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WORLD UNIVERSITY DIRECTORY
Medical Education European Journal of Public Health - current issue
<span class="paragraphSection">As the European Public Health Association, we are proud to officially welcome the Ukrainian Public Health Association (UPHA) as a new member. UPHA’s dedication to public health, especially during a time of war, underscores their resilience and commitment to advancing health for all Ukrainians. Their innovations in mental health, environmental health, and public health governance offer vital lessons for the global public health community. As they become part of the EUPHA network, we look forward to collaborating and learning together to address the significant challenges ahead.</span>
<span class="paragraphSection">Medical Research Council10.13039/501100000265MC_UU_00022/2Scottish Government Chief Scientist OfficeSPHSU17UK Prevention Research PartnershipMR/S037608/1NIHR10.13039/100006662NIHR303651NHS10.13039/100030827Department of Health and Social Care10.13039/501100000276</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Recognizing and addressing vulnerability during the first thousand days of life can prevent health inequities. It is necessary to determine the best data for predicting multidimensional vulnerability (i.e. risk factors to vulnerability across different domains and a lack of protective factors) at population level to understand national prevalence and trends. This study aimed to (1) assess the feasibility of predicting multidimensional vulnerability during pregnancy using routinely collected data, (2) explore potential improvement of these predictions by adding self-reported data on health, well-being, and lifestyle, and (3) identify the most relevant predictors. The study was conducted using Dutch nationwide routinely collected data and self-reported Public Health Monitor data. First, to predict multidimensional vulnerability using routinely collected data, we used random forest (RF) and considered the area under the curve (AUC) and F1 measure to assess RF model performance. To validate results, sensitivity analyses (XGBoost and Lasso) were done. Second, we gradually added self-reported data to predictions. Third, we explored the RF model’s variable importance. The initial RF model could distinguish between those with and without multidimensional vulnerability (AUC = 0.98). The model was able to correctly predict multidimensional vulnerability in most cases, but there was also misclassification (F1 measure = 0.70). Adding self-reported data improved RF model performance (e.g. F1 measure = 0.80 after adding perceived health). The strongest predictors concerned self-reported health, socioeconomic characteristics, and healthcare expenditures and utilization. It seems possible to predict multidimensional vulnerability using routinely collected data that is readily available. However, adding self-reported data can improve predictions.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Unemployment has been associated with increased risk of cardiovascular disease (CVD) and all-cause mortality. However, factors behind this association remain unsettled. A primary care CVD prevention programme was conducted in two Finnish towns in 2005–07. Of the participants (<span style="font-style:italic;">n</span> = 4450), a cohort of apparently healthy CVD risk subjects belonging to the labour force (<span style="font-style:italic;">n</span> = 1487) was identified. Baseline depressive symptoms were assessed by Beck’s Depression Inventory. Data on employment status and mortality were obtained from official statistics. The effect of employment status and depressive symptoms on all-cause mortality after a median follow-up of 15 years was estimated in models adjusted for age, sex, body mass index, non-high-density lipoprotein cholesterol, physical activity, alcohol use, current smoking, glucose metabolism, and hypertension. In comparison to employed non-depressive subjects, fully adjusted hazard ratio (HR) for all-cause mortality was 3.53 (1.90–6.57) in unemployed subjects with increased depressive symptoms, 1.26 (0.68–2.34) in unemployed non-depressive subjects, and 1.09 (0.63–1.90) in employed depressive subjects. Factors independently associated with mortality were unemployment with increased depressive symptoms [HR 3.56 (95% CI 1.92–6.61)], screen-detected diabetes [HR 2.71 (95% CI 1.59–4.63)], current smoking [HR 1.77 (95% CI 1.19–2.65)], and higher age [HR 1.10 (95% CI 1.05–1.15)]. Unemployment in itself was not associated with all-cause mortality. If unemployment was accompanied with increased depressive symptoms, risk of death was significantly elevated.