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Aim: The goal of this paper is to analyze the COVID-19 policies of 10 European countries, including Sweden, Finland, Norway, Italy, France, Germany, Poland, Belgium, the Netherlands, and Hungary, with a time-series policy analysis tool. Subject and methods: The results of the COVID-19 policy analysis are based on a single time-series indicator, or daily population mortality rate: the number of COVID-19 daily cumulative deaths divided by the population in millions. The lower the score, the better the policy. Although many experts believe that the COVID-19 policy outcome analysis is premature, time series analysis is an excellent analysis that can provide information on the progress and transition of policy outcomes. In other words, the proposed time series analysis tool allows policymakers to identify and quantify when mistakes were made during the on-going COVID-19 pandemic. Results: The COVID-19 policy analysis discovered many useful facts. Sweden failed due to the herd immunity approach. Hungary made a fundamental mistake in COVID-19 tactics. Countries such as Sweden, Hungary, Belgium, and Poland showed time-series changes that differed from the others. Conclusion: Public health interventions can play a key role in mitigating the COVID-19 pandemic. The proposed policy analysis tool, hiscovid demonstrated the effectiveness of the time-series score behavior for discovering when policymakers made mistakes. [ABSTRACT FROM AUTHOR]

Background: The Sarcoma Policy Checklist was created by a multidisciplinary expert group to provide policymakers with priority areas to improve care for sarcoma patients.Main Body: This paper draws on this research, by looking more closely at how France, Germany, Italy, Spain, Sweden and the United Kingdom are addressing each of these priority areas. It aims to highlight key gaps in research, policy and practice, as well as ongoing initiatives that may impact the future care of sarcoma patients in different European countries. A pragmatic review of the published and web-based literature was undertaken. Telephone interviews were conducted in each country with clinical and patient experts to substantiate findings. Research findings were discussed within the expert group and developed into five core policy recommendations. The five identified priority areas were: the development of designated and accredited centres of reference; more professional training; multidisciplinary care; greater incentives for research and innovation; and more rapid access to effective treatments. Most of the countries studied have ongoing initiatives addressing many of these priorities; however, many are in early stages of development, or require additional funding and resources.Conclusion: Gaps in access to quality care are particularly concerning in many of Europe's lower-resourced countries. Equitable access to information, clinical trials, innovative treatments and quality specialist care should be available to all sarcoma patients. Achieving this across Europe will require close collaboration between all stakeholders at both the national and European level. [ABSTRACT FROM AUTHOR]

The aim of this paper is to investigate, from a generational perspective, the effect of human capital on individual earnings and earnings differences in Germany, France and Italy, three developed countries in Western Europe with similarconservativewelfare regimes but with important differences in their education systems. Income inequalitiesbetweenandwithineducation levels are explored using a two-stage probit model with quantile regressions in the second stage. More precisely, drawing upon 2005 EU-SILC data, returns on schooling and experience are estimated separately for employees and self-employed full-time workers by means of Mincerian earnings equations with sample selection; the sample selection correction accounts for the potential individual self-selection into the two labour force types. Although some determinants appear to be relatively similar across countries, state-specific differentials are drawn in light of the institutional features of each national context. The study reveals how each dimension of human capital differently affects individuals’ earnings and earnings inequality and, most of all, how their impacts differ along the conditional earnings distribution and across countries. In the comparative perspective, the country's leading position in terms of the highest rewards on education also depends on which earnings distribution (employee vs. self-employed) is analysed. [ABSTRACT FROM PUBLISHER]

Objective: Local wound infections are a major challenge for patients and health professionals. Various diagnostic and therapeutic options are available. However, a generally accepted standard is still lacking in Europe. The aim was to develop an easy-to-use clinical score for the early detection of local wound infections, as a basis for decisionmaking on antiseptic therapy or decolonisation. Method: An interdisciplinary and interprofessional panel of experts from seven European countries was brought together to discuss the various aspects of diagnosing local wound infections. Results: The result was the adoption of the Therapeutic Index for Local Infections (TILI) score, developed in Germany by Initiative Chronische Wunden e.V., specifically for health professionals not specialised in wound care. Available in six European languages, the TILI score could also be adapted for different European countries, depending on their specific national healthcare requirements. The six clinical criteria for local wound infection are erythema to surrounding skin; heat; oedema, induration or swelling; spontaneous pain or pressure pain; stalled wound healing; and increase and/or change in colour or smell of exudate. Meeting all criteria indicates that antiseptic wound therapy could be started. Regardless of these unspecific clinical signs, there are also health conditions for the clinical situation which are a direct indication for antimicrobial wound therapy. These include the presence of wound pathogens, such as meticillin-resistant Staphylococcus aureus, septic surgical wound or the presence of free pus. Conclusion: The development of the new internationally adapted TILI score, which could also be used by any caregiver in daily practice to diagnose local infections in acute and hard-to-heal wounds, is the result of expert consensus. However, the score system has to be validated through a clinical evaluation. This is to be performed in expert centres throughout Europe. Declaration of interest: JD has received research support, lecture fees and travel-cost reimbursements from 4M, Coloplast, Convatec, Draco, Engelhardt, Paul Hartmann, KCI, Lohmann&Rauscher, Mölnlycke, SastoMed and Urgo. RL has received research support, lecture fees and travel-cost reimbursements from Mölnlycke and Urgo. AK has received research support, lecture fees and travel-cost reimbursements from 3M, B. Braun Melsungen, Bode/Paul Hartmann, Ethicon, Lohmann&Rauscher, Mundipharma, Oculus, SastoMed Schülke&Mayr, SERAG-WIESSNER and Urgo. JVS has received research support, lecture fees and travel-cost reimbursements from Mundipharma, Histocell, Quesper and Urgo. This work was supported by an unlimited grant from Urgo Medical. The views expressed are those of the authors and do not necessarily reflect those of Urgo Medical. The company had no direct influence on the content of this paper. [ABSTRACT FROM AUTHOR]

