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Background: Cervical cancer remains a significant public health concern in Europe. Effective introduction and scaling up of human papillomavirus (HPV) detection-based cervical cancer screening (CCS) requires a systematic assessment of health systems capacity. However, there is no validated capacity assessment methodology for CCS programmes, especially in European contexts. Addressing this gap, our study introduces an innovative and adaptable protocol for evaluating the capacity of CCS programmes across varying European health system settings. Methods: Our research team developed a three-step capacity assessment framework, incorporating a health policy review checklist, a facility visit survey, and key informants' interview guide followed by a strengths, weaknesses, opportunities and threats (SWOT) analysis. Piloting this comprehensive approach, we explored the CCS capacity in three countries: Estonia, Portugal and Romania. These countries were selected due to their contrasting healthcare structures and resources, providing a diverse overview of the European context. Results: Conducted over a period of 9 months, the capacity assessment covered multiple resources, 27 screening centres, 16 colposcopy and treatment centres and 15 key informant interviews. Our analysis highlighted both shared and country-specific challenges. A key common issue was ensuring high compliance to follow-up and management of screen-positive women. We identified considerable heterogeneity in resources and organization across the three countries, underscoring the need for tailored, rather than one-size-fits-all, solutions. Conclusions: Our study's novelty lies in the successful development of this capacity assessment methodology implementable within a relatively short time frame, proving its feasibility for use in various contexts and countries. The resulting set of materials, adaptable to different cancer types, is a ready-to-use toolkit to improve cancer screening processes and outcomes. This research marks a significant stride towards comprehensive capacity assessment for CCS programmes in Europe. Future directions include deploying these tools in other countries and cancer types, thereby contributing to the global fight against cancer. [ABSTRACT FROM AUTHOR]

Background: Patients' online record access (ORA) enables patients to read and use their health data through online digital solutions. One such solution, patient-accessible electronic health records (PAEHRs) have been implemented in Estonia, Finland, Norway, and Sweden. While accumulated research has pointed to many potential benefits of ORA, its application in mental healthcare (MHC) continues to be contested. The present study aimed to describe MHC users' overall experiences with national PAEHR services. Methods: The study analysed the MHC-part of the NORDeHEALTH 2022 Patient Survey, a large-scale multi-country survey. The survey consisted of 45 questions, including demographic variables and questions related to users' experiences with ORA. We focused on the questions concerning positive experiences (benefits), negative experiences (errors, omissions, offence), and breaches of security and privacy. Participants were included in this analysis if they reported receiving mental healthcare within the past two years. Descriptive statistics were used to summarise data, and percentages were calculated on available data. Results: 6,157 respondents were included. In line with previous research, almost half (45%) reported very positive experiences with ORA. A majority in each country also reported improved trust (at least 69%) and communication (at least 71%) with healthcare providers. One-third (29.5%) reported very negative experiences with ORA. In total, half of the respondents (47.9%) found errors and a third (35.5%) found omissions in their medical documentation. One-third (34.8%) of all respondents also reported being offended by the content. When errors or omissions were identified, about half (46.5%) reported that they took no action. There seems to be differences in how patients experience errors, omissions, and missing information between the countries. A small proportion reported instances where family or others demanded access to their records (3.1%), and about one in ten (10.7%) noted that unauthorised individuals had seen their health information. Conclusions: Overall, MHC patients reported more positive experiences than negative, but a large portion of respondents reported problems with the content of the PAEHR. Further research on best practice in implementation of ORA in MHC is therefore needed, to ensure that all patients may reap the benefits while limiting potential negative consequences. [ABSTRACT FROM AUTHOR]

Background: Early childhood education offers opportunities for stimulation in multiple developmental domains and its positive impact on long-term outcomes and wellbeing for children is well documented. Few studies have explored early education in children born very preterm (VPT; <32 weeks of gestation) who are at higher risk of neurodevelopmental disorders and poor educational outcomes than their term-born peers. The purpose of the study is to describe and compare the educational environment of children born VPT in European countries at 5 years of age according to the degree of perinatal risk. Methods: Data originated from the population-based Screening to Improve Health In very Preterm infants (SHIPS) cohort of children born VPT in 2011/2012 in 19 regions from 11 European countries. Perinatal data were collected from medical records and the 5-year follow-up was conducted using parental questionnaires. Outcomes at 5 years were participation in early education (any, type, intensity of participation) and receipt of special educational support, which were harmonized across countries. Results: Out of 6,759 eligible children, 3,687 (54.6%) were followed up at 5 years (mean gestational age 29.3 weeks). At 5 years, almost all children (98.6%) were in an educational program, but type (preschool/primary), attendance (full-time/part-time) and use and type of school support/services differed by country. In some countries, children with high perinatal risk were more likely to be in full-time education than those with low risk (e.g. Estonia: 97.9% vs. 87.1%), while the inverse pattern was observed elsewhere (e.g. Poland: 78.5% vs. 92.8%). Overall, 22.8% of children received special educational support (country range: 12.4–34.4%) with more support received by children with higher perinatal risk. Large variations between countries remained after adjustment for socio-demographic characteristics. Conclusions: There are marked variations in approaches to early education for children born VPT in Europe, raising opportunities to explore its impact on their neurodevelopment and well-being. [ABSTRACT FROM AUTHOR]

Background: Afforestation of non-forestland is a new measure by the European Union to enhance climate mitigation and biodiversity. Hybrid aspen (Populus tremula L. × P. tremuloides Michx.) is among the suitable tree species for afforestation to produce woody biomass. However, the best performing genotypic material for intensive biomass production and its physiological adaptation capacity is still unclear. We compared 22 hybrid aspen genotypes growth and leaf physiological characteristics (stomatal conductance, net photosynthesis, intrinsic water-use efficiency) according to their geographical north- or southward transfer (European P. tremula parent from 51° to 60° N and North American P. tremuloides parent from 45° to 54° N) to hemiboreal Estonia (58° N) in a completely randomized design progeny trial. We tested whether the growth ranking of genotypes of different geographical origin has changed from young (3-year-old) to mid-rotation age (13-year-old). The gas exchange parameters were measured in excised shoots in 2021 summer, which was characterised with warmer (+ 4 °C) and drier (17% precipitation from normal) June and July than the long-term average. Results: We found that the northward transfer of hybrid aspen genotypes resulted in a significant gain in growth (two-fold greater diameter at breast height) in comparison with the southward transfer. The early selection of genotypes was generally in good accordance with the middle-aged genotype ranking, while some of the northward transferred genotypes showed improved growth at the middle-age period in comparison with their ranking during the early phase. The genotypes of southward transfer demonstrated higher stomatal conductance, which resulted in higher net photosynthesis, and lower intrinsic water-use efficiency (iWUE) compared with northward transfer genotypes. However, higher photosynthesis did not translate into higher growth rate. The higher physiological activity of southern transferred genotypes was likely related to a better water supply of smaller and consequently more shaded trees under drought. Leaf nitrogen concentration did not have any significant relation with tree growth. Conclusions: We conclude that the final selection of hybrid aspen genotypes for commercial use should be done in 10–15 years after planting. Physiological traits acquired during periods of droughty conditions may not fully capture the growth potential. Nonetheless, we advocate for a broader integration of physiological measurements alongside traditional traits (such as height and diameter) in genotype field testing to facilitate the selection of climate-adapted planting material for resilient forests. [ABSTRACT FROM AUTHOR]

Background: The mosquito-borne zoonotic parasite Dirofilaria immitis continues to spread northwards in Europe. This parasite can cause potentially life-threatening heartworm disease in dogs and pulmonary dirofilariasis in humans and is, therefore, a major health concern in both the veterinary medicine and human medical fields. This is the first report of D. immitis infections and heartworm disease in the Baltic country Estonia. Methods: Data on canine D. immitis infections and heartworm disease were collected from the electronic patient records database of the Small Animal Clinic of Estonian University of Life Sciences, the only university clinic in Estonia. The patient records of dogs with confirmed diagnosis of D. immitis infection or heartworm disease were reviewed and summarised. Results: Six dogs had been diagnosed with confirmed D. immitis infection or heartworm disease at the university clinic in 2021–2022. The confirmed diagnoses had been reached following international guidelines, based on a combination of different tests. Molecular confirmation of the parasite species had not been performed. Two of the dogs had been imported while four had no travel history outside of the country. Conclusions: Four of the dogs with a confirmed D. immitis infection or heartworm disease had no history of being imported or travelling outside of the country, indicating autochthonous infections and, consequently, local circulation of the parasite in Estonia. These findings represent the new northernmost autochthonous cases of D. immitis infection and canine heartworm disease reported in the European Union. [ABSTRACT FROM AUTHOR]

