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Background: Within the European Union (EU), substantial efforts are being made to achieve economic and social cohesion, and the reduction of health inequalities between EU regions is integral to this process. This paper is the first to examine how self-reported conditions and non-communicable diseases (NCDs) vary spatially between and within countries. Methods: Using 2014 European Social Survey (ESS) data from 20 countries, this paper examines how regional inequalities in self-reported conditions and NCDs vary for men and women in 174 regions (levels 1 and 2 Nomenclature of Statistical Territorial Units, 'NUTS'). We document absolute and relative inequalities across Europe in the prevalence of eight conditions: general health, overweight/obesity, mental health, heart or circulation problems, high blood pressure, back, neck, muscular or joint pain, diabetes and cancer. Results: There is considerable inequality in self-reported conditions and NCDs between the regions of Europe, with rates highest in the regions of continental Europe, some Scandinavian regions and parts of the UK and lowest around regions bordering the Alps, in Ireland and France. However, for mental health and cancer, rates are highest in regions of Eastern European and lowest in some Nordic regions, Ireland and isolated regions in continental Europe. There are also widespread and consistent absolute and relative regional inequalities in all conditions within countries. These are largest in France, Germany and the UK, and smallest in Denmark, Sweden and Norway. There were higher inequalities amongst women. Conclusion: Using newly available harmonized morbidity data from across Europe, this paper shows that there are considerable regional inequalities within and between European countries in the distribution of self-reported conditions and NCDs. [ABSTRACT FROM AUTHOR]

Background: It has been suggested that cross-national variation in educational inequalities in health outcomes (e.g. NCDs) is due to cross-national variation in risky health behaviour. In this paper we aim to use highly recent data (2014) to examine educational inequalities in risky health behaviour in 21 European countries from all regions of the continent to map cross-national variation in the extent to which educational level is associated with risky health behaviour. We focus on four dimensions of risky health behaviour: smoking, alcohol use, lack of physical activity and lack of fruit and vegetable consumption. Methods: We make use of recent data from the 7th wave of the European Social Survey (2014), which contains a special rotating module on the social determinants of health. We performed logistic regression analyses to examine the associations between educational level and the risky health behaviour indicators. Educational level was measured through a three-category version of the harmonized International Standard Classification of Education (ISCED). Results: Our findings show substantial and mostly significant inequalities in risky health behaviour between educational groups in most of the 21 European countries examined in this paper. The risk of being a daily smoker is higher as respondents' level of education is lower (Low education (L): OR = 4.24 (95% CI: 3.83^.68); Middle education (M): OR = 2.91 (95% CI: 2.65-3.19)). Respondents have a lower risk of consuming alcohol frequently if they have a low level of education (L: OR = 0.59 (95% CI: 0.54-0.64); M: OR = 0.70 (95% CI: 0.65-0.76)), but a higher risk of binge drinking frequently (L: OR = 1.29 (95% CI: 1.16-1.44); M: OR = 1.15 (95% CI: 1.04-1.27)). People are more likely to be physically active at least 3 days in the past week when they have a higher level of education (M: OR = 1.42 (95% CI: 1.34-1.50); H: OR = 1.67 (95% CI: 1.55-1.80)). Finally, people are more likely to consume fruit and vegetables at least daily if they have a higher level of education (fruit: M: OR = 1.09 (95% CI: 1.03-1.16); H: OR = 1.77 (95% CI: 1.63-1.92); vegetables: M: OR = 1.34 (95% CI: 1.26-1.42); H: OR = 2.35 (95% CI: 2.16-2.55)). However, we also found considerable cross-national variation in the associations between education and risky health behaviour. Conclusions: Our results yield a complex picture: the lowest educational groups are more likely to smoke and less likely to engage in physical activity and to eat fruit and vegetables, but the highest educational groups are at greater risk of frequent alcohol consumption. Additionally, inequalities in risky health behaviour do not appear to be systematically weakest in the South or strongest in the North and West of Europe. [ABSTRACT FROM AUTHOR]

Background To address social inequalities in adolescent substance use and consequent disparities in health, it is important to identify the mechanisms of the association between substance use and academic performance. We study the role of health literacy (HL) in the association between academic performance and weekly smoking, monthly alcohol use and cannabis ever-use among adolescents in Europe. Methods SILNE-R school survey data, which was collected in 2016–17 with paper-and-pencil-method from Hanover (GE), Amersfoort (NL) and Tampere (FI), were used (N  = 5088, age 13–19). Health Literacy for School-aged Children instrument was used to assess students' HL. Logistic regression analyzed the association of substance use with academic performance and HL, separately and in the same model. Linear and multinomial logistic regression analyzed the association between academic performance and HL. Results Poor academic performance compared with high was associated with smoking [odds ratio (OR) 3.94, 95% confidence interval (CI) 2.83–5.49], alcohol use (OR: 2.94, 95% CI: 2.34–3.68) and cannabis use (OR: 2.56, 95% CI: 1.89–3.48). Poor HL was also associated with each substance use (with ORs of 2.32, 1.85 and 1.29). HL was positively associated with academic performance (β = 1.04, 95% CI: 0.89–1.20). The associations between academic performance and substance use were only slightly attenuated after controlling for HL. Conclusions Academic performance and HL were both determinants of substance use, confirming their role in tackling the disparities in substance use. However, HL did not demonstrably mediate the association between academic performance and substance use. A wider set of factors needs to be tackled to address emerging social inequalities in adolescent substance use. [ABSTRACT FROM AUTHOR]

Background: Impaired glucose regulation represents an opportunity to prevent Type 2 diabetes mellitus. It is important to have a clear understanding of the prevalence of this condition in order to be able to plan interventions and health care provision. This paper presents a meta-analysis of literature assessing the prevalence of impaired glucose regulation in the general population of developed countries in Europe. Methods: Five electronic databases were systematically searched in March 2014 to identify English language articles with general population samples aged 18 and over from developed countries in Europe. Values for the measures of interest were combined using a random effects model and analysis of the effects of moderator variables was carried out. Results: A total of 5594 abstracts were screened, with 46 studies included in the review. Overall prevalence of impaired glucose regulation was 22.3%. Mean prevalence of impaired glucose tolerance was 11.4% (10.1-12.8) and did not differ by gender. Sample age, diagnostic criteria and country were found to have a significant univariate effect on prevalence of impaired glucose tolerance but only diagnostic criteria remained significant in multivariate analysis. Mean prevalence of impaired fasting glucose was significantly higher in men at 10.1% (7.9-12.7) compared with 5.9% in women (4-8.7). The only moderator variable with a significant effect on impaired fasting glucose prevalence was country. Conclusions: This meta-analysis shows a moderate prevalence of impaired glucose regulation in developed Europe with over one in five people meeting the criteria for either impaired glucose tolerance, impaired fasting glucose or both. [ABSTRACT FROM AUTHOR]

Context/problem: Comparative analysis of relative and absolute mortality differentials between socioeconomic groups are now available. These show consistently increasing relative increases in mortality differentials but complex trends in absolute mortality differentials. Objective: This paper provides an analysis of relative and absolute trends in mortality by cause of death and socioeconomic group (SEG) from 1984 to 2008 among men and active women aged 30-64 years in Ireland and compares these results with recent European and US studies to give an overview of trends. Methods: This paper uses mortality data from the Irish Central Statistics Office from 1984 to 2008 to calculate standardized death rates by age, sex, socioeconomic status and cause of death showing trends in SEG inequalities in mortality in Ireland. These show which specific causes of death are driving all-cause mortality trends. Results: SEG differentials in all-cause mortality among men and women have been increasing since the 1980s. Some of this increase reflects larger falls in cardiovascular causes among advantaged groups, but the trend is largely accounted for by increasing inequalities in mortality in digestive, neoplasm and external causes of deaths. Conclusions: These findings are in line with international findings that show that socioeconomic differentials in digestive, neoplasm and external cause deaths are driving general socioeconomic differentials in all-cause mortality. External cause deaths may have been influenced by levels of economic activity, particularly in construction, during the economic boom among manual workers. Furthermore, deaths from digestive diseases during the 1990s and 2000s may well be the result of increases in liver disease associated with excessive alcohol consumption. [ABSTRACT FROM AUTHOR]