Background The European Union has used Healthy Life Years (HLY) as an indicator to monitor the health of its aging populations. Scholarly and popular interest in HLY across countries has grown, particularly regarding the ranking of countries. It is important to note that HLY is based on self-assessments of activity limitations, raising the possibility that it might be influenced by differences in health reporting behaviours between populations, a phenomenon known as differential item functioning (DIF). Methods We estimated DIF-adjusted HLY at age 50 for Belgium, France, Germany, Greece, Italy, the Netherlands, Spain, and Sweden to determine the extent to which differences in HLY might be influenced by reporting heterogeneity across countries. We used anchoring vignettes, taken from the 2004 Survey of Health, Ageing and Retirement in Europe, to estimate DIF-adjusted prevalence rates of activity limitations measured by the Global Activity Limitations Indicator (GALI). The Sullivan method was used to calculate DIF-adjusted HLY. Results Changes in HLY before and after adjustment ranged from a 1.20-year decrease for men in Italy to a 1.61-year increase for women in Spain. Adjustment for DIF produced changes in the rankings of the countries by HLY, with upward and downward movements of up to three positions. Conclusion Our results show that DIF is likely to affect HLY estimates, thereby posing a challenge to the validity of comparisons of HLY across European countries. The findings suggest that HLY should be used to monitor population health status within a country, rather than to make comparisons across countries. [ABSTRACT FROM AUTHOR]

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online., (© 2022 European Society of Cardiology This article has been co-published with permission in European Heart Journal (published by Oxford University Press on behalf of European Society of Cardiology) and European Journal of Heart Failure (published by John Wiley & Sons Ltd on behalf of European Society of Cardiology).)

Background: The effectiveness of allergen immunotherapy (AIT) in seasonal and perennial allergic rhinitis (AR) depends on the definition of pollen exposure intensity or time period. We recently evaluated pollen and symptom data from Germany to examine the new definitions of the European Academy of Allergy and Clinical Immunology (EAACI) on pollen season and peak pollen period start and end. Now, we aim to confirm the feasibility of these definitions to properly mirror symptom loads for grass and birch pollen-induced allergic rhinitis in other European geographical areas such as Austria, Finland and France, and therefore their suitability for AIT and clinical practice support., Methods: Data from twenty-three pollen monitoring stations from three countries in Europe and for 3 years (2014-2016) were used to investigate the correlation between birch and grass pollen concentrations during the birch and grass pollen season defined via the EAACI criteria, and total nasal symptom and medication scores as reported with the aid of the patient's hay-fever diary (PHD). In addition, we conducted a statistical analysis, together with a graphical investigation, to reveal correlations and dependencies between the studied parameters., Results: The analysis demonstrated that the definitions of pollen season as well as peak pollen period start and end as proposed by the EAACI are correlated to pollen-induced symptom loads reported by PHD users during birch and grass pollen season. A statistically significant correlation (slightly higher for birch) has been found between the Total Nasal Symptom and Medication Score (TNSMS) and the pollen concentration levels. Moreover, the maximum symptom levels occurred mostly within the peak pollen periods (PPP) following the EAACI criteria., Conclusions: Based on our analyses, we confirm the validity of the EAACI definitions on pollen season for both birch and grass and for a variety of geographical locations for the four European countries (including Germany from a previous publication) analyzed so far. On this basis, the use of the EAACI definitions is supported in future clinical trials on AIT as well as in daily routine for optimal patient care. Further evaluation of the EAACI criteria in other European regions is recommended., (© 2019 The Authors. Allergy published by John Wiley & Sons Ltd.)

Objective: The development and current state of hemorrhagic fever with renal syndrome (HFRS) over the past 40 years are analyzed in this study, along with explored and discovered the hotspots and frontiers in the field, which serve as the foundation for future investigation., Methods: CiteSpace and VOSviewer analysis software were used to visually analyze the literature data on HFRS from 1980 to 2022, including the annual number of publications, countries and research institutions, authors, co-cited literature and keywords., Results: The number of pertinent papers published in the field of HFRS displayed an overall upward trend from 1980 to 2022. The United States, China, Germany, Sweden, and France are the top 5 countries in terms of publishing volume, with high intermediate centrality mainly concentrated in Europe and the United States. The top 10 co-occurring keywords were hemorrhagic fever, renal syndrome, infection, virus, epidemic, nephropathia epidemical, disease, hantavirus, outbreak, and transmission. According to keyword cluster analysis, there were 4 main research fields. In the HFRS-related study, there were mainly 21 notable keywords and "Korean hemorrhagic fever" had the highest hemorrhagic value (28.87)., Conclusion: The United States, China, Germany, Sweden and other countries attached great importance to the HFRS-related research. Moreover, the collaboration between authors and institutions in various collaborator clusters should be strengthened. In recent decades, investigations have focused on the study of viral infection and the clinical symptoms and pathophysiology of HFRS. Future research may concentrate on factors affecting host population distribution and density, such as vaccine development and meteorological factors pertaining to virus transmission., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

