The European Journal of Public Health - current issue

Public health, the environment and the 21st century: a wider field of vision

McMichael, A. J. — 2008-03-13

A Lisbon agenda on health innovation

Sakellarides, C. — 2008-03-13

Decentralization, re-centralization and future European health policy

Saltman, R. B. — 2008-03-13

Towards Bamako: a European perspective on the global health research agenda

McKee, M., Ricciardi, W. — 2008-03-13

'All under one roof?' differences in food availability and shopping patterns in Southern France and Central England

Pettinger, C., Holdsworth, M., Gerber, M. — 2008-03-13

Background: This study investigates patterns of food shopping and availability of fruit and vegetables and snack foods in a northern European (Central England) and southern European region (Southern France). Methods: Two studies were conducted in England (Nottingham) and France (Montpellier): (i) Cross-sectional population surveys using self-administered postal questionnaires to assess type of outlets used for food shopping in random population samples (England: n = 826; Montpellier: n = 766). (ii) Food availability studies to determine: the number of food outlets in defined comparable geographical areas; the number stocking fruit and vegetables, their quality and energy dense snacks. Results: The English respondents used supermarkets most regularly (P < 0.001), whereas the French preferred to use smaller local shops, such as bakers (P < 0.001), butchers (P < 0.001) and markets (P < 0.001). Overall a larger proportion of outlets in Montpellier than Nottingham sold fresh fruit and vegetables and a wider variety of fresh fruit. However, a range of vegetables and all other types of fruit were as widely available in English shops. Although the quality of fresh fruit and vegetables tended to be better in Montpellier, the difference was not significant. Crisps (P < 0.05) and confectionary items (P < 0.05) were more widely available in England. Conclusions: Food shopping was done ‘under one roof’ more often in England, whereas in France, shopping was done in smaller specialist shops, which was reflected in their presence within the locality. Even though availability of fruit and vegetables was good in both countries, snack foods were more abundant in England. This clearly impacts on the food environment and could explain the higher prevalence of obesity in England, factors which are also influenced by culture, habits and convenience.

Food-allergic consumers' labelling preferences: a cross-cultural comparison

2008-03-13

Background: Recent changes in European food safety legislation have resulted in the implementation of statutory requirements regarding the traceability and labelling of 12 food allergens. This article describes research conducted to establish if current food labelling practices are perceived to be adequate by food-allergic consumers, and whether further policy changes need to be implemented in order to optimize consumer protection. Methods: A total of 40 food-allergic consumers were recruited in both the Netherlands and Greece. Participants were people suffering from one or more of the three most common food-allergies, milk, egg, and/or peanut or tree nut. In a retail environment, participants were given a list of 15 potentially problematic food products which they were asked to buy as if for their own household. The participants were observed during the course of product selection and questioned about specific problems they experienced, as well as information preferences for food allergy information. Results: Participants reported many problems linked to the readability of the label (e.g. font size, contrast). Not all packages contained relevant allergy information, and many participants reported that the ingredients list was insufficient for their needs. Personal experience of particular products was an important factor in the selection process. Dutch participants reported frustration regarding frequent changes in recipes of products available in the supermarket. Conclusions: In general, food-allergic consumers were not satisfied with the current labelling practices. Information was thought to be unclear or insufficient, which resulted in personal stress and feelings of insecurity. Further research is needed to identify how best allergy information might be provided.

Trends in overweight, obesity and blood pressure among Israeli working adults--implications for public health

Sheffer, R., Calderon-Margalit, R. — 2008-03-13

Backgrounds: Reports from the last decade suggest an epidemic of overweight and obesity in Western countries. Since obesity has been associated with increased blood pressure, we aimed to describe the secular trends in overweight and obesity and blood pressure among Israeli working adults. Methods: Two cross-sectional studies were conducted in the setting of the Civil Servant Registry, Tel-Aviv District Health Office, Ministry of Health, Israel, including 1949 adults aged 17–69 years, who entered the Israeli civil service in 1993 and 2002. Results: Compared with other reports, the overall prevalence rate (32.2%) of overweight and obesity was relatively low in our study population, however, an increase of 34% in the odds of being overweight or obese was noted during the study period (adjusted odds ratio: 1.34, 95% CI: 1.09–1.65). Despite this increase, the adjusted mean systolic blood pressure significantly fell from 119.3 (18.2) to 117.0 (14.3) mmHg (P < 0.001) during the 10-year period, and the respective mean diastolic blood pressure declined from 74.5 (9.0) mmHg to 73.2 (9.8) mmHg (P < 0.001). Conclusion: Israel joined the universal trend of increase in overweight and obesity. This study demonstrated a concomitant decline in blood pressure that could not be attributed to antihypertensive treatment. The decrease in blood pressure could partially explain the decrease in cardiovascular morbidity and mortality seen in Israel.