Background: Polycystic ovary syndrome (PCOS) is a complex multifactorial disorder with a substantial genetic component. However, the clinical manifestations of PCOS are heterogeneous with notable differences between lean and obese women, implying a different pathophysiology manifesting in differential body mass index (BMI). We performed a meta-analysis of genome-wide association study (GWAS) data from six well-characterised cohorts, using a case–control study design stratified by BMI, aiming to identify genetic variants associated with lean and overweight/obese PCOS subtypes. Results: The study comprised 254,588 women (5,937 cases and 248,651 controls) from individual studies performed in Australia, Estonia, Finland, the Netherlands and United States of America, and separated according to three BMI stratifications (lean, overweight and obese). Genome-wide association analyses were performed for each stratification within each cohort, with the data for each BMI group meta-analysed using METAL software. Almost half of the total study population (47%, n = 119,584) were of lean BMI (≤ 25 kg/m2). Two genome-wide significant loci were identified for lean PCOS, led by rs12000707 within DENND1A (P = 1.55 × 10–12) and rs2228260 within XBP1 (P = 3.68 × 10–8). One additional locus, LINC02905, was highlighted as significantly associated with lean PCOS through gene-based analyses (P = 1.76 × 10–6). There were no significant loci observed for the overweight or obese sub-strata when analysed separately, however, when these strata were combined, an association signal led by rs569675099 within DENND1A reached genome-wide significance (P = 3.22 × 10–9) and a gene-based association was identified with ERBB4 (P = 1.59 × 10–6). Nineteen of 28 signals identified in previous GWAS, were replicated with consistent allelic effect in the lean stratum. There were less replicated signals in the overweight and obese groups, and only 4 SNPs were replicated in each of the three BMI strata. Conclusions: Genetic variation at the XBP1, LINC02905 and ERBB4 loci were associated with PCOS within unique BMI strata, while DENND1A demonstrated associations across multiple strata, providing evidence of both distinct and shared genetic features between lean and overweight/obese PCOS-affected women. This study demonstrated that PCOS-affected women with contrasting body weight are not only phenotypically distinct but also show variation in genetic architecture; lean PCOS women typically display elevated gonadotrophin ratios, lower insulin resistance, higher androgen levels, including adrenal androgens, and more favourable lipid profiles. Overall, these findings add to the growing body of evidence supporting a genetic basis for PCOS as well as differences in genetic patterns relevant to PCOS BMI-subtype. [ABSTRACT FROM AUTHOR]

Background: A minority of European countries have compulsory training in palliative care within all medical schools. The aim of the study was to examine palliative care education in Estonia. Methods: We used the adapted version of the Palliative Education Assessment Tool (PEAT) to evaluate palliative care education at the University of Tartu, the only medical school in Estonia. The PEAT comprises of different palliative care domains and allows for assessing the curricula for palliative care education. Results: 26 hours (h) of palliative care is taught within the basic medical curriculum, which is divided between 14 courses. Ethical issues (4 h, lecture and seminar) and basics of palliative care (2.5 h, lecture) are well covered however, pain and symptom management (12.5 h, lecture, seminar, workshop), psychosocial, spiritual aspects (5.5 h, seminar), and communication (1.5 h, lecture) teaching do not reach the recommended number of hours. Teamwork and self-reflection are not taught at all. Conclusions: Increased time, more diverse teaching strategies and clear learning outcomes are required to enable the development of palliative care education in Estonia. The teaching and learning of palliative care is a process that requires constant development and collaboration. [ABSTRACT FROM AUTHOR]

The era of precision medicine requires the achievement of accurate risk assessment. Polygenic risk scores (PRSs) have strong potential for increasing the benefits of nationwide cancer screening programs. The current pool of evidence on the role of a PRS as a risk stratification model in actual practice and implementation is limited. To better understand the impact of possible method-induced variance, we constructed and validated two PRSs for cervical cancer (CC) using the Estonian Biobank female population (691 CC cases and 13,820 controls) and evaluated their utility in predicting incident cervical neoplasia (CIN), cancer, and human papillomavirus (HPV) infection using two methods (LDPred and BayesRR-RC). This study demonstrated that two genetic risk scores were significantly associated with CIN, CC, and HPV infection incidence. Independent of the method, we demonstrated that women with elevated PRS values reached the observed cumulative risk levels of CIN or CC much earlier. Our results indicated that the PRS-based discrimination rules could differ substantially when the PRSs contain similar predictive information. In summary, our analysis indicated that PRSs represent a personalized genetic component that could be an additional tool for cervical cancer risk stratification, and earlier detection of abnormalities provides invaluable information for those at high risk. [ABSTRACT FROM AUTHOR]

Background: The Baltic countries–Lithuania, Latvia and Estonia–are characterized by a high rate of fully alcohol-attributable mortality, compared with Poland. Alcohol control policy measures implemented since 2001 in the Baltic countries included a restriction on availability and an increase in excise taxation, among others. The aim of the current study was to evaluate the relationship between alcohol control policy implementation and alcohol-attributable mortality in the Baltic countries and Poland. Methods: Alcohol-attributable mortality data for 2001–2020 was defined by codes 100% alcohol-attributable for persons aged 15 years and older in the Baltic countries and Poland. Alcohol control policies implemented between 2001 and 2020 were identified, and their impact on alcohol-attributable mortality was evaluated using an interrupted time-series methodology by employing a generalized additive model. Results: Alcohol-attributable mortality was significantly higher in the Baltic countries, compared with Poland, for both males and females. In the final reduced model, alcohol control policy significantly reduced male alcohol-attributable mortality by 7.60% in the 12 months post-policy implementation. For females, the alcohol control policy mean-shift effect was higher, resulting in a significant reduction of alcohol-attributable mortality by 10.77% in the 12 months post-policy implementation. The interaction effects of countries and policy tested in the full model were not statistically significant, which indicated that the impact of alcohol control policy on alcohol-attributable mortality did not differ across countries for both males and females. Conclusions: Based on the findings of the current study, alcohol control policy in the form of reduced availability and increased taxation was associated with a reduction in alcohol-attributable mortality among both males and females. [ABSTRACT FROM AUTHOR]

Background: Migratory insects are important for the provision of ecosystem services both at the origin and destination sites but – apart from some iconic species – the migration routes of many insect species have not been assessed. Coastlines serve as a funnel where migrating animals including insects accumulate. Migratory behaviour and captures of dragonflies in bird traps suggest autumn migration of dragonflies along coastlines while the origin and regularity of this migration remain unclear. Methods: Dragonfly species were caught at the bird observatory Kabli at the Baltic coast in Estonia in 2009, 2010 and 2015. For the 2015 data set, we used a stable hydrogen (H) approach to trace the potential natal origin of the migrant hawker (Aeshna mixta). Results: 1079 (2009), 701 (2010) and 88 (2015) A. mixta individuals were caught during the study periods (35, 37 and 11 days in 2009, 2010 and 2015, respectively). The migration period lasted from end of August to end of September. Based on the results from our stable isotope analysis, we identified two populations of A. mixta: One (range of isotope signatures of non-exchangeable H [δ2Hn wing]: −78‰ to −112‰) had a local likely origin while the other (δ2Hn wing: −113‰ to −147‰) migrated from northerly directions even in headwind from the South. The former showed an even sex ratio whereas the actively migrating population was dominated by males. Conclusions: Our results suggest a regular southbound autumn migration of A. mixta along the Baltic coast. However, nearly half of the sampled individuals originated from the surroundings suggesting either no, partial or "leap-frog" migration. Contrary to our expectation, A. mixta did not select favourable wind conditions but continued the southbound autumn migration in the flight boundary layer even in case of headwinds. The dominance of males might indicate migration as a result of competition for resources. Further repeated, large-scale studies along the Baltic coast are necessary to pinpoint the migratory pattern and the reason for migration of A. mixta. Such studies should also comprise locations north of the known species range of A. mixta because of the rapid climate-change induced range expansion. [ABSTRACT FROM AUTHOR]

Background: Routine oral anticoagulation (OAC) is recommended for almost all high-risk patients with atrial fibrillation, yet registries show that OACs are still underused. Our aim was to study the lifeday coverage (LDC) of OAC prescriptions and its relationship with one-year mortality rates of AF patients aged ≥ 65 in Estonia for the years 2019 and 2020. Methods: Medical data for AF patients aged ≥ 65 years from 2018 and alive as of 01.01.2019 (cohort I) and new AF documentation from 2019 and alive as of 01.01.2020 (cohort II) was obtained from the Health Insurance Fund's electronic database. The data was linked to the nationwide Estonian Medical Prescription Centre's database of prescribed OACs. For LDC analysis, daily doses of guideline-recommended OACs were used. The patients were categorized into three LDC groups: 0%, 1–79%, and ≥ 80%. The data was linked to the Estonian Causes of Death Registry to establish the date of death and mortality rate for the whole Estonian population aged ≥ 65. Results: There were 34,018 patients in cohort I and 9,175 patients with new AF documentation (cohort II), previously not included in cohort I. Of the patients, 77.7% and 68.6% had at least one prescription of OAC in cohorts I and II respectively. 57.4% in cohort I and 44.5% in cohort II had an LDC of ≥ 80%. The relative survival estimates at 1 year for LDC lifeday coverage groups 0%, 1–79%, and ≥ 80% were 91.2%, 98.2%, and 98.5% (cohort I), and 91.9%, 95.2%, and 97.6% (cohort II), respectively. Conclusions: Despite clear indications for OAC use, LDC is still insufficient and anticoagulation is underused for stroke prevention in Estonia. Further education of the medical community and patients is needed to achieve higher lifeday coverage of prescribed OACs. [ABSTRACT FROM AUTHOR]