Background Social inequalities in multimorbidity may occur due to familial and/or individual factors and may differ between men and women. Using population-based multi-generational data, this study aimed to (1) assess the roles of parental and individual education in the risk of multimorbidity and (2) examine the potential effect modification by sex. Methods Data were analysed from 62 060 adults aged 50+ who participated in the Survey of Health, Ageing and Retirement in Europe, comprising 14 European countries. Intergenerational educational trajectories (exposure) were High–High (reference), Low–High, High–Low and Low–Low, corresponding to parental–individual educational attainments. Multimorbidity (outcome) was ascertained between 2013 and 2020 as self-reported occurrence of ≥2 diagnosed chronic conditions. Inequalities were quantified as multimorbidity-free years lost (MFYL) between the ages of 50 and 90 and estimated via differences in the area under the standardized cumulative risk curves. Effect modification by sex was assessed via stratification. Results Low individual education was associated with higher multimorbidity risk regardless of parental education. Compared to the High–High trajectory, Low–High was associated with −0.2 MFYL (95% confidence intervals: −0.5 to 0.1), High–Low with 3.0 (2.4–3.5), and Low–Low with 2.6 (2.3–2.9) MFYL. This pattern was observed for both sexes, with a greater magnitude for women. This effect modification was not observed when only diseases diagnosed independently of healthcare-seeking behaviours were examined. Conclusions Individual education was the main contributor to intergenerational inequalities in multimorbidity risk among older European adults. These findings support the importance of achieving a high education to mitigate multimorbidity risk. [ABSTRACT FROM AUTHOR]

Background: Financial difficulties in childhood may be associated with immediate and long-term consequences for mental health. The aim of the current paper is to investigate the association between childhood financial difficulties and adult depression, and assess the relative contribution of financial difficulties in childhood to symptoms of adult depression across different age groups. Methods: Using three age cohorts (25-40, 41-59, 60-75) from 19 countries in the European Social Survey Round 7 (N=18 401), multi-level and country-wise OLS regression analyses were used to investigate the association between financial difficulties in childhood and adult depression, while adjusting for age, education, gender, highest education in family, level of family conflict, number of social meetings and marital status. Results: Financial difficulties in childhood was found to be influential predictors of depression scores for 25-40 year olds in 10 out of 19 countries in fully adjusted models. In older participants, depression scores were mostly influenced by frequency of social meetings and marital status. There was great variation in the pattern of influential risk factors across countries, and the predicted effect childhood financial difficulties had on adult depression scores. Conclusion: Childhood financial difficulties as predictors of depression appear to, by themselves, exert the strongest influence in younger adults. There was, however, large variation between countries in the magnitude of associated risk, and in the pattern of risk factors contributing to adult depression, which underscores the need to account for country-level factors when aiming to gain knowledge about mental health. [ABSTRACT FROM AUTHOR]

Background: A range of non-communicable diseases (NCDs) has been found to follow a social pattern whereby socioeconomic status predicts either a higher or lower risk of disease. Comprehensive evidence on the socioeconomic distribution of NCDs across Europe, however, has been limited. Methods: Using cross-sectional 2014 European Social Survey data from 20 countries, this paper examines socioeconomic inequalities in 14 self-reported NCDs separately for women and men: heart/circulatory problems, high blood pressure, back pain, arm/ hand pain, foot/leg pain, allergies, breathing problems, stomach/digestion problems, skin conditions, diabetes, severe headaches, cancer, obesity and depression. Using education to measure socioeconomic status, age-controlled adjusted risk ratios were calculated and separately compared a lower and medium education group with a high education group. Results: At the pooled European level, a social gradient in health was observed for 10 NCDs: depression, diabetes, obesity, heart/circulation problems, hand/arm pain, high blood pressure, breathing problems, severe headaches, foot/leg pain and cancer. An inverse social gradient was observed for allergies. Social gradients were observed among both genders, but a greater number of inequalities were observed among women. Country-specific analyses show that inequalities in NCDs are present everywhere across Europe and that inequalities exist to different extents for each of the conditions. Conclusion: This study provides the most up-to-date overview of socioeconomic inequalities for a large number of NCDs across 20 European countries for both women and men. Future investigations should further consider the diseases, and their associated determinants, for which socioeconomic differences are the greatest. [ABSTRACT FROM AUTHOR]

Background: Health inequalities persist between and within European countries. Such inequalities are usually explained by health behaviours and according to the conditions in which people work and live. However, little is known about the relative contribution of these factors to health inequalities in European countries. This paper aims to investigate the independent and joint contribution of a comprehensive set of behavioural, occupational and living conditions factors in explaining social inequalities in self-rated health (SRH). Method: Data from 21 countries was obtained from the 2014 European Social Survey and examined for respondents aged 25-75. Adjusted rate differences (ARD) and adjusted rate risks (ARR), generated from binary logistic regression models, were used to measure health inequalities in SRH and the contribution of behavioural, occupational and living conditions factors. Result: Absolute and relative inequalities in SRH were found in all countries and the magnitude of socio-economic inequalities varied considerably between countries. While factors were found to differentially contribute to the explanation of educational inequalities in different European countries, occupational and living conditions factors emerged as the leading causes of inequalities across most of the countries, contributing both independently and jointly with behavioural factors. Conclusion: The observed shared effects of different factors to health inequalities points to the interdependent nature of occupational, behavioural and living conditions factors. Tackling health inequalities should be a concentred effort that goes beyond interventions focused on single factors. [ABSTRACT FROM AUTHOR]

Background: Research has shown that individual socio-economic circumstances throughout life affect health in older ages. However, little attention has been paid to the broad economic context affecting individual's life-chances. This paper examines whether economic downturns experienced during young and mid-adulthood have long-run effects on physical health. Methods: We exploit data on economic fluctuations in the period 1945-2010 in 11 European countries, linked to longitudinal data from three waves of the Survey of Health, Ageing and Retirement in Europe. We estimate a country fixed effect model assessing whether downturns experienced at 5-year intervals between ages 25 and 54 are associated with levels and onset of new limitations with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) in older age (55-80). Results: Experiencing an economic downturn at ages 45-59 is associated with increased risk of having at least one disability limitation in later-life (odds ratio [OR] for ADL = 1.66, 95% CI [Confidence Interval] 1.24, 2.22; OR for IADL = 1.46, 95% CI 1.10, 1.94). Economic downturns at ages 40-44 and 45-49 also increase the risk of a new functional limitation in later-life (OR for IADL ages 40-44 = 1.20, 95% CI 1.03, 1.40; OR for IADL ages 45-49 = 1.44, CI 1.10-1.88). Economic downturns experienced around these ages are also associated with significantly greater risks of smoking and excessive alcohol consumption as well as lower incomes in older age. Conclusions: Exposure to an economic downturn at ages 40-49 is associated with poorer health in older ages, possibly by increasing risk of unhealthy behaviours and low incomes persisting into older age. [ABSTRACT FROM AUTHOR]

Background: Refugees, asylum seekers and undocumented migrants are at risk of sexual and gender-based violence (SGBV) and subsequent ill-health in Europe; yet, European minimum reception standards do not address SGBV. Hence, this paper explores the nature of SGBV occurring in this sector and discusses determinants for ‘Desirable Prevention’. Methods: Applying community-based participatory research, we conducted an SGBV knowledge, attitude and practice survey with residents and professionals in eight European countries. We conducted logistic regression using mixed models to analyse the data in R. Results: Of the 562 respondents, 58.3% reported cases of direct (23.3%) or peer (76.6%) victimization. Our results indicate that when men were involved, it most likely concerned sexual perpetration (adjusted odds ratio [aOR]: 4.09, confidence interval [CI]: 1.2; 13.89) and physical victimization (aOR: 2.57, CI: 1.65; 4), compared with females, who then rather perpetrated emotional violence (aOR: 1.85, CI: 1.08; 3.13) and underwent sexual victimization (aOR: 7.14, CI: 3.33; 16.67). Compared with others, asylum seekers appeared more likely to perpetrate physical (aOR 7.14, CI: 4; 12.5) and endure socio-economic violence (aOR: 10, CI: 1.37; 100), whereas professionals rather bore emotional (aOR: 2.01, CI: 0.98; 4.12) and perpetrated socio-economic violence (aOR: 25.91, CI: 13.41; 50.07). When group perpetration (aOR: 2.13, CI: 1.27; 3.58) or victimization (aOR: 1.84, CI: 1.1; 3.06) occurred, it most likely concerned socio-economic violence. Conclusion: Within the European asylum reception sector, residents and professionals of both sexes experience SGBV victimization and perpetration. Given the lack of prevention policies, our findings call for urgent Desirable Prevention programmes addressing determinants socio-ecologically. [ABSTRACT FROM AUTHOR]

Background Many countries have sought to incentivise soft drinks manufacturers to reduce sugar in their products as part of efforts to address a growing prevalence of obesity. Are their policies effective? Methods Using a difference-in-differences design, we compared trends in the sugar content of 10 695 new sugar-sweetened beverages (SSB) launched between 2010 and 2019 in six European markets, including the UK and France (taxes designed to incentivise reformulation), the Netherlands (policy based on voluntary agreements to reduce sugar), Germany, Italy and Spain (no national policies). Results The announcement in 2016 and adoption in 2018 of the UK tax led to yearly reductions in average sugar content of 17% (95% CI: 15–19%) to 31% (13–48%) between 2016 and 2019, compared to 2015, while the 2018 French tax produced a 6% (95% CI: 5–7%) sugar reduction only in 2018, compared to 2017, shortly after it was redesigned to provide a stronger incentive for reformulation. Voluntary agreements implemented in the Netherlands in 2014 led to an 8% (95% CI: 4–13%) sugar reduction only in 2015, compared to 2013. Conclusion The analysis supports the conclusions that sugar reductions in new SSBs have been greater in countries that have adopted specific policies to encourage them; a sugar-based tax design encourages more sugar reductions than a volume-based tax design; the tax rate and the amount of the tax reduction from switching to the next lower tier in a sugar-based tax design may be critical to incentivize reformulation. [ABSTRACT FROM AUTHOR]