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The proposal for a regulation on the European Health Data Space (EHDS) contains provisions that would significantly change health data management systems in European member states (MS). This article presents results of a country mapping exercise conducted during the Joint Action ‘Towards the European Health Data Space’ (TEHDAS) in 2022. It presents the state-of-play of health data management systems in 12 MS and their preparedness to comply with the EHDS provisions. The country mapping exercise consisted of virtual or face-to-face semi-structured interviews to a selection of key stakeholders of the health information systems. A semi-quantitative analysis of the reports was conducted and is presented here, focusing on key aspects related to the user journey through the EHDS. This article reveals a heterogenous picture in countries’ readiness to comply with the EHDS provisions. There is a need to improve digitalization and quality of health data at source across most countries. Less than half of the countries visited have or are developing a national datasets catalogue. Although the process to access health data varies, researchers can analyse health data in secure processing environments in all countries visited. Most of the countries use a unique personal identifier for health to facilitate data linkage. The study concluded that the current landscape is heterogeneous, and no member state is fully ready yet to comply with the future regulation. However, there is general political will and ongoing efforts to align health data management systems with the provisions in the EHDS legislative proposal.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Despite evidence of correlations between low-skilled jobs and poor health, the longitudinal perspective on this research topic has been neglected in Germany for decades. Therefore, we investigate (i) the causal relationship between accumulated employment in low- or medium-skilled jobs on self-rated health and (ii) the selective association of self-rated health on transitions from medium- to low-skilled jobs. About 26 313 dependent employees and persons aged 25–50 from 2010 to 2020 in the German Socio-Economic Panel were included. Linear fixed-effects models were used to analyse the impact of accumulated employment in low- or medium-skilled jobs on self-rated health. Linear probability models with fixed effects were calculated to identify the effect of self-rated health on transitions between low- and medium-skilled jobs. Accumulated employment in low-skilled jobs impacts self-rated health significantly. There is no confirmation for accumulated employment in medium-skilled jobs concerning health. Poor self-rated health increases the probability of transitioning from medium- to low-skilled jobs but does not impact the reverse transition. Poor self-rated health can push employees into low-skilled jobs. Against the background of extended working lives and preserving the labour force potential, there is a need for action and research concerning employees in low-skilled jobs.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Prior research has indicated that residents who perceive their neighborhood as more cohesive have better mental and physical health than those with lower perceived neighborhood social cohesion. However, because most studies are based on cross-sectional data, it remains unclear whether improving the perceptions of social cohesion leads to better health over time. This study applied random effects within-between models to examine the within-individual and between-individual associations of perceived neighborhood social cohesion and poor self-assessed health (SAH) in a cohort of Dutch adults with 17-year follow-up. We also tested whether such associations varied by age, educational level, and gender. The results of pooled analyses indicated that higher perceived neighborhood social cohesion was associated with better SAH [odds ratio (OR): 0.72; 95% confidence interval (CI): 0.65, 0.80], but did not find conclusive evidence that within-individual changes in perceived neighborhood social cohesion were associated with SAH (OR: 0.96; 95% CI: 0.89, 1.04). We also did not observe any moderating effects for age, educational level, or gender. This study provides some evidence that improving social cohesion in neighborhoods may be a beneficial health promotion strategy.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Hugely concerning changes to health outcomes have been observed in the UK since the early 2010s, including reductions in life expectancy and widening of inequalities. These have been attributed to UK Government ‘austerity’ policies which have profoundly affected poorer populations. Studies in mainland Europe have shown associations between austerity and increases in adverse birth outcomes such as low birthweight (LBW). The aim here was to establish whether the period of UK austerity was also associated with higher risks of such outcomes. We analysed all live births in Scotland between 1981 and 2019 (<span style="font-style:italic;">n</span> = 2.3 million), examining outcomes of LBW, preterm birth (PB) and small-for-gestational-age (SGA). Descriptive trend analyses, segmented regression (to identify changes in trends) and logistic regression modelling (to compare risk of outcomes between time periods) were undertaken, stratified by