What are the prospects for trilateral concord among Britain, France and Germany in terms of defence policies? Would more institutionalised links among them lead to more convergence of their defence policies? To answer these interrogations, this article investigates the relation between policy convergence and institutionalised cooperation, in particular by studying whether and when one is a prerequisite to the other. First, this article examines the extent to which these countries' defence policies have converged since the end of the cold war based on several indicators: their attitudes towards international forums, their defence budgets, the structure of their armed forces and their willingness to use force. Second, we study each of the bilateral relations between the three states to qualitatively analyse their degree of institutionalisation and the convergence of their defence policies. This article concludes that contrary to the arguments of many discussions, think-tank reports and political actors, there is no evidence that institutionalised cooperation leads to policy convergence as far as defence is concerned. [ABSTRACT FROM PUBLISHER]

Background: Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach. Methods: We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists. Results: Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care. Conclusions: According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care. [ABSTRACT FROM AUTHOR]

Background: Though the disease burden of varicella in Europe has been reported previously, the economic burden is still unknown. This study estimated the economic burden of varicella in Europe in the absence of Universal Varicella Vaccination (UVV) in 2018 Euros from both payer (direct costs) and societal (direct and indirect costs) perspectives.Methods: We estimated the country specific and overall annual costs of varicella in absence of UVV in 31 European countries (27 EU countries, plus Iceland, Norway, Switzerland and the United Kingdom). To obtain country specific unit costs and associated healthcare utilization, we conducted a systematic literature review, searching in PubMed, EMBASE, NEED, DARE, REPEC, Open Grey, and public heath websites (1/1/1999-10/15/2019). The number of annual varicella cases, deaths, outpatient visits and hospitalizations were calculated (without UVV) based on age-specific incidence rates (Riera-Montes et al. 2017) and 2018 population data by country. Unit cost per varicella case and disease burden data were combined using stochastic modeling to estimate 2018 costs stratified by country, age and healthcare resource.Results: Overall annual total costs associated with varicella were estimated to be €662,592,061 (Range: €309,552,363 to €1,015,631,760) in Europe in absence of UVV. Direct and indirect costs were estimated at €229,076,206 (Range €144,809,557 to €313,342,856) and €433,515,855 (Range €164,742,806 to €702,288,904), respectively. Total cost per case was €121.45 (direct: €41.99; indirect: €79.46). Almost half of the costs were attributed to cases in children under 5 years, owing mainly to caregiver work loss. The distribution of costs by healthcare resource was similar across countries. France and Germany accounted for 49.28% of total annual costs, most likely due to a combination of high numbers of cases and unit costs in these countries.Conclusions: The economic burden of varicella across Europe in the absence of UVV is substantial (over 600 M€), primarily driven by caregiver burden including work productivity losses. [ABSTRACT FROM AUTHOR]

This article provides a comparative study of the labour market and social policy measures introduced in light of the COVID-19 crisis in Denmark, France, Germany, Italy and the United Kingdom between March 2020 and January 2021. Its main aim is to understand whether the crisis response has changed the structures of the welfare states concerned. Focusing in particular on the differences regarding the crisis measures taken for individuals in 'standard employment' and 'non-standard workers' in each country, it argues that, although extensive temporary protection instruments were introduced for both groups during the crisis, these did not lead to an immediate convergence as regards these groups' social protection. Rather than changing the underlying structures of welfare systems, many of the measures in fact highlighted the specific vulnerabilities of large segments of Europe's labour markets. States have, however, granted social compensation at unprecedented levels, which could result in improved infrastructures and a clearer understanding of the responsibility of the welfare state in future emergencies. [ABSTRACT FROM AUTHOR]

Background The extent to which patients are involved in their care can be influenced by hospital policies and interventions. Nevertheless, the implementation of patient participation and involvement (PPI) at the organisational (meso) level has rarely been assessed systematically. The aim of this study was to assess the occurrence of PPI practises in hospitals in Belgium, France, Germany and Luxembourg and to analyze if, and to what extent, the hospital vision and the presence of a patient committee influence the implementation of PPI practises. Methods A cross-sectional study was carried out using an online questionnaire in hospitals in the border regions of the four countries. The data were analyzed for differences between regions and the maturity of PPI development. Results Full responses were obtained from 64 hospitals. A wide range of practices were observed, the degree of maturity was mixed. A majority of hospitals promoted patient partnership in the hospital's philosophy of care statement. However, the implementation of specific interventions for PPI was not found uniformly and differences could be observed between the countries. Conclusions Hospitals in the region seem to be motivated to include patients more fully, however, implementation of PPI interventions seems incomplete and only partially integrated into the general functioning of the hospitals. The implementation of the concept seems to be more mature in the francophone part of the region perhaps due, in part, to a more favourable political context. [ABSTRACT FROM AUTHOR]

Background: The objective of this work was to analyse the prevalence trends of multimorbidity among European community-dwelling adults.Methods: A temporal series study based on waves 1, 2, 4, 5, 6 and 7 of the Survey of Health, Ageing and Retirement in Europe (SHARE) was conducted, and community-dwelling participants aged 50+ (n = 274,614) from 15 European countries were selected for the period 2004-2017. Prevalence, adjusted by age, Average Annual Percentage Change (APC) and 95% confidence interval (95% CI) were all calculated. Trend analyses were realised by period, age groups and groups of diseases.Results: The results showed a large variability in the prevalence of multimorbidity in adults aged 50 and over among European countries. Increase in the prevalence of multimorbidity in the countries of central Europe (Austria, Belgium, Czech Republic, France, Germany and Switzerland) and Spain in both sexes, and in the Netherlands among men. Stability was observed in northern and eastern European countries. Musculoskeletal and neurodegenerative groups showed more significant changes in the trend analyses.Conclusions: This information can be useful for policy makers when planning health promotion and prevention policies addressing modifiable risk factors in health. [ABSTRACT FROM AUTHOR]