Background Governments across Europe deployed non-pharmaceutical interventions to mitigate the spread of coronavirus disease 2019 (COVID-19), which not only showed clear benefits but also had negative consequences on peoples' health. Health inequalities increased, disproportionally affecting people with higher age or lower education. This study analyzed associations between social factors and worsened self-rated health of elderly people in the course of the COVID-19 pandemic, taking different stringencies of government mandates as well as infection rates into account. Methods Data stem from the European SHARE survey. The main outcome was a binary indicator of worsened self-rated health. Analyses included data from two waves (2020 and 2021) during the pandemic (N  = 48 356 participants, N = 96 712 observations). Predictors were age, sex, education and living together with a partner, and two macro indicators that reflected the stringency of government response mandates and COVID-19 infection rates. Data were analyzed using logistic mixed-effects regression models. Results Older age [odds ratio (OR) 1.73, confidence interval (CI) 1.65–1.81] and female sex (OR 1.26, CI 1.20–1.32) were positively associated and higher education (OR 0.74, CI 0.70–0.79) was negatively associated with worsened self-rated health. Not living together with a partner showed higher odds of worsened self-rated health (OR 1.30, CI 1.24–1.36). Inequalities increased from 2020 to 2021. Associations between worsened self-rated health and government response mandates or infection rates were inconsistent. Conclusion Self-rated health worsened in the course of the pandemic and health disparities increased. Possible future pandemics require targeted interventions to minimize adverse health outcomes, in particular among old, potentially isolated, and deprived people. [ABSTRACT FROM AUTHOR]

Background As populations age, the possible consequences of increased frailty are a major concern for the health sector. Here, we investigate how life expectancy with and without frailty has changed during a 10–11-year-period across Europe. Methods The Sullivan method was used to investigate changes in life expectancy with and without frailty in 10 European countries. Frailty status (non-frail, pre-frail and frail) was determined by use of the Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI). Data on frailty prevalence was obtained from 21 698 individuals in wave 1 (2004–05) and 38 859 individuals in wave 6 (2015) of the SHARE. Information on mortality was obtained from the Eurostat Database. Results In 2015, women aged 70 spent 25.0% (95% CI: 24.0–26.1) of their remaining life expectancy in a frail state, and the number for men was 11.5% (95% CI: 10.7–12.3). Southern Europeans spent 24.2% (95% CI: 22.9–25.4) of their remaining life expectancy in a frail state and the numbers for Central Europeans and Northern Europeans were 17.0% (95% CI: 16.0–17.9) and 12.2% (95% CI: 10.9–13.5), respectively. From 2004–05 to 2015, life expectancy increased by 1.1 years (from 15.3 to 16.4 years) for 70-year-old Europeans. Similarly, non-frail life expectancy increased by 1.1 years (95% CI: 0.8–1.4), whereas no significant changes in life expectancy in frail states were observed. Conclusions This study suggests that Europeans today spend more years in a non-frail state than Europeans did 10–11 years ago. Our findings reflect a considerable inequality by gender and region. [ABSTRACT FROM AUTHOR]

Background This aggregated population study investigated the impact of the seemingly quasi-randomly assigned school winter holiday in weeks 6–10 (February to early March) on excess mortality in 219 European regions (11 countries) during the COVID-19 pandemic in the spring 2020. A secondary aim was to evaluate the impact of government responses to the early inflow of infected cases. Methods Data on government responses weeks 8–14 were obtained from the Oxford COVID-19 Government Response Tracker. Regional data on total all-cause mortality during weeks 14–23 in 2020 were retrieved from Eurostat and national statistical agencies and compared with the average mortality during same period 2015–2019. Variance-weighted least square regression was used with mortality difference as dependent variable with adjustment for country, population density and age distribution. Results Being a region with winter holiday exclusively in week 9 was in the adjusted analysis associated with 16 weekly excess deaths [95% confidence interval (CI) 13–20] per million inhabitants during weeks 14–23, which corresponds to 38% of the excess mortality in these regions. A more stringent response implemented in week 11, corresponding to 10 additional units on the 0–100 ordinal scale, was associated with 20 fewer weekly deaths (95% CI 18–22) per million inhabitants. Conclusions Winter holiday in week 9 was an amplifying event that contributed importantly to the excess mortality observed in the study regions during the spring 2020. Timely government responses to the resulting early inflow of cases reduced the excess in mortality. [ABSTRACT FROM AUTHOR]

Background Frailty is a geriatric condition associated with adverse health outcomes. As physical inactivity, low protein intake and poor social network are known risk factors, we aimed to assess the influence of these parameters and their interaction in an 11-year follow-up study on a Europe-wide level. Methods Data from the Study on Health, Ageing and Retirement in Europe were used, including 22 226 community-dwelling robust and prefrail persons aged ≥50 years, from 11 countries. Frailty was assessed with the 'Frailty Instrument for Primary care of the Survey of Health, Ageing and Retirement in Europe'. Additionally, self-reported physical activity (PA), protein intake and satisfaction with social network were assessed. The impact of these parameters on the development of frailty was calculated using multivariate cox regressions. Results Performing no regular PA, was associated with higher hazards ratio (HRs) for frailty compared with performing regular PA [men: 1.90 (95%CI: 1.50–2.42); women: 1.65 (95%CI: 1.25–2.18)]; HRs for low protein intake were 1.16 (95%CI: 0.93–1.46) for men and 1.05 (95%CI: 0.80–1.37) for women. And HR for poor social network were 0.92 (95%CI: 0.74–1.15) for men and 1.72 (95%CI: 1.31–2.27)] for women. In general, persons with a combination of two of the assessed risk factors had a higher risk for frailty compared with those with no or only one of the risk factors. However, no significant synergy index could be found. Conclusion The results illustrate the importance of PA, but also of nutritional and social network to prevent frailty. [ABSTRACT FROM AUTHOR]

Background Cross-national comparison studies on gender differences have mainly focussed on life expectancy, while less research has examined differences in health across countries. We aimed to investigate gender differences in cognitive function and grip strength over age and time across European regions. Methods We performed a cross-sectional study including 51 292 men and 62 007 women aged 50 + participating in the Survey of Health, Ageing and Retirement in Europe between 2004–05 and 2015. Linear regression models were used to examine associations. Results In general, women had better cognitive function than men, whereas men had higher grip strength measures. Sex differences were consistent over time, but decreased with age. Compared with men, women had higher cognitive scores at ages 50–59, corresponding to 0.17 SD (95% CI 0.14, 0.20) but slightly lower scores at ages 80–89 (0.08 SD, 95% CI 0.14, 0.00). For grip strength, the sex difference decreased from 18.8 kg (95% CI 18.5, 19.1) at ages 50–59 to 8.5 kg (95% CI 7.1, 9.9) at age 90 +. Northern Europeans had higher cognitive scores (19.6%) and grip strength measures (13.8%) than Southern Europeans. Gender differences in grip strength were similar across regions, whereas for cognitive function they varied considerably, with Southern Europe having a male advantage from ages 60–89. Conclusion Our results illustrate that gender differences in health depend on the selected health dimension and the age group studied, and emphasize the importance of considering regional differences in research on cognitive gender differences. [ABSTRACT FROM AUTHOR]

Background Adverse childhood experiences (ACEs) can increase risks of health-harming behaviours and poor health throughout life. While increases in risk may be affected by resilience resources such as supportive childhood relationships, to date few studies have explored these effects. Methods We combined data from cross-sectional ACE studies among young adults (n = 14 661) in educational institutions in 10 European countries. Nine ACE types, childhood relationships and six health outcomes (early alcohol initiation, problem alcohol use, smoking, drug use, therapy, suicide attempt) were explored. Multivariate modelling estimated relationships between ACE counts, supportive childhood relationships and health outcomes. Results Almost half (46.2%) of participants reported ≥1 ACE and 5.6% reported ≥4 ACEs. Risks of all outcomes increased with ACE count. In individuals with ≥4 ACEs (vs. 0 ACEs), adjusted odds ratios ranged from 2.01 (95% CIs: 1.70–2.38) for smoking to 17.68 (95% CIs: 12.93–24.17) for suicide attempt. Supportive childhood relationships were independently associated with moderating risks of smoking, problem alcohol use, therapy and suicide attempt. In those with ≥4 ACEs, adjusted proportions reporting suicide attempt reduced from 23% with low supportive childhood relationships to 13% with higher support. Equivalent reductions were 25% to 20% for therapy, 23% to 17% for problem drinking and 34% to 32% for smoking. Conclusions ACEs are strongly associated with substance use and mental illness. Harmful relationships are moderated by resilience factors such as supportive childhood relationships. Whilst ACEs continue to affect many children, better prevention measures and interventions that enhance resilience to the life-long impacts of toxic childhood stress are required. [ABSTRACT FROM AUTHOR]

