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M. Moore will present the solutions and next steps highlighted in WFPHA position paper to create a sense of ownership by all health professionals to align their efforts and advocacy for equitable and effective immunization.

Background The continued prevalence of positive samples to banned performance-enhancing drugs confirms the importance to maintain the anti-doping efforts. Though the role of socio-cognitive variables in doping attitudes is well identified (e.g., Ntoumanis et al., 2014), the role of implicit processes remains sparsely studied in sports’ doping, especially in high level cyclists. While the potential of traditional computer-IAT has been developed to capture individuals’ implicit attitudes toward doping (Brand et al., 2014ab; Schindler et al., 2015), paper-and-pen IAT offers unquestionably ease-of-administration prospects (Chan and al., 2017). The aim of this study was thus to test and provide a preliminary validation of a French paper-and-pen IAT as an alternative method to measure implicit attitudes toward doping: the IAT-Dop. Method This work was based on the testing procedure of the paper-and-pen Personalized Single-Category IAT test (i.e., p&p SC-IAT-P) of Bardin et al. (2016), which we enriched with the procedure of Boateng et al. (2018). This paper was built around four studies: (a) the first study consisted in the development of a preliminary version of the IAT-Dop, (b) the second study measured the dimensionality and criterion validity of the IAT-Dop to confirm the structure of the p&p version, (c) the third study verified its test-retest reliability, and (d) the fourth study explored the relations between the p&p and computerized versions of the IAT-Dop as a first approach to construct validity. Results Study 1 developed a preliminary French version of the IAT-Dop based on Chan et al.’s IAT proposal (2017). Study 2 provided preliminary support to the dimensionality and criterion validity of the tool. Study 3 demonstrated the test-retest reliability of the instrument. Finally, Study 4 suggested the construct validity of the IAT-Dop through a significant correlation between the computerized and p&p versions. Conclusion The IAT-Dop is a preliminary tested French-language version of a tool for measuring athletes’ implicit attitudes toward doping, with the advantages of simplicity, low cost, and quick administration. This tool should contribute to the better assessment and understanding of the mechanisms related to doping and may be a useful new indicator in the evaluation of prevention programs.

Background In Denmark, undocumented immigrants have restricted access to health care including maternity care. Nordic studies describe that undocumented immigrant women face many barriers to access maternity care during pregnancy however, literature in a Danish setting is lacking. This study aims at exploring undocumented immigrant women's experience of and their access to maternity care services in Denmark. Methods The study setting was a non-governmental Health Clinic in Denmark, that provides primary health care, including maternity care, to undocumented immigrants. We recruited 21 undocumented immigrant women, conducted semi-structured interviews from 01.2018 to 01.2019. The data was analyzed through systematic text condensation. Results Undocumented immigrant women experience several barriers to access maternity care services in Denmark. We identified four themes with subthemes. i) Access to public maternity care services; the experiences with public maternity care providers, fear of deportation and concerns about having to pay for care. ii) Use of private and non-governmental maternity care services; the feeling of being safe at the Health Clinic, reaching care is challenged by logistics and choosing to pay for private health care services. iii) Perception of entitlements to care; wishing for a fair treatment, and uncertainty of what to expect when reaching a public health care facility. iv) Being dependent; dependency on the Health Clinic, social support from network and seeking information from other sources. Conclusions Our findings contribute with insights to understand the health behavior of undocumented immigrant women. Accessing public maternity care services is, apart from legal restrictions, dominated by fear of being reported to the immigration authorities, concerns about payment, and the management of rules from the health provider's perspective. Many of them depend on the Health Clinic as well as their personal networks for care and protection. Key messages Undocumented immigrant women face many barriers to access maternity care services. Inclusive policies for access to maternity care are needed to safeguard the health of the women and children.