infant sex and quintiles of socioeconomic deprivation. There were marked increases in LBW and PB rates in the austerity period, particularly in the most deprived areas. However, rates of SGA decreased, suggesting prematurity as the main driver of LBW rather than intrauterine growth restriction. The regression analyses confirmed these results: trends in LBW and PB changed within 1–3 years of the period in which austerity was first implemented, and that period was associated with higher risk of such outcomes in adjusted models. The results add to the European evidence base of worsening birth outcomes associated with austerity-related economic adversity. The newly elected UK government needs to understand the causes of these changes, and the future implications for child and adult health.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Risks to older adults (OA) (aged 65+ years) associated with hot and cold weather in the UK are well-documented. The study aim is to explore OA perception of health risks from high and low temperatures, health-protective measures undertaken, and implications for public health messaging. In 2019/20, Ipsos MORI conducted face-to-face surveys with OA in England (<span style="font-style:italic;">n</span> = 461 cold weather survey, <span style="font-style:italic;">n</span> = 452 hot weather survey). Participants reported temperature-related symptoms, risk perceptions for different groups, and behaviours during hot and cold weather. Analysis involved binomial logistic regression models to assess potential factors (demographics, vulnerability, behaviours) associated with older adults’ health risk perception in hot and cold weather. Less than half of OA in both surveys agreed that hot or cold weather posed a risk to their health. OA with higher education, annual income >£25 000 or home ownership were less likely to perceive their health at risk during cold weather and regional differences in hot weather were identified. OA who recognized those the same age or living alone as at an increased risk were more likely to perceive their own health as at risk. OA were more likely to self-identify health risks when reporting those aged 65 yrs+ to be at an increased risk in cold weather. Various temperature-related protective behaviours were associated with older adults’ risk perception in hot and cold weather. These findings provide evidence for public health agencies to target high risk individuals, and modify temperature-related public health messaging to protect OA.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Migrant mortality advantage is established in various studies, but there is a lack of evidence on migrant mortality trends in old age. Previous studies have primarily concentrated on all-cause mortality, and few include older age groups. Discussions about the migrant mortality advantage continue due to concerns about data availability and accuracy. Additionally, the mechanisms explaining the migrant mortality advantage remain unclear. This study examines all-cause and cause-specific mortality among older migrant and nonmigrant adults aged 70 and above using Finnish Cause of Death register data (2002–20) and the corresponding risk population. We investigate differences in overall and cause-specific mortality between migrant and Finnish-born population and by geographical region of origin. We calculated direct age-standardized mortality rates and age group-specific death rates followed by Poisson regression to study relative mortality differences. Age at death, sex, income, region of residence, and year of death were controlled for in the regression analysis. We found evidence of migrant mortality advantage across various causes of death, but there was variation by regions of origin groups and sex. Notably, women exhibit the strongest advantage in respiratory and digestive system diseases, while men demonstrated pronounced advantages in external causes and respiratory diseases. Our study challenges the notion of a general diminishing healthy migrant effect in old age. Our findings emphasize the need for nuanced investigations into socioeconomic factors and tailored interventions for older migrants.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Proportion of normal deliveries is decreasing worldwide. This study analysed operative vaginal deliveries (OVD) and Caesarean sections (CS) with some background factors in Estonia and Finland from 1992 to 2016. Data on all deliveries from 1992 to 2016 were obtained from the Finnish Medical Birth Registry (1 481 160 births) and the Estonian Medical Birth Registry (356 063 births). Time trends were analysed by joinpoint regression, and factors associated with OVD and CS by logistic regression. Odds ratios with 95% CIs were calculated, adjusted for year, maternal age, foetal birthweight, and use of epidural/spinal anaesthesia. One out of four deliveries were operative in Estonia and in Finland by 2016. By 2016, the Estonian CS rate had tripled to 20.9% and the OVD rate had increased by nine times to 5.6%. In Finland, the CS rate increased slightly to 16.4% while the OVD rate nearly doubled to 9.4%. In Estonia, the incidence of OVD was 24% lower (aOR 0.76, 95% Cl 0.74–0.78) and the incidence of CS 9% higher (aOR 1.09, 95% Cl 1.07–1.10) than in Finland. Use of epidural/spinal anaesthesia and foetal birthweight increased the risk of OVD in both countries, maternal age increased the risk of CS in both countries. Even if the CS and OVD rates are different, operative delivery rates may be similar in different countries. Combined analysis of operative deliveries together with background factors gives a better understanding of the trends in birthcare than monitoring CS rates alone.