Differences in prevalence of overweight and stunting in 11-year olds across Europe: The Pro Children Study

2008-03-13

Objectives: To assess country differences in prevalence of overweight, obesity, underweight and stunting in the Pro Children Survey. Methods: A cross-sectional study conducted in a random sample of schools in nine European countries in 2003. The subjects were 8317 11-year-old children from Austria, Belgium, Denmark, Iceland, The Netherlands, Norway, Portugal, Spain and Sweden. Parents reported height and weight of the children, and BMI values were analysed using the US Centers of Disease Control and Prevention and the International Obesity Task Force reference populations. Continuous variables were compared with one-way analysis of variance (ANOVA) with Games-Howell post hoc tests. Categorical variables were analysed using chi-square tests. Results: The prevalence of overweight + obesity varied between the countries from 8.6% to 30.6% and 5.9% to 26.5%, respectively, depending on the reference population, with the lowest prevalence in Dutch girls, the highest in Portuguese boys. Obesity prevalence varied from 1.1% (Dutch and Danish girls) to 10.7% (Portuguese boys) and from 0.3% (Dutch girls) to 6.2% (Portuguese boys), respectively. Portugal and Spain had the highest prevalence of overweight and obesity for both genders. The ranking of the countries according to overweight and obesity prevalence was roughly the same, independent of reference population. The prevalence of underweight varied from 2.3% (Swedish boys) to 12.3% (Belgian boys), using the American reference population. The proportion of stunted children was highest in Portugal, Spain and Belgium. Conclusions: The highest levels of overweight, obesity and stunting in the pro children material are found in Portugal and Spain.

Do risk factors explain more of the social gradient in self-reported health when adjusting for baseline health?

Arendt, J. N., Lauridsen, J. — 2008-03-13

Background: It has often been debated the extent to which known risk factors explain socio-economic differences in health. While common in mortality studies, few studies of morbidity adjust for baseline health. In this study, we argue that there are sound reasons to do so, and examine whether a set of risk factors explain a larger part of social gradients in men and women's self-rated health (SRH) in Denmark when controlling for previous health. Methods: We use interval regression models on longitudinal survey data from 1990 and 1995 separately for Danish male and female workers aged 18–59. Results: Large social gradients are found in SRH for both men and women. The included risk factors (smoking, body mass index, high blood pressure and job satisfaction) reduce the educational gradient in SRH by 40% (based on highest versus no education), the wage gradient by 18% and leaves occupational gradients (based on no employment versus white collar workers) unaltered for men. For women, similar gradients are altered by 6 and 22 and 14% in cross-sectional models. Controlling for baseline health 5 years earlier, the risk factors reduce the education, occupation and wage gradients by 45, –15 and 17% for men and by 5, 25 and 15% for women. Conclusion: The findings suggest that common risk factors do not explain a larger fraction of social health inequalities in dynamic than in static models of self-reported health.

Health inequalities among older adults in Sweden 1991-2002

Fors, S., Lennartsson, C., Lundberg, O. — 2008-03-13

Background: Current research has shown a decline in health among older adults in Sweden. This study examines health inequalities among older adults in Sweden in 1991–1992 and 2000–2002 and explores the development of these inequalities during this period. Methods: A data set was constructed out of four levels of living surveys, comprising 4085 individuals aged 55 and above. Multivariate logistic regressions were used to assess the association between social class, sex, age and four different domains of self-reported health: global self-rated health, impaired mobility, musculoskeletal pain and psychological distress. Adjustments were made for period of interview. Interaction terms were also used to assess change over time. Levin's attributable risk was used to assess the magnitude of the health inequalities. Results: The results indicate an increase in reports of all specific health problems, but not in the global health measure during the period. Significant sex differences and a clear social gradient in health were discernible during both periods. Women were more likely than men to report problems with impaired mobility, pain and psychological distress. Manual workers were significantly more likely than non-manuals to report problems in all four domains of health. However, both the sex differences and the social gradient seemed to remain constant during the period. Conclusion: Although it seems there are significant differences in health depending on sex and social class among older adults in Sweden, these inequalities appear to be unaffected by the general increase in ill health that has been observed in these groups over the last decade.

