Showing papers in "European Journal of Public Health in 2010"

Barriers to HIV testing in Europe: a systematic review

Abstract: Background: In the European Union (EU) and neighbouring countries, HIV/AIDS, of all infectious diseases, has one of the highest morbidity and mortality rates. An estimated 30% of people living with HIV are unaware of their infection, and may therefore not benefit from timely treatment or may transmit HIV to others, unknowingly. Evidence shows that opportunities are being missed to diagnose HIV infections in EU Member States, particularly in regular health care settings. There is a need to better understand the barriers to HIV testing and counselling with the aim to contribute to the decrease of the number of undiagnosed people. Methods: A systematic review of literature on HIV testing barriers in Europe was conducted, applying a free text strategy with a set of search terms. Results: A total of 24 studies published in international peer-reviewed journals and meeting the review’s eligibility criteria were identified. Fourteen studies report on barriers at the level of the patient; six on barriers at health care provider level and seven on institutional barriers referring to the policy level. The barriers described are centralized around low-risk perception; fear and worries; accessibility of health services, reluctance to address HIV and to offer the test; and scarcity of financial and well trained human resources. Conclusions: Some barriers to HIV testing and counselling have been illustrated in the literature. Nevertheless, there is lack of structured information on barriers considering (i) legal, administrative and financial factors, (ii) attitudes and practices of health care providers and (iii) perception of patients. Such data is critical to improve effectiveness of HIV testing and counselling.

Migrants' utilization of somatic healthcare services in Europe--a systematic review.

Abstract: Background : Utilization of services is an important aspect of migrants’ access to healthcare. The aim was to review the European literature on utilization of somatic healthcare services related to screening, general practitioner, specialist, emergency room and hospital by adult first-generation migrants. Our study question was: ‘Are there differences in migrants’ utilization of somatic healthcare services compared to non-migrants?’ Methods : Publications were identified by a systematic search of PUBMED and EMBASE. Appropriateness of the studies was judged independently by two researchers based on the abstracts. Additional searches were conducted via the references of the selected articles. The final number of studies included was 21. Results: The results suggested a diverging picture regarding utilization of somatic healthcare services by migrants compared to non-migrants in Europe. Overall, migrants tended to have lower attendance and referral rates to mammography and cervical cancer screening, more contacts per patient to general practitioner but less use of consultation by telephone, and same or higher level of use of specialist care as compared to non-migrants. Emergency room utilization showed both higher, equal and lower levels of utilization for migrants compared to non-migrants, whereas hospitalization rates were higher than or equal to non-migrants. Conclusion: Our review illustrates lack of appropriate epidemiological data and diversity in the categorization of migrants between studies, which makes valid cross-country comparisons most challenging. After adjusting for socio-economic factors and health status, the existing studies still show systematic variations in somatic healthcare utilization between migrants and non-migrants.

Factors in vaccination intention against the pandemic influenza A/H1N1

Abstract: Background: Vaccination against pandemic influenza A/H1N1 is an effective strategy to mitigate the spread of the disease. While the vaccine is now available, social acceptance remains relatively uncertain in many societies. The purpose of this study was to examine the beliefs, attitudes and practices associated with the intention to get vaccinated against the A/H1N1 virus among the general population in France. Methods: A representative sample of 1001 individuals (stratified random recruitment procedure, ages 16–90 years) was interviewed by telephone. The questionnaire included a variety of items associated with socio-demographic characteristics, risk perceptions, illness perceptions, political attitudes and worldviews as well as intention to get vaccinated. Results: More than 6 out of 10 of the respondents indicated that they planned to get vaccinated when the vaccine becomes available. The same proportion of parents also reported the intention to vaccinate their children against the disease. In multiple regression analyses, socio-cognitive factors consistently predicting influenza A/H1N1 vaccination were: level of worry, risk perception and previous experience of vaccine against seasonal flu. Conclusions: The factors found to predict vaccination intention and their distribution are assumed to be a consequence of the fact that people perceive the risk of swine flu to be similar to that of seasonal flu. As a result, in the absence of an increase of the risk perception of pandemic influenza A/H1N1, a very low level of actual vaccination is forecasted. Behavioural change would require that the risks and consequences of pandemic influenza A/H1N1 be perceived as highly different from seasonal flu.