Background Many studies on readability have shown that patient information is written at the reading level too high for the average population. It is particularly important for patients in hospitals when they are signing informed consent for certain diagnostic procedure and surgical treatment. The aim of this study was to determine the reading level of patient to understand information on written informed consent used in clinical hospital in Croatian language. Methods The study was done in four clinical hospitals in Zagreb, Croatia. SMOG (Simple Measure Of Gobbledegook) formula, as one of the standard methodology to test the readability of written materials, was used. SMOG formula was adapted to the Croatian language. The adaptation was based on the results of the comparation between the core vocabularies of English, based on Brown Corpus and of Croatian language, based on the Croatian National Corpus. SMOG formula was applied on 34 different written information given to patients to be signed before diagnostic and/or surgical procedures. Results The obtained SMOG readability grades for patient information ranged from 11 to 14, with the mean of 12, 7. With reading ability of the population being below the years of school completed, we may estimate that at least 75% of the adult population in Croatia would not understand the information tested in this study. Conclusions The SMOG readability grades obtained in this study indicate to a very complex writing not adapted to the reading ability of the general population. Writers of patient information on written informed consent should be aware of the limited reading ability of patients, test materials with intended readers and adopt their materials. Key messages Adequate readability of written materials is important for documents which will guarantee the active role of patients in making health decisions. This should decrease the health inequalities and improve health communication and health literacy.

Studies from several countries have shown that the COVID-19 pandemic has disproportionally affected migrants. Many have numerous risk factors making them vulnerable to infection and poor clinical outcome. Policies to mitigate this effect need to take into account public health principles of inclusion, universal health coverage and the right to health. In addition, the migrant health agenda has been compromised by the suspension of asylum processes and resettlement, border closures, increased deportations and lockdown of camps and excessively restrictive public health measures. International organizations including the World Health Organization and the World Bank have recommended measures to actively counter racism, xenophobia and discrimination by systemically including migrants in the COVID-19 pandemic response. Such recommendations include issuing additional support, targeted communication and reducing barriers to accessing health services and information. Some countries have had specific policies and outreach to migrant groups, including facilitating vaccination. Measures and policies targeting migrants should be evaluated, and good models disseminated widely.

There has been an unprecedented global effort by researchers from many disciplines to obtain and synthesize knowledge to inform policy responses to SARS-CoV-2. While many major advances have been made in generating and applying knowledge on a pandemic caused by a novel pathogen, some things could have been done better, as revealed by the devastating loss of life and economic impact on livelihoods and communities. We reflect on the context in which the pandemic emerged, characterized by underinvestment in public health and growing distrust in institutions, followed by an overview of three broad areas: generation of new knowledge, synthesis of existing knowledge, both what was known prior to the pandemic and what emerged during it, and the challenges of translating knowledge into policy. We also consider areas that were largely overlooked in the research effort. Across all areas, we aim to draw out relevant lessons for future research and public health practice.

Background As digitalization is progressively permeating all aspects of society, how can be it fruitfully employed to sustain the public health goals of quality, accessibility, efficiency and equity in health care and prevention? In this paper, we reflect on the potential of applying digital tools to public health and discuss some key challenges. Methods We first define ‘digitalization’ in its broader sense, as well as applied to public health. We then build a conceptual framework where key public health domains are associated to available digital technologies in a matrix that help to identify digital features that bolster public health action. We also provide illustrative data and evidence on the application of digital solutions on selected public health areas. In the second part, we identify the strategic pillars for a successful European strategy for public health digitalization and we outline how the approach being pursued by the European Public Health Association (EUPHA) applies to digital health. Results From a public health perspective, digitalization is being touted as providing several potential benefits and advantages, including support for the transition from cure to prevention, helping to put people and patients at the center of care delivery, supporting patient empowerment and making healthcare system more efficient, safer and cheaper. These benefits are enabled through the following features of digital technologies: (i) Personalization and precision; (ii) Automation; (iii) Prediction; (iv) Data analytics and (v) Interaction. Conclusion A successful European strategy for public health digitalization should integrate the following pillars: political commitment, normative frameworks, technical infrastructure, targeted economic investments, education, research, monitoring and evaluation. EUPHA acknowledges digitalization is an asset for public health and is working both to promote the culture of “public health digitalization”, as well as to enable its planning, implementation and evaluation at the research, practice and policy level.