Induced abortion in Denmark: effect of socio-economic situation and country of birth

Rasch, V., Gammeltoft, T., Knudsen, L. B., Tobiassen, C., Ginzel, A., Kempf, L. — 2008-03-13

Background: Equal access to health care is considered a key in Scandinavian healthcare policy. However, problematic differences between the socio-economic situation of immigrants and that of native Scandinavians are increasingly challenging this aspect of the Scandinavian welfare model. The present study focuses on how socio-economic characteristics and country of birth are associated with induced abortion. Methods: A structured questionnaire was used to collect information among 1351 women requesting abortion and a control group of 1306 women intending birth. Results: The strongest factor associated with the decision to have an abortion was being single (OR 39.1; 23.8–64.2), followed by being aged 19 years or below (OR 29.6; 13.4–65.5), having two children or more (OR 7.05; 5.29–9.39) and being unskilled (OR 2.48; 1.49–4.10), student (OR 2.29; 1.52–3.43) or unemployed (OR 1.65; 1.11–2.46). When evaluating the effect of social exposure on abortion among Danish-born and foreign-born women, the higher rate of abortion among non-Westerners was found to be caused by the composition of non-Westerners more often being unemployed, having a low income and having two or more children rather than the fact that they are coming from a non-Western country. Conclusion: Immigrant women comprise a vulnerable group, with a poor socio-economic status. This situation exposes immigrant women to increased risk of induced abortion. In a society with an increasing heterogeneous population, the vulnerable situation of immigrant women has to be addressed, if equal access to health care is to be maintained.

Selective international migration by social position, health behaviour and personality

2008-03-13

Background: Immigrants is an important minority in many countries, but little is known how they are self-selected. We analysed differences in psycho-social and health behavioural factors between international migrants and non-migrants prior to migration in a large cohort of Finnish twins. Methods: A questionnaire was sent to Finnish twins in 1975 (response rate 89%, N = 26555 twin individuals). Follow-up data on migration and mortality were derived from population registries in Finland and Sweden up to 31 March 2002. In 1998, another questionnaire was sent to Finnish twins migrated to Sweden and their co-twins (response rate 71%, N = 1534 twin individuals). The data were analysed using Cox and conditional logistic regression models. Results: Life dissatisfaction, higher alcohol use and smoking at baseline predicted future migration. In men additionally, unemployment, neuroticism and extroversion increased the probability to migrate. Similar associations were found for alcohol use in men and smoking in men and women within twin pairs discordant for migration. Twins also reported retrospectively that prior to migration the migrated twin had been less satisfied with his/her educational institution or job and was generally less satisfied with life, used more alcohol (men) and smoked more (women) than the co-twin stayed in Finland. Conclusion: Migrants are self-selected by health behavioural and personality factors, which may compromise their health. The special requirements of migrants should be recognized in health care.

Discrimination, mental problems and social adaptation in young refugees

Montgomery, E., Foldspang, A. — 2008-03-13

Background: Mental problems have been hypothesized to impede social adaptation and vice versa, and discrimination is assumed to interact with both. The available empirical documentation is, however, limited. The objective of this study is to contribute to a more comprehensive understanding of associations and pathways between discrimination, mental problems and social adaptation in young refugees. Methods: Structural Equation Modelling (SEM) was used for the analysis of cross-sectional data from interviews with 131 young Middle Eastern refugees residing in Denmark. Results: Participants reported a mean of 1.8 experiences of discrimination, and the prevalence of five indicators of positive social adaptation was 47–92%. Discrimination, mental problems and social adaptation were strongly mutually associated, without gender difference. Discrimination predicted internalizing behaviour. Improved social adaptation correlated negatively with discrimination and with externalizing and internalizing behaviour. Conclusion: Perceived discrimination among young refugees from the Middle East is associated with mental problems and social adaptation. Discrimination seems to provoke internalizing but not externalizing behaviour. The direction of other pathways is ambiguous, suggesting a certain amount of recursive interaction between mental health, discrimination and social adaptation.