Fatigue and chronic fatigue syndrome-like complaints in the general population

Abstract: Background: Most knowledge on chronic fatigue (CF) and chronic fatigue syndrome (CFS) is based on clinical studies, not representative of the general population. This study aimed to assess the prevalence of fatigue in an adult general population and to identify associations with lifestyle factors. Methods: Total 22 500 residents of Nijmegen were selected at random and interviewed by questionnaire. Data on 9062 respondents (43% response) were analysed, taken into account age, gender and concomitant disease. Subjects were classified into four groups: not fatigued (NF, reference group), short-term fatigue (SF, <6 months), chronic fatigue (CF, ≥6 months) and CFS-like fatigue (in accordance with the Center for Disease Control criteria for CFS, without clinical confirmation). Results: Our study population showed the following breakdown: NF 64.4% (95% CI 63.6–65.6%), SF 4.9% (95% CI 4.5–5.4%), CF 30.5% (95% CI 29.5–31.4%) and CFS-like fatigue 1.0% (95% CI 0.8–1.2%). Compared with the NF group, more of the CFS respondents were female [odds ratio (OR) = 1.9], obese (OR = 4.1), using analgesics (OR = 7.8), had a low alcohol intake (OR = 0.4), were eating less healthy food (OR = 0.5) and were physically less active (OR = 0.1). These associations largely applied to the SF and CF group. The fatigue could have been due to a concomitant disease in 34 and 55.5% of the SF and CF cases, respectively. Conclusion: The prevalence of CF in the general population appears to be much higher than previously indicated. Even with strict criteria for CFS, it is estimated that ∼1% of the adult population experiences this condition. Interestingly, a large part of this group remains unrecognized by the general practitioner. A striking similarity in lifestyle pattern between SF, CF and CFS calls for further research.

Living longer, working longer? The impact of subjective life expectancy on retirement intentions and behaviour.

Abstract: Background: Virtually all Western countries are seeking to bring retirement ages more in line with increases in longevity. The central question in this article is whether individuals choose a retirement age that fits their life expectancy. This would be ideal from a public policy perspective. The present study aims to test empirically whether retirement planning varies with expectations of survival among a sample of older employees in the Netherlands. Two questions are addressed: (i) what are older employees’ expectations of their remaining lifetime, and what factors influence this subjective life expectancy? (ii) Are individuals who perceive longer life horizons (high subjective life expectancy) more inclined to retire later than people who expect to live shorter? Methods: Using data from a panel study on retirement behaviour in the Netherlands ( N = 1621 older employees aged 50–60 years), regression and survival models are estimated to examine the effect of subjective life expectancy on retirement planning and behaviour. Results: The results indicate that subjective life expectancy is a factor that is taken into account in retirement decision making, at least as far as retirement intentions are concerned. Older employees with longer time horizons have a preference for later retirement. When it comes to actual behaviour, however, time horizon does not appear to play a role. Conclusion : The results suggest that particularly employees with a high perceived life expectancy and an intention to work longer do not succeed in carrying their intentions into effect.

Social inequities in environmental risks associated with housing and residential location--a review of evidence.

Abstract: Background: Housing conditions and environmental quality of residential areas are differentially distributed in the population. Less affluent population groups are more often affected by inadequate housing conditions and higher environmental burden in their residential neighbourhoods. A synthesis of the dispersed evidence on health-related housing characteristics and social status is needed to provide support for housing policies addressing social inequities. Methods: The literature on social inequities and environmental risks related to housing and residential location was searched in health, environmental and geographical databases and reviewed to summarize the evidence. Household-level socio-economic status and income were considered as indicators of social status. The review was limited to European evidence. Results: Adequate studies were only available for few countries. Most studies identified the less affluent population groups as most exposed to environmental risks in the place of residence. Inequities were reported for risks experienced within the dwelling (such as exposure to dampness, chemical contamination, noise, temperature problems and poor sanitation) and related to residential location (neighbourhood quality, traffic-related pollution, proximity to pollution sites). Increased exposure to environmental risks within more affluent population groups was rarely identified. Conclusions: The review indicates that social status and especially low income are strongly associated with increased exposure to environmental risks in the private home or related to residential location. However, due to the methodological variety of the available studies and the lack of data for many countries, it is not possible to provide a general assessment of the magnitude of inequity in Europe at the present time.

Social inequalities resulting from health risks related to ambient air quality—A European review

Abstract: Background: Environmental nuisances, including ambient air pollution, are thought to contribute to social inequalities in health. There are two major mechanisms, which may act independently or synergistically, through which air pollution may play this role. Disadvantaged groups are recognized as being more often exposed to air pollution (differential exposure) and may also be more susceptible to the resultant health effects (differential susceptibility). Method: European research articles were obtained through a literature search in the Medline database using keywords ‘Socioeconomic Factors, Air Pollution, Health’ and synonymous expressions. Results: Some studies found that poorer people were more exposed to air pollution whereas the reverse was observed in other papers. A general pattern, however, is that, irrespective of exposure, subjects of low socio-economic status experience greater health effects of air pollution. So far as we are aware, no European study has explored this relationship among children. Conclusion: The housing market biases land use decisions and may explain why some subgroups suffer from both a low socio-economic status and high exposure to air pollution. Some data may be based on inaccurate exposure assessment. Cumulative exposures should be taken into account to explore health problems more accurately. The issue of exposure and health inequalities in relation to ambient air quality is complex and calls for global appraisal. There is no single pattern. Policies aimed at reducing the root causes of these inequalities could be based on urban multipolarity and diversity, two attributes that require long-term urban planning.