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>This study aims to investigate the relationship between education and alcohol-related morbidity and the role that low job control and heavy physical workload play in explaining these associations among men and women in Sweden. This register-based cohort study (SWIP cohort) includes over three million individuals registered in Sweden in 2005. Job control and physical workload were measured using a job exposure matrix linked to the index person based on their registered occupation at baseline. Alcohol-related morbidity was measured through diagnoses in the national patient registers between 2006 and 2020. Cox proportional hazards regression models were built to estimate associations between education and alcohol-related morbidity. Reductions in hazard ratios (HRs) were calculated after adjusting for job control, physical workload, and other covariates. Models were also stratified by sex. Lower levels of education predicted a higher risk of alcohol-related morbidity (HR: 2.55 95% confidence interval: 2.49–2.62 for the lowest educated compared to the highest). Low job control and heavy physical workload both played roles in explaining educational differences in alcohol-related morbidity even after accounting for sociodemographic and health factors (15.1% attenuation for job control and 18.3% for physical workload among the lowest educated). Physical workload explained a larger proportion of the associations among men compared to women. Lower levels of education were associated with an increased risk of alcohol-related morbidity and working conditions partly explained these associations beyond what was explained by sociodemographic and health factors. Improving working conditions could therefore prevent some cases of alcohol-related morbidity.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Seventeen percent of people living in the UK are migrants. In high-income countries, migrants have been shown to have better all-cause mortality but worse mortality for some specific causes such as infectious diseases. This observational study aims to quantify the extent to which mortality from coronavirus disease 2019 (COVID-19) differed between migrants and non-migrants for the population of England and Wales, 2020-2021. We use Official National Statistics data to compare mortality from COVID-19 in 2020 and 2021 by country/region of birth, expressed as the standardized mortality ratio with those born in England and Wales as the reference population. Migrants from 17 of 19 countries/regions examined had higher mortality from COVID-19 than non-migrants. The highest mortality was those born in Bangladesh (females SMR = 3.39, 95% CIs 3.09–3.71; males 4.41, 95% CIs 4.09–4.75); Pakistan (females 2.73, 95% CIs 2.59–2.89; males 3.02, 95% CIs 2.89–3.14); and the Caribbean (females 2.03, 95% CIs 1.87–2.20; males 2.48, 95% CIs 2.37–2.60). Migrants born in Antarctica and Oceania (females 0.54, 95% CI 0.42–0.40; males 0.71, 95% CI 0.51–0.88), and North and Central America (females 0.95, 95% CI 0.80–1.11; males 0.85, 95% CI 0.72–0.99) had lower mortality than non-migrants. Most migrant populations had higher mortality from COVID-19 than non-migrants in England and Wales. Policy-makers must work to integrate migration status into routine data collection to inform future research and understand the causes of the inequalities seen.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Knowledge about health literacy challenges among the general population is valuable for initiatives targeting social inequity in health. We investigated health literacy in various population groups and the impact of healthcare-seeking behaviour by analysing the associations between (i) lifestyle, socioeconomics, self-rated health, chronic disease, and health literacy and (ii) symptom burden, contact to general practitioner (GP), and health literacy. In total, 27 488 individuals participated in a population-based survey. Questionnaire data comprised information about symptoms, GP contact, lifestyle, self-rated health, chronic disease, and four aspects of health literacy: feeling understood and supported by healthcare providers, having sufficient information about health, having social support for health, and being able to actively engage with healthcare providers. Socioeconomics were obtained from registers. Descriptive statistics and