Invasive cervical cancer: a failure of screening

Spayne, J., Ackerman, I., Milosevic, M., Seidenfeld, A., Covens, A., Paszat, L. — 2008-03-13

Background: Cervical screening is an effective prevention measure. It is unclear whether cervical cancer results from non-participation in screening or from failures in detection by screening. Analysis of the screening history of patients with cervix cancer may contribute to understanding failures in prevention. Methods: A cohort of patients presenting during 1 year was identified. Dates and results of cervical smears in the 4 years prior to presentation were extracted from a screening database. Patients were grouped as follows: ‘No screening’—no Pap records; ‘Pre-diagnostic’—one or more Pap tests within 6 months of presentation; ‘Sporadic screening’—one Pap test between 6 and 48 months prior to presentation; and ‘Regular screening’—at least two Pap tests 6–48 months before presentation. Results: 225 patients were identified (median age: 48 years, range 25–107). Eighty- eight had no records of screening; a further 66 were categorized as pre-diagnostic. These two groups (68% of incident cases) were considered not to have participated in routine screening. A further 15% had sporadic screening tests, but only 37 patients (16%) had evidence of regular screening. Clinically, 53, 41 and 6% presented with early, locally advanced and metastatic disease, respectively. Older patients (>50 years) were more likely to present with advanced disease (61 vs 37% at least Stage II). Conclusions: These results suggest that the failure to prevent invasive cervix cancer in this population can largely be attributed to failures in recruitment for screening.

Population health and the health system: a comparative analysis of avoidable mortality in three nations and their world cities

Weisz, D., Gusmano, M. K., Rodwin, V. G., Neuberg, L. G. — 2008-03-13

Background: Access to timely and effective medical services can reduce rates of premature mortality attributed to certain conditions. We investigate rates of total and avoidable mortality (AM) and the percentage of avoidable deaths in France, England and Wales and the United States, three wealthy nations with different health systems, and in the urban cores of their world cities, Paris, Inner London and Manhattan. We examine the association between AM and an income-related variable among neighbourhoods of the three cities. Methods: We obtained mortality data from vital statistics sources for each geographic area. For two time-periods, 1988–90 and 1998–2000, we assess the correlation between area of residence and age- and gender-adjusted total and AM rates. In our comparison of world cities, regression models are employed to analyse the association of a neighbourhood income-related variable with AM. Results: France has the lowest mortality rates. The US exhibits higher total, but similar AM rates compared to England and Wales. Rates of AM are lowest in Paris and highest in London. Avoidable mortality rates are higher in poor neighbourhoods of all three cities; only in Manhattan is there a correlation between the percentage of deaths that are avoidable and an income related variable. Conclusions: Beyond the well-known association of income and mortality, persistent disparities in AM exist, particularly in Manhattan and Inner London. These disparities are disturbing and should receive greater attention from policy makers.

Coverages and factors associated with influenza vaccination among subjects with chronic respiratory diseases in Spain

2008-03-13

Background: The main influenza complications particularly affect patients over the age of 65 years and those with associated chronic diseases, such as respiratory disorders. This study aims to assess vaccination coverage among Spanish children and adults with chronic respiratory diseases (CRDs), and to describe the factors associated with vaccination in 2003. Methods: We analysed 28 113 records of individuals (6869 children and 21 244 adults) included in the Spanish National Health Survey (NHS) for 2003. As a dependent variable, we used the reply (‘yes’ or ‘no’) to the question: ‘Did you have a ‘flu shot in the latest campaign?’ We calculated influenza vaccine coverage as the percentage of individuals with a respiratory disorder (asthma and/or chronic bronchitis and/or emphysema) who reported having been vaccinated against influenza in the most recent campaign. We analysed the influence of sociodemographic, health-status, medical visits and lifestyle variables on vaccination. Results: Vaccination coverage was 19.9% in children and 54.7% in adults suffering CRD. In both age groups, coverages were significantly higher than those observed for non-CRD sufferers. Among adults, older age, not smoking and medical visits to their physician in the preceding 2 weeks were the variables independently and significantly associated with a higher likelihood of receiving the vaccine. Among children, financial factors influence vaccination. Conclusions: Vaccination coverage among children with CRDs is very low. Also among adult CRD sufferers, vaccination remains below the desired level, thereby making it necessary for strategies to be implemented aimed at improving the use of influenza vaccine.