What makes you work while you are sick? Evidence from a survey of workers.

Abstract: Background: Sickness absenteeism has been a focus of the EU Labour Force Surveys since the early 1970s. In contrast, sickness presenteeism is a newcomer. Based on surveys, this concept emerged in the empirical literature as late as the 1990s. Knowledge of the determinants of sickness presenteeism is still relatively sparse. Methods: The article examines the prevalence of sickness presenteeism in comparison with sickness absenteeism, using survey data covering 725 Finnish union members in 2008. We estimate logit models. The predictor variables capture working-time arrangements and the rules at the workplace. We include control variables such as the sector of the economy and educational attainment. Results: Controlling for worker characteristics, we find that sickness presenteeism is much more sensitive to working-time arrangements than sickness absenteeism is. Permanent full-time work, mismatch between desired and actual working hours, shift or period work and overlong working weeks increase sickness presenteeism. We also find an interesting trade-off between sickness categories: regular overtime decreases sickness absenteeism, but increases sickness presenteeism. Conclusions: Two work-related sickness categories, absenteeism and presenteeism, are counterparts. However, the explanations for their prevalence point to different factors.

Inequalities, inequities, environmental justice in waste management and health

Abstract: Background: The scientific evidence on the health effects of waste-related exposure is not conclusive. Differential exposure to waste by socio-economic status (SES) is often documented, but the interplay between environmental and social factors, crucial for policy making, is not well known. This review aims at investigating the role of health inequalities and inequities in waste management. Methods: Grey and peer-reviewed literature, published after 1983, was reviewed from Europe and the USA. Results: Available data provide consistent indications that waste facilities are often disproportionally more located in areas with more deprived residents, or from ethnical minorities. This applies to waste incinerators, landfills, hazardous waste sites, legal and illegal. In studies considering health effects (mainly from Europe), risks are estimated with standardization for SES. Such standardization almost always decreases risk estimates for several cancers and reproductive outcomes. However, effect modification is not investigated in these studies. Conclusions: The patterns of association between waste-related environmental pressures and SES suggest that some of the observed inequalities in exposure and health represent a case of environmental injustice as they are the result of social processes and may be prevented, at least partly. Disentangling the possible health effects remains difficult, due to limitations in the methodology. It seems important to investigate if disadvantaged people are more vulnerable, i.e. risks differ in different social groups living in the same area. Notwithstanding these open questions, public health officers and decision makers should identify waste management policies to minimize their potential health impacts and their unequal distribution.

The socio-economic determinants of the health status of Roma in comparison with non-Roma in Bulgaria, Hungary and Romania.

Abstract: Backgrounds: Roma people from Central and Eastern Europe suffer some of the worst health conditions in the industrialized world. This article aims at identifying the determinants of health status among Roma in comparison with non-Roma in Bulgaria, Romania and Hungary. Methods: Non-linear models were estimated for three different health indicators: self-reported health compared with the previous year, probability of reporting chronic conditions and feeling threatened by illness because of sanitary and hygienic circumstances. Ethnic origin differentiated by Roma, national population and other ethnic minorities is self-reported. The data used are from a unique data set provided by the United Nations Development Programme household survey on Roma and populations living in their close proximity for 2004. Sample sizes are 2536 for Bulgaria, 2640 for Hungary and 3292 for Romania. Results: After controlling for demographic variables the Roma were significantly more likely to report worse health in any indicator than the non-Roma everywhere. However, after including socio-economic variables, Roma had a significantly higher probability of reporting chronic conditions only in Romania. For the probability of feeling threatened by illness because of unhygienic circumstances, being Roma was a main determinant in Hungary and Romania, but not in Bulgaria. The results for self-reported health were inconclusive. Conclusions: While these results in part support the development of health policies targeting Roma, the finding that poorly educated and less wealthy people, as well as other ethnic minorities also experience health inequalities suggests that broader multisectoral polices are needed in the countries studied.

Environmental inequalities among children in Europe--evaluation of scientific evidence and policy implications.

Abstract: BACKGROUND: Socio-economic inequalities in the living environment are major contributing factors to health inequalities. Consequently, protecting children from undesirable environmental exposures by taking socio-economic conditions into account has been identified as a policy priority area in Europe. This review aims to evaluate the evidence on environmental inequalities among children in Europe and to discuss its policy implications. METHODS: A systematic literature search was conducted in various literature databases. Further sources for information were reviews, international reports and working documents for a WHO expert meeting on environmental inequalities in 2009. One major inclusion criterion for publications was consideration of socio-economic factors as influencing factors, not merely as confounder. RESULTS: The overall pattern based on the available fragmentary data is that children living in adverse social circumstances suffer from multiple and cumulative exposures. A low socio-economic position is associated with an increased exposure of children to traffic-related air pollution, noise, lead, environmental tobacco smoke, inadequate housing and residential conditions and less opportunities for physical activity. For most topics and exposures reviewed here there were no studies investigating the modification of the exposure-response function by socio-economic factors. Due to a variety of methodological approaches and studies on one hand and lack of data for many topics and countries on the other hand it was not possible to quantify the magnitude of environmental inequalities. CONCLUSION: Action is needed along the whole causal pathway of the social divide in environmental hazards with priority to policy measures aiming at removing socially determined differences in environmental conditions. Language: en

Living longer and feeling better: healthy lifestyle, self-rated health, obesity and depression in Ireland.