Background Opioids, antipsychotics and hypnotics are recommended for comfort care in dying. We studied their prescription during the last 3 days in residents deceased in the long-term care facility (LTCF). Methods In a retrospective, cross-sectional survey in Belgium, England, Finland, Italy, the Netherlands and Poland, LTCFs, selected by proportional stratified random sampling, reported all deaths over the previous 3 months. The nurse most involved in the residents' care reviewed the chart for opioid, antipsychotic and hypnotic prescription, cause of death and comorbidities. Multivariable logistic regression was performed to adjust for resident characteristics. Results Response rate was 81.6%. We included 1079 deceased residents in 322 LCTFs. Opioid prescription ranged from 18.5% (95% CI: 13.0–25.8) of residents in Poland to 77.9% (95% CI: 69.5–84.5) in the Netherlands, antipsychotic prescription from 4.8% (95% CI: 2.4–9.1) in Finland to 22.4% (95% CI: 14.7–32.4) in Italy, hypnotic prescription from 7.8% (95% CI: 4.6–12.8) in Finland to 47.9% (95% CI: 38.5–57.3) in the Netherlands. Differences in opioid, antipsychotic and hypnotic prescription between countries remained significant (P < 0.001) when controlling for age, gender, length of stay, cognitive status, cause of death in multilevel, multivariable analyses. Dying from cancer showed higher odds for receiving opioids (OR 3.51; P < 0.001) and hypnotics (OR 2.10; P = 0.010). Conclusions Opioid, antipsychotic and hypnotic prescription in the dying phase differed significantly between six European countries. Further research should determine the appropriateness of their prescription and refine guidelines especially for LTCF residents dying of non-cancer diseases. [ABSTRACT FROM AUTHOR]

Background Mental health problems are a risk factor for loss of paid employment. This study investigates (i) the relation between depressive symptoms and different involuntary pathways of labour force exit and (ii) explores gender and geographical differences in this relation. Methods The study population consisted of 5263 individuals in paid employment aged between 50 years and the country-specific retirement age from 11 European countries participating in the longitudinal Survey of Health, Ageing and Retirement in Europe (SHARE). Self-reported depressive symptoms at baseline were assessed using the EURO-D. Employment status was derived from interviews after 2 and 4 years. Cox proportional hazards regression analyses were used to investigate the association between depressive symptoms and labour force exit via disability benefit and unemployment. Population attributable fractions (PAFs) were calculated to estimate the contribution of depressive symptoms to these pathways of labour force exit. Results Both men and women with a EURO-D score ≥4 had a >2-fold increased risk of a disability benefit (HR: 2.46, 95%CI 1.68–3.60) after adjustment for demographics and work-related characteristics. Among men depressive symptoms elevated the risk of becoming unemployed at follow-up (HR 1.55; 95%CI: 0.94–2.57). The PAF was 0.18 for disability benefit and 0.04 for unemployment, and varied across European regions. Conclusions Individuals with depressive symptoms are at increased risk of losing paid employment, which in turn may aggravate their symptoms. Targeting depressive symptoms with public health and occupational policies should be considered to reduce the burden of mental diseases in Europe. [ABSTRACT FROM AUTHOR]

Background Depressive symptoms are more common in adults with diabetes and may arise from the physical and psychosocial burden of disease. Better quality of diabetes care may be associated with a reduced disease burden and fewer depressive symptoms. Methods This cross-sectional study included 34 420 participants from 19 countries in the European Social Survey Round 7 (2014–2015). Countries were grouped into quartiles based on their quality of diabetes care as measured in the Euro Diabetes Index 2014. Individual-level depressive symptoms were measured using the 8-item Center for Epidemiologic Studies—Depression Scale. Negative binomial regression was used to compare the number of depressive symptoms between adults with and without diabetes in each quartile of diabetes care quality. Analyses included adjustment for covariates and survey weights. Results In countries with the highest quality of diabetes care, having diabetes was associated with only a 3% relative increase in depressive symptoms (95% CI 1.00–1.05). In countries in the second, third and fourth (lowest) quartiles of diabetes care quality, having diabetes was associated with a 13% (95% CI 1.08–1.17), 13% (1.08–1.19) and 22% (1.14–1.31) relative increase in depressive symptoms, respectively. Conclusion The association between diabetes and depressive symptoms appears stronger in European countries with lower quality of diabetes care. Potential pathways for this association include the financial aspects of diabetes care, access to services and differential exposure to the social determinants of heath. Further research is needed to unpack these mechanisms and improve the quality of life of people with diabetes across Europe. [ABSTRACT FROM AUTHOR]

Background Unemployment in early adulthood is associated with higher rate of disability due to common mental disorders (CMDs). We investigated to what extent the association between unemployment and sub-sequent long-term sickness absence due to CMDs is direct or whether it is dependent on accumulation of mental health problems and socioeconomic disadvantage. Methods In this longitudinal study, a population-based 60% sample of Finnish young adults born between 1983 and 1985 (N = 116 878) was followed up for the incidence of CMDs from 2006 to 2010. Sociodemographic and health-related covariates were identified using several nationwide registers. Hazard ratios (HRs) with 95% confidence intervals (CIs), and survival and cumulative hazard functions for CMD were calculated. A matching procedure was applied to account for the systematic differences in the distribution of the baseline characteristics. Results A total of 1416 (2.4%) of men and 2539 (4.4%) of women were granted a long-term sickness allowance for CMD during the follow-up. After matching, HR (95% CI) of CMD for men decreased from 2.38 (2.12–2.68) to 1.31 (1.03–1.67) and for women from 1.97 (1.79–2.18) to 1.39 (1.18–1.65). Approximately half of the effect of the unemployment on CMDs was explained by the background variables. Conclusion Using a causal approach, our study suggests that unemployment is consistently associated with an increased risk of work disability due to CMDs. Considering the young unemployed as a risk group may help in targeting interventions promoting mental health and improving educational and employment opportunities. [ABSTRACT FROM AUTHOR]

Background: Comparisons of outcomes of health care in different systems can be used to inform health policy. The EuroHOPE (European Healthcare Outcomes, Performance and Efficiency) project investigated the feasibility of comparing routine data on selected conditions including breast cancer across participating European countries. Methods: Routine data on incidence, treatment and mortality by age and clinical characteristics for breast cancer in women over 24years of age were obtained (for a calendar year) from linked hospital discharge records, cancer and death registers from Finland, the Turin metropolitan area, Scotland and Sweden (all 2005), Hungary (2006) and Norway (2009). Age-adjusted breast cancer incidence and 1-year survival were estimated for each country/region. Results: In total, 24576 invasive breast cancer cases were identified from cancer registries from over 13 million women. Age-adjusted incidence ranged from 151.1 (95%CI 147.2-155.0) in Hungary to 234.7 (95%CI 227.4-242.0)/100 000 in Scotland. One-year survival ranged from 94.1% (95%CI 93.5-94.7%) in Scotland to 97.1% (95%CI 96.298.1%) in Italy. Scotland had the highest proportions of poor prognostic factors in terms of tumour size, nodal status and metastases. Significant variations in data completeness for prognostic factors prevented adjustment for case mix. Conclusion: Incidence of and survival from breast cancer showed large differences between countries. Substantial improvements in the use of internationally recognised common terminology, standardised data coding and data completeness for prognostic indicators are required before international comparisons of routine data can be used to inform health policy. [ABSTRACT FROM AUTHOR]

Background: In pregnancy early interventions are recommended for prevention of mother-to-child-transmission (PMTCT) of HIV. We examined whether pregnant women who live with HIV in Europe and are migrants encounter barriers in accessing HIV testing and care. Methods: Four cohorts within the European Pregnancy and Paediatric HIV Cohort Collaboration provided data for pooled analysis of 11 795 pregnant women who delivered in 2002-12 across ten European countries. We defined a migrant as a woman delivering in a country different from her country of birth and grouped the countries into seven world regions. We compared three suboptimal PMTCT interventions (HIV diagnosis in late pregnancy in women undiagnosed at conception, late anti-retroviral therapy (ART) start in women diagnosed but untreated at conception and detectable viral load (VL) at delivery in women on antenatal ART) in native and migrant women using multivariable logistic regression models. Results: Data included 9421 (79.9%) migrant women, mainly from sub-Saharan Africa (SSA); 4134 migrant women were diagnosed in the current pregnancy, often (48.6%) presenting with CD4 count <350 cells/µl. Being a migrant was associated with HIV diagnosis in late pregnancy [OR for SSA vs. native women, 2.12 (95% CI 1.67, 2.69)] but not with late ART start if diagnosed but not on ART at conception, or with detectable VL at delivery once on ART. Conclusions: Migrant women were more likely to be diagnosed in late pregnancy but once on ART virological response was good. Good access to antenatal care enables the implementation of PMTCT protocols and optimises both maternal and children health outcomes generally. [ABSTRACT FROM AUTHOR]