The current health crisis has particularly affected the elderly population. Nursing homes have unfortunately experienced a relatively large number of deaths. On the basis of this observation and working with European data (from SHARE), we want to check whether nursing homes were lending themselves to excess mortality even before the pandemic. Controlling for a number of important characteristics of the elderly population in and outside nursing homes, we conjecture that the difference in mortality between those two samples is to be attributed to the way nursing homes are designed and organized. Using matching methods, we observe excess mortality in Sweden, Belgium, Germany, Switzerland, Czech Republic and Estonia but not in the Netherlands, Denmark, Austria, France, Luxembourg, Italy and Spain. This raises the question of the organization and management of these nursing homes, but also of their design and financing., (© 2022 John Wiley & Sons Ltd.)

The global spread of degree courses taught in English as a Medium of Instruction raises questions about the identity or "branding" of English-taught degree programs in non-Anglophone countries and whether they differ from their equivalents in the national languages. To answer this question, we have examined a sample of master's degree programs in the same domain, International Relations, across Italy, France and Germany from a quantitative and a qualitative perspective. Our findings suggest that they present a similar branding strategy in line with the standardization process of EU higher education, also reflecting the global trend toward the "entrepreneurial university." [ABSTRACT FROM AUTHOR]

BACKGROUND: Several studies have been performed on the relationship between working conditions and health. Numerous parameters still require further study, including working hours and obesity among different groups, specifically older workers in national, regional, and international levels. OBJECTIVE: Working hours have considerable effects on the socio-cultural, psychological, and economic aspects of people's lives and health. While long working hours increases income level and raises living standards, it increases the risk of certain health problems. This study investigated whether working hours are associated with obesity in upper-middle-aged workers. METHODS: The Survey of Health, Ageing and Retirement in Europe (SHARE) dataset was used for the analyses. Analyses were carried out by means of a Cox regression of the panel dataset created with the data in question, surveyed by European Commission to 12,000 participants. RESULTS: The survey was performed in Austria, Belgium, Switzerland, Germany, Denmark, Spain, France, Greece, Italy, the Netherlands, Sweden, the Czech Republic, Poland, and Ireland. We found that in most countries, especially Sweden and the Netherlands, upper-middle-aged employees working > 59 hours per week are more likely to gain weight than their counterparts working < 59 hours. CONCLUSIONS: Our findings raise awareness of obesity in older workers, and highlight the need to regulate working conditions and hours in the European Union and other countries. [ABSTRACT FROM AUTHOR]

This paper reports on an investigation examining provision of physical education continuing professional development (CPD) in European countries undertaken to identify the types of practices being employed. We begin by providing a brief overview of what we currently know about CPD internationally in general education and physical education. Data are reported to reflect Parker and Patton's (2017) key characteristics of CPD that highlight effective CPD, summarise current trends and issues in physical education, and are intended to serve as a guide to how teachers learn and how they might be better served in that learning in these European countries. Studying current practices in CPD provision identified in this study provided modest insight to inform teacher education programmes and CPD providers on the current status of physical education CPD currently being employed in Europe. We propose these findings might inform international and comparative education with respect to CPD and set the foundation for physical education colleagues in Europe to develop a CPD network where endeavours such as sharing of CPD practices, engaging in discussion of those practices, and the design of collaborative research on such CPD practices are based.

Purpose: To define based on expert opinion and practical experience using a systematic and scientific approach, (1) the perceived most effective exercise-based strategies to prevent muscle injury in elite footballers; and, (2) when and how these exercise programs are prescribed based on the number of days between games i.e. implementation strategy. Methods: A Delphi survey obtained opinions and assessed for agreement. Delphi respondents consisted of 21 experienced sports practitioners (12 ± 5.3 years in elite football and with an academic background) belonging to 18 teams from the Big-5 European football leagues; England, France, Germany, Italy, Spain. Three teams were represented collaboratively by two experts. The Delphi process involves sequential rounds each evolving based on the responses from the previous. The number of rounds is not pre-defined and continues until an agreement is either achieved or it is clear that no agreement will be reached. Frequency of responses was recorded where the agreement was sought (i.e. in closed questions) and an agreement was achieved if ≥ 13/18 (70%) respondents agreed. For open-ended questions, a qualitative content analysis was performed to identify recurring themes and when themes were specified by ≥ 13 (70%), these were also considered as reaching an agreement. Practitioners had the opportunity to raise concerns if they disagreed with the 'agreement from recurrent themes'. Results: There were four Delphi rounds (100% response for each round). Sprinting and High-Speed Running (HSR) focused exercises were agreed as most effective (perceived) to prevent muscle injuries. Eccentric exercise was perceived as the next most effective. It was agreed that sprinting and HSR be integrated into coaches training, and target 100% of players worst-case match scenario (e.g. volume, intensity) based on individual maximum speeds. Eccentric exercise was recommended to be implemented according to the context of the main football session and planned/actual sprinting and HSR content. It was agreed that eccentrics can be performed before or after training, context dependent. The day to perform specific sprinting and HSR or eccentric exercises depended on the proximity of previous and upcoming matches. Other exercises reaching agreement as 'somewhat effective' included concentric and isometric, horizontal and vertical plyometrics, coordination, core and dynamic flexibility in addition to core stability. No agreement was reached for multi-joint, resisted sprinting, kicking or agility exercises nor simultaneous single-leg strength and stability. Finally, no agreement was reached regarding programming variables e.g. sets, repetitions as deemed too contextual. Conclusion: Regarding exercise-based strategies, particular importance agreed by the Delphi expert group was to focus on sprinting, HSR and eccentric exercises, integrated with a variety of other exercise modes which also carry some level of effectiveness in a multidimensional programme. Context was agreed to be key and decision-making about when to undertake/ how to prescribe exercise strategies to be made according to the content of normal football training and the proximity of matches. [ABSTRACT FROM AUTHOR]