multivariable linear regression models were applied. Individuals who smoked, lived alone, had different ethnicity than Danish, and low self-rated health had more health literacy challenges reflected in lower scores for all aspects of health literacy. Individuals with high symptom burden and those who had presented a high absolute number of symptoms to their GP were less likely to have sufficient information about health and be able to actively engage, whereas individuals reporting GP contact with a high relative percentage of their symptoms were more likely to feel understood and supported by healthcare providers. Health literacy challenges are related to healthcare-seeking behaviour and several individual factors. To address social inequity in health and society, interventions aimed at both the individual and community-based health literacy are essential.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The aim of this paper was to study ethnic and socioeconomic (SEP) factors’ association with provision and participation in a type 2 diabetes disease-management program. In 2016–21, 3464 persons were referred to type 2 diabetes management in Copenhagen municipality. Personalized plans included a mix of activities; <span style="font-style:italic;">program consultations</span>, <span style="font-style:italic;">dietary education</span>, <span style="font-style:italic;">telephone conversations</span>, <span style="font-style:italic;">patient education</span>, and <span style="font-style:italic;">physical training</span>. We estimated the association between education, income, civic status, employment, and country of origin with the number of booked and participated activities using Poisson regression models. A total of 55 394 program sessions were scheduled. Small differences in booked <span style="font-style:italic;">dietary education</span>, <span style="font-style:italic;">program consultations</span>, <span style="font-style:italic;">telephone conversations</span>, and <span style="font-style:italic;">patient education</span> were seen between SEP groupings. In situations where groups with lower SEP had booked more sessions (e.g. unemployed bookings of dietary education), these were predominantly translated into equal or more participated sessions among persons with high SEP. Regarding <span style="font-style:italic;">physical training</span>, considerably more booked and participated sessions were delivered to women with lower SEP and ethnic minorities. This study is unique, in the sense that it is the first of its kind to analyze data on diabetes-management programs, systematically collected by primary healthcare workers. Our results suggest that specific elements of the program together with a higher number of booked sessions promoted vulnerable women to participate in more physical training sessions. In closing, these findings have the potential to provide motivation and ideas for policymakers and health professionals in how to design equitable type 2 diabetes management activities.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>During the coronavirus disease 2019 (COVID-19) pandemic, Sweden emphasized voluntary guidelines over mandates. We exploited a rapid change and reversal of the Public Health Agency of Sweden’s COVID-19 testing guidelines for vaccinated and recently infected individuals as a quasi-experiment to examine sociodemographic differences in the response to changes in pandemic guidelines. We analyzed daily polymerase chain reaction tests from 1 October 2021 to 15 December 2021, for vaccinated or recently infected adults (≥20 years; <span style="font-style:italic;">n</span> = 1 596 321) from three Swedish regions (Stockholm, Örebro, and Dalarna). Using interrupted time series analysis, we estimated abrupt changes in testing rates at the two dates when the guidelines were changed (1 November and 22 November). Stratified analysis and meta-regression were employed to explore sociodemographic differences in the strength of the response to the guideline changes. Testing rates declined substantially when guideline against testing of vaccinated and recently infected individuals came into effect on 1 November [testing rate ratio: 0.50 (95% confidence interval, CI 0.41, 0.61)], and increased again from these lowered levels by a similar amount upon its reversal on 22 November [testing rate ratio: 2.19 (95% CI: 1.69, 2.85)]. Being Sweden-born, having higher household income, or higher education, were all associated with a stronger adherent response to the guideline changes. Adjusting for stratum-specific baseline testing rates and test-positivity did not influence the results. Our findings suggest that the population was responsive to the rapid changes in testing guidelines, but with clear sociodemographic differences in the strength of the response.