Health indicators in the European regions--ISARE II

2008-03-13

Background: Most comparisons of health data in Europe take place at the national level. However, there is increased interest in looking at health data at a sub-national level. This is because of the increased importance in many European countries, of regions and devolved powers to them. This study aimed to establish the availability of health data at a regional level and to construct an experimental database. Methods: Using a network of country correspondents, data were collected on a series of topics from all the regions of that country. In addition, a supplementary list of data was collected from one region of each country. Results: Out of the then 15 Member States of the European Union (EU), 14 countries participated in the study. Thirteen countries were able to supply data. Where data were available, using the criteria we developed, these were of relatively good quality. Data on mortality was most readily available, but data on the important public health topics such as obesity was much more difficult to obtain, and absent in many cases. Conclusions: It is possible to construct a database and a resultant set of indicators for relevant sub-national areas of Member States in the EU. This is not likely to be achieved through current routine data collection systems unless significant changes are made to the data collection processes such as those undertaken by Eurostat. There is, also, an urgent need to introduce comprehensive sub-national data collections on important public health topics such as obesity and smoking.

Imported malaria in children: a national surveillance in the Netherlands and a review of European studies

Driessen, G. J., Pereira, R. R., Brabin, B. J., Hartwig, N. G. — 2008-03-13

Background: Falciparum malaria or malaria tropica is one of the leading causes of childhood mortality worldwide. Malaria-related deaths occur mainly in sub-Saharan Africa, where an estimated 365 million clinical cases of Plasmodium falciparum malaria occur each year. In Europe, imported malaria cases occur due to returning travellers or immigration mostly from African countries. Children are more at risk than adults. The objective of this study was to identify high risk groups for imported childhood malaria in Europe in order to guide development of strategies for prevention, early recognition and management. Methods: In the period May 2003–January 2005 we reviewed all cases of paediatric malaria in the Netherlands notified by the Dutch Paediatric Surveillance System (Nederland Signalerings Centrum Kindergeneeskunde, NSCK) and the literature on imported malaria in children in Europe published between 1996 and 2006. Results: Malaria occurred mainly in children of long-term (n = 15, 47%) and new (n = 8, 25%) immigrants and was mostly acquired in sub-Saharan Africa. The dominant species was P. falciparum. Only one quarter of children had used adequate malaria chemoprophylaxis. Complicated disease occurred in 10 (31%) of cases. We also reviewed the literature and found 6082 reported cases of imported malaria among children in Europe; among these, four died and only one was reported to develop neurological sequelae. Conclusion: Imported malaria in children remains an important problem and is unlikely to decrease unless the reasons for inadequate prophylaxis are addressed.

The effect of non-response on estimates of health care utilisation: linking health surveys and registers

Gundgaard, J., Ekholm, O., Hansen, E. H., Rasmussen, N. Kr. — 2008-03-13

Background: Non-response in health surveys may lead to bias in estimates of health care utilisation. The magnitude, direction and composition of the bias are usually not well known. When data from health surveys are merged with data from registers at the individual level, analyses can reveal non-response bias. Our aim was to estimate the composition, direction and magnitude of non-response bias in the estimation of health care costs in two types of health interview surveys. Methods: The surveys were (1) a national personal interview survey of 22 484 Danes (2) a telephone interview survey of 5000 Danes living in Funen County. Data were linked with register information on health care utilisation in hospitals and primary care. Health care utilisation was estimated for respondents and non-respondents, and the difference was explained by a decomposition method of bias components. Results: The surveys produced the same pattern of non-response, but with slight differences in non-response bias. Response rates for the interview and telephone surveys were 75 and 69%, respectively. Refusal was the most frequent reason for non-response (22 and 20% of those sampled, respectively), whereas illness, non-contact, and other reasons were less frequent. Respondents used 3–6% less health care than non-respondents at the aggregate level, but the opposite was true for some specific types of health care. Non-response due to illness was the main contributor to non-response bias. Conclusions: Different types of non-response have different bias effects. However, the magnitude of the bias encourages the continued use of interview health surveys.