Background: Transition of dairy cows from a tied to a loose housing system may affect their behaviour, health and production. Such housing system changes have become more frequent in Estonia but knowledge is lacking on how cows adapt to a new system. The aim of this study was to evaluate how cows' behaviour, milk production and composition, and different aspects of their health changed after transition from tied to loose housing. Results: A herd of 400 dairy cows was moved to a new system on the same farm, so that effects of transport were not confounding factors. Behavioural observations were made for approximately 4 months following transition. Milk production data were recorded from 12 months before to 12 months after transition. Examination for skin alterations and cleanliness, as well as body condition scoring were carried out before transition, and thereafter monthly throughout the study. Significant effects on behaviour were observed just after the transition, with increases in the behaviour indicative of poor welfare, such as vocalisation and aggression, and decreases in those indicative of a good state of welfare, such as ruminating, resting and grooming. These effects were of short duration, with most returning to a steady state after the first week. Milk production declined already before the transition but fell significantly after transition, and this fall lasted longer in older cows. Likewise, somatic cell counts were higher in all cows following transition, but older cows were affected significantly more than cows in the first lactation. The frequency of lameness and skin alterations increased on average after transition. Body condition scores fell after transition but recovered by the second month. Therefore, there were adverse effects on the behaviour, health and production of the dairy cows transferred, although, apart from older cows, of short duration. Conclusion: The transition from tied to loose housing first had negative impacts on the welfare of the cows, although by the tenth day the behavioural indicators had returned to normal values. Impacts were more severe in higher parity cows, indicating that the change was more of a challenge for older cows. The findings of this study suggest that animals' behaviour and health should be more carefully observed within about 2 weeks after transition. It is quite likely that more and more farmers in Estonia and elsewhere will recognize the benefits of keeping their dairy cattle in loose housing, aimed at improving animal welfare and the value of the production chain. [ABSTRACT FROM AUTHOR]

Background: Ischemic stroke (IS) is a major health risk without generally usable effective measures of primary prevention. Early warning signals that are easy to detect and widely available can save lives. Estonia has one nation-wide Electronic Health Record (EHR) database for the storage of medical information of patients from hospitals and primary care providers. Methods: We extracted structured and unstructured data from the EHRs of participants of the Estonian Biobank (EstBB) and evaluated different formats of input data to understand how this continuously growing dataset should be prepared for best prediction. The utility of the EHR database for finding blood- and urine-based biomarkers for IS was demonstrated by applying different analytical and machine learning (ML) methods. Results: Several early trends in common clinical laboratory parameter changes (set of red blood indices, lymphocyte/neutrophil ratio, etc.) were established for IS prediction. The developed ML models predicted the future occurrence of IS with very high accuracy and Random Forests was proved as the most applicable method to EHR data. Conclusions: We conclude that the EHR database and the risk factors uncovered are valuable resources in screening the population for risk of IS as well as constructing disease risk scores and refining prediction models for IS by ML. [ABSTRACT FROM AUTHOR]

Digital dermatitis (DD) is the most significant infectious hoof disorder of cattle in Europe. Hoof baths are one of the most common control methods. Copper sulphate and formalin are commonly used in hoof baths, but their use is problematic in many European countries for health, environmental and safety reasons. Ozonated water and acidified copper sulphate were tested as prevention of DD in a 5-month study. Data were derived from 302 hind feet of Holstein and Estonian Red cows (no. of cows = 151) from a commercial dairy farm in Estonia. Altogether 168 hind feet were included in the acidified copper sulphate group and 134 feet in the ozonated water group. Hoof bathing was carried out three days a week (Mon, Wed, Fri) for two months and then two days a week (Mon, Wed) for three and a half months, in both groups. Ozonated water was sprayed on to the digital skin of hind feet of cows twice a day on treatment days, while the cows were eating. The copper sulphate bath consisted of copper sulphate (2%) mixed with an organic acid compound to acidify and ionize the solution. Cows walked through acidified copper sulphate solution twice a day on treatment days as they were exiting the milking parlor. DD negative and DD positive test results in both groups were compared and statistically tested for differences. The copper sulphate solution was more effective than ozonated water at preventing acute DD lesions. A random maximum likelihood model demonstrated that the odds ratio for DD in the ozonated water group was six times higher compared with DD in the acidified copper sulphate group. Most of the cows that were initially without any DD lesions (M0 + no other severe hoof lesion), remained lesion-free in both groups (copper sulphate group 97% and ozonated water group 88%). Despite trial design deficiencies, the findings indicate that acidified copper sulphate was a more effective solution in preventing DD than ozonated water. [ABSTRACT FROM AUTHOR]

Background: The introduction of highly effective direct-acting antiviral therapy has changed the hepatitis C virus (HCV) treatment paradigm. However, a recent update on HCV epidemiology in incarcerated settings is necessary to accurately determine the extent of the problem, provide information to policymakers and public healthcare, and meet the World Health Organization's goals by 2030. This systematic review and meta-analysis were performed to determine the prevalence of HCV Ab and RNA in incarcerated settings. Methods: For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and Web of Science for papers published between January 2013 and August 2021. We included studies with information on the prevalence of HCV Ab or RNA in incarcerated settings. A random-effects meta-analysis was done to calculate the pooled prevalence and meta-regression to explore heterogeneity. Results: Ninety-two unique sources reporting data for 36 countries were included. The estimated prevalence of HCV Ab ranged from 0.3% to 74.4%. HCV RNA prevalence (available in 46 sources) ranged from 0% to 56.3%. Genotypes (available in 19 sources) 1(a) and 3 were most frequently reported in incarcerated settings. HCV/HIV coinfection (available in 36 sources) was highest in Italy, Estonia, Pakistan, and Spain. Statistical analysis revealed that almost all observed heterogeneity reflects real differences in prevalence between studies, considering I2 was very high in the meta-analysis. Conclusions: HCV in incarcerated settings is still a significant problem with a higher prevalence than in the general population. It is of utmost importance to start screening for HCV (Ab and RNA) in incarcerated settings to give clear, reliable and recent figures to plan further treatment. This is all in the context of meeting the 2030 WHO targets which are only less than a decade away. Trial registration: PROSPERO: CRD42020162616 [ABSTRACT FROM AUTHOR]

Background: Despite being two Baltic countries with similar histories, Estonia and Lithuania have diverged in life expectancy trends in recent years. We investigated this divergence by comparing cause-specific mortality trends.Methods: We obtained yearly mortality data for individuals 20 + years of age from 2001-2019 (19 years worth of data) through Statistics Lithuania, the Lithuanian Institute for Hygiene, and the National Institute for Health Development (Estonia). Using ICD-10 codes, we analyzed all-cause mortality rates and created eight major disease categories: ischemic heart disease, cerebrovascular disease, all other cardiovascular disease, cancers (neoplasms), digestive diseases, self-harm and interpersonal violence, unintentional injuries and related conditions, and other mortality (deaths per 100,000 population). We used joinpoint regression analysis, and analyzed the proportional contribution of each category to all-cause mortality.Results: There was a steeper decline in all-cause mortality in Estonia (average annual percent change, AAPC = -2.55%, 95% CI: [-2.91%, -2.20%], P < .001) as compared to Lithuania (AAPC = -1.26%, 95% CI: [-2.18%, -0.57%], P = .001). For ischemic heart disease mortality Estonia exhibited a relatively larger decline over the 19-year period (AAPC = -6.61%, 95% CI: [-7.02%, -6.21%], P < .001) as compared to Lithuania (AAPC = -2.23%, 95% CI: [-3.40%, -1.04%], P < .001).Conclusion: Estonia and Lithuania showed distinct mortality trends and distributions of major disease categories. Our findings highlight the role of ischemic heart disease mortality. Differences in public health care, management and prevention of ischemic heart disease, alcohol control policies may explain these differences. [ABSTRACT FROM AUTHOR]

Background: The increased knowledge of cervical cancer (CC) risk factors and suboptimal performance of present screening programs has generated interest in shifting from a universal screening approach to one based on individual risk assessment. To inform the future development of risk-based CC screening programs, it is crucial to gain insight into the factors influencing the acceptability of such approach among screening target group women. The aim of this study was to prospectively investigate the acceptability of risk-based CC screening and to identify potential barriers., Methods: In this qualitative study, one-to-one semi-structured interviews were conducted with a purposeful sample including women aged 30-65 years to explore women's perspectives on the acceptability of risk-based CC screening. The study was conducted in Estonia, and interviews were conducted from March to September 2023. Potential participants were approached in person by a member of the study team or by their healthcare providers at primary care or gynaecology clinics. The interview guides were developed based on the concept of acceptability of healthcare interventions., Results: Twenty participants (mean age 44.5, SD = 8.6) with diverse backgrounds were interviewed. The seven components of acceptability (affective attitude, burden, ethicality, opportunity costs, perceived effectiveness, self-efficacy, and intervention coherence) were explored as key themes. Generally, women supported risk-based screening. However, we identified several factors that may compromise the acceptability of risk-based screening. The participants were reluctant to accept less intense screening for low-risk women and anticipated that if risk-based approach was implemented, more frequent testing would remain an option. Providing in-person clinician support was expected, requiring additional healthcare resources. Knowledge gaps in CC prevention highlighted the need for accessible information and education. Most women were unworried about sensitive data inclusion in risk score calculations. However, some participants were concerned about potential confidentiality breaches by healthcare workers., Conclusion: This study indicates that risk-based CC screening is acceptable, except for testing low-risk women less frequently. Our findings underscore the necessity for comprehensive understanding of the needs and concerns of the target group women for program development. Healthcare organizations are required to proactively address these needs by implementing comprehensive information dissemination and efficient communication approaches., (© 2024. The Author(s).)