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Cancers represent the primary cause of mortality among people living with HIV (PLWH). However, comprehensive nationwide data regarding cancer incidence remains limited. Our objective was to evaluate the incidence rates of cancers, particularly those associated with human papillomavirus (HPV), within a nationwide study cohort. Using data from the Estonian Health Insurance Fund and the National Cancer Registry from 2004 to 2021, we calculated standardized incidence ratios (SIRs) for various cancer types among PLWH to compare to the general population with special emphases on HPV-associated cancers. A total of 7011 individuals (65.7% men) diagnosed with HIV were identified. HPV-associated cancers accounted for 21.4% of all incident cancer cases among PLWH. SIRs for HPV-associated cancers were 3.7 [95% confidence interval (CI) 2.2–6.2] among men living with HIV (MLWH) and 5.7 (95% CI 4.0–7.9) among women living with HIV (WLWH). In MLWH, the highest SIRs were for penile 12.5 (95% CI 4.0–38.7), followed by oropharyngeal 3.6 (95% CI 1.7–7.6) and anal–rectal cancers 2.7 (95% CI 1.1–6.4) in comparison to the general population. In WLWH, an increased incidence of cervical (SIR = 5.8, 95% CI 3.9–8.5), oropharyngeal (SIR = 6.1, 95% CI 1.5–24.3), and anal–rectal (SIR = 3.6, 95% CI 1.2–11.2) cancers was observed. A significantly increased risk of AIDS-defining and non-AIDS-defining cancers is reported. We demonstrate a substantially heightened risk of HPV-associated cancers among PLWH compared to the general population, underscoring the imperative for intensified screening and scaled-up vaccination along with improvement in adherence to antiretroviral therapy.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>This study explores the potential implementation of social prescribing in the Republic of Srpska, Bosnia and Herzegovina, where the approach is non-existent, and supporting structures are underdeveloped despite a recognized need for intervention. As social prescribing gains global recognition for improving health, the study investigates its feasibility in an uncharted area. The research assesses the necessity for social prescribing by examining loneliness rates and healthcare utilization in the Republic of Srpska, a region seldom studied in public health literature. Data from 1231 individuals aged 16–86 were collected in May 2021, marking the first initiative to gather information on loneliness and healthcare usage in the country. Loneliness rates in the Republic of Srpska were comparable to the UK. Using a negative binomial model, the study establishes significant links between loneliness, chronic health conditions, age, and healthcare service utilization. Loneliness, chronic health conditions, and age predict the use of general practitioner services. In the 44–54 and 65+ age groups, loneliness predicts accident and emergency service use. Specialist healthcare services are positively predicted by loneliness, having one chronic health condition, and being above 44 years of age. Notably, a COVID-19 diagnosis negatively predicts the use of all healthcare services. Gender and place of residence do not significantly impact healthcare service utilization. The study concludes that observed loneliness rates and correlated healthcare usage patterns in the Republic of Srpska indicate a need for social prescribing. The paper discusses the feasibility of implementing social prescribing in this particular case.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Frailty is associated with adverse health outcomes in ageing populations, yet its long-term effect on the development of disability is not well defined. The study examines to what extent frailty affects disability trajectories over 15 years in older adults aged 50+. Using seven waves of data from the Survey of Health, Ageing and Retirement in Europe (SHARE), the study estimates the effect of baseline frailty on subsequent disability trajectories by multilevel growth curve models. The sample included 94 360 individuals from 28 European countries. Baseline frailty was assessed at baseline, using the sex-specific SHARE-Frailty-Instrument (SHARE-FI), including weight loss, exhaustion, muscle weakness, slowness, and low physical activity. Disability outcomes were the sum score of limitations in activities of daily living (ADL) and Instrumental ADL (IADL). Analyses were stratified by sex. Over 15 years, baseline frailty score was positively associated with disability trajectories in men [βADL = 0.074, 95% confidence interval (CI) = 0.064; <span style="font-style:italic;">P</span> = .083; βIADL = 0.094, 95% CI = 0.080; <span style="font-style:italic;">P</span> = 0.107] and women (βADL = 0.097, 95% CI = 0.089; <span style="font-style:italic;">P</span> = .105; βIADL = 0.108, 95% CI = 0.097; <span style="font-style:italic;">P</span> = .118). Frail participants showed higher ADL and IADL disability levels, independent of baseline disability, compared with prefrail and robust participants across all age groups. Overall, participants displayed higher levels of IADL disability than ADL disability. Study findings indicate the importance of early frailty assessment using the SHARE-FI in individuals 50 and older as it provides valuable insight into future disability outcomes.