Abstract: Background: The combination of four protective lifestyle behaviours (being physically active, a nonsmoker, a moderate alcohol consumer and having adequate fruit and vegetable intake) has been estimated to increase life expectancy by 14 years. However, the effect of adopting these lifestyle behaviours on general health, obesity and mental health is less defined. We examined the combined effect of these behaviours on self-rated health, overweight/obesity and depression. Methods: Using

Interrelationships between education, occupational class, income and sickness absence

Abstract: Background: Socio-economic position measures, such as education, occupational class and income, are well-known determinants of health. However, previous studies have not paid attention to mutual interrelationships between these socio-economic position measures and medically confirmed sickness absence. Methods: The study is a register-based study. The participants were municipal employees of the City of Helsinki aged 25–59 years in 2003. There were 21 599 women and 5841 men participants. Three socio-economic position measures were used, namely three-level education, four-level occupational class and gross individual income quartiles. Main outcome measure was medically confirmed sickness absence spells of 4 days or longer. Inequality indices were calculated using Poisson regression analysis. R esults: High education, occupational class and individual income were all consistently associated with lower sickness absence rates among both women and men. After mutual adjustment, education and occupational class remained independent determinants of sickness absence. The association of individual income with sickness absence was practically explained by temporally preceding education and occupational class. Conclusions: Our results indicate that education and occupational class—rather than income—are strong determinants of sickness absence. Education, occupational class and income are complementary socio-economic position measures. To better inform sickness absence policy, future studies should aim to establish whether the observed socio-economic differences reflect broader differences in ill-health, lifestyle and working conditions.

The aftershock of deindustrialization—trends in mortality in Scotland and other parts of post-industrial Europe

Abstract: Background: Post-industrial decline is frequently cited as one of the major underlying reasons behind the poor health profile of Scotland and, especially, West Central Scotland (WCS). This begs the question: to what extent is poor health a common outcome in other post-industrial regions and how does Scotland's experience compare to these other comparable regions? Methods: Regions were identified by means of an expert-based consultation, backed up by analysis of regional industrial employment loss over the past 30 years. Mortality rates and related statistics were calculated from data obtained from national and regional statistical agencies. Results: Twenty candidate regions (in: Belgium; France; Germany; Netherlands; UK; Poland; Czech Republic) were identified, of which ten were selected for in-depth analyses. WCS mortality rates are generally higher and—crucially—appear to be improving at a slower rate than in the other post-industrial regions. This relatively poor rate of improvement is largely driven by mortality among the younger working age (especially male) and middle-aged female populations. Conclusion: WCS mortality trends compare badly with other, similar, post-industrial regions of Europe, including regions in Eastern Europe which tend to be characterized by higher levels of poverty. This finding challenges any simplistic explanation of WCS's poor health being caused by post-industrial decline alone, and begs the question as to what other factors may be at work.

Adolescents' health-related dietary patterns by parental socio-economic position, the Nord-Trøndelag Health Study (HUNT).

Abstract: Background: Nutrition is among the important determinants of diseases, and the social patterning of early eating habits may offer keys to prevention. We studied associations between selected indicators of adolescents’ health-related dietary habits (daily intake of candy, soft drinks, fruit and vegetables) and parental socio-economic position (education, social class and income). Methods: The material consisted of participants in the adolescent part (Young-HUNT) of the Nord-Trondelag Health Study during the period 1995–97, 8817 girls and boys aged 13–19 years (89% of all students in junior high schools and high schools in a Norwegian county). Data on parental socio-economic position was available from the adult part of HUNT and Statistics Norway. Cross-sectional data analyses were performed using cross-tables and binary logistic regression. Results: Of the indicators of socio-economic position used, the parent's educational level, in particular the mother's education, showed the highest impact on adolescents’ health-related dietary habits. Girls with the least educated mothers had a prevalence odds ratio of 2.5 (1.8–3.3) for drinking soft drinks daily and 0.6 (0.5–0.8) for eating vegetables daily as compared to girls with the most educated mothers. The corresponding numbers for boys were 1.9 (1.5–2.4) and 0.6 (0.5–0.8). Parental social class also showed gradients in adolescents’ health-related dietary habits, but there was virtually no gradient by income. Conclusion: Higher levels of parental education, in particular the mother's education, are clearly associated with healthier dietary habits among adolescents. This social patterning should be recognized in public health interventions.

Soft drink consumption in adolescence: associations with food-related lifestyles and family rules in Belgium Flanders and the Veneto Region of Italy.

