The European Journal of Public Health - current issue

Health inequalities in European welfare states

Lahelma, E., Lundberg, O. — Mon, 21 Sep 2009 07:35:31 PDT

Human ecology and public health

Tarkowski, S. — Mon, 21 Sep 2009 07:35:31 PDT

Privatization processes in health care in Europe--a move in the right direction, a 'trendy' option, or a step back?

Albreht, T. — Mon, 21 Sep 2009 07:35:31 PDT

The role of the private sector in health financing and service delivery

Fidler, A. H. — Mon, 21 Sep 2009 07:35:31 PDT

Causality, social selectivity or artefacts? Why socioeconomic inequalities in health are not smallest in the Nordic countries

Huijts, T., Eikemo, T. A. — Mon, 21 Sep 2009 07:35:31 PDT

Too early to stop immigrant vaccination programmes

Petrignani, M. W. F., Kroneman, A., van Hunen, R., Vennema, H., Koopmans, M. — Mon, 21 Sep 2009 07:35:31 PDT

Association between political ideology and health in Europe

Subramanian, S. V., Huijts, T., Perkins, J. M. — Mon, 21 Sep 2009 07:35:31 PDT

Studies have largely examined the association between political ideology and health at the aggregate/ecological level. Using individual-level data from 29 European countries, we investigated whether self-reports of political ideology and health are associated. In adjusted models, we found an inverse association between political ideology and self-rated poor health; for a unit increase in the political ideology scale (towards right) the odds ratio (OR) for reporting poor health decreased (OR 0.95, 95% confidence interval 0.94–0.96). Although political ideology per se is unlikely to have a causal link to health, it could be a marker for health-promoting latent attitudes, values and beliefs.

Physical and psychosocial working conditions as explanations for occupational class inequalities in self-rated health

Kaikkonen, R., Rahkonen, O., Lallukka, T., Lahelma, E. — Mon, 21 Sep 2009 07:35:31 PDT

Background: Socio-economic health inequalities are well documented, but efforts to explain health inequalities are less. However, previous studies suggest that working conditions provide potential explanations for inequalities in health. Methods: Cross-sectional questionnaire survey data, collected from municipal employees of the City of Helsinki, aged 40–60 years (n = 8960, response rate 67%) in 2000–02, were examined using binomial regression analysis. Socio-economic position was measured by six occupational social classes ranging from top managers to manual workers, and the outcome was self-rated health (SRH). Key physical and psychosocial working conditions and work arrangements were included as explanatory factors for inequalities in health. Results: Occupational class inequalities in SRH were clear among women [prevalence ratio (PR) 1.89, 95% confidence interval (CI) 1.54–2.32] and men (PR 1.78, 95% CI 1.40–2.25). Heavy physical workload explained a half of the health inequalities among women and almost one-third among men. Physical and chemical exposures at work explained one-fifth of the health inequalities among women and a half among men. Job control explained 24% of the men's and 40% of women's inequalities, whereas job demands widened the inequalities by 13–14%. The effects of shift work and working hours were negligible. In the fully adjusted model, 60% of the women's and 32% of the men's inequalities in SRH were explained. Conclusion: Physical working conditions explained a large part and job control, a somewhat smaller part of socio-economic inequalities in SRH. Improving physical working conditions and increasing job control provide potential routes to reduced inequalities in health among employees.

Is bullying equally harmful for rich and poor children?: a study of bullying and depression from age 15 to 27

Due, P., Damsgaard, M. T., Lund, R., Holstein, B. E. — Mon, 21 Sep 2009 07:35:31 PDT

Background: Exposure to bullying in childhood and adolescence is harmful to health, well-being and social competence of the victim. However, little is known about the long-term consequences of bullying victimization. In this paper, we use a longitudinal study from age 15 to 27 to examine whether childhood socioeconomic position (CSP) modifies the association between exposure to bullying in childhood and symptoms of depression in young adulthood. Methods: Nationally representative baseline sample in 1990 (n = 847), followed up 2002 (n = 614). We used multivariate analyses of variance to examine the influence of bullying on symptoms of depression at age 27. Results: Analyses showed that exposure to bullying, low CSP and female gender significantly increased the risk of depression in young adulthood. There was a statistically significant interaction between bullying and CSP, so that bullying increased the risk of depression for people from low CSP, while there was only a weak association between bullying victimization and depressive symptoms for people from more affluent childhood socioeconomic backgrounds. The same pattern was found for analyses stratified by sex. Conclusion: Our study suggests that the effects of bullying may have more serious long-term implications on health for children from less affluent backgrounds. Our study points at bullying exposure as another pathway through which social adversity in childhood influences social inequalities in adult health. Political efforts are needed to improve norms and legislations about how to treat children and more specific interventions should take place in schools to reduce the exposure to bullying.