Background: The problem of underestimating the burden of mental health-related mortality is widely discussed in the public health literature. Relevant scientific evidence from societies experiencing the largest burden of mental health mortality is important for better understanding global and national mental health challenges and improving policies. Three Baltic States - Estonia, Lithuania, and Latvia - are countries in the Central and Eastern European region that experienced post-soviet transition trauma and showed among the highest suicide and alcohol-related mortality rates in Europe. This study aimed to examine the change in the burden of mental health-related mortality in three Baltic States in the context of consistent growth in life expectancy in 2007-2018.Methods: We calculated age-standardized years of life lost due to specific mental health-related causes of death in three Baltic countries from 2007 to 2018. Four mental health-related causes of death groups were analyzed: (i) all mental and behavioural disorders; (ii) intentional self-harm; (iii) main substance use-related causes of death; and (iv) external causes of death. The number of deaths came from the WHO Mortality Database; population exposures were extracted from the Human Mortality Database.Results: We found that the proportion of age-standardized years of life lost due to mental disorders was relatively low in all three countries. It varied from 0.2% for females in Lithuania in 2009 to 2.4% for males in Estonia in 2007. However, the proportion of age-standardized years of life lost from self-harm and substance use remained high. In 2018, the proportion of age-standardized years of life lost due to self-harm was highest among males in Lithuania (4.1%) while the highest proportion due to substance use-related causes of death was among males in Estonia (7.3%).Conclusions: Our findings indicate that the burden of mental health-related mortality remained high and showed divergent temporal changes across the three countries. In the context of the Baltic States and other post-soviet countries, fractions of various external causes of death and alcohol-related causes of death should be considered in assessing the total burden of mental health-related mortality. [ABSTRACT FROM AUTHOR]

Key message: Bird assemblages in planted spruce (Picea abies L.) forests were compositionally distinct from those in naturally regenerated mixed stands. Despite rapid stand development on productive soils, even-aged silviculture cannot host most old-forest species. However, their habitat quality could be supported in landscape mosaics with retention forestry and set-asides. Context: The most productive forest lands have naturally the richest bird assemblages but tend to be also most intensively managed. Sustainable solutions to this conflict are unclear. Aim: To assess bird assemblages and their successional dynamics in planted Norway spruce (Picea abies L.) stands compared to naturally developing stands. Methods: We mapped breeding bird assemblages in forty 5-ha plots on highly productive soils in Estonia. The plots included sets of naturally regenerated and planted stands, and (as successional endpoints) clear-cuts and old stands. Results: Planted stands had fewer bird species and pairs than naturally regenerated stands; the latter having a species composition resembling late-successional deciduous-dominated stands. Importantly, the species composition in mature spruce plantations converged toward the composition observed in late-successional conifer-dominated stands. Downed dead wood, stand age, deciduous trees, and stock density were the most significant stand characteristics shaping bird assemblages. Conclusion: The habitat value of established spruce plantations can be primarily improved by allowing for some deciduous trees and gaps with deciduous undergrowth. At the landscape scale, the bird diversity of even-aged systems would be enhanced by multi-scale applications of retention forestry—from retention trees to old-growth set-asides. [ABSTRACT FROM AUTHOR]

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: Diarrhea is one of the most common diseases and causes of death in calves during the first month of life. Pre-calving vaccination programme (PVP) against the most common diarrhea-causing pathogens could help to avoid this threat if hyperimmune transition milk (TM) is fed to calves throughout the whole susceptibility period. The aim of this retrospective cohort study was to reveal the implementation practices of PVPs in large commercial dairy farms and to compare calf-level mortality hazards during the first year of vaccination (V+ period) and a year before implementing the vaccination programme (V- period). A questionnaire was filled out in 15 large-scale dairy farms in Estonia that used PVP. The farms were assigned into three groups based on compliance with the vaccine directions for use and TM feeding practices. Calf-level time-to-event data was analyzed with an observation period of 21 days and on-farm mortality due to diarrhea being the event of interest. Results: During the V+ period, a significant decline in diarrhea-induced calf mortality was identified in three out of six herds that followed vaccination instructions and fed TM for at least 14 days. On average, calf mortality hazard due to diarrhea decreased among these herds (hazard rate ratio (HR) = 0.72, 95% confidence interval (CI) 0.63; 0.81). In the group of correctly vaccinating herds where TM was fed for less than 14 days, diarrhea-induced calf mortality decreased in two herds and remained unchanged in two herds with average diarrhea-induced calf mortality hazard declining significantly during the vaccination period (HR = 0.24, 95% CI 0.14; 0.41). Among the three farms that deviated from the vaccination instructions, the average calf mortality hazard increased in the V+ period (HR = 1.61, 95% CI 1.21; 2.14). Conclusions: This study revealed that implementing a PVP might aid to reduce diarrhea-induced calf mortality in large commercial dairy farms. There is a need to increase veterinarians´ and farmers´ awareness about the importance of including pregnant heifers into the vaccination programme and emphasize the importance of prolonged feeding of hyperimmune TM to calves. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to assess the cost savings from medication reviews conducted for individuals living in nursing homes in Estonia. Medication reviews performed as part of the automated dose dispensing (ADD) service by community pharmacies might help identify suboptimal medicine regimens., Methods: We use a case study approach to identify suboptimal use of medication in treatment plans and estimate the potential cost saving from medication reviews. To achieve this, we assess 101 treatment plans submitted for medication review by nursing homes in Estonia between 2021 and 2023. Additionally, we run OLS regressions to identify the most important determinants of medication cost savings., Results: We estimate an average direct cost saving of €43.62 per patient per year, which corresponds to 8.27% of the average annual medication costs. If medication reviews were conducted for all elderly individuals over 75 years old who use six or more prescription medicines, nearly 2% of Estonia's pharmaceutical budget could be saved. Regression analysis indicates that the most significant contributors to these cost savings are suboptimal use of generics, incorrect dosages (too high), and the elimination of incorrect medications., Conclusions: Our study suggests that annual medication reviews conducted as part of the ADD service might help reduce medication expenditure when offered to a wider public., (© 2024. The Author(s).)

Background: Relatively high rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported, but register-based, objective real-world data is scarce. We aimed to analyse adherence to guideline-recommended medications for secondary prevention of MI in 2017 to 2018 (period II) and compare the results with data from 2004 to 2005 (period I) in Estonia.Methods: Study populations were formed based on data from the Estonian Health Insurance Fund's database and on Estonian Myocardial Infarction Register. By linking to the Estonian Medical Prescription Centre database adherence to guideline-recommended medications for MI secondary prevention was assessed for 1 year follow-up period from the first hospitalization due to MI. Data was analysed using the defined daily dosages methodology.Results: Total of 6694 and 6060 cases of MI were reported in periods I and II, respectively. At least one prescription during the follow up period was found for beta-blockers in 81.0% and 83.5% (p = 0.001), for angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) in 76.9% and 66.0% (p < 0.001), and for statins in 44.0% and 67.0% (p < 0.001) of patients in period I and II, respectively. P2Y12 inhibitors were used by 76.4% of patients in period II. The logistic regression analysis adjusted to gender and age revealed that some drugs and drug combinations were not allocated similarly in different age and gender groups.Conclusions: In Estonia, adherence to MI secondary prevention guideline-recommended medications has improved. But as adherence is still not ideal more attention should be drawn to MI secondary prevention through systematic guideline implementation. [ABSTRACT FROM AUTHOR]

Background: Rickettsia spp. are human pathogens that cause a number of diseases and are transmitted by arthropods, such as ixodid ticks. Estonia is one of few regions where the distribution area of two medically important tick species, Ixodes persulcatus and I. ricinus, overlaps. The nidicolous rodent-associated Ixodestrianguliceps has also recently been shown to be present in Estonia. Although no data are available on human disease(s) caused by tick-borne Rickettsia spp. in Estonia, the presence of three Rickettsia species in non-nidicolous ticks has been previously reported. The aim of this study was to detect, identify and partially characterize Rickettsia species in nidicolous and non-nidicolous ticks attached to rodents in Estonia. Results: Larvae and nymphs of I.ricinus (n = 1004), I. persulcatus (n = 75) and I.trianguliceps (n = 117), all removed from rodents and shrews caught in different parts of Estonia, were studied for the presence of Rickettsia spp. by nested PCR. Ticks were collected from 314 small animals of five species [Myodes glareolus (bank voles), Apodemus flavicollis (yellow necked mice), A.agrarius (striped field mice), Microtus subterranius (pine voles) and Sorex araneus (common shrews)]. Rickettsial DNA was detected in 8.7% (103/1186) of the studied ticks. In addition to identifying R.helvetica, which had been previously found in questing ticks, we report here the first time that the recently described I.trianguliceps-associated Candidatus Rickettsia uralica has been identified west of the Ural Mountains. [ABSTRACT FROM AUTHOR]

Background: Estonia has a typical Eastern European HIV epidemic where the most frequent co-infection is chronic hepatitis C (HCV). We aimed to describe the changes in HCV prevalence, the distribution of HCV genotypes (GT), and HCV treatment in Estonian people living with HIV over 15 years.Methods: We used data of subjects included to the Estonian HIV Cohort Study (E-HIV) before 31st of December 2015. We compared two time periods-first, 1st of January 2000 to 31st of December 2008 when the HIV epidemic was mostly spreading among people who inject drugs (PWID) and second, 1st of January 2009 to 31st of December 2015 when HIV started to emerge to the general population.Results: Of 4422 HIV positives 3708 (84%) had information about their HCV serostatus; 2706 (61%) were HCV seropositive, of latter 1625 (60%) were HCV RNA positive, 239 (9%) had their HCV GT determined, and 141 (5%) received treatment for HCV. The dominating subtypes were 1b (42%) and 3a (37%) followed by 1a (16%), and the few cases of 2 (1.5%). HCV prevalence was 1.5 times (95% CI 1.4-1.6) higher in subjects diagnosed with HIV in first as compared to those diagnosed in second period (84% vs 56%, respectively). There were more men and the median age at HIV diagnosis was lower in HIV/HCV co-infected than in HIV mono-infected patients (70% vs 47% and 24 years vs. 30 years, respectively; both p < 0.001).Conclusion: There is a decrease in HCV prevalence but it remains high among HIV positive PWID, suggesting that there is need for improvement of harm reduction programs among PWID. [ABSTRACT FROM AUTHOR]