Background Advertising, promotion and sponsorship of electronic cigarettes (ECAPS) have increased in recent years. Since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) prohibits ECAPS in various advertising channels, including media that have cross-border effects. The objective of this study was to investigate changes in exposure to ECAPS in a cohort of smokers from six European Union member states after implementation of TPD2. Methods Self-reported exposure to ECAPS overall and in various media and localities was examined over two International Tobacco Control Policy Evaluation survey waves (2016 and 2018) in a cohort of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal generalized estimating equations models. Results Self-reported ECAPS exposure at both timepoints varied between countries and across examined advertising channels. Overall, there was a significant increase in ECAPS exposure [adjusted odds ratio (aOR): 1.25, 95% CI: 1.09–1.44]. Between waves, no consistent patterns of change in ECAPS exposure across countries and different media were observed. Generally, ECAPS exposure tended to decline in some channels regulated by TPD2, particularly on television and radio, while exposure tended to increase in some unregulated channels, such as at points of sale. Conclusions The findings suggest that the TPD2 was generally effective in reducing ECAPS in regulated channels. Nonetheless, further research is warranted to evaluate its role in reducing ECAPS exposure, possibly by triangulation with additional sources of data.

The European Tobacco Products Directive (TPD) introduced a ban on characterizing flavours in cigarettes (2016), including menthol (2020). The longitudinal data analysis of the EUREST-PLUS International Tobacco Control (ITC) Project Europe Surveys (n = 16 534; Wave 1 in 2016 and Wave 2 in 2018) found significant but small declines in the weighted prevalence of menthol (by 0.94%; P = 0.041) and other flavoured cigarette use (by 1.32%; P

BackgroundThe European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design.MethodsData from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented).ResultsThere was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands.ConclusionsFindings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD.

BackgroundThe 2016 European Tobacco Products Directive (TPD) required Member States (MS) to implement new regulations for electronic cigarettes (ECs). We conducted a longitudinal study to assess changes over 2 years in smokers’ support for EC policies and identify predictors of support in seven European countries after TPD implementation.MethodsProspective cohort surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain and England in 2016 (n = 9547; just after TPD) and 2018 (n = 10 287; 2 years after TPD). Multivariable logistic regression models employing generalized estimating equations assessed changes in support for four EC policies, and tested for country differences and strength of key predictors of support.ResultsBanning EC use in smoke-free places was supported by 53.1% in 2016 and 54.6% in 2018 with a significant increase in Greece (51.7–66.0%) and a decrease in Spain (60.1–48.6%). Restricting EC/e-liquid nicotine content was supported by 52.2 and 47.4% in 2016 and 2018, respectively, with a significant decrease in England (54.2–46.5%) and Romania (52.5–41.0%). An EC promotion ban was supported by 41.1 and 40.2%. A flavour ban was supported by 33.3% and 32.3% with a significant increase in Hungary (34.3–43.3%). Support was generally higher in Poland, Hungary and Greece vs. England. Support was lower among dual and EC-only users, and low-income smokers.ConclusionsSmokers in all countries strongly supported banning EC use in smoke-free places and restricting nicotine content after TPD implementation, with no clear trends for changes in policy support.

In this article, we examine the essential role of law in achieving the health-related Sustainable Development Goals (SDGs). Following the World Health Organization’s broad definition of health, all SDGs can be seen to impact on human health and hence the health goal (SDG3) should be right at the centre of the entire 2030 Agenda for Sustainable Development. We note recent research on the contribution of law, including international human rights law, to achieving health for all and discuss the role of law in addressing seven emerging health challenges. Law can and should play an important role in achieving all health-related SDGs, by respecting, protecting and fulfilling the right to health, ensuring that no one is left behind.

The 2030 Agenda for the Sustainable Development Goals (SDGs) represents a common framework of international cooperation to promote sustainable development. Nutrition is the key point for the SDG 2 ‘End hunger, achieve food security and improved nutrition and promote sustainable agriculture’ and is an essential component for achieving many of the other targets: overall, the nutritional aspects of the SDGs aim to promote healthy and sustainable diets and ensure food security globally. While undernutrition is of minimal concern in the European Union Member States, trends in childhood obesity are still alarming and far from any desirable target. European food production systems have improved over the last years, with immediate impact on several environmental aspects; however, a comprehensive regulatory framework to fulfil the environmental and climate targets is still lacking. Policy actions at multinational level are needed to achieve global nutrition targets designed to guide progress towards tackling all forms of malnutrition while preserving the environment through virtuous food production and food systems.