Background: The aim was to compare alcohol drinking patterns in economically active people aged 50-64 years before the last economic crisis (2006) and during the crisis (2013). Methods: Cross-sectional study with data from 25 479 economically active people aged 50-64 years resident in 11 European countries who participated in wave 2 or wave 5 of the SHARE project (2006 and 2013). The outcome variables were hazardous drinking, abstention in previous 3 months and the weekly average number of drinks per drinker. The prevalence ratios of hazardous drinking and abstention, comparing the prevalence in 2013 vs. 2006, were estimated with Poisson regression models with robust variance, and the changes in the number of drinks per week with Poisson regression models. Results: The prevalence of hazardous drinking decreased among both men (PR = 0.75; 95%CI = 0.63-0.92) and women (PR = 0.91; 95%CI = 0.72-1.15), although the latter decrease was smaller and not statistically significant. The proportion of abstainers increased among both men (PR = 1.11; 95%CI = 0.99-1.29) and women (PR = 1.18; 95%CI = 1.07-1.30), although the former increase was smaller and not statistically significant. The weekly average number of drinks per drinker decreased in men and women. The decreases in consumption were larger in Italy and Spain. Conclusion: From 2006 to 2013, the amount of alcohol consumed by late working age drinkers decreased in Europe, with more pronounced declines in the countries hardest hit by the economic crisis. [ABSTRACT FROM AUTHOR]

Background: We aimed to describe gender and region differences in the prevalence of binge drinking and in the association between binge drinking and well-being, among older adult Europeans. Methods: This is a cross-sectional study using the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 4, conducted between 2011 and 2012, including 58 489 individuals aged 50 years or older. Sixteen European countries were grouped in four drinking culture regions: South, Central, North and East. We categorized drinking patterns as: never, former, no-binge and binge drinkers. We used the CASP-12 questionnaire to measure well-being. To assess the association between binge drinking and well-being, we fitted two-level mixed effects linear models. Results: The highest percentage of binge drinkers was found in Central Europe (17.25% in men and 5.05% in women) and the lowest in Southern Europe (9.74% in men and 2.34% in women). Former, never and binge drinkers had a significant negative association with well-being as compared with no-binge drinkers. There was a significant interaction in this association by gender and region. Overall, associations were generally stronger in women and in Southern and Eastern Europe. The negative association of binge drinking with well-being was especially strong in Southern European women (β = -3.80, 95%CI: -5.16 to -2.44, P value <0.001). Conclusion: In Southern and Eastern European countries the association between binge drinking and well-being is stronger, especially in women, compared with Northern and Central Europe. Cultural factors (such as tolerance to drunkenness) should be further explored. [ABSTRACT FROM AUTHOR]

Background: Access to healthcare services for undocumented migrants is one of the main public health issues currently being debated among European countries. Exclusion from primary healthcare services may lead to serious consequences for migrants' health. We analyzed the risk among undocumented migrants, in comparison with regular migrants, of being hospitalized for preventable conditions in the Region of Sicily (Italy). Methods: We performed a hospital-based cross-sectional study of the foreign population hospitalized in the Sicily region between 1 January 2003 and 31 December 2013. The first outcome was the proportion of avoidable hospitalization (AHs) among regular and irregular migrants. Second outcomes were the subcategories of AHs for chronic, acute and vaccine preventable diseases. Results: 85 309 hospital admissions were analyzed. In the hospitalized population, in comparison to regular migrants, undocumented migrants show a higher proportion of hospitalization for diseases preventable through primary and preventive care (AOR1-48, 95%CI 1-37-1-59). The proportion of avoidable hospitalizations associated with the lack of legal status is higher for vaccine preventable conditions (AOR 2-06, 95%CI 1-66-2-56) than for chronic conditions (AOR 1-47, 95%CI 1-42-1-63) and acute conditions (AOR 1-37; 95%CI 1-23 1-53). Between 2003 and 2013, the proportion of avoidable hospitalizations decreased both in regular and undocumented migrants but decreased faster for regular than for undocumented migrants. Conclusions: Undocumented migrants experience higher proportion of hospitalization for preventable conditions in comparison with regular migrants probably due to a lack of access to the national healthcare service. Policies and strategies to involve them in primary healthcare and preventive services should be developed to tackle this inequality. [ABSTRACT FROM AUTHOR]

Background: Ischaemic heart disease (IHD) is one of the leading causes of death worldwide with a higher risk of dying among people with a lower socioeconomic status. We investigated the potential for reducing educational differences in IHD mortality in 21 European populations based on two counterfactual scenarios--the upward levelling scenario and the more realistic best practice country scenario. Methods: We used a method based on the population attributable fraction to estimate the impact of a modified educational distribution of smoking, overweight/obesity, and physical inactivity on educational inequalities in IHD mortality among people aged 30-79. Risk factor prevalence was collected around the year 2000 and mortality data covered the early 2000s. Results: The potential reduction of educational inequalities in IHD mortality differed by country, sex, risk factor and scenario. Smoking was the most important risk factor among men in Nordic and eastern European populations, whereas overweight and obesity was the most important risk factor among women in the South of Europe. The effect of physical inactivity on the reduction of inequalities in IHD mortality was smaller compared with smoking and overweight/obesity. Although the reduction in inequalities in IHD mortality may seem modest, substantial reduction in IHD mortality among the least educated can be achieved under the scenarios investigated. Conclusion: Population wide strategies to reduce the prevalence of risk factors such as smoking, and overweight/obesity targeted at the lower socioeconomic groups are likely to substantially contribute to the reduction of IHD mortality and inequalities in IHD mortality in Europe. [ABSTRACT FROM AUTHOR]

Background: Social gradients have been found across European populations, where less affluent groups are more often affected by poor housing and neighbourhood conditions. While poor housing and neighbourhood quality have been associated with a range of non-communicable diseases (NCDs), these conditions have rarely been applied to the examination of socioeconomic differences in NCDs. This study therefore asks 'to what extent does adjusting for poor housing and neighbourhood conditions reduce inequalities in NCDs among men and women in Europe'? Methods: Our analysis used pooled-data from 20 European countries for women (n=12 794) and men (n=11 974), aged 25-75, from round 7 of the European Social Survey. Fourteen NCDs were investigated: heart/circulatory problems, high blood pressure, back pain, arm/hand pain, foot/leg pain, allergies, breathing problems, stomach/digestion problems, skin conditions, diabetes, severe headaches, cancer, obesity and depression. We used binary logistic regression models, stratified by gender, and adjusted rate ratios to examine whether educational inequalities in NCDs were reduced after controlling for poor housing and neighbourhood quality. Results: Overall, we find that adjusting for poor housing and neighbourhood quality reduces inequalities in NCDs. While reductions were relatively small for some NCDs-for high blood pressure, reductions were found in the range of 0-4.27% among women--for other conditions reductions were more considerable. Controlling for both housing and neighbourhood conditions for example, reduced inequalities by 16-24% for severe headaches and 14-30% for breathing problems. Conclusions: Social gradients in poor housing and neighbourhood quality could be an important contributor to educational inequalities in some NCDs. [ABSTRACT FROM AUTHOR]

Background: Autism spectrum disorders (ASDs), once considered to be rare, are now reaching prevalence estimates of 1% and higher. Studies conducted in North America indicate large racial/ethnic disparities in the diagnosis of ASDs. Others show, that immigrant children have similar prevalence rates of ASDs as native children, although they are diagnosed later compared with native children. In relation to a EU funded network action, Enhancing the Scientific Study of Early Autism, it was considered important to review the literature on this subject. Method: A comprehensive literature search was undertaken for original articles reporting on prevalence and risk for ASD in Europe among immigrants and ethnic minorities and data across studies were compared. Results: Seventeen studies conducted in Europe concerning immigrants and ethnic minorities were found. Fifteen studies suggest a higher prevalence rate of ASDs among children of immigrants in comparison to native children (RR = 1.02-1.74; OR =0.6-10.5). One study revealed higher prevalence of autism (OR = 2.2; 95% CI 1.6-3.1) and lower prevalence of Asperger syndrome in immigrants (OR = 0.6; 95% CI 0.3-0.97). One study showed a lower prevalence of Asperger syndrome in immigrants (aOR = 0.1, 95% CI 0.01-0.5). The majority of those analyses involved immigrants from outside Europe, e.g. from Africa and South America. Conclusion: After analysing the results of studies conducted in Europe, it is unclear if higher prevalence estimates of ASDs among immigrants in this region reflect true differences, especially considering many potential confounding factors, e.g. genetic, biological, environmental and cultural. Considering the number of people migrating within Europe there is a substantial need to study further the prevalence of ASDs in immigrant groups. [ABSTRACT FROM AUTHOR]

A correction to the article "The Role of the Three Lifestyle Risk Factors in Reducing Educational Differences in Ischaemic Heart Disease Mortality in Europe" by Ivana Kulhánová is presented.