In this comparative study focusing on the population aged 50 and over in three European countries, we investigate the association between household debt and depressive symptoms, and possible country differences in this association, using data from Waves 1, 2, 4, 5 and 6 of the Surveys of Health, Ageing and Retirement in Europe (SHARE) for Belgium, France and Germany. Multi-level regression models with random intercepts for individuals were used to analyse the association between household debt status and number of depressive symptoms (EURO-D score). Country differences in the household debt–depression nexus were tested using country interaction models. After controlling for other measures of socio-economic position and physical health, low or substantial financial debt was associated with a higher number of depressive symptoms in all countries. Housing debt was strongly linked to depressive symptoms for women while the association was weaker for men. The only country difference was that for both sexes substantial financial debt (more than €5,000) was strongly associated with depressive symptoms in Belgium and Germany, but the association was weak or non-significant in France. Associations between financial debt and depression were also evident in analyses of within-individual changes in depressive symptoms for a longitudinal sub-group, and in analyses using a dichotomised, rather than a continuous, measure of depression. The findings indicate that measures of household indebtedness should be taken into consideration in investigations of social inequalities in depression and suggest a need for mental health services targeted at indebted older people. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to carry out an empirical examination of the supply-side factors influencing dropout rates in MBA programs. We analyze the extent to which the resources and characteristics of the program (content, teaching methodology, course load, class size, partnerships, reputation) influence these rates. A GLM analysis was conducted on data obtained from a final sample of 94 executive MBA programs in Western Europe. The results indicate that several supply side factors significantly affect dropout: intensity of case study learning, number of credits per month, class size, and proportion of lessons given at partner institutions. Several implications for the design and management of higher education programs have been drawn from this research.

Background Decreasing gender differences in mental health are found largely in countries in which the roles of men and women have improved in terms of opportunities for employment, education, child care and other indicators of increasing gender equality. In this study, we examine how European welfare regimes influence this association between mental health and the social roles that men and women occupy. Methods The EU-World Mental Health data are used, which covers the general population in 10 European countries (n = 37 289); Countries were grouped into four welfare regions: Liberal regime (Northern Ireland), Bismarckian regime (Belgium, Germany, the Netherlands and France), Southern regime (Spain, Italy, Portugal) and Central-Eastern regime (Romania and Bulgaria). The lifetime prevalence of mood, anxiety and alcohol disorders was determined by using the Composite International Diagnostic Interview 3.0. Overall prevalence rates along with odds ratios by means of bivariate logistic regression models are calculated to compare the presence of common mental disorders in women versus men per welfare regime. Results Overall prevalence of common mental disorders is highest in the Liberal regime and lowest in the Central/Eastern regime. The gender gap in mental disorders is largest in the Southern regime and smallest in the Liberal regime. Marital status and certain employment positions help to explain variation in mental disorders across and within welfare regimes. Conclusion Most prominent pathways linking gender to mental ill-health being are related to marital status and certain employment positions. However, these pathways also show substantial variation across welfare regimes. [ABSTRACT FROM AUTHOR]

Background: Bronchoscopic lung volume reduction (BLVR) using valves and coils has been approved for use since 2003 and 2010, respectively. Objective(s): To study adoption patterns of BLVR in an early-adopting country, and to estimate potential treatment volumes in other European countries. Methods: Therapy- and age-specific volumes for endobronchial valve and coil procedures were obtained from German federal statistics for 2007–2016. Therapy-specific and total BLVR procedure volumes and growth were computed, and patterns in treatment age and device utilization analyzed. Patient volumes for other European countries were predicted using mean German patient volumes of the last 3 data years and age-specific population and emphysema incidences. Results: Over the study period, annual BLVR procedure volumes grew from 91 to 2,053 (+2,256%), reaching a peak of 2,556 procedures in 2013. Coil procedures constituted 36% of the total volume in 2016. Treatment age was stable over time, with highest procedure counts in age group 60–64 years for valves and 65–69 years for coils. A limited increase in device use per procedure was observed. For -Germany, 1,655 newly treated BLVR patients were estimated per year, approximating about 5% of the annual newly diagnosed severe emphysema cases. Predicted volume estimates for other European countries ranged from 1 for Liechtenstein to 1,226 for France. Conclusions: Analysis of -German procedure data show pronounced BLVR therapy uptake in the early years of adoption, with the more recently introduced coil therapy used in about one-third of patients. Estimated patient volumes to date constitute only a small fraction of the severe emphysema population. [ABSTRACT FROM AUTHOR]