Background: Radiation therapy is an important part of multimodal breast cancer treatment. The aim was to examine the impact of sociodemographic factors on radiation therapy use in breast cancer (BC) patients in Estonia, linking cancer registry data to administrative databases. Methods: Estonian Cancer Registry provided data on women diagnosed with BC in Estonia in 2007–2018, including TNM stage at diagnosis. Use of radiation therapy within 12 months of diagnosis was determined from Estonian Health Insurance Funds claims, and sociodemographic characteristics from population registry. Receipt of radiation therapy was evaluated over time and by clinical and sociodemographic factors. Poisson regression with robust variance was used to calculate univariate and multivariate prevalence rate ratios (PRR) with 95 % confidence intervals (CI) for receipt of radiation therapy among stage I–III BC patients age < 70 years who underwent primary surgery. Results: Overall, of 8637 women included in the study, 4310 (50 %) received radiation therapy within 12 months of diagnosis. This proportion increased from 39 to 58 % from 2007 to 2009 to 2016–2018 (p < 0.001). Multivariate regression analysis showed that compared to women with stage I BC, those with more advanced stage were less likely to receive radiation therapy. Receipt of radiation therapy increased significantly over time and was nearly 40 % higher in 2016–2018 than in 2007–2009. Use of radiation therapy was significantly lower for women with the lowest level of education compared to those with a university degree (PRR 0.88, 95 % CI 0.80–0.97), and for divorced/widowed women (PRR 0.95, 95 % CI 0.91–0.99) and single women (PRR 0.92, 95 % CI 0.86–0.99), compared to married women. Age at diagnosis, nationality and place of residence were not associated with receipt of radiation therapy. Conclusions: The study showed considerable increase in the use of radiation therapy in Estonia over the study period, which is in line with increases in available equipment. The lack of geographic variations suggests equal access to therapy for patients living in remote regions. However, educational level and marital status were significantly associated with receipt of radiation therapy, highlighting the importance of psychosocial support in ensuring equal access to care. [ABSTRACT FROM AUTHOR]

Background: Between December 2018 and January of 2019, we evaluated the accuracy of the point-of-care Hepatitis C (HCV) antibody test (POC; OraQuick HCV) used at a community-based needle and syringe exchange program serving persons who inject drugs in Tallinn, Estonia. Methods: We compared the results of screening for HCV antibodies by OraQuick (oral swab) and enzyme immunoassay (EIA; blood draw) and assessed test results implications in a high prevalence setting. Findings Of the 100 participants, 88 (88%) had reactive POC test results, and 93 were HCV antibody positive on EIA testing. Sensitivity, specificity and negative predictive value (NPV) for the POC assay with EIA as the relevant reference test were as follows: 94.6% (95% CI 90.0–99.2%), 100% and 58.3% (95% CI 30.4–86.2%). Of the 12 testing, HCV-negative with the POC only 7 (58.3%) were true negatives. Conclusions: Oral swab rapid testing HCV screening in this nonclinical setting was sensitive and specific but had unacceptably low NPV. In high prevalence settings, POC tests with high sensitivity and that directly measure HCV RNA may be warranted. [ABSTRACT FROM AUTHOR]

Background: The World Health Organisation (WHO) calls for the elimination of cervical cancer (CC) as a public health issue. To achieve elimination, efforts must be aligned and accelerated. Women living with HIV (WLWH) have excess risk for developing, and dying from, CC over the general population. Estimates of cervical cancer screening programme coverage in Eastern European countries that have experienced HIV epidemics since the early 2000's are scarce.Method: This population-based retrospective study uses a healthcare administrative database and follows cohorts of all WLWH in a ratio of 1:3 randomly matched (age, region) HIV negative women from 2009 to 2018. Annual and longitudinal (over the whole study period) coverage for cervical cancer screening (opportunistic, organised, HIV specific) and adjusted odds ratios (AORs) for longitudinal screening coverage predictors were estimated from 2009 to 2018.Results: Among WLWH and HIV-negative women, the mean annual coverage with opportunistic screening was 61.45 and 65.59%; and organised screening was 20.4 and 28.7%, respectively (both: p < 0.00001). 19.01% (95% CI 18.05-19.97) HIV-negative and 13.9% (95% CI 12.35-15.45) WLWH were longitudinally covered with organised cervical cancer screening. Among WLWH, the mean annual HIV-specific cervical cancer screening coverage was 49.4, and 24.3% were longitudinally covered. Longitudinal coverage with HIV-specific cervical cancer screening was inversely associated with age, hepatitis C virus (HCV) co-infection (AOR 0.754, 95% CI 0.619, 0.916), not having insurance (AOR 0.331, 95% CI 0.264, 0.412), drug abuse (AOR 0.459, 95% CI 0.336, 0.618) and higher among those retained in HIV care (AOR 1.972, 95% CI 1.615, 2.410). Among HIV-negative women, longitudinal coverage with organised cervical cancer screening was inversely associated with residence in the region and higher among older women.Conclusions: Our results highlight unacceptably low coverage of cervical cancer screening of WLWH in Estonia. There is need for dedicated cervical cancer screening efforts for WLWH considering the high cancer risk and rate in the study population. [ABSTRACT FROM AUTHOR]

Background: We aimed to study the mortality and intensity of health care in patients with advanced lung cancer who received systemic anti-cancer treatment (SACT) compared with patients who were not eligible for SACT (no-SACT).Methods: A retrospective cohort of patients with lung cancer, who were treated at the North Estonia Medical Centre from 2015 to 2017, was linked to population-based health care data from the Estonian Health Insurance Fund. We calculated 14- and 30-day mortality after SACT and used a composite measure of intensity of care, comprised from the following: emergency department visit, admission to hospital, admission to intensive care unit, receipt of radiotherapy or systemic treatment.Results: The median overall survival (OS) of patients who received at least one cycle of SACT (n = 489) was 9.1 months and in patients with no-SACT (n = 289) 1.3 months (hazard ratio [HR] = 4.23, 95% CI = 3.60-5.00). During the final 30 days of life, intensive EOL care was received by 69.9% of the SACT patients and 43.7% of the no-SACT patients. Intensive EOL care in the last 30 days of life is more probable among patients in the SACT group (odds ratio [OR] = 3.58, 95% CI = 2.54-5.04, p <  0.001), especially in those with a stage IV disease (OR = 1.89, 95% CI = 1.31-2.71, p = 0.001). In the SACT group 6.7 and 14.7% of patients died within 14 days and 30 days after the last cycle, respectively.Conclusions: Significant proportion of patients with advanced lung cancer continue to receive intensive care near death. Our results reflect current patterns of EOL care for patients with lung cancer in Estonia. Availability of palliative care and hospice services must be increased to improve resource use and patient-oriented care. [ABSTRACT FROM AUTHOR]

Polyporous fungi, a morphologically delineated group of Agaricomycetes (Basidiomycota), are considered well studied in Europe and used as model group in ecological studies and for conservation. Such broad interest, including widespread sampling and DNA based taxonomic revisions, is rapidly transforming our basic understanding of polypore diversity and natural history. We integrated over 40,000 historical and modern records of polypores in Estonia (hemiboreal Europe), revealing 227 species, and including Polyporus submelanopus and P. ulleungus as novelties for Europe. Taxonomic and conservation problems were distinguished for 13 unresolved subgroups. The estimated species pool exceeds 260 species in Estonia, including at least 20 likely undescribed species (here documented as distinct DNA lineages related to accepted species in, e.g., Ceriporia, Coltricia, Physisporinus, Sidera and Sistotrema). Four broad ecological patterns are described: (1) polypore assemblage organization in natural forests follows major soil and tree-composition gradients; (2) landscape-scale polypore diversity homogenizes due to draining of peatland forests and reduction of nemoral broad-leaved trees (wooded meadows and parks buffer the latter); (3) species having parasitic or brown-rot life-strategies are more substratespecific; and (4) assemblage differences among woody substrates reveal habitat management priorities. Our update reveals extensive overlap of polypore biota throughout North Europe. We estimate that in Estonia, the biota experienced ca. 3-5% species turnover during the twentieth century, but exotic species remain rare and have not attained key functions in natural ecosystems. We encourage new regional syntheses on long studied fungal groups to obtain landscape-scale understanding of species pools, and for elaborating fungal indicators for biodiversity assessments. [ABSTRACT FROM AUTHOR]

This article focuses on the process of designing the vital, participatory school-based intervention program aiming to increase the physical activity in schools. The program analyzed is Estonian nationwide comprehensive physical activity program Schools in Motion (SiM) that recently received European Commission's #BeActive Education Award. The program has a good performance in terms of willingness of schools to participate in co-creation of program development, the high interest to join the program and zero dropouts, and strong partnership with ministries which enables to actively participate in policy making. Authors analyze the key elements of the planning, piloting, implementation, and scaling phases of the SiM program and share their lessons learnt in co-working with schools. The difficulties faced during the development process, the strengths and challenges associated with an interdisciplinary approach, and involvement of schools as experts have been addressed. [ABSTRACT FROM AUTHOR]

Introduction: This study examines the association between healthcare indicators and hospitalization rates in three high-income European countries, namely Estonia, Latvia, and Lithuania, from 2015 to 2020., Method: We used a sex-stratified generalized additive model (GAM) to investigate the impact of select healthcare indicators on hospitalization rates, adjusted by general economic status-i.e., gross domestic product (GDP) per capita., Results: Our findings indicate a consistent decline in hospitalization rates over time for all three countries. The proportion of health expenditure spent on hospitals, the number of physicians and nurses, and hospital beds were not statistically significantly associated with hospitalization rates. However, changes in the number of employed medical doctors per 10,000 population were statistically significantly associated with changes of hospitalization rates in the same direction, with the effect being stronger for males. Additionally, higher GDP per capita was associated with increased hospitalization rates for both males and females in all three countries and in all models., Conclusions: The relationship between healthcare spending and declining hospitalization rates was not statistically significant, suggesting that the healthcare systems may be shifting towards primary care, outpatient care, and on prevention efforts., (© 2024. The Author(s).)