Socio-economic factors and active commuting to school in urban Spanish adolescents: the AVENA study

Mon, 21 Sep 2009 07:35:31 PDT

Background: This study aimed: (i) to describe the patterns of commuting to school in urban Spanish adolescents; and (ii) to examine the associations between active commuting to school (ACS) and socio-economic factors.

Methods: From the AVENA Study, 2183 adolescents (1142 females) aged 13–18.5 years were gathered. Mode and time of transportation to school were self-reported by the adolescents. Parental education level (primary, secondary or university degree), parental professional level (managerial, skilled worker or unskilled worker/unemployed) and the type of school (public or private) were self-reported by the parents. The relationships between ACS and socio-economic factors were analysed by binary logistic regression.

Results: Nearly <65% of the adolescents reported ACS and 83% of them spent <15 min travelling to school. In male adolescents, maternal primary education level showed an odds ratio (OR) of 1.55 (95% confidence interval, 1.12–2.15), with respect to mothers with a university degree. In female adolescents, mothers with a primary education level showed an OR of 0.68 (0.50–0.92), with respect to mothers with a university degree. Low maternal professional level showed an OR of 1.70 (1.29–2.24), with respect to high maternal professional levels. Students attending public schools showed an OR of 3.47 (2.46–4.90), with respect to students from private schools.

Conclusion: Most of the adolescents actively commuted to school, yet the time spent commuting was low. Socio-economic level seems to be inversely related to the ACS in adolescents. Type of school and maternal educational level were the main predictors of ACS.

Educational inequalities in self-rated health within the Arab minority in Israel: explanatory factors

Daoud, N., Soskolne, V., Manor, O. — Mon, 21 Sep 2009 07:35:31 PDT

Background: Studies on factors explaining the socioeconomic inequalities in health within ethnic minorities are scarce. This study examines the contribution of material conditions, and psychosocial, community, cultural and behavioural factors to explaining educational disparities in self-rated health (SRH) within the Arab minority in Israel. Methods: In 2005, a national random sample of 902 persons aged 30–70 was selected in a multistage sampling procedure for interviewing. We used multistage logistic regression modelling to examine the percent of attenuations in odds ratios (OR) of extreme categories for education (low vs. high) in the associations with SRH after inclusion of explanatory variables. Results: Education was significantly associated with SRH [odds ratio (OR) = 3.86, 95% confidence interval (CI) = 2.30–6.47]. The separate inclusion of material conditions reduced the OR of poor SRH by 43%. Psychosocial, community or behavioural variables reduced it by 17%, 26% and 11%, respectively. Combining each group of factors with material conditions led to small additional reductions in OR. Integrating all explanatory variables reduced OR by 54%, with the association becoming non-significant. Cultural variables were not associated with SRH and were therefore not included in the multivariate analysis. Conclusions: Material conditions are a major factor in explaining the educational disparities in SRH among Arabs in Israel. Most of the impact of psychosocial and health behaviours, together with part of the community effects, operated through material conditions. Reduction of educational inequalities in SRH requires provision of educational attainment opportunities accompanied by employment opportunities assuring equivalent material gains. Further examination of factors explaining health inequalities among other minorities is warranted.