Abstract: Background: The number of studies among adolescents that focus on several lifestyle behaviours and family rules as determinant of soft drink consumption are limited. The aim of this study is to investigate the associations between daily soft drink consumption, food-related lifestyles and family rules in adolescence. Methods: The data are part of the Health Behavior in School-aged Children (HBSC) cross-sectional survey. Adolescents between 11 and 16 years of age were included, resulting in a final sample of 14 407 adolescents representative of Belgium Flanders ( N = 7904) and the Veneto Region of Italy ( N = 6503). Binary logistic regression was used to test the association between soft drink consumption and food-related lifestyle (breakfast habits, family meals, snacking, meals in fast food restaurants and television viewing) and family rules (restriction and obligation rules) by region and gender. Results: Each independent variable is significantly associated with daily soft drink consumption, despite some sub-groups exceptions. When we entered all the variables into the same statistical model, the positive association with daily soft drink consumption remained significant for frequent meals in fast food restaurants, television variables and low restriction rules. Breakfast during weekdays, evening meal with parents and obligation rules remained significant only in specific sub-groups and not the entire sample. Finally, the association with breakfast with parents and during the weekend disappeared. Conclusion: These findings suggest that considering gender and cultural differences, involving parents and limiting adolescents’ exposure to television would increase the effectiveness of interventions aimed to reduce soft drink consumption in adolescence.

The epidemiology of domestic injurious falls in a community dwelling elderly population: an outgrowing economic burden.

Abstract: In Italy, more than 3 million people annually sustain a domestic injury; the elderly experience it the most. From a healthcare perspective, elderly falls are a major clinical issue with an outgrowing socioeconomic burden. The aim of the study was to evaluate the epidemiology of injurious falls in a community dwelling population, admitted to the emergency room (ER) because of a domestic injury, to assess the socioeconomic burden. Seventy-four hospitalized patients among 227 were examined. Falls represented the main cause of admittance to the ER; the average cost for fall-related hospitalization was of €5479.09.

Children's physical activity, TV watching and obesity in Cyprus: the CYKIDS study

Abstract: Background: Even though there is a severe obesity problem in Cyprus, information about the contribution of predisposing lifestyle factors is limited. Our aim was to investigate the relationship between physical activity (PA), sedentary behaviour and various obesity indices [i.e. body mass index (BMI), waist circumference (WC), percentage of body fat (BF%) and ‘total & abdominal obesity’ (TAO)]. Methods: A national cross-sectional study of 1140 children (mean age = 10.7 0.98 years) selected by multistage sampling in Cyprus was conducted during 2004–05. Children completed a 32-item, semiquantitative PA questionnaire, which assessed organized and free-time PA and sedentary behaviours. Weight, height and WC were collected from a random sub-sample of 622 children and obesity was defined by IOTF criteria. Body fat percentage was calculated, and TAO status was computed based on obesity status and WC [i.e. (i) both BMI/WC, (ii) either BMI/WC abnormal and (iii) both BMI/WC abnormal]. Linear and logistic regression analyses with obesity indices as dependent variables were applied after adjusting for several potential confounders. Results: Only variables describing sedentary behaviours were retained in the final regression models in both boys and girls. Girls who spent 4 h/day on TV and DVD watching were almost three times more likely to be overweight or obese [OR = 2.84 (95% CI 1.08–7.47)], three times more likely to have WC 75th percentile [OR = 3.25 (95% CI 1.06–9.98)] and 3.5 times more likely to have 30% body fat [OR = 3.63 (95% CI 1.01–12.98)], while in boys, even though the same variable was retained in almost all final models, it did not reach statistical significance. Conclusion: Sedentary behaviours such as TV watching may be more important predictors of children’s various obesity indices than PA behaviours. Interventions targeting sedentary behaviours, such as TV watching, may help in the prevention and treatment of obesity among Cypriot children.

Are women getting relevant information about mammography screening for an informed consent: a critical appraisal of information brochures used for screening invitation in Germany, Italy, Spain and France

Abstract: Background: The aim was to find out if information brochures on mammography screening in Germany, Italy, Spain and France contain more information to facilitate informed consent than in similar studies carried out over the last few years in Sweden, Canada, USA and the UK, countries with different medical cultures. Methods: We generated a list of essential information items on mammography screening for the purpose of informed consent. We mostly used the same items of information as had been used in previous studies and analysed the information brochures of major national initiatives in Germany and France, and three brochures each from regionalized programmes in Italy and Spain. We cross-checked which of our items were covered in the brochures and if correct numbers were given. Results: We found that the information brochures contained only about half of the information items we defined. Six of the eight brochures mentioned the reduction in breast-cancer fatalities. Four of the eight provided information on false positives, and four of the brochures highlighted the side-effects of radiation. The information on side-effects and risks provided by the brochures was generally of poor quality, and none of them referred to over diagnosis. When numbers were given, they were only indicated in terms of relative numbers. Conclusion: The information brochures currently being used in Germany, Italy, Spain and France are no better than the brochures analysed some years ago. Our results suggest that the providers of mammography screening programmes continue to conceal information from women that is essential when making an informed decision.