Background: Culling is a major cost for dairy farms but also an essential part in managing herd productivity. This study aimed to identify the culling rates of Estonian dairy cows, identify the farmers' stated reasons and risk factors for culling. This observational study used registry data of all cows from herds with ≥20 cow-years in 2013–2015. Cow lactation-level analyses included data of 86,373 primiparous cows from 409 herds and 177,561 lactations of 109,295 multiparous cows from 410 herds. Weibull proportional hazard regression models were used to identify risk factors for culling due to slaughter or death. Results: The overall culling rate of Estonian dairy cows was 26.24 (95% CI 26.02; 26.46) per 100 cow-years. The most common reasons farmers stated for culling were feet/claw disorders (26.4%), udder disorders (22.6%), metabolic and digestive disorders (18.1%) and fertility problems (12.5%). Animal-level risk factors for culling were Holstein breed, older parity, lower milk yield breeding value, older age at first calving, longer previous calving interval, having assisted calving, stillbirth and birth of twins/triplets. Lower milk yield, somatic cell count over 200,000 cells/ml and fat/protein ratio over 1.5 at first test-milking after calving were associated with greater culling hazard during the lactation. Cows from larger herds, herds with decreasing size and higher milk yields had a higher culling probability. Conclusions: This study emphasises the need for improved management of hoof health and prevention of mastitis and metabolic diseases. It is essential to ensure easy calving and good health of cows around calving in order to lower the culling hazard. [ABSTRACT FROM AUTHOR]

Background: Interactions between pharmaceutical and medical device industries and students can lead to commercial influences on educational messages, with a potential to bias future treatment choice. This is the first study in the Baltic countries describing exposure and attitudes of medical, pharmacy and nursing students towards cooperation with industry. Methods: A cross-sectional on-line survey of current medical, pharmacy and nursing students (n = 918) in three Baltic countries was carried out. Results: We found that most students participate in events organized or sponsored by industry and accept a range of gifts and benefits. Students in the Baltic countries consider cooperation with industry important; at the same time, most do not feel that they have sufficient training on how to ethically interact with pharmaceutical and medical device companies and believe that these interactions can influence their prescribing or dispensing patterns. There is a tendency to rationalize cooperation with industry by referring to the current economic situation and patient benefits. Pharmacy students have higher rates of participation and they accept gifts and other benefits more often than nursing or medical students; therefore, they are likely to be more vulnerable to potential industry influence. Conclusions: The findings highlight the need to include topics on ethics and conflicts of interests in cooperation with industry in curriculum of health care students in Baltic countries. Without proper training, students continue to be at risk to industry influence and may develop habits for their further practice differing from evidence-based practice in prescribing and dispensing of medicines, as well as use of medical devices. [ABSTRACT FROM AUTHOR]

Background: Before the era of targeted therapies, cytokines were the main therapy for metastatic renal cell carcinoma (mRCC). Our aim was to analyze the changes in treatments and overall survival (OS) of all mRCC patients in Estonia in relation to the introduction of new medications.Methods: All patients with mRCC who started medical therapy in Estonia during the years 2004-2012 were identified using the database of the Estonian Health Insurance Fund. Tumor and treatment data were gathered from medical records. Vital status data were obtained from the Estonian Population Registry. The only available therapy before 2008 was interferon alpha-2A (INFa2A), targeted agents added from 2008. For survival analysis, patients were divided into 2 groups: INFa therapy only (group 1) and INFa followed by targeted agents or targeted agents therapy only (group 2).Results: Out of 416 identified patients, 380 were eligible for analysis. The most common 1st-line treatments were INFa (55%), sunitinib (32%) and INFa+bevacizumab (13%). 28% of patients received 2nd-line therapies and 15% 3rd-line treatments. Median survival of all patients was 13.7 months [95% confidence interval (CI) 11.3-16.2]; 7.6 months (CI 6.4-8.6) for group 1 and 19.8 months (CI 15.6-22.9) for group 2. In multivariate analysis, group 1 had nearly four times higher risk of dying than group 2 [hazard ration (HR) 3.88, 95% CI 2.64-5.72].Conclusions: The implementation of targeted therapies significantly changed the outcomes of mRCC in Estonia: it prolonged median survival, reduced the risk of death and also enlarged the proportion of patients who received medical therapy. [ABSTRACT FROM AUTHOR]

Background: Most European countries have implemented a form of school health services (SHS) to provide young children and adolescents with various types of healthcare. No estimations on SHS expenditure for European countries have been published until now. We estimated SHS workforce expenditure in Europe, expected to serve as the main driver of school healthcare costs.Methods: Using two networks of experts on healthcare provision for children we contacted various country representatives to provide data on the number of professionals working in SHS and salaries. These data were used, together with publicly available data, to estimate annual SHS workforce expenditure on the national level.Results: We received sufficient data for five European countries, and estimated the SHS workforce expenditure. Nurses were the most widely reported professionals working in this field, followed by doctors and psychologists. Our SHS expenditure estimations ranged from €43,000 for Estonia to €195,300 in Norway (per 1000 pupils). For Norway, Estonia, Finland and Iceland, school nurses were the main drivers of SHS expenditure, mainly due to their large numbers, while in Austria, school doctors played the largest role in SHS expenditure.Conclusions: We estimated the spending on SHS workforce for five European countries, which comprises relatively minor parts of total healthcare spending (0.16 to 0.69%). Many questions regarding SHS spending in Europe remain, due to a general lack of data on national levels. [ABSTRACT FROM AUTHOR]

Aims: The aims of the study were to investigate prevalence trends of respiratory symptoms, asthma and asthma treatment among young adults in Estonia and to estimate changes in symptom profile among subjects who self-report asthma attacks or use asthma medications.Methods: Two similar questionnaires on respiratory health were sent to subjects in Tartu, Estonia, aged between 20 and 44 years; first in 1993/94, and then in 2014/15. To study the impact of different respiratory symptoms on asthma diagnosis and treatment, the log-binomial regression was used to estimate the association between 'attack of asthma' (as a proxy for current asthma) and respiratory symptoms as well as asthma treatment and respiratory symptoms, adjusted for age, sex and smoking history.Results: Self-reported prevalence of asthma attack, asthma medication use and nasal allergies increased over the twenty years between studies, whereas there was no change in prevalence of asthma-related symptoms, and the prevalence of most respiratory symptoms either decreased, or remained unchanged. For women experiencing asthma attacks, the prevalence of nasal allergies increased and waking with chest tightness decreased. For men using asthma medication, the prevalence of a wheeze without a cold decreased. Women using asthma medication reported decreased prevalence of waking with chest tightness.Conclusion: Self-reported asthma attacks and asthma medication use has increased in last 20 years, while the prevalence of most respiratory symptoms either decreased or did not change. It is likely that changes in asthma symptom profile have had an impact on the prevalence of asthma and asthma treatment. [ABSTRACT FROM AUTHOR]

Background: Childhood cancers represent a small proportion of all cancers but are still a major public health problem. The study analysed long-term trends in childhood cancer incidence and survival in Estonia in relation to societal and health care transition.Methods: Data on all malignant tumours, diagnosed in children aged 0-14 during 1970-2016, were derived from the Estonian Cancer Registry. Age-standardised (World standard) incidence rates were calculated by ICCC-3 site groups and joinpoint regression was used to estimate annual percentage change (APC) for incidence trends. Cohort and period approach were used to estimate 5-year survival. Internal age standardisation was applied.Results: A total of 1628 incident cancer cases were diagnosed during the study period and overall incidence increased significantly at a rate of 0.5% per year. Significant increases were seen for neuroblastoma and germ cell tumours, for lymphoid leukemias and some CNS sub-sites. At the same time, decline in incidence was seen in almost all subgroups of unspecified neoplasms. The overall 5-year survival improved from 24% in 1970-1979 to 73% in 2010-2016, with the largest changes occurring in the 1990s and 2000s. For many sites, survival increase thereafter has been marginal.Conclusion: In this first comprehensive population-based study of childhood cancer incidence and survival in Estonia, long-term trends are shown in the context of societal and health care changes. Even though the increasing incidence of some sites may, at least partially, be explained by improved diagnostics reflected in the decreased incidence of unspecified neoplasms, the overall cancer incidence in children seems to be rising. Rapid progress in diagnosis and care have improved childhood cancer survival immensely, but deficit in Estonia persists compared to other European countries. Results of the study accentuate the need for a more in-depth analysis of clinical data, but also for the prioritization of childhood cancer in Estonia, to ensure access to standard care and innovative treatments. [ABSTRACT FROM AUTHOR]