In 2015, the world’s governments committed, in the Sustainable Development Goals (SDGs), to achieve universal health coverage by 2030, something they will be held accountable for. We examine progress in the WHO European Region using data from several sources. We assess effective coverage using data from the Global Burden of Disease Programme, including access to 9 key interventions for maternal and child health and communicable and non-communicable diseases and mortality from 32 conditions amenable to health care. Progress is mixed; while Finland and Iceland have already achieved the 2030 target already, other countries, including in the Caucasus and Central Asia have not yet, and are unlikely to by 2030. We then examine financial protection, where progress lags in Central and South East Europe and the former Soviet Union, where high out-of-pocket healthcare payments and catastrophic spending are still common. We stress the need to consider inequalities within countries, with the most vulnerable groups, such as Roma or newly arrived migrants (from the Middle East and Africa) often underserved, while their needs are frequently undocumented. To make progress on the SDGs, governments must invest more heavily in health services research and support the infrastructure and capacity required to enable it.

The adoption of the 2030 Agenda for Sustainable Development in 2015 opened new opportunities to work towards healthy environments through ‘whole of government’ and ‘whole of society’ approaches. It created a strong policy platform that acknowledges health as a result and an enabler of sustainable policies across all sectors of government. Five years into the process, an initial analysis of emerging trends indicates that, despite some encouraging developments in policy as well as overall progress in economy and technology, there remains a gap between rhetoric, ambition and reality. In particular, the monitoring system for environment and health-related sustainable development goals (SDGs) and targets requires further development; inequalities in environment and health persist and in some areas have increased; equity is not yet a central element of implementation and reporting on the achievement of the SDGs; and, most worrying of all, trends in key environmental indicators that are vital to the survival of the human species, such as those related to climate change and biodiversity, are still on an overall negative path. In summary, governments must significantly and rapidly increase action to secure the habitability and safety of planet Earth. The public health community assumes an unprecedented role in placing and maintaining health and equity at the heart of the political agenda. This demands new governance models conferring on the health sector a clear mandate and legitimacy to operate across sectors. It also requires enhancing capacities among health professionals to embrace this new level of complexity, understand the multiple links between sectoral policies and health, and successfully engage with other government sectors and stakeholders.

The Sustainable Development Goals (SDGs) are a set of goals that aspire to ‘leave no one behind’, adopted by all members of the United Nations and to be achieved by 2030. Now, four years after the SDGs entered into force, we examine the progress towards the health-related SDGs in the European region. In this region, least progress is made towards the targets set for alcohol consumption, smoking prevalence, child overweight, and suicide mortality. For each of these challenges we take stock of current policies, continuing challenges, and ways forward. Written from the perspective of European Public Health Association (EUPHA) we emphasize the potential contribution of civil society organizations in attaining the health-related SDGs.

Background Forty-three out of 53 of the WHO European Member States have set up political and institutional mechanisms to implement the United Nations (UN) 2030 Agenda for Sustainable Development. This includes governance and institutional mechanisms, engaging stakeholders, identifying targets and indicators, setting governmental and sectoral priorities for action and reporting progress regularly. Still, growing evidence suggests that there is room for advancing implementation of some of the Sustainable Development Goals (SDGs) and targets at a higher pace in the WHO European Region. This article proposes the E4A approach to support WHO European Member States in their efforts to achieve the health-related SDG targets. Methods The E4A approach was developed through a 2-year, multi-stage process, starting with the endorsement of the SDG Roadmap by all WHO European Member States in 2017. This approach resulted from a mix of qualitative methods: a semi-structured desk review of existing committal documents and tools; in-country policy dialogs, interviews and reports; joint UN missions and discussion among multi-lateral organizations; consultation with an advisory group of academics and health policy experts across countries. Results The E—engage—functions as the driver and pace-maker; the 4 As—assess, align, accelerate and account—serve as building blocks composed of policies, processes, activities and interventions operating in continuous and synchronized action. Each of the building blocks is an essential part of the approach that can be applied across geographic and institutional levels. Conclusion While the E4A approach is being finalized, this article aims to generate debate and input to further refine and test this approach from a public health and user perspective.