Equity in access to health care in Italy: a disease-based approach

Abstract: Background: Equitable access to health care is a core objective of the Italian health care system. Despite having achieved universal coverage for a fairly comprehensive set of health services for decades, there is still evidence of inequities systematically associated with income. Method: Income-related inequity indices were estimated for the probability of general practitioner (GP), specialist, inpatient care and also emergency care using a variety of need indicators. The data used were the Multiscopo survey, 2000 matched with the European Community Household Panel survey for Italy. The contribution of regional inequality was also estimated. Horizontal inequity indices for health care utilization measures were computed separately for people reporting hypertension, arthritis, tumour and heart disease. Results: Significant pro-rich income related inequity was found for GP, specialist and emergency care, no inequity was found for inpatient care. The disease approach showed statistically significant inequity in the probability of specialist care in three of the four chronic conditions analysed, and pro-poor inequity in GP care for all conditions. Inequity was mainly caused by income and regional variations. Conclusions: By reducing regional variation it would be possible to significantly reduce the pro-rich inequity in GP, specialist and emergency care. For specialist care inequity was found for the overall adult population and also among people with serious chronic conditions, and was caused not only by income and regional variation, but also by educational attainment and insurance.

Socio-economic differences in self-esteem of adolescents influenced by personality, mental health and social support

Abstract: Background: Previous studies indicate that self-esteem is lower among adolescents of low socio-economic status and is associated with a number of intrapersonal, interpersonal and socio-cultural factors. Evidence on the mechanisms by which these factors contribute to the connection between socio-economic status and developing self-esteem is incomplete, however. The purpose of this cross-sectional study is to assess whether personality, mental health and social support contribute to the relationship between socio-economic status and self-esteem. Methods: A sample of 3694 elementary-school students from Slovakia (mean age = 14.3 years, 49% boys) filled out the Rosenberg Self-esteem Scale, the Family Affluence Scale, the Ten-Item Personality Inventory, the 12-item General Health Questionnaire and the Perceived Social Support Scale. Results: Hierarchical linear regression showed family affluence, personality dimensions of extroversion, emotional stability and openness to experience, as well as mental health subscales and social support from family and significant others to be associated with self-esteem. Results indicate that personality dimensions and mental health subscales contribute to the association between family affluence and self-esteem. Conclusion: The contribution of personality and mental problems in the relation between socio-economic status and self-esteem may have important implications for the design of promotional programs aimed at enhancing self-esteem.

Value for money or making the healthy choice: the impact of proportional pricing on consumers' portion size choices

Abstract: Background : Large food portion sizes are determinants of a high caloric intake, especially if they have been made attractive through value size pricing (i.e. lower unit prices for large than for small portion sizes). The purpose of the two questionnaire studies that are reported in this article was to assess the impact of proportional pricing (i.e. removing beneficial prices for large sizes) on people's portion size choices of high caloric food and drink items. M ethods : Both studies employed an experimental design with a proportional pricing condition and a value size pricing condition. Study 1 was conducted in a fast food restaurant ( N = 150) and study 2 in a worksite cafeteria ( N = 141). Three different food products (i.e. soft drink, chicken nuggets in study 1 and a hot meal in study 2) with corresponding prices were displayed on pictures in the questionnaire. Outcome measures were consumers’ intended portion size choices. R esults : No main effects of pricing were found. However, confronted with proportional pricing a trend was found for overweight fast food restaurant visitors being more likely to choose small portion sizes of chicken nuggets (OR = 4.31, P = 0.07) and less likely to choose large soft drink sizes (OR = 0.07, P = 0.04). Conclusion : Among a general public, proportional pricing did not reduce consumers’ size choices. However, pricing strategies can help overweight and obese consumers selecting appropriate portion sizes of soft drink and high caloric snacks. More research in realistic settings with actual behaviour as outcome measure is required.

Intimate partner violence: last year prevalence and association with socio-economic factors among women in Madrid, Spain.