Background: Smoking is a risk factor for several diseases. Physicians are role models for their patients. Physicians who smoke underestimate the health risks of smoking and may be less likely to offer advice to help their patients to quit. The aim of this study was to: provide an overview of smoking behaviour among Estonian physicians; assess the relationship between smoking and ischaemic heart disease (IHD), chronic bronchitis (CB), and lung emphysema (LE); and estimate fractions of prevalences of the three diseases attributable to smoking.Methods: Self-administered questionnaires were sent to practising physicians (n = 5666) in Estonia in 2014. Prevalence of smoking and relative risks for IHD, CB and LE as well as the risks of IHD, CB and LE attributable to smoking were calculated by age and sex. Post-stratification was used to compensate non-response.Results: There were 535 male and 2404 female physicians participating. The prevalence of daily smoking was 12.4% (95% CI 10.4-14.4%) among men and 5.0% (95% CI 4.4-5.6%) among women. Mean duration of smoking among male and female daily smokers was 28.6 (95% CI 26.1-31.1) and 28.6 (95% CI 27.1-30.2) years. Compared to lifelong non-smokers, the age-adjusted risk for IHD was 1.29 times (95% CI 0.88-1.89) higher for men, but 1.69 times (95% CI 1.17-2.40) lower for all women who have ever smoked. The risk for CB was 2.29 (95% CI 1.30-4.03) times higher for smokers among men and, 1.32 (95% CI 0.95-1.82) among women; the risk ratio for LE was 4.92 (95% CI 1.14-21.1) among men and 2.45 (95% CI 0.63-9.52) among women. The smoking-attributable risk for IHD was 3.2% (95% CI 2.3-4.1%) among men and - 0.1% (95% CI -0.7-0.4%) among women; for CB 6.9% (95% CI 6.0-7.8%) and 4.2% (95% CI 3.5-4.8%); and for LE 18.8% (95% CI 17.0-22.5%) and 22.6% (95% CI 18.5-26.9%), respectively.Conclusion: Prevalence of daily smoking was relatively low among Estonian physicians (and twice lower among female physicians). The risk attributable to smoking was higher for LE and CB than for IHD. [ABSTRACT FROM AUTHOR]

Background: Apical periodontitis (AP) is an inflammatory disease around the apex of a tooth root. Reported prevalence of AP ranges from 27% to 83% while the data about most post-Soviet countries are still missing. Knowing the prevalence of AP within a certain population helps to plan the treatment need and evaluate the success of endodontic interventions. We aimed to collect data about prevalence and determining factors of AP for the first time in Estonia. Methods: The cross-sectional study included 6552 patients (age 35.5±19.2 years). Radiographic examination was applied to investigate the prevalence of AP and quality of endodontic treatment. Results: AP was diagnosed in 54.7% of subjects. Endodontically treated teeth were present in 58.2% of subjects. Periapical finding was present in 44.6% of endodontically treated and in 30.8% of untreated teeth. Out of 181,495 teeth, 52.7% were intact. AP was diagnosed in 6.3% of teeth, 6.9% of teeth were endodontically treated. Risk factors for AP included caries (OR = 2.30), male gender (OR = 1.44), too short (OR = 1.76) or too long root canal filling (OR = 2.51), root canal filling of low density (OR= 1.61) while not orthodontic appliance. Lower AP risk was associated with restoration of the tooth - filling (OR = 0.45), crown (OR = 0.34) and bridge (OR = 0.33). Conclusions: AP is highly prevalent in Southern Estonian population. Most cases are associated with root canal-treated teeth. The overall quality of root canal fillings tends to be low, consistent with the mediocre outcome of treatment. Considerable efforts are required to improve the standards of endodontic treatment. [ABSTRACT FROM AUTHOR]

Background: Lung cancer (LC) is the leading cause of cancer deaths in men and the second most frequent cause of cancer deaths in women in Estonia. The study aimed to analyze time trends in LC incidence and mortality in Estonia over the 30-year period, which included major social, economic and health care transition. The results are discussed in the context of changes in tobacco control and smoking prevalence. Long-term predictions of incidence and mortality are provided.Methods: Data for calculating the incidence and mortality rates in 1985-2014 were obtained from the nationwide population-based Estonian Cancer Registry and the Causes of Death Registry. Joinpoint regression was used to analyze trends and estimate annual percentage change (APC) with 95% confidence interval (CI). Nordpred model was used to project future incidence and mortality trends for 2015-2034.Results: Incidence peaked among men in 1991 and decreased thereafter (APC: -1.5, 95% CI: -1.8; -1.3). A decline was seen for all age groups, except age ≥ 75 years, and for all histological types, except adenocarcinoma and large cell carcinoma. Incidence among women increased overall (APC: 1.6, 95% CI: 1.1; 2.0) and in all age groups and histological types, except small cell carcinoma. Age-standardized incidence rate (world) per 100,000 was 54.2 in men and 12.9 in women in 2014. Changes in mortality closely followed those in incidence. According to our predictions, the age-standardized incidence and mortality rates will continue to decrease in men and reach a plateau in women.Conclusions: The study revealed divergent LC trends by gender, age and histological type, which were generally consistent with main international findings. Growing public awareness and stricter tobacco control have stimulated overall favorable changes in men, but not yet in women. Large increase in incidence was observed for adenocarcinoma, which in men showed a trend opposite to the overall decline. LC will remain a serious public health issue in Estonia due to a high number of cases during the next decades, related to aging population, and previous and current smoking patterns. National tobacco control policy in Estonia should prioritize preventing smoking initiation and promoting smoking cessation, particularly among women. [ABSTRACT FROM AUTHOR]

Background: Most countries face an ageing population, increasing chronic diseased, and constrictions on budget for providing health services. Involving patients in their own care by allowing them access to their patient data is a trend seen in many places.Methods: Data on the type and level of access citizens have to their own health data in three countries was gathered from public sources.Results: Data from each individual country is presented and the experiences of Denmark, Estonia and Australia are examined whilst similarities and differences explored. The discussion adopts a citizen-centred perspective to consider how the different e-portal systems support, protect and structure citizen interactions with their own health data in three key areas: Security, privacy and data protection; User support; and Citizen adoption and use.Conclusions: The paper highlights the impact of opt-in/opt-out approaches on citizen access and the lack of a structured approach to addressing differences in citizen health and e-health literacy. This research also confirms while current data provides detail on the availability and use of personal health data by citizens, questions still remain over the ultimate impact on patient outcomes of these initiatives. It is anticipated the insights generated from the three countries experiences, supporting citizen access to their health data will be useful to improve these initiatives and guide other countries aspiring to support similar initiatives. [ABSTRACT FROM AUTHOR]

Background: Smoking surveys among physicians have proved useful in highlighting the importance of physicians as healthy life style exemplars and role models in tobacco control and smoking cessation. The aim of this study was to give an overview of smoking behaviour among Estonian physicians from 1982 to 2014.Methods: Three cross-sectional postal surveys using a self-administered questionnaire were carried out among all practising physicians in Estonia. The number of physicians participating in this study was 3786 in 1982, 2735 in 2002, and 2902 in 2014. Data analysis involved calculating the age-standardized prevalences of smoking, prevalences of smoking by age group and mean age of smoking initiation. A non-parametric test for trend was used to assess significant changes in smoking over time.Results: Age-standardized prevalence of current smoking among men was 39.7% in 1982, 20.9% in 2002, and 14.3% in 2014 and among women 12.2%, 8.0%, and 5.2%, respectively (p < 0.0001 for trends). From 1982 to 2014, the biggest decline of current smoking among men and women was in age groups under 35 (from 55.2% to 16.7% and from 16.7% to 2.8%, respectively) and 35-44 (from 47.1% to 8.3% and from 19.5% to 5.1%, respectively) (p < 0.0001 for trends). Mean age of smoking initiation decreased from 20.4 to 19.3 among men and from 24.5 to 20.4 among women over the study period.Conclusions: In 1982-2014, smoking prevalence among Estonian physicians declined substantially. This may influence the willingness of society to recognize the health consequences of smoking which could give a support to the decline of the smoking epidemic in the country. Differences between smoking among male and female physicians persisted over the study period, but mean age of smoking initiation decreased. A further decline in smoking among Estonian physicians should be encouraged by special efforts targeted at physicians. [ABSTRACT FROM AUTHOR]

Background: Tobacco smoking is known to be the single largest cause of premature death worldwide. The aim of present study was to analyse the effect of smoking on general and cause-specific mortality in the Estonian population.Methods: The data from 51,756 adults in the Estonian Genome Center of the University of Tartu was used. Information on dates and causes of death was retrieved from the National Causes of Death Registry. Smoking status, general survival, general mortality and cause-specific mortality were analysed using Kaplan-Meier estimator and Cox proportional hazards models.Results: The study found that smoking reduces median survival in men by 11.4 years and in women by 5.8 years. Tobacco smoking produces a very specific pattern in the cause of deaths, significantly increasing the risks for different cancers and cardiovascular diseases as causes of death for men and women. This study also identified that external causes, such as alcohol intoxication and intentional self-harm, are more prevalent causes of death among smokers than non-smokers. Additionally, smoking cessation was found to reverse the increased risks for premature mortality.Conclusions: Tobacco smoking remains the major cause for losses of life inducing cancers and cardiovascular diseases. In addition to the common diseases, external causes also reduce substantially the years of life. External causes of death indicate that smoking has a long-term influence on the behaviour of smokers, provoking self-destructive behaviour. Our study supports the idea, that tobacco smoking generates complex harm to our health increasing mortality from both somatic and mental disorders. [ABSTRACT FROM AUTHOR]