Objective: The main goal of this study was to determine the knowledge and beliefs of otorhinolaryngologists in a secondary setting in selected economically advanced European countries concerning severe hearing loss, hearing aids, and cochlear implants (CIs). Secondary goals of the study looked into the information sources of the otorhinolaryngologists and into key topics of importance for these professionals. In Europe, many adults, who could benefit from a CI, do not have one despite their availability via national health care systems. This lack of coverage might be due, in part, to the knowledge and beliefs of otorhinolaryngologists.Methods: Otorhinolaryngologists in a secondary setting in Germany, England, France, Austria, and Sweden were emailed a custom-made questionnaire on their knowledge and beliefs regarding hearing loss and its treatments. Results were presented in relative frequencies (%) according to each nation.Results: Two-hundred and forty otorhinolaryngologists responded (50 from each nation except Sweden). Each nation regarded rehabilitation and hearing preservation as particularly important in CIs. National and international conferences and conversations with colleagues were much more popular methods of keeping abreast of medical issues than other information sources such as online media or company information.Conclusion: The otorhinolaryngologists of the surveyed nations share many common beliefs about hearing loss, hearing aids, and CIs, although some national variation in opinion is present. The otorhinolaryngologists of each nation are knowledgeable, but could still benefit from an increased knowledge and awareness of hearing loss treatment modalities. [ABSTRACT FROM AUTHOR]

The literature addressing attitudes about social policy and the welfare state has been telling us for decades that welfare interventions are supported by those individuals who benefit from a specific measure. The diffusion of ‘demanding’ active labour market policies (ALMPs), however, challenges this relationship. Using a novel dataset, I analyse which individual- and country-level factors explain public support for demanding ALMPs in five Western European countries. The results show that labour market risk and ideological orientation influence public attitudes towards these ALMPs. Thereby, unemployed individuals sympathising with the political right are more strongly opposed to demanding measures than employed individuals with the same political preferences. Moreover, aggregate support is found to be correlated with the country's ALMP legacy, varying from high levels in Germany and the UK to low levels in Denmark and France. The findings suggest that most ALMPs are in fact implemented despite the opposition of their beneficiaries. [ABSTRACT FROM PUBLISHER]

In the context of the prospective increase in the numbers of older adults in Europe and of conflicting findings regarding recent disability trends, the present study uses cross-sectional data from four waves of the Survey of Health, Ageing and Retirement in Europe (SHARE), covering the period 2004–2013, and aims at the assessment of trends in disability by sex and broad age group (50–64 and 65 and over) for the ten countries participating in all waves, based on four different measures: limitations in activities of daily living (ADLs), limitations in instrumental ADLs, mobility difficulties and the Global Activity Limitation Indicator. The analysis uses logistic regression models adjusted for age and, subsequently, also for chronic conditions. The findings indicate improvements both in mild/moderate activity restrictions and in functional limitations for several countries, especially among men and women aged 65 and over. Regarding severe disability (ADLs) there is mostly a lack of any significant trend and only a few declines. In several instances, the observed trends are linked to changes in chronic conditions; significant improvements net of chronic conditions are found mainly in Sweden but also in the Netherlands, Austria, Germany, Italy and France. Overall, the estimated trends often differentiate by country, age group and sex while they depend upon the specificities of the measures used in the analysis. [ABSTRACT FROM PUBLISHER]

Objective To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers' educational level. Methods Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change. Findings Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001). Conclusions The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers. [ABSTRACT FROM AUTHOR]

In 1924 the Carnegie Endowment for International Peace published a volume investigating the teaching of school history in former belligerent states in Europe. The project sought to reconcile former enemies through mutual understanding and educational exchange and reflected a widely held belief that although the military conflict had finished, its ideas still resounded and served to perpetuate antagonism. The CEIP project, conceived in the internationalist spirit, was itself derailed by nationalist enmity, a consequence of the Franco-Belgian occupation of the Ruhr in January 1923, demonstrating the limits of cultural reconciliation in the early 1920s, and the resultant volume showed that belligerent views of recent history were still being taught to schoolchildren in France and Germany in the early 1920s. [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]

Based on small case-study illustrations from a variety of European countries, this study aims to explore methodological aspects of the study of curriculum history by expanding its traditional research scope. In so doing, it is argued that sociolinguistic issues are essential to this discussion. The main argument is that sociolinguistics and curriculum history are more closely intertwined than has been proposed by previous academic literature. Under the examination are often two sides of the same coin which are viewed from different, albeit closely related, research angles. In effect, the curriculum's contextualisation is also structured and modified by sociolinguistic considerations. In the conclusion, it is maintained that citizenship education--understood here as the historical manifestation of the dominant cultural expectations towards the citizens as the bearers of a particular nation state during a specific timeframe--should be better informed by sociolinguistic literature, and by that, also placed against those language controversies that surround the curriculum. On this basis, by adding value to the study of the curriculum as part of educational history--and by blurring unnecessary academic boundaries--this paper provides interdisciplinary insights into the study of curriculum history vis-à-vis sociolinguistics, which have so far remained too separated.