Abstract: BACKGROUND: Intimate partner violence (IPV) is a public health problem with significant consequences on women's health. This study estimates the prevalence of intimate partner violence by type among Madrid's female population and assesses the association with socio-economic variables. METHODS: We conducted a cross-sectional study in 2004, 2136 women aged 18-70 years, living in the Madrid region with a partner or who had been in contact with an ex-partner in the previous year, were interviewed by telephone. The questionnaire used to measure past-year intimate partner violence, consisted of a Spanish translation of the psychological and sexual violence module of the French National Survey on Violence against Women, and the physical violence module of the Conflict Tactics Scale-1. To assess the association with socio-economic factors, logistic regression models were fitted. Results: About 10.1% [confidence interval (CI) 8.9-11.5] of the women had suffered some type of IPV in the previous year. 8.6% (CI 7.4-9.8) experienced psychological violence, 2.4% (CI 1.8-3.1) physical violence and 1.1% (CI 0.68-1.6) sexual violence; the prevalence of psychological-only violence (non-physical/non-sexual) was 6.9% (CI 5.8-8.0). Factors associated with psychological-only violence were divorced or separated status and Group III (clerical workers; supervisors of manual workers) or V (unskilled manual workers) occupation. Unemployment and divorced or separated status were associated with physical violence. CONCLUSIONS: Spanish women in our study, experienced past year partner violence at a similar level as in other industrialized countries. Unemployment and low occupational status are associated with physical and psychological-only violence, respectively. Language: en

Inequalities that hurt: demographic, socio-economic and health status inequalities in the utilization of health services in Serbia.

Abstract: Background: The aim of this study was to analyse demographic, socio-economic and health status inequalities by gender in the utilization of health services in Serbia. Methods: Data from 2006 National Health Survey for Serbia were used. A total of 14 522 persons from six geographical regions of Serbia aged ≥20 years were completely interviewed. Logistic regression analyses were used to study the effects of demographic (age, gender, marital status and type of settlement), socio-economic (education and Wealth Index) and health status (self-perceived health) variables on the utilization of health services [visits to general practitioner (GP), private doctor, dentist and hospitalization]. All analyses were carried out separately for males and females. Results: As compared with women (reference category), a lower percentage of men visited a GP [odds ratio (OR) = 0.61; 95% confidence interval (95% CI) = 0.57–0.65], private doctor (OR = 0.62; 95% CI = 0.57–0.67) and dentist (OR = 0.81; 95% CI = 0.76–0.87), but there were no gender differences in hospitalization. Both males and females who belong to disadvantaged classes were less likely to have visited a GP, a private doctor or a dentist in 12 months before the interview, regardless of their health status. No inequalities by social class were observed for the hospitalization among persons with poor self-perceived health status, i.e. those in most need. Conclusions: This study has shown that demographic, socio-economic and health status inequalities in the utilization of health services exist in Serbia. Wise health policy with equitable utilization of health services, regardless these inequalities should be a priority in shaping Serbian health care system reform.

Sex-specific impact of socio-economic factors on suicide risk: a population-based case–control study in Denmark

Abstract: Background: Although many authors have investigated the impact of sex on the association between socio-economic status (SES) and suicide, a definite consensus has not yet emerged. Using Danish population registration data including 15 648 suicide deaths of individuals aged 18–65 year during 1981–97 and matched population controls, we investigate the associations of multiple SES factors with suicide risk and explore the sex-specific aspects of these associations. Methods: We use conditional logistic regression models to estimate the statistical relationship between SES, sex and suicide. Results: SES, proxied by low income, unskilled blue-collar work, non-specific wage work and unemployment, increases suicide risk more prominently for men than for women. Marital status has a comparable influence on suicide risk in both sexes; parenthood is protective against suicide, and the effect is larger for women. Living in a large city raises suicide risk for women but reduces it for men; residents with a foreign citizenship in Denmark have a lower risk of suicide compared with Danish citizens, but this protection is confined to male immigrants. Conclusions: Our results demonstrate that suicide risk is associated with a range of SES proxies but the strength and/or direction of the association can differ by sex. Risk assessement and, therefore, prevention approaches should take this into consideration.

Work-family interference and long-term sickness absence: a longitudinal cohort study.

Abstract: Background : Alongside work environment factors, interference between work and domestic life has been proposed as an important explanation for long-term sickness absence, particularly for women. The aim was to investigate the association between work-to-family interference, family-to-work interference and long-term sickness absence among women and men in different family- and work-related settings. Methods : The study population was a random sample of 2867 gainfully employed adults in Sweden aged 25–50. In 2004, telephone interview data were collected that included questions about family, work and health. The outcome measure was having at least one spell of long-term sickness absence (>14 days) in 2005 based on social insurance register data. Associations were analysed by logistic regression. Results : Work-to-family interference was more common than family-to-work interference and more often reported by women. The overall associations with long-term sickness absence were weak. However, after adjustment for age and self-reported health, work-to-family interference was associated with long-term sick leave among men with higher socioeconomic status (odds ratio 2.87; 95% CI 1.36–6.07), and there was also a tendency to association among women bearing the main responsibility for housework and family (1.59; 0.99–2.54). Conclusions : These findings suggest that work-to-family interference is associated with long-term sickness absence in the working population, but in a gender- and situation-specific manner. Hence, extensive work responsibilities for men, and probably extensive family responsibilities for women, could hamper the balance between work and family and increase the risk of long-term sick leave. Further studies are warranted within this area.

The contribution of qualitative research to the development of tailor-made community-based interventions in primary care: a review.