Background: Estimates of hip fracture mortality in Eastern Europe are scarce. We aimed to estimate the magnitude and duration of excess mortality after hip fracture in Estonia.Methods: Retrospective, population-based 10-year study of persons aged ≥50 in two cohorts: with hip fracture and an age- and sex-matched (in a 1:4 ratio) random sample from the national health insurance fund database for comparison. Cumulative risks, excess risks and relative risks of death were estimated using Poisson regression with 95% bootstrap confidence intervals (CI). Risks were adjusted for age and Charlson comorbidity index.Results: We identified 8298 (2383 men, 5915 women) incident hip fracture patients from 2005 to 2013 and 33,191 (9531 men, 23,660 women) individuals for the reference group. 5552 (1564 men, 3988 women) cases and 14,037 (3514 men, 10,523 women) reference individuals died during the 10-year follow-up period. Among hip fracture patients we observed a pronounced and durable excess risk of death that was highest within 3-6 months after fracture and persisted for the full 10-year follow-up period. After adjustment for age and Charlson index, hip fracture was associated with a 21.1% (95% CI 20.0-22.5%) 10-year cumulative excess risk of death (RR 1.37, 95% CI 1.35-1.40). We found a high immediate excess risk of death in older age groups (≥80 years) and gradually accumulating excess risk in younger age groups (50-79 years). The excess risk was more pronounced among men than women.Conclusions: By the end of the 10-year follow-up, 1 in 4 deaths in the hip fracture group was attributable to the hip fracture. The results indicate a high attributable impact of hip fracture as an independent risk factor for death. [ABSTRACT FROM AUTHOR]

Background: Different methods have been used to map species and habitat distributions. In this paper, similaritybased reasoning--a methodological approach that has received less attention--was applied to estimate the distribution and coverage of Dasiphora fruticosa for the region in the Baltic states where grows the most abundant population of this species. Methods: Field observations, after thinning to at least 50 m interval, included 1480 coverage estimations in the species presence locations and 8317 absence locations. Species coverage for the 750 km2 of directly unobserved area was calculated using machine learning in the similarity-based prediction system Constud. Separate predictive sets of site features (e.g. land cover, soil type) and exemplar weights were calibrated for spatial partitions of the study area (probable presence region, unclear region, proved absence region). A modified version of the Gower's distance metric, as used in Constud, is described. Results: The resulting maps depicted the predicted coverage, the certainty of decision when predicting presence or absence, and the mean similarity to the exemplar locations used while predicting. Coverage prediction errors were smaller in the unclear partition--where the species was mostly absent--than in the probable presence partition, where coverage ranged from 0 to 90%. Conclusions: We call for methodological comparisons using the same data set. [ABSTRACT FROM AUTHOR]

Background: Less than one-third of patients who are estimated to be infected with multidrug-resistant tuberculosis (MDR-TB) receive MDR-TB treatment regimens, and only 48% of those who received treatment have successful outcomes. Despite current regimens, newer, more effective and cost-effective approaches to treatment are needed. The aim of the study was to project health outcomes and impact on healthcare resources of adding bedaquiline to the treatment regimen of MDR-TB in selected high burden countries: Estonia, Russia, South Africa, Peru, China, the Philippines, and India.Methods: This study adapted an existing Markov model to estimate the health outcomes and impact on total healthcare costs of adding bedaquiline to current MDR-TB treatment regimens. A price threshold analysis was conducted to determine the price range at which bedaquiline would be cost-effective.Results: Adding bedaquiline to the background regimen (BR) resulted in increased disability-adjusted life years (DALYs) averted, and reduced total healthcare costs (excluding treatment acquisition costs) compared with BR alone in all countries analyzed. Addition of bedaquiline to BR resulted in savings to healthcare costs compared with BR alone in all countries analyzed, with the highest impact expected in Russia (US$194 million) and South Africa (US$43 million). The price per regimen at which bedaquiline would be cost-effective ranged between US$23,904-US$203,492 in Estonia, Russia, Peru, South Africa, and China (high and upper middle-income countries) and between US$6,996-US$20,323 in the Philippines and India (lower middle-income countries); however, these cost-effective prices do not necessarily address concerns about affordability.Conclusions: Adding bedaquiline to BR provides improvements in health outcomes and reductions in healthcare costs in high MDR-TB burden countries. The range of prices per regimen for which bedaquiline would be cost-effective varied between countries. [ABSTRACT FROM AUTHOR]

Background: Evidence shows the positive influence of moderate and vigorous physical activity (MVPA) and negative influence of sedentary time on health and academic achievement. Although schools can significantly contribute to overall physical activity, little is known about MVPA and sedentary behaviour in different school subjects in different grades.Methods: Physical activity of 646 students from 18 schools (94 classes) and from three school stages (grades 1-9, aged 7-16) was measured with accelerometry for 5 school days. Time and proportion of MVPA and sedentary time, also average sedentary bout length was calculated for native language (Estonian), mathematics, science, foreign language, music and crafts lessons.Results: A total of 6363 lessons were measured, with lesson duration of 45 min. The average lesson time MVPA remained below 2.2 min in all school stages and in all subjects. Students in grades 4-6 had greatest decline in the proportion of lesson time MVPA in science (β = -1.9, 95%CI -3.1- -0.6) and music (-1.2, -2.1- -0.4) and in grades 7-9 in music (-1.7, -3.1- -0.3) lessons compared to grades 1-3. In grades 1-3 students spent on average 76% of lesson time (34.0 ± 7.0 min) as sedentary, whereas in grades 7-9 the average proportion of sedentary time was 87% (38.9 ± 5.7 min). An average sedentary bout length increased from 13 min in grades 1-3 to 20 min in grades 7-9. An increase in sedentary bout length from grades 1-3 compared to grades 7-9 was present in most subjects, except crafts, with smallest increase in foreign language (6 min, 3.5-8.9) and greatest in music lessons (16.6 min, 11.9-21.3). Lessons with prolonged sedentary bouts formed a maximum 36% of all lessons in grades 1-3 and 73% in grades 7-9.Conclusion: The long sedentary time, bout length and low MVPA in most subjects were unfavourable in respect of both health and academic achievement. Significantly increasing sedentary time and sedentary bout length in older school stages highlights the need for interventions in all subjects and especially in older grades in order to combat the inactivity of children. [ABSTRACT FROM AUTHOR]

Background: Self-rated health (SRH) and socioeconomic position (SEP) as important determinants of health differences are associated with health and economic changes in society. The objectives of this paper were (1) to describe trends in SRH and (2) to analyze associations between SRH and SEP among adults in Estonia in 1996-2014. Methods: The study was based on a 25-64-year-old subsample (n = 18757) of postal cross-sectional surveys conducted every second year in Estonia during 1990-2014. SRH was measured using five-point scale and was dichotomized to good and less-than-good. Standardized prevalence of SRH was calculated for each study year. Poisson regression with likelihood ratio test was performed for testing trends of SRH over study years. Age, nationality, marital status, education, work status and income were used to determine SEP. Logistic regression analysis was used to assess association between SRH and SEP. Results: The prevalence of dichotomized good self-rated health increased significantly over the whole study period with slight decrease in 2008-2010. Until 2002, good SRH was slightly more prevalent among men, but after that, among women. Good SRH was significantly associated with younger age, higher education and income and also with employment status among both, men and women. Good SRH was more prevalent among Estonian women and less prevalent among single men. Conclusions: There was a definite increase of good SRH over two decades in Estonia following economic downturn between 2008 and 2010. Good SRH was associated with higher SEP over the study period. Further research is required to study the possible reasons behind increase of good SRH, and it's association with SEP among adults in Estonia. [ABSTRACT FROM AUTHOR]

Background: Sufficient daily physical activity (PA) is necessary for physical, social and mental health benefits during growth. Most of the available data on children is based on subjective reports, while only limited data on objective PA and sedentary levels is available for primary school children. Increased PA is also an important health indicator of body composition parameters, especially body adiposity indices. The aim of the present study was to determine objectively the amount of daily PA levels at different intensities and sedentary time in normal-weight (NW) and overweight (OW) 7-9-year-old boys and girls, and to find associations between objectively measured PA levels and sedentary time with different body composition values.Methods: Two hundred and seventy eight (142 boys and 136 girls) primary school children aged 7.9 ± 0.7 years participated in this study. Objective PA intensity and sedentary levels were measured over 7 days by accelerometry. Indices of total fat mass (body fat %, sum of skinfolds), fat distribution (waist-to-height ratio) and muscular component (fat free mass [FFM]) were calculated from measured anthropometric parameters.Results: There were no differences (p > 0.05) in PA intensity levels and sedentary time between boys and girls as well as between NW and OW children. About 11 % of children met the current guidelines of at least 60 min per day of moderate-to-vigorous PA (MVPA). Sedentary time was positively and negatively associated (p < 0.05) with all body fat and FFM values, respectively. Moderate and vigorous PA along with MVPA were negatively and positively associated (p < 0.05) with all body fat and FFM indices, respectively.Conclusions: The results of present study showed that about 11 % of primary school children were engaged in PA of at least 60 min of MVPA daily. While MVPA is negatively associated with fat mass indices and positively associated with FFM regardless of different confounders, sedentary time is negatively related to FFM and positively with fat mass values after adjusting for several confounders. These results suggest that higher MVPA level and lower sedentary time level are important in maintaining and developing healthy body composition in primary school children during growth. [ABSTRACT FROM AUTHOR]