This article is based on research on preschool childcare services and analyses the issues of its provision in Russia in comparison to Western and Eastern European countries. A micro-level cross-sectional data analysis of the first waves of the Generations and Gender Survey (GGS) is performed. The results show that variations in using childcare services can be partly explained by the age and number of children in the family, mother’s education and characteristics of her employment. [ABSTRACT FROM AUTHOR]

Background: The burden of advanced non-small cell lung cancer (NSCLC) is not well understood, and the number of patients likely to receive treatment in Europe has not been quantified. The aim of this study was to forecast the annual number of patients with squamous and non-squamous advanced NSCLC likely to receive second and third lines of therapy (LOT) from 2016 to 2020 in France, Germany, Italy, and Spain. Methods: A patient count model (PCM) was developed in Microsoft Excel to estimate the number of patients with refractory advanced NSCLC eligible to receive systemic treatment. Using historical population-based cancer registry data, segmented linear regression ("Joinpoint") was used to forecast age- and sex-stratified lung cancer incidence rates in each country through 2020. Yearly incident case count totals by country were apportioned according to NSCLC histology and stage at diagnosis. Country-specific treatment rates came from a recent medical chart review study, and early- to advanced-stage disease progression rates were estimated over a 10-year interval. A probabilistic sensitivity analysis (PSA) was performed to estimate variability in the patient counts. Results: The combined number of squamous and non-squamous advanced NSCLC patients estimated to receive second and third LOT, respectively, in 2016 were France = 11,600 and 3500; Germany = 15,100 and 4900; Italy = 13,500 and 2500; Spain = 9400 and 2100. The forecasted numbers of patients receiving second and third LOT, respectively, in 2020 were France = 13,900 and 4200; Germany = 16,200 and 5200; Italy = 15,100 and 2600; Spain = 11,000 and 2500. Conclusions: Driven by growth in the incidence of NSCLC among women, the model forecasts an overall increase in the number of patients with advanced-stage squamous and non-squamous NSCLC likely to receive systemic treatment in the year 2020. The results highlight the significant burden of refractory advanced NSCLC and the need for more robust surveillance data to accurately quantify the burden of disease. [ABSTRACT FROM AUTHOR]

Background: Migraine is a distinct neurological disease that imposes a significant burden on patients, society, and the healthcare system. This study aimed to characterize the incremental burden of migraine in individuals who suffer from ≥4 monthly headache days (MHDs) by examining health-related quality of life (HRQoL), impairments to work productivity and daily activities, and healthcare resource utilization (HRU) in the EU5 (France, Germany, Italy, Spain, United Kingdom).Methods: This retrospective cross-sectional study used data from the 2016 National Health and Wellness Survey (NHWS; N = 80,600). Short-Form 36-Item Health Survey, version 2 (SF-36v2) physical and mental component summary scores (PCS and MCS), Short-form-6D (SF-6D), and EuroQoL (EQ-5D), impairments to work productivity and daily activities (Work Productivity and Activity Impairment Questionnaire (WPAI), and HRU were compared between migraine respondents suffering from ≥4 MHDs (n = 218) and non-migraine controls (n = 218) by propensity score matching using sociodemographic characteristics. Chi-square, T-tests, and Mann-Whitney tests were performed to determine significant differences between the groups after propensity score matching.Results: HRQoL was lower in migraine individuals suffering from ≥4 MHDs compared with non-migraine controls, with reduced SF-36v2 PCS (46.00 vs 50.51) and MCS (37.69 vs 44.82), SF-6D health state utility score (0.62 vs 0.71), and EQ-5D score (0.68 vs 0.81) (for all, p < 0.001). Respondents with migraine suffering from ≥4 MHDs also reported higher levels of absenteeism from work (14.43% vs 9.46%; p = 0.001), presenteeism (35.52% vs 20.97%), overall work impairment (38.70% vs 23.27%), and activity impairment (44.17% vs 27.75%) than non-migraine controls (for all, p < 0.001). Additionally, HRU was significantly higher for individuals with ≥4 MHDs compared to their matched controls. Consistently, migraine subgroups (4-7 MHDs, 8-14 MHDs and CM) had lower HRQoL, greater overall work and activity impairment, and higher HRU compared to non-migraine controls.Conclusions: Migraine of ≥4 MHDs was associated with poorer HRQoL, greater work productivity loss, and higher HRU compared with non-migraine controls. The findings of the study suggest that an unmet need exists among individuals suffering from ≥4 MHDs in the EU5 suggesting the need for effective prophylactic treatments to lessen the humanistic and economic burden of migraine. [ABSTRACT FROM AUTHOR]

In recent years, there has been a revival of the term "structural violence (SV)" which was coined by Johan Galtung in the 1960s in the context of Peace Studies. "Structural violence" refers to social structures-economic, legal, political, religious, and cultural-that prevent individuals, groups and societies from reaching their full potential. In the European context, very few studies have investigated health and well-being using an SV perspective. Therefore, this paper sought to systematically and descriptively review studies that used an SV framework to examine health-related outcomes across European countries. The review included two studies each from Spain and France, one each from the UK, Ukraine and Russia, and another study including the three countries Sweden, Portugal and Germany. With the exception of one mixed-method study, the studies used a qualitative design. Furthermore, the eight studies in the review used different conceptualizations of SV, which indicates the complexity of using SV as a concept in public health in the European context. Future research that attempts to identify and standardize measures of SV is needed; the knowledge gained is hoped to inform appropriate interventions aiming to reduce the effects of SV on population health.