Large-scale epidemiological data on cardiovascular diseases and diabetes in migrant and ethnic minority groups in Europe

Rafnsson, S. B., Bhopal, R. S. — Mon, 21 Sep 2009 07:35:31 PDT

Background: Data on differences by ethnicity in cardiovascular diseases (CVDs) and diabetes, reflecting the influence of diverse cultural, social and religious factors, are important to providing clues to disease aetiology and directing public health interventions and health care resources. Methods: Through a network of European public health researchers and searches of bibliographic databases and internet sites, we determined the availability and characteristics of ethnically relevant data on mortality and morbidity from coronary heart disease (CHD), stroke and diabetes, in current European Union countries; data from the four countries comprising the UK were assessed separately. Results: In total, 25 countries had one or more relevant data sets (72 in total); however, two-thirds (n = 47) of the data sources came from only eight Nordic and Western European countries. For several countries, no data could be identified. Ethnically relevant, national death registers were available in 24 countries. Country of birth was the most common indicator of ethnicity. Data on CHD, stroke and diabetes morbidity among migrant and ethnic minority populations are currently scarce; both between and within countries, there are important differences in how ethnicity as well as disease outcomes are defined and measured which limits data comparability. Conclusion: Reliable routine data are key to evidence-based public health policies at both national and EU level. EU countries have a relatively weak base for assessing needs and planning health care interventions for its migrant and ethnic minority populations. The lack of ethnically relevant data on CVD and diabetes across the EU needs to be addressed urgently.

Language-group mortality differentials in Finland in 1988-2004: assessment of the contribution of cause of death, sex and age

Sipila, P., Martikainen, P. — Mon, 21 Sep 2009 07:35:31 PDT

Background: The higher mortality among Finnish-speaking than Swedish-speaking Finns is well established and has been shown to be very persistent. However, the most recent comprehensive documentation on the language-group differential extends only to the mid-1980s. We study recent trends in sex- and age-specific language-group mortality from 1988 to 2004, focusing on the relative contribution of the main causes of death and differences in sociodemographic structure. Methods: The register data are based on an 11% sample of Finns aged ≥30 years at the end of 1987—which further includes an oversample of deaths covering 80% of all deaths in the period 1988–2004. Results: Finnish-speaking men had 19% and women 11% higher age-adjusted mortality rates than the Swedish speakers. Further adjustments for sociodemographic composition explained 47% and 36%, respectively, of these differences. Age group-specific analyses showed the steepest differences in the young and middle-aged groups (30–49 years) in both men and women. The cause-specific differences were most pronounced in alcohol-related diseases, suicide and other external causes, for which a slight increase in differentials was also observed. Conclusion: The relative difference in mortality between the two main language groups in Finland persists, with a slight narrowing of the gap among women. Moreover, the largest differences and indications of diverging trends were found among the youngest age groups. The causes of death in which the difference is greatest highlight the importance of health-related behaviour and cultural differences in lifestyle.

Results of a cervical cancer screening programme from an area of Barcelona (Spain) with a large immigrant population

Mon, 21 Sep 2009 07:35:32 PDT

Background: To assess the participation rate and results of cytological assessment in the context of cervical cancer screening activities in an area of Barcelona (Spain) with a large immigrant population. Methods: Descriptive retrospective study of cytologies performed between 2001 and 2006 in women ≥14 years of age living in 2 out of 10 districts of Barcelona (n = 129 327) and participating in cervical cancer screening activities within a sexual and reproductive health care programme. Results: Between 2001 and 2006, overall participation among women aged 20- to 64-years old was 50.7%, with higher participation among women aged 20–34 years than among those aged 50–64 years (63.8 and 36.0%, respectively; P < 0.01). The median frequency was 0.5 cytologies/year. The rate of pathological results increased from 11.4 in 2001 to 29.0 in 2006 (P < 0.001). This increase was higher among younger women and was mainly due to an increase in the rate of atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (L-SIL). Conclusions: These results show a low rate of participation in the public cervical cancer screening programme and an increase in the number of pathological results during the study period. These results provide useful information at a time when significant changes in the prevention of cervical cancer are being planned.

Fear of racism, employment and expected organizational racism: their association with health

Becares, L., Stafford, M., Nazroo, J. — Mon, 21 Sep 2009 07:35:32 PDT

Background: Racism has been argued to be a focal element of larger societal inequalities which generate ethnic health disparities. Despite suggestions that socio-demographic characteristics of the victim may influence the impact of racism on health, little is known in the United Kingdom about how self-reported experiences of racism vary by socio-demographic characteristics, whether racism contributes to ethnic differences in health and whether there is a differential association between racism and health for certain socio-demographic groups. Methods: Multilevel logistic regression models were conducted using data from the 2005 Citizenship Survey to identify the demographic characteristics associated with reporting experienced racism; explore the association between health, racism and its contribution to ethnic inequalities in health; and explore the moderating role that gender, age, ethnicity and socio-economic position (SEP) have in the relationship between racism and health. Results: Females were significantly more likely to report fear of racial and religious attacks, but reported lower odds of experiencing employment and expected organizational discrimination. A trend was observed for decreasing employment discrimination as SEP decreased. A reverse association was found for SEP and expected organizational discrimination, where people in the lowest employment categories reported lower odds of experiencing discrimination. Conclusion: This study highlights variations in the types of racial discrimination most commonly reported across different socio-demographic characteristics. Despite substantial differences in the experience of racial discrimination, the detrimental impact of racism on health was the same across socio-demographic groups.