Background: Many EU nations experienced a significant housing crisis during the Great Recession of 2008-10. We evaluated the consequences of housing payment problems for people's self-reported overall health. Methods: We used longitudinal data from the EU Statistics on Income and Living Conditions survey covering 27 countries from 2008 to 2010 to follow a baseline sample of persons who did not have housing debt and who were employed (45 457 persons, 136 371 person-years). Multivariate linear regression and multilevel models were used to evaluate the impact of transitions into housing arrears on self-reported health, correcting for the presence of chronic illness, health limitations, and other potential socio-demographic confounders. Results: Persons who transitioned into housing arrears experienced a significant deterioration in self-reported overall health by -0.03U (95% CI -0.01 to -0.04), even after correcting for chronic illness, disposable income and employment status, and individual fixed effects. This association was independent and similar in magnitude to that for job loss (-0.02, 95% CI: -0.01 to -0.04). We also found that the impact of housing arrears was significantly worse among renters, corresponding to a mean 0.11 unit additional drop in health as compared with owner-occupiers. These adverse associations were only evident in persons below the 75th percentile of disposable income. Discussion: Our analysis demonstrates that persons who suffer housing arrears experience increased risk of worsening self-reported health, especially among those who rent. Future research is needed to understand the role of alternative housing support systems and available strategies for preventing the health consequences of housing insecurity. [ABSTRACT FROM AUTHOR]

Background: Roma comprise the largest ethnic minority in Europe, with an estimated population of 10-12 million. Roughly 50-60% of European Roma live in the countries of Central and Eastern Europe. In this study, we set out to quantify and explain disparities in unmet health needs for Roma populations relative to non-Roma populations, using self-reported access to health care. Methods: The United Nations Development Programme/World Bank/European Commission 2011 regional Roma survey was used for this study (12 countries, 8735 Roma and 4572 non-Roma living in same communities), with self-reported unmet health need (did not consult a doctor or health professional when they felt it was necessary in past year) as the primary outcome. Multivariable logistic regressions were performed to study the determinants of unmet health need for Roma populations relative to non-Roma populations. Covariates controlled for included sociodemographic characteristics, economic ability, health status and healthcare access. Results: We found in unadjusted models that Roma throughout Central and Eastern Europe, with the exception of Montenegro, are two to three times more likely to report having an unmet health need in the past 12 months than non-Roma living nearby. These disparities largely remain significant, even after adjusting for gender, age, marital status, employment status, education, number of chronic conditions, health insurance status and geographical proximity to medical providers. Conclusions: Controlling for conventional measures of access to medical care (i.e. geographic access to providers and health insurance) does not eliminate observed disparities in unmet need. Although improving funding and routine access to healthcare services for Roma is important in its own right as a means of increasing inclusion, there is a need for detailed assessments of the barriers that exist in each country, within and outside the health system, coupled with measures to implement existing commitments on Roma rights. [ABSTRACT FROM AUTHOR]

Background: Cross-national comparisons of health in European countries provide crucial information to monitor health and disease within and between countries and to inform policy and research priorities. However, variations in estimates might occur when information from cross-national European surveys with different characteristics are used. We compared the prevalence of very good or good self-perceived health across 10 European countries according to three European surveys and investigated which survey characteristics contributed to differences in prevalence estimates. Methods: We used aggregate data from 2004 to 2005 of respondents aged 55-64 years from the European Union Statistics on Income and Living Conditions (EU-SILC), the Survey of Health, Ageing and Retirement in Europe (SHARE) and the European Social Survey (ESS). Across the surveys, self-perceived health was assessed by the same question with response options ranging from very good to very bad. Results: Despite a good correlation between the surveys (intraclass correlation coefficient: 0.77), significant differences were found in prevalence estimates of very good or good self-perceived health. The survey response, sample size and survey mode contributed statistically significantly to the differences between the surveys. Multilevel linear regression analyses, adjusted for survey characteristics, showed a higher prevalence for SHARE (+6.96, 95% CIs: 3.14 to 10.8) and a lower prevalence (-3.12; 95% CIs: -7.11 to 0.86) for ESS, with EU-SILC as the reference survey. Conclusion: Three important health surveys in Europe showed substantial differences for presence of very good or good self- perceived health. These differences limit the usefulness for direct comparisons across studies in health policies for Europe. [ABSTRACT FROM AUTHOR]

Background: Tobacco-related heath inequalities are a major public health concern, with smoking being more prevalent among lower socioeconomic groups. The aim of this study is to investigate the mechanisms leading to socioeconomic inequalities in smoking among 15-year-old adolescents by examining the mediating role of psychosocial factors in the peer group, family and school environment. Methods: Data were derived from the international WHO-collaborative ‘Health Behaviour in School-aged Children (HBSC)' study 2005/2006, including 52 907 15-year-old students from 35 European and North American countries. Socioeconomic position was measured by the Family Affluence Scale. Multilevel logistic regression models were conducted to examine the contribution of family, school and peer factors in explaining the association between family affluence and weekly smoking. Results: Across countries, adolescents from low affluent families had an increased risk of weekly smoking (ORboys 1.14, confidence interval (CI) 1.05-1.23; ORgirls 1.36, CI 1.26-1.46) compared with adolescents from high affluent families. Family and school factors mediated the association between family affluence and smoking to a high extent up to 100% (boys) and 81% (girls) in joint analyses. The most important single factors were family structure, relationships with parents, academic achievement and school satisfaction. Peer factors did not mediate the association between family affluence and adolescent smoking. Conclusion: The association between socioeconomic status and adolescent weekly smoking can largely be explained by an unequal distribution of family- and school-related factors. Focusing on the parent-adolescent relationship and adolescent school achievement can help to better understand inequalities in adolescent smoking behaviour. [ABSTRACT FROM AUTHOR]

Background: Lowering energy (calorie) intake is essential in managing a healthy weight. One method of doing this is substituting sugar with low/no-calorie sweeteners. The safety of sweeteners has been debated, but little is known about how they are perceived by professionals responsible for weight management advice. We sought to explore dietitian perceptions of sweeteners and to identify the practical advice they provide about them. Methods: We collected data in France, Germany, Hungary, Portugal and the United Kingdom. We used face-toface interviews and a novel online tool designed to engage people with online content in a way that approximates everyday processes of making sense of information. Results: We identified four approaches to sweeteners that dietitians took: (1) sweeteners should not be used, (2) they should be limited and used primarily as a transitional product, (3) sweetener use was decided by the client and (4) sweeteners should be recommended or at least allowed. Where dietitians are reticent to recommend sweeteners this is because they feel it is important for consumers to reduce their attachment to sweet tastes and of evidence linking the consumption of sweeteners to increased appetite. There is also uncertainty about the possible negative health effects of sweeteners. Conclusions: Dietitians' perceptions about sweeteners are uncertain, ambivalent and divergent, sometimes explicitly being linked to fears about adverse health effects. Clear and authoritative guidance is required on scientific evidence around sweeteners as well as the ways in which they can be used in dietetic practice. [ABSTRACT FROM AUTHOR]

Background: Fruit and vegetable consumption is linked to many positive health outcomes, nevertheless many adolescents do not consume fruit and vegetables on a daily basis. Methods: Data of 488,951 adolescents, aged 11-, 13- and 15- years, from 33 mainly European and North American countries/regions participating in the cross-sectional Health Behaviour in School-aged Children surveys in 2002, 2006 and 2010, were used to investigate trends in daily fruit and vegetable consumption between 2002 and 2010. Results: Multilevel logistic regression analyses showed an increase in daily fruit and vegetable consumption between 2002 and 2010 in the majority of countries for both genders and all three age groups. A decrease in consumption was noticed in five countries for fruit and five countries for vegetables. Conclusion: Overall, a positive trend was noticed, however increases in daily fruit and vegetable consumption are still indicated. [ABSTRACT FROM AUTHOR]