The effects of coronavirus disease 2019 (COVID-19) have been well documented across the world with an appreciation that older people and in particular those with dementia have been disproportionately and negatively affected by the pandemic. This is both in terms of their health outcomes (mortality and morbidity), care decisions made by health systems and the longer-term effects such as neurological damage. The International Dementia Alliance is a group of dementia specialists from six European countries and this paper is a summary of our experience of the effects of COVID-19 on our populations. Experience from England, France, Germany, the Netherlands, Spain and Switzerland highlight the differential response from health and social care systems and the measures taken to maximise support for older people and those with dementia. The common themes include recognition of the atypical presentation of COVID-19 in older people (and those with dementia) need to pay particular attention to the care of people with dementia in care homes; the recognition of the toll that isolation can bring on older people and the complexity of the response by health and social services to minimise the negative impact of the pandemic. Potential new ways of working identified during the pandemic could serve as a positive legacy from the crisis., (© 2021 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

With the implementation of European integration policies such as the single market, the Euro and the Schengen Visa, the EU member states are developing closer economic ties through tourism, and their level of tourism integration is constantly improving. Taking the 28 EU member states as research objects, this paper constructs a tourism economic connection network among them, measures the strength of their tourism economic connections from 1995 to 2018 by using the modified gravity model and social network method, and analyzes the spatial structure characteristics and effects of the EU tourism economy. The results are as follows: (1) The tourism economic ties of EU member states are growing increasingly close, enhancing network stability. (2) Germany, France, Italy, Austria and the United Kingdom are the top five countries in the degree centrality and closeness centrality rankings, meaning that they are located in the center of the network and have great influence, and the network is becoming increasingly concentrated. Germany, Italy, Sweden, Austria and France play an important intermediary role in the network, and the centrality of most member states has increased. (3) The core areas are mainly concentrated in Western Europe, Southern Europe, Mediterranean mainland countries and Central Europe, while the marginal areas are mainly concentrated in Eastern Europe, Northern Europe and Mediterranean island countries; the network connection density of the core area, the network connection density of the marginal area, and the network connection density between the core and marginal area overall show an increasing trend. (4) Improvements in the complete network connectedness and a reduction in graph efficiency can significantly reduce differences in EU tourism economic development levels and improve spatial equity.

Studying weekend-weekday variation in ground-level ozone (O 3 ) allows one to better understand O 3 formation conditions, with a potential for developing effective strategies for O 3 control. Reducing inappropriately the O 3 precursors emissions can either produce no reduction or increase surface O 3 concentrations. This paper analyzes the weekend-weekday differences of O 3 at 300 rural and 808 urban background stations worldwide from 2005 to 2014, in order to investigate the O 3 weekend effect over time and assess the effectiveness of the precursors emissions control policies for reducing O 3 levels. Data were analyzed with the non-parametric Mann-Kendall test and Theil-Sen estimator. Rural sites typically did not experience a weekend-weekday effect. In all urban stations, the mean O 3 concentration on the weekend was 12% higher than on weekdays. Between 2005 and 2014, the annual mean of daily O 3 concentrations increased at 74% of urban sites worldwide (+ 0.41 ppb year -1 ) and decreased in the United Kingdom (- 0.18 ppb year -1 ). Over this time period, emissions of O 3 precursors declined significantly. However, a greater decline in nitrogen oxides (NO x ) emissions caused an increase in Volatile Organic Compounds (VOCs) to NO x ratios leading to O 3 formation. In France, South Korea and the United Kingdom, most urban stations showed a significant upward trend (+ 1.15% per year) for O 3 weekend effect. Conversely, in Canada, Germany, Japan, Italy and the United States, the O 3 weekend effect showed a significant downward trend (- 0.26% per year). Further or inappropriate control of anthropogenic emissions in Canada, Southern Europe, Japan, South Korea and the United States might result in increased daily O 3 levels in urban areas., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Dystonia is a heterogeneous disorder that, when refractory to medical treatment, may have a favorable response to deep brain stimulation (DBS). A practical way to have an overview of a research domain is through a bibliometric analysis, as it makes it more accessible for researchers and others outside the field to have an idea of its directions and needs., Objective: To analyze the 100 most cited articles in the use of DBS for dystonia treatment in the last 30 years., Methods: The research protocol was performed in June 2019 in Elsevier's Scopus database, by retrieving the most cited articles regarding DBS in dystonia. We analyzed authors, year of publication, country, affiliation, and targets of DBS., Results: Articles are mainly published in Movement Disorders (19%), Journal of Neurosurgery (9%), and Neurology (9%). European countries offer significant contributions (57% of our sample). France (192.5 citations/paper) and Germany (144.1 citations/paper) have the highest citation rates of all countries. The United States contributes with 31% of the articles, with 129.8 citations/paper. The publications are focused on General outcomes (46%), followed by Long-term outcomes (12.5%), and Complications (11%), and the leading type of dystonia researched is idiopathic or inherited, isolated, segmental or generalized dystonia, with 27% of articles and 204.3 citations/paper., Conclusions: DBS in dystonia research is mainly published in a handful of scientific journals and focused on the outcomes of the surgery in idiopathic or inherited, isolated, segmental or generalized dystonia, and with globus pallidus internus as the main DBS target.

Since 2015, a series of papers which describe the systems for the provision of health and oral healthcare in nine European Union (EU) countries (France, Germany, Greece, Ireland, Italy, Poland, Romania, Spain and Sweden) have been published in this journal. This tenth and final paper in the series compares aspects of the systems for each country, with each other and with that in the United Kingdom (UK). The topics which have been covered are the organisation and funding of oral healthcare, national populations and oral healthcare workforce, education of dentists, uptake of oral healthcare, expenditure on oral healthcare and oral epidemiology. The comparison shows that there are wide differences between the care provision systems between the individual countries. In all of them, oral healthcare continues to operate outside the mainstream healthcare systems. In particular, the proportion of costs paid for them from public funds, raised through taxation or through compulsory social insurances, and those paid for by individual patients varies greatly. No comparable data exist on quality of care.