Diabetes prevalence and risk factors among ethnic minorities

Mon, 21 Sep 2009 07:35:32 PDT

Background: Ethnic minorities living in Western societies may have a higher prevalence of diabetes. We investigated whether the prevalence of diabetes among Turkish and Moroccan migrants differs from the indigenous urban population in the Netherlands, and whether these differences can be explained by differences in risk factors. Methods: In 2004 a general health survey, stratified by ethnicity and age, was carried out among the population of Amsterdam. The current study included 375 Turkish, 314 Moroccan and 417 Dutch individuals aged 18–70 years. Participants underwent a physical examination and a health interview. Diabetes was based on self-report, the use of anti-diabetic medicine, blood glucose levels and HbA1c. Results: The prevalence of diabetes in the Amsterdam population was significantly higher in Turkish (5.6%) and Moroccan (8.0%), compared to Dutch individuals (3.1%). These differences, which were much larger after adjustment for age, were only partly explained by the lower socioeconomic status and higher frequency of obesity among ethnic minorities. The difference between Dutch and Moroccan individuals remained significant even after adjustments for multiple risk factors. The typical age of onset of diabetes in both Turks and Moroccans is respectively one and two decades younger than in the indigenous population. Conclusion: Diabetes is more prevalent among Turkish and Moroccan migrants as compared to the indigenous population. Only part of this difference can be explained by differences in demographic and lifestyle risk factors.

Investment decisions in influenza pandemic contingency planning: cost-effectiveness of stockpiling antiviral drugs

Lugner, A. K., Postma, M. J. — Mon, 21 Sep 2009 07:35:32 PDT

Background: The threat of an influenza pandemic has led to stockpiling of antiviral drugs in order to mitigate a plausible outbreak. If the stockpile would be used in relation to the recent pandemic alert, an investment decision about renewing the stock for a possible subsequent pandemic is essential. The decision should include cost-effectiveness considerations. Methods: We constructed a cost-effectiveness analysis in the Dutch context, explicitly including risk of an outbreak. Outcomes from a dynamic transmission model, comparing an intervention with a non-intervention scenario, were input in our health economic calculations. Results: Stockpiling was cost-effective from the health-care perspective if the actual risk is 37% for 30 years. If less than 60% of the population would take the antiviral drugs or the attack rate is about 50%, the investment would not be cost-effective from this perspective. Conclusion: Risk perception, realistic coverage among population and size of a pandemic are crucial parameters and highly decisive for the investment decision.

Pneumonia mortality in a UK general practice population cohort

Mon, 21 Sep 2009 07:35:32 PDT

Background: Pneumonia is a common diagnosis in general practice in the United Kingdom and yet there is little known about the short- and long-term prognosis of people with a diagnosis of pneumonia in general practice. We investigated the short- and long-term survival of people with pneumonia diagnosed in general practice as compared to the general population for all ages. Methods: This was a general population-based cohort study. Data was obtained from a comprehensive general practice database called The Health Improvement Network (THIN) database which has computerized medical records from 300 general practice surgeries in the United Kingdom. We used Cox regression for our analyses. Results: For pneumonia cases the 30-day mortality was 18.5% and the 3-year mortality was 30.8%. The equivalent figures for the general population controls were 0.4% and 10.3% respectively. The adjusted hazard ratio (HR) for all-cause mortality (for total follow-up time) in pneumonia cases vs. general population was 4.64 (95% CI 4.35–4.95). For the first 30 days the risk of mortality in cases was 46 times more (adj. HR 45.90, 95% CI 36.80–55.20). Even in the period of follow-up 91 days after diagnosis cases were almost 20% more likely to die compared to general population (adj. HR 1.19, 95% CI 1.08–1.31). Conclusion: People in general practice who have a diagnosis of pneumonia have a markedly increased mortality in the short-term but some increase in mortality persists during longer-term follow-up.