Background: Recent efforts to characterize integration policy towards immigrants and to compare immigrants' health across countries have rarely been combined so far. This study explores the relationship of country-level integration policy with immigrants' health status in Europe. Methods: Cross-sectional study with data from the 2011 European Union Survey on Income and Living Conditions. Fourteen countries were grouped according to a typology of integration policies based on the Migrant Integration Policy Index: 'multicultural' (highest scores: UK, Italy, Spain, Netherlands, Sweden, Belgium, Portugal, Norway, Finland), 'exclusionist' (lowest scores: Austria, Denmark) and 'assimilationist' (high or low depending on the dimension: France, Switzerland, Luxembourg). People born in the country (natives, n = 177 300) or outside the European Union with >10 years of residence (immigrants, n = 7088) were included. Prevalence ratios (PR) of fair/poor self-rated health between immigrants in each country cluster, and for immigrants versus natives within each, were computed adjusting by age, education, occupation and socio-economic conditions. Results: Compared with multicultural countries, immigrants report worse health in exclusionist countries (age-adjusted PR, 95% CI: men 1.78, 1.49-2.12; women 1.58, 1.37-1.82; fully adjusted, men 1.78, 1.50-2.11; women 1.47, 1.26-1.70) and assimilationist countries (ageadjusted, men 1.21, 1.03-1.41; women 1.21, 1.06-1.39; fully adjusted, men 1.19, 1.02-1.40; women 1.22, 1.07-1.40). Health inequalities between immigrants and natives were also highest in exclusionist countries, where they persisted even after adjusting for differences in socio-economic situation. Conclusion: Immigrants in 'exclusionist' countries experience poorer socio-economic and health outcomes. Future studies should confirm whether and how integration policy models could make a difference on migrants' health. [ABSTRACT FROM AUTHOR]

Background: Winter deaths are a known health and social care challenge for many countries. A previous international comparison showed significant differences in excess winter deaths across Europe in the 1990s, with the northern countries having lower excess winter mortality than those in southern Europe. Methods: The Excess Winter Deaths Index (EWDI) is the ratio of deaths in the winter period (December to March) compared with deaths in the non-winter period. Data from the Eurostat database and national registries were used to calculate the EWDI for 31 countries in Europe across the time period 2002/2003 to 2010/2011. Results: National EWDI values show heterogeneity, with a broad pattern of increasing EWDI values from northern to southern Europe and increasing mean winter temperature (r2= 0.50, P > 0.0001). Malta, Portugal, Spain, Cyprus and Belgium all had an EWDI that was statistically significantly higher than the average EWDI for the other 30 European countries. There was no clear association between country-level EWDI and the level of inter-annual variability in winter temperature across Europe. Discussion: This article demonstrates the differences in EWDI that exist between European countries with implications for both research and policy. Many deaths may be avoidable as environmental, social and personal factors are known to contribute to winter mortality. We now need to work to better understand the causes of inter-country differences. [ABSTRACT FROM AUTHOR]

Background: Although C-section is a highly effective procedure, literature abounds with evidence of overuse and particularly misuse, in lower-value indications such as low-risk deliveries. This study aims to quantify utilization of C-section in low-risk cases, mapping out areas showing excess-usage in each country and to estimate excess-expenditure as a proxy of the opportunity cost borne by healthcare systems. Methods: Observational, ecologic study on deliveries in 913 sub-national administrative areas of five European countries (Denmark, England, Portugal, Slovenia and Spain) from 2002 to 2009. The study includes a cross-section analysis with 2009 data and a time-trend analysis for the whole period. Main endpoints: age-standardized utilization rates of C-section in low-risk pregnancies and deliveries per 100 deliveries. Secondary endpoints: Estimated excess-cases per geographical unit of analysis in two scenarios of minimized utilization. Results: C-section is widely used in all examined countries (ranging from 19% of Slovenian deliveries to 33% of deliveries in Portugal). With the exception of Portugal, there are no systematic variations in intensity of use across areas in the same country. Cross-country comparison of lower-value C-section leaves Denmark with 10% and Portugal with 2%, the highest and lowest. Such behaviour was stable over the period of analysis. Within each country, the scattered geographical patterns of use intensity speak for local drivers playing a major role within the national trend. Conclusion: The analysis conducted suggests plenty of room for enhancing value in obstetric care and equity in women’s access to such within the countries studied. The analysis of geographical variations in lower-value care can constitute a powerful screening tool. [ABSTRACT FROM AUTHOR]

Introduction: Potentially avoidable hospitalizations in chronic conditions are used to evaluate health-care performance. However, evidence comparing different countries at small geographical areas is still scarce. The aim of the present study is to describe and discuss differences in rates and time-trends across health-care areas from five European countries. Methods: Observational, ecological study, on virtually all discharges produced in five European countries between 2002 and 2009. Potentially avoidable hospitalizations were operationally defined as a joint indicator composed of six chronic conditions. Episodes flagged as potentially avoidable were allocated to 913 geographical health-care areas. Age-sex standardized rates and standardized hospitalization ratios, as well as several statistics of variation, were estimated. Results: Four hundred sixty-two thousand seven hundred and ninety-two episodes were flagged as potentially avoidable. Variation in rates across countries was notable, from 93.7 cases per 10 000 inhabitants in Denmark to 34.8 cases per 10 000 inhabitants in Portugal. Within-country variation was also noteworthy, from 3.12 times among extreme areas in Spain to a 1.46-fold difference in Denmark. The highest systematic variation was found in Denmark (empirical Bayes 0.45) and the lowest in England (empirical Bayes 0.08). Rates and systematic variation remained fairly stable over time, with Denmark and England experiencing a statistically significant decrease (20% and 10%, respectively). Income and educational level, hospital utilization propensity, and region of residence were found to be associated with avoidable admissions. Conclusion: The dramatic variation across countries, beyond age and sex differences, and its consistency over time, implies systemic, although differential, behaviour of the five health-care systems with regard to chronic care. [ABSTRACT FROM AUTHOR]

Background: As part of the ROAMER (ROAdmap for MEntal health Research in Europe) project, aiming to create an integrated European roadmap for mental health research, we set out to map the hitherto unmapped territory of public mental health research in Europe. Methods: Five electronic databases (CINAHL, Health Management, Medline, PsycINFO, Social Services Abstracts) were used for identifying public mental health research articles published between January 2007 and April 2012. The number of publications for each European country in five research domains (i.e. mental health epidemiology, mental health promotion, mental disorder prevention, mental health policy and mental health services) was analysed by population size and gross domestic product (GDP), and mean impact factors were compared. Results: In all, 8143 unique publications were identified. Epidemiology research dominates public mental health research, while promotion, prevention and policy research are scarce. Mental health promotion is the fastest growing research area. Research targeting older adults is under-represented. Publications per capita were highest in northwestern Europe, and similar trends were found also when adjusting the number of publications by GDP per capita. The most widely cited research origins from Italy, Switzerland, the UK, the Nordic countries, the Netherlands, Greece and France. Conclusion: In Europe, public mental health research is currently a matter of the affluent northern and western European countries, and major efforts will be needed to promote public mental health research in south and east Europe. In spite of a smaller public mental health research output, some Mediterranean countries produce highly cited public mental health research. [ABSTRACT FROM AUTHOR]

Background: Roma in Central and Eastern Europe (CEE) face problems in accessing health care, and a lack of access to statutory health insurance schemes is a key factor. This study seeks to quantify differences in health insurance coverage between Roma and non-Roma and assess whether variations can be explained by socio-economic factors. Methods: Secondary household survey data collected in 12 CEE countries in 2011 were analysed. A univariate analysis assessed the effect of Roma status on insurance coverage by country. Multivariate analyses were used to progressively adjust for socio-demographic factors, employment status and income. Country-specific literature was drawn on to examine the context of the findings. Results: Lack of insurance coverage for Roma populations varied considerably between countries, from 2.8% without insurance in Slovakia to 67.7% in Albania. Roma were significantly less likely to have health insurance than non-Roma in all countries except Slovakia and Serbia. The greatest differences in Roma and non-Roma insurance coverage were in Montenegro, Bosnia and Herzegovina, Croatia, Bulgaria and Romania. When adjusting for employment status and income, the gap between Roma and non-Roma remained significant in Montenegro, Croatia, Bosnia and Herzegovina, Bulgaria, Romania and Moldova. Conclusion: Roma are significantly less likely to have insurance coverage in most CEE countries, and this gap remains when adjusting for socio-economic differences between Roma and non-Roma in many countries. Much needs to be done to address the known barriers that Roma face in accessing insurance coverage, such as tackling problems related to documentation and the receipt of social benefits. [ABSTRACT FROM AUTHOR]

Background: The rising number of deaths from cancer and other life-limiting illnesses is accompanied by a growing number of family carers who provide long-lasting care, including end-of-life care. This population-based epidemiological study aimed to describe and compare in four European countries the prevalence of and factors associated with physical or emotional overburden and difficulties in covering care-related costs among family carers of people at the end of life. Methods: A cross-national retrospective study was conducted via nationwide representative sentinel networks of general practitioners (GPs). Using a standardized form, GPs in Belgium, The Netherlands, Italy and Spain recorded information on the last 3 months of life of every deceased adult practice patient (1 January 2009–31 December 2010). Sudden deaths were excluded. Results: We studied 4466 deaths. GPs judged family carers of 28% (Belgium), 30% (The Netherlands), 35% (Spain) and 71% (Italy) of patients as physically/emotionally overburdened (P < 0.001). For 8% (Spain), 14% (Belgium), 36% (The Netherlands) and 43% (Italy) patients, GPs reported difficulties in covering care-related costs (P < 0.001). Patients <85 years of age (Belgium, Italy) had higher odds of having physically/emotionally overburdened family carers and financial burden. Death from non-malignant illness (vs. cancer) (Belgium and Italy) and dying at home compared with other locations (The Netherlands and Italy) were associated with higher odds of difficulties in covering care-related costs. Conclusion: In all countries studied, and particularly in Italy, GPs observed a considerable extent of physical/emotional overburden as well as difficulties in covering care-related costs among family carers of people at the end of life. Implications for health- and social care policies are discussed. [ABSTRACT FROM AUTHOR]