Abstract: Background: In recent years, a trend in the use of tailor-made approaches and pragmatic trial methodology for evaluating effectiveness has been visible in programs ranging from large-scale national health prevention campaigns to community-based initiatives. Qualitative research is used more often for tailoring interventions towards communities and/or local care practices. This article systematically reviews the contribution of qualitative research in developing tailor-made community-based interventions in primary care evaluated by means of the pragmatic trial methodology. Methods: A systematic search of Pubmed/Medline and Embase revealed 33 articles. Using a literature mapping process, the articles were arranged according to the development phases identified in the MRC framework for the development of complex interventions to improve health. Results: The review showed qualitative research is mainly used to provide insight into the contextual circumstances of the interventions’ implementation, delivery and evaluation. To a lesser extent, qualitative research findings are used for tailoring and improving the design of the interventions for a better fit with daily primary care practice. Moreover, most qualitative findings are used for tailoring the interventions’ contextual circumstances so that the interventions are performed in practice as planned, rather than adjusted to local circumstances. Conclusions: Pragmatic trials seem to be oxymoronic. Although the pragmatic trial methodology establishes the effectiveness of interventions under natural, non-experimental conditions, no pragmatic fit is allowed. Qualitative research's contribution to the development of tailor-made community-based interventions lies in providing ongoing evaluations of the dilemmas faced in pragmatic trials and allowing for the development of true tailor-made interventions.

The prevalence of sedentary behaviours and physical activity in Hungarian youth

Abstract: Background: The study of sedentary behaviour is becoming much more visible, alongside research on physical activity. Few published studies, however, originate from Eastern or Central Europe. Method: Prevalence and point estimate data of key leisure time sedentary and active behaviours are reported from Hungary, a country that has been through an important political transition in the past two decades. Participants ( n = 301) aged 13–18 years completed time-use diaries over 4 days for time outside of school. Sedentary and active behaviours were coded and analysed. Results: TV viewing reflected trends found elsewhere and was the most prevalent sedentary behaviour. Physical activity levels were low. The next most time-consuming sedentary weekday activities were homework, motorized transport, sitting and talking and playing computer/video games. Gender differences were different to some other countries, with girls reporting more computer game use and boys more sitting and talking, but these may reflect cultural and reporting differences. Conclusion: This study provides the first comprehensive description of sedentary behavioural prevalence in Hungarian youth.

Child home injury mortality in Europe: a 16-country analysis.

Abstract: Background: Child injury mortality and morbidity are a public health concern in European countries and data are scarce. Cross-national efforts are needed to identify high-risk groups, follow trends and assist in establishing European-wide safety legislation. This study investigates fatal child injuries in the home, as compared to those in transport in European countries. Methods: Injury mortality was extracted from the World Health Organization Mortality Database for the years 2002–04. The mortality rate per 100 000 population was calculated by age group for 16 contributing countries, grouped by their economic level of development. Results: Fatal home injuries were highest in children under 5 years of age and then sharply decreased, as opposed to road traffic injuries, which increased with age. The majority of the upper-middle-economy countries tended to have higher home injury incidence rates compared to the high-income countries. The top five injury causes all countries aggregated were drowning/submersion, thermal injuries, poisoning, falls and homicide, all of which account for almost 90% of home injury deaths. Conclusion: Home injuries were the leading cause of injury death in children under 5 years of age in the countries under study and the inequalities found among the countries indicate potential for improvement. Evidence-based interventions exist to prevent these injuries and the barriers to their implementation ought to be determined and addressed.

Adolescents' response to text-only tobacco health warnings: results from the 2008 UK Youth Tobacco Policy Survey.

Abstract: Background: As of June 2009 most (89%) European Union member states continue to use mandated text-only health warnings on tobacco products. This study assessed adolescent (aged 11–16 years) perceptions of and reactions to these text warnings on cigarette packs in the UK. Methods: Data comes from wave five of the cross-sectional Youth Tobacco Policy Survey in 2008. A total of 1401 adolescents were recruited and health warnings were assessed in terms of salience (noticing, reading), comprehension and credibility, memorability (recall), depth of processing (contemplating, discussing) and persuasiveness (put off smoking, make more likely to stop). Smokers were also asked about behavioural compliance (foregoing cigarettes due to warnings, avoidance of warnings) and perceptions of harm from their smoking (to indirectly assess possible knowledge gained from warnings). Results: Despite moderately high salience of warnings, memorability and, in particular, depth of processing was quite low, with warnings only sometimes thought about and very rarely discussed. Warnings were however considered comprehensible, credible and a reasonable deterrent for occasional and never smokers. Additionally, a third of regular smokers indicated that, in the last month, warnings had stopped them from having a cigarette. However, only 6% of smokers indicated that warnings made them forego cigarettes frequently. Conclusion: Text warnings help to communicate the dangers associated with smoking and, resultantly, prompt a small number of smokers to forgo cigarettes and take action to avoid warnings, but depth of processing is low and warnings do not appear to be achieving their full potential among smokers.