Assessment and proposal of a new combination of screening criteria for hepatitis C in France

Mon, 21 Sep 2009 07:35:32 PDT

Background: The current French hepatitis C virus infection screening programme is not yet reaching all populations at risk. In order to better identify individuals that would benefit from a screening test, we investigated an expanded combination of personal characteristics as potential screening criteria for this infection. Methods: We constructed two multiple-regression models predicting hepatitis C antibody seropositivity using the population sample from the 2004 French national hepatitis C antibody seroprevalence survey (SPS) (n = 14 416): one representing current screening guidelines and another constructed from personal characteristics collected for the SPS. Performance of the two predictive models was statistically compared and we internally validated the better performing model. Results: The expanded screening criteria model better discriminated seropositive and seronegative individuals [area under the ROC curve (AUC) 0.869 (95% CI 0.861–0.873)] than the current screening guidelines model [AUC 0.821 (95% CI 0.810–0.824)]. This performance difference was statistically significant (P < 0.00001). The expanded criteria model contains the variables age, sex, pre-1992 blood transfusion, intra-venous drug use, receipt of medical welfare for precarious individuals, previous surgeries, illicit nasal drug use, previous hepatitis C screening, tattoo, raised alanine aminotransferase level and birth in a hepatitis C high/moderate-prevalence country. Conclusion: Results indicate that an expanded combination of screening criteria better predicted hepatitis C antibody status and thus individuals needing screening than the current French-screening guidelines. The proposed combination of screening criteria could more effectively target hepatitis C risk-populations in France and could serve as the basis for a decision-making screening tool for the general population.

Health status of 'Ruhr-City' in 2025 - predicted disease burden for the metropolitan Ruhr area in North Rhine-Westphalia

Mon, 21 Sep 2009 07:35:32 PDT

Background: Demographic change is a driving force of disease burden. The German population is aging and simultaneously shrinking, due to a rising life expectancy and a declining fertility rate. North Rhine-Westphalia (NRW) is the most populous federal state of Germany including the Ruhr metropolitan area. The NRW population is expected to shrink by 2.5% until 2025, the population of the Ruhr area by 9.5%. At the same time, the population forecast predicts a growth of 30% in the age group ≥55 years for NRW. Methods: The ‘burden of disease’ approach of the World Health Organisation (WHO) summarizes the health status of populations. This approach was used to predict the regional disease burden in 2025 by calculating disability adjusted life years (DALY) as the sum of life years lost due to premature death and years lived with disability due to selected diseases. Our projection included selected tumours, myocardial infarction (MI) and dementia. Results: For the Ruhr area, increases in DALYs are expected for all causes studied, i.e. selected tumours (20%), MI (17%) and dementia (36%). The increase in the Ruhr area was estimated to be proportionally lower than in NRW in total, but the disease burden per inhabitant is higher. Conclusion: The population shrinking is no cure for ‘Ruhr City’. The projection of disease burden shows that health status will decrease due to the demographic change. DALY estimates show the potential health gains, which can be won by implementing measures to reduce premature deaths and to prevent new cases.

Measuring burden of disease in Estonia to support public health policy

Lai, T., Habicht, J., Kiivet, R.-A. — Mon, 21 Sep 2009 07:35:32 PDT

Background: Many countries have an overview on mortality and morbidity but few have performed contextualized national burden of disease studies. The objective of the present study is to provide a first set of national and sub-national burden of disease estimates for Estonia. Further, we present the causes and age-gender distribution of the burden. We conclude with the description of result uptake and impact of the study in Estonian public health policy arena. Methods: A burden of disease estimation procedure modified for best fit to country situation was used. That included disease classification reflecting Estonian disease profile, national disease severity assessments, mortality and morbidity prevalence data. Calculations were performed on national and sub-national levels. Results: Estonian population lost 446 361 (327/1000 persons) disability adjusted life-years in 2002. Premature mortality caused majority of the burden and cardiovascular diseases, external causes (e.g. suicide and injuries) and cancers were main sources of burden. Working age population (16–64 years) shouldered 60% of the burden. Sub-national levels of burden range from 114 to 725 disability adjusted life-years per 1000 persons and are correlated to regional socioeconomic development. Conclusion: Cardiovascular disease and injuries, premature mortality, working age population, male and people from economically less developed regions should be the priority targets for public health interventions. Estonian main public health strategies now address burden of disease concerns highlighted by our study.

