both genders negative affect was the most important correlate of depression, well-being and SRH, whereas hostility was closely associated only with depression. Job insecurity, low control and low social support at work, weekend work hours, job-related life events and dissatisfaction with work and with boss were independent mental health risk factors, but there were important gender differences. Job related factors seem to be equally important predictors of mental health as social support from family. Conclusion: The results of this large national representative study indicate that independent of negative affect and hostility, a cluster of stressful work-related psychosocial conditions accounts for a substantial part of variation in self-reported mental and physical health of the economically active population in Hungary.

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

McKee, M., Balabanova, D., Steriu, A. — 2007-03-28

2006-10-13