Sensitivity analysis in summary measure of population health in France

Lapostolle, A., Lefranc, A., Gremy, I., Spira, A. — 2008-03-13

Background: The aim of this study is to provide estimates of the French burden of disease, using the WHO Global Burden of Disease methodology and to perform sensitivity analysis on different set of mortality data. Methods: The burden of disease is measured by disability-adjusted life years (DALYs) that take into account both mortality and morbidity data. Results were obtained using French mortality data for the years 2000 and 2001 and morbidity data estimated by WHO for France. Sensitivity analyses were conducted using different mortality data sets and various life tables as mortality norms. Calculations were also performed with and without discounting and age-weighting. Results: In France, the annual burden of disease was about 12.4 million DALYs. Depending on the mortality data set and the choice of social values used for calculation, results could be quite different. The use of WHO estimates for mortality resulted in an underestimation of 2.6% of total DALYs with respect to French data. Changes of the mortality norm imply changes in the number of years of life lost (YLLs), whereas the use of discounting and age-weighting mainly modifies the ranking of diseases. Conclusion: DALYs constitute a summary measure of population health, which is a powerful tool for the grading of health problems, allowing to compare fatal and non-fatal diseases. Nevertheless, the validity of results obtained depends primarily on the validity of the input data. Collecting morbidity data (mainly incidence) at the national level is hence an important step in order to assess more accurately the specific burden of diseases in France.

Reporting of diabetes on death certificates of 1872 people with type 2 diabetes in Tayside, Scotland

Evans, J. M. M., Barnett, K. N., McMurdo, M. E. T., Morris, A. D. — 2008-03-13

Background: It has been suggested that diabetes is under-recorded on death certificates. Methods: We examined the death certificates of 1,872 people with type 2 diabetes in Tayside, Scotland, to determine how frequently diabetes was recorded. Results: Diabetes was mentioned on the certificates of 42.8% and was the underlying cause of death for 6.4%. There was mention of diabetes for 51.3% of the 811 people for whom cardiovascular disease was the underlying cause of death. Being male was associated with less frequent mention of diabetes, with more frequent mention associated with increasing duration of diabetes, increasing age and underlying cardiovascular cause of death. Conclusions: This study highlights the limitations of using routine mortality data for monitoring the burden of diabetes in populations.

'Ethnic cleansing' bleaches the atrocities of genocide

Blum, R., Stanton, G. H., Sagi, S., Richter, E. D. — 2008-03-13

Genocide has been the leading cause of preventable violent death in the 20th–21st century, taking even more lives than war. The term ‘ethnic cleansing’ is used as a euphemism for genocide despite it having no legal status. Like ‘Judenrein’ and ‘racial hygiene’ in Nazi medicine, it expropriates pseudo-medical terminology to justify massacre. Use of the term reifies a dehumanized view of the victims as sources of filth and disease, and propagates the reversed social ethics of the perpetrators. Timelines for recent genocides (Bosnia, 1991–1996, 200 000; Kosovo 1998–2000, 10 000–20 000; Rwanda, 1994, 800 000; Darfur 2002–2006, >400 000) show that its use bears no relationship to death tolls or the scale of atrocity. Bystanders’ use of the term ‘ethnic cleansing’ signals the lack of will to stop genocide, resulting in huge increases in deaths, and undermines international legal obligations to acknowledge genocide. The term ‘ethnic cleansing’ corrupts observation, interpretation, ethical judgment and decision-making, thereby undermining the aim of public health. Public health should lead the way in expunging the term ‘ethnic cleansing’ from official use. ‘Ethnic cleansing’ bleaches the atrocities of genocide, leading to inaction in preventing current and future genocides.

Response to Hayden: Comment on 'ethnic cleansing' and 'genocide'

Richter, E. D., Stanton, G. H. — 2008-03-13

EUPHA President's column: equity, solidarity and EUPHA * NEWS from EUPHA office: EUPHA-ASPHER collaboration: taking friendship one step further * The Intergovernmental Working Group on Public Health, Innovation and Intellectual Property (IGWG)

Keskimaki, I., Paget, D. Z. — 2008-03-13