Self-reporting weight and height: misclassification effect on the risk estimates for acute myocardial infarction

Oliveira, A., Ramos, E., Lopes, C., Barros, H. — Mon, 21 Sep 2009 07:35:32 PDT

Background: The accuracy of self-reported weight and height to measure obesity has been evaluated, but no information is available on the possible error effects of self-reporting when estimating the association between body mass index (BMI) categories and the occurrence of acute myocardial infarction (AMI). We aim to evaluate if two different sources of information on height and weight (reported vs. measured) result in different risk estimates for non-fatal AMI events. Methods: A population-based case–control study was conducted with 732 cases of first AMI and 1914 community controls, recruited from the same catchment area of hospitals. As part of an interview, participants self-reported weight and height immediately before having it measured. Data were analysed separately by sex and age strata (≤45; >45 years). Results: Women under-reported their weight and over-reported their height, and the mean differences between measured and self-reported data were significantly larger in controls. Male controls also under-reported their weight, but cases over-reported it. After adjustment, in younger women the use of self-reported data underestimated the AMI risk according to BMI categories, but in older ones the self-reporting overestimated AMI risk, although with no statistical significance. In younger men, the association between AMI and self-reported obesity (BMI ≥ 30 kg/m²) was overestimated in ~50% (measured: OR = 2.05, 95% CI 1.08–3.87; self-reported: OR = 3.06, 95% CI 1.56–6.00). In older participants, a significant association was only found for overweight men when using self-reported data. Conclusions: Self-reporting of height and weight produced a differential misclassification and biased risks for AMI according to BMI, affecting not only the magnitude, but also the estimates direction.

Staff reports of psychosocial climate at school and adolescents' health, truancy and health education in Finland

Mon, 21 Sep 2009 07:35:32 PDT

Background: Psychosocial climate at school reported by school personnel may be related to pupils’ reports of being heard at school, depression, physical and psychological symptoms, truancy and received health education. Methods: Cross-sectional study combining data from two independent surveys conducted between 2004 and 2005 in 136 public schools in Finland. The pupil sample comprised 11 583 boys and 12 706 girls from the eighth and ninth grades of lower secondary school and first and second grades of upper secondary school. A personnel survey (n = 1946) was used to measure psychosocial climate indexed by trust and opportunity for participation, support for innovation, orientation towards high-quality work and accepted and clear goals. Results: After adjustment for individual and school-level covariates, multilevel analyses revealed odds for pupils’ opinion of not being heard were higher in schools where personnel reported poor trust and opportunity for participation (OR = 1.33) and low support for innovation (OR = 1.37). Poor trust and opportunity for participation and unclear work goals among staff were associated with high truancy among pupils (ORs = 1.54 and 1.39). Poor trust and opportunity for participation among staff were also related to pupils’ depression [cumulative odds ratio (COR = 1.14)], and physical and psychological symptoms (COR = 1.17). Unclear goals among staff were associated with pupils’ opinions that health education was insufficient (OR = 1.40). Conclusions: school climate is associated with adolescents’ health, wellbeing and received health education.

'Ethnic Cleansing Bleaches the Atrociites of Genocide'--correction

Richter, E. D., Stanton, G. — Mon, 21 Sep 2009 07:35:32 PDT

Sandra Dawson, Zoe Slote Morris (editors). Future public health.

McCarthy, M. — Mon, 21 Sep 2009 07:35:32 PDT

Raj Bhopal. Concepts of Epidemiology: Integrating the Ideas, Theories, Principles and Methods of Epidemiology

Leyland, A. H — Mon, 21 Sep 2009 07:35:32 PDT

Getting busy doing the right things: a review of Public Health Branding * Evans WD and Hastings G (editors).

Lefebvre, R. C. — Mon, 21 Sep 2009 07:35:32 PDT

European Public Health Association * EUPHA takes first STEPS * 59th Session of the WHO Regional Committee for Europe

Paget, D. Z., Barnhoorn, F. — Mon, 21 Sep 2009 07:35:32 PDT