Background: Since the 1970s, legislation has led to progress in tackling several air pollutants. We quantify the annual monetary benefits resulting from reductions in mortality from the year 2000 onwards following the implementation of three European Commission regulations to reduce the sulphur content in liquid fuels for vehicles. Methods: We first compute premature deaths attributable to these implementations for 20 European cities in the Aphekom project by using a two-stage health impact assessment method. We then justify our choice to only consider mortality effects as short-term effects. We rely on European studies when selecting the central value of a life-year estimate (€2005 86 600) used to compute the monetary benefits for each of the cities. We also conduct an independent sensitivity analysis as well as an integrated uncertainty analysis that simultaneously accounts for uncertainties concerning epidemiology and economic valuation. Results: The implementation of these regulations is estimated to have postponed 2212 (95% confidence interval: 772–3663) deaths per year attributable to reductions in sulphur dioxide for the 20 European cities, from the year 2000 onwards. We obtained annual mortality benefits related to the implementation of the European regulation on sulphur dioxide of €2005 191.6 million (95% confidence interval: €2005 66.9–€2005 317.2). Conclusion: Our approach is conservative in restricting to mortality effects and to short-term benefits only, thus only providing the lower-bound estimate. Our findings underline the health and monetary benefits to be obtained from implementing effective European policies on air pollution and ensuring compliance with them over time. [ABSTRACT FROM AUTHOR]

Background: Whether socioeconomic inequalities in health and well-being persist into old age and are narrower in more generous welfare states is debated. We investigated the magnitude of socioeconomic inequality in the quality of life of Europeans in early old age and the influence of the welfare regime type on these relationships. Methods: Data from individuals aged 50–75 years (n = 16 074) residing in 13 European countries were derived from Waves 2 and 3 of the Survey of Health, Ageing and Retirement in Europe. Slope indices of inequality (SIIs) were calculated for the association between socioeconomic position and CASP-12, a measure of positive quality of life. Multilevel linear regression was used to assess the overall relationship between socioeconomic position and quality of life, using interaction terms to investigate the influence of the type of welfare regime (Southern, Scandinavian, Post-communist or Bismarckian). Results: Socioeconomic inequalities in quality of life were narrowest in the Scandinavian and Bismarckian regimes, and were largest by measures of current wealth. Compared with the Scandinavian welfare regime, where narrow inequalities in quality of life by education level were found in both men (SII = 0.02, 95% CI: −1.09 to 1.13) and women (SII = 1.11, 95% CI: 0.05–2.17), the difference in quality of life between the least and most educated was particularly wide in Southern and Post-communist regimes. Conclusion: Individuals in more generous welfare regimes experienced higher levels of quality of life, as well as narrower socioeconomic inequalities in quality of life. [ABSTRACT FROM AUTHOR]

Background: Partial implementation may explain modest effectiveness of many school-based preventive programmes against substance use. We studied whether specific characteristics of the class could predict the level of implementation of a curriculum delivered by class teachers in schools from some European countries. Methods: Secondary analysis of data from an evaluation trial. In seven European countries, 78 schools (173 classes) were randomly assigned to a 12-unit, interactive, standardized programme based on the comprehensive social influence model. Curriculum completeness, application fidelity, average unit duration and use of role-play were monitored using structured report forms. Predictors of implementation were measured by aggregating at class level information from the baseline student survey. Class size, gender composition, mean age, factors related to substance use and to affection to school were analysed, with associations estimated by multilevel regression models. Results: Implementation was not significantly predicted by mean age, proportion of students with positive academic expectation or liking school. Proportion of boys was associated with a shorter time devoted to each unit [β = −0.19, 95% confidence intervals (CI) −0.32 to −0.06]. Class size was inversely related to application fidelity [Odds ratio (OR) 0.92, 95% CI 0.85 to 0.99]. Prevalence of substance use was associated with a decreased odds of implementing all the curriculum units (OR 0.81, 95% CI 0.65 to 0.99). Students’ connectedness to their class was associated with increased odds of teachers using role-play (OR 1.52, 95% CI 1.03 to 2.29). Conclusions: Teachers’ implementation of preventive programmes may be affected by structural and social characteristics of classes and therefore benefit from organizational strategies and teachers’ training in class management techniques. [ABSTRACT FROM AUTHOR]

Introduction: Food allergy is a recognized health problem, but little has been reported on its cost for health services. The EuroPrevall project was a European study investigating the patterns, prevalence and socio-economic cost of food allergy. Aims: To investigate the health service cost for food-allergic Europeans and the relationship between severity and cost of illness. Methods: Participants recruited through EuroPrevall studies in a case–control study in four countries, and cases only in five countries, completed a validated economics questionnaire. Individuals with possible food allergy were identified by clinical history, and those with food-specific immunoglobulin E were defined as having probable allergy. Data on resource use were used to estimate total health care costs of illness. Mean costs were compared in the case–control cohorts. Regression analysis was conducted on cases from all 9 countries to assess impact of country, severity and age group. Results: Food-allergic individuals had higher health care costs than controls. The mean annual cost of health care was international dollars (I$)2016 for food-allergic adults and I$1089 for controls, a difference of I$927 (95% confidence interval I$324–I$1530). A similar result was found for adults in each country, and for children, and was not sensitive to baseline demographic differences. Cost was significantly related to severity of illness in cases in nine countries. Conclusions: Food allergy is associated with higher health care costs. Severity of allergic symptoms is a key explanatory factor. [ABSTRACT FROM AUTHOR]

Background: Circulatory disease mortality inequalities by country of birth (COB) have been demonstrated for some EU countries but pan-European analyses are lacking. We examine inequalities in circulatory mortality by geographical region/COB for six EU countries. Methods: We obtained national death and population data from Denmark, England and Wales, France, the Netherlands, Scotland and Sweden. Mortality rate ratios (MRRs) were constructed to examine differences in circulatory, ischaemic heart disease (IHD) and cerebrovascular disease mortality by geographical region/COB in 35–74 years old men and women. Results: South Asians in Denmark, England and Wales and France experienced excess circulatory disease mortality (MRRs 1.37–1.91). Similar results were seen for Eastern Europeans in these countries as well as in Sweden (MRRs 1.05–1.51), for those of Middle Eastern origin in Denmark (MRR = 1.49) and France (MRR = 1.15), and for East and West sub-Saharan Africans in England and Wales (MRRs 1.28 and 1.39) and France (MRRs 1.24 and 1.22). Low ratios were observed for East Asians in France, Scotland and Sweden (MRRs 0.64–0.50). Sex-specific analyses showed results of similar direction but different effect sizes. The pattern for IHD mortality was similar to that for circulatory disease mortality. Two- to three-fold excess cerebrovascular disease mortality was found for several foreign-born groups compared with the local-born populations in some countries. Conclusions: Circulatory disease mortality varies by geographical region/COB within six EU countries. Excess mortality was observed for some migrant populations, less for others. Reliable pan-European data are needed for monitoring and understanding mortality inequalities in Europe’s multiethnic populations. [ABSTRACT FROM PUBLISHER]

Background: Important differences in cardiovascular disease (CVD) mortality by country of birth have been shown within European countries. We now focus on CVD mortality by specific country of birth across European countries. Methods: For Denmark, England and Wales, France, The Netherlands, Scotland and Sweden mortality information on circulatory disease, and the subcategories of ischaemic heart disease, and cerebrovascular disease, was analysed by country of birth. Information on population was obtained from census data or population registers. Directly age-standardized rates per 100 000 were estimated by sex for each country of birth group using the WHO World Standard population 2000–25 structure. For differences in the results, at least one of the two 95% confidence intervals did not overlap. Results: Circulatory mortality was similar across countries for men born in India (355.7 in England and Wales, 372.8 in Scotland and 244.5 in Sweden). For other country of birth groups—China, Pakistan, Poland, Turkey and Yugoslavia—there were substantial between-country differences. For example, men born in Poland had a rate of 630.0 in Denmark and 499.3 in England and Wales and 153.5 in France; and men born in Turkey had a rate of 439.4 in Denmark and 231.4 in The Netherlands. A similar pattern was seen in women, e.g. Poland born women had a rate of 264.9 in Denmark, 126.4 in England and Wales and 54.4 in France. The patterns were similar for ischaemic heart disease mortality and cerebrovascular disease mortality. Conclusion: Cross-country comparisons are feasible and the resulting findings are interesting. They merit public health consideration. [ABSTRACT FROM AUTHOR]