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>It is unclear how much costs economic difficulties in families with children incur to the health and social care sector. We examined the health and social service costs after families entered into, and transitioned out of, social assistance used as a proxy measure for economic difficulties. We analyzed register data on all Finnish children born in 1997 and used the non-randomized target trial framework. The two target trials of entry to economic difficulties (social assistance) and continued economic difficulties included 697 680 and 71 131 children-year observations, respectively, in total. Inverse probability treatment weighting techniques were used to make the comparison group similar to the treatment group in terms of health, socioeconomic and demographic-related pretreatment variables. Entry to social assistance use was associated with some 1511–2619€ (50% compared to the control group) higher cumulative health and social care costs of the children three years after their families transitioned to social assistance, compared to the group that did not enter to social assistance system. This difference was primarily attributed to higher social care costs. Continued social assistance use was associated with some 1007–2709€ (31%) higher costs compared to the comparison group that exited social assistance. These findings support an economic argument to prevent families from entering economic difficulties and to help those in such situations to transition out.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Influenza is an important public health issue given its significant burden of disease. In Italy, the unsatisfactory coverage rate in people ≥65 years underlines the need to improve the current vaccination pathway. This study aims to define an integrated pathway across primary and secondary care, facilitated by a digital clinical decision support system (CDSS), to enhance vaccination coverage in people ≥65 years by actively recruiting patients in hospitals and administering vaccination. Moreover, the study seeks to gauge the potential epidemiological and economic impact of this approach. The methodology consisted of two main phases: definition of the integrated pathway and CDSS and estimation of the potential epidemiological and economic impact resulting from the implementation of the pathway in the whole Lazio region. Assuming an increase of influenza vaccination coverage from the current rate of 60% to 65% in ≥65 years old population in the Lazio region thanks to the pathway implementation, an increase of 8% in avoided influenza cases, avoided influenza- or pneumonia-related hospitalizations and avoided influenza-related outpatient visits was estimated with a relative increase in savings for hospitalizations and outpatient visits of up to 11.85%. Setting the vaccination coverage at 70%, the impact is doubled. Alongside offering a predictive estimate of the pathway’s potential impact, both epidemiological and economic, this project, with its robust methodology, may serve as a scalable and transferable model for enhancing vaccination coverage at national and international level.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Medical State Assistance is a French public health insurance programme that allows undocumented migrants (UM) to access primary, secondary, and tertiary care services free of user charge, either premium or out-of-pocket. The objective of this study is to assess the effect of Medical State Assistance on access to healthcare services and on usual source of care (USC). We rely on representative data of 1,223 UM attending places of assistance to vulnerable populations in Paris and in the greater area of Bordeaux (France). In this sample, 51% of UM are covered by Medical State Assistance. We use probit and ordinary least square regressions to model healthcare uses of undocumented migrants. The results show that UM covered by Medical State Assistance are more likely to access outpatient healthcare services (by +22.4 percentage points) and less likely to do so on non-governmental organizations (by −6.7 percentage points) than their eligible but uncovered counterpart. Additionally, covered undocumented migrants made 36.9% more medical visits in outpatient healthcare services and 65.4% fewer visits in non-governmental organizations than eligible but uncovered ones. Moreover, covered UM are also more likely to report that primary care services are their USC, in preference to emergency departments and other outpatient care services. UM covered by Medical State Assistance are more likely to consult in outpatient healthcare services.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Low socioeconomic position (SEP) has been identified as a risk factor for type 2 diabetes mellitus (T2DM), and psychosocial resources might be on the pathway in this association. We examined two poor psychosocial resources, low control beliefs and inferiority beliefs, that might link low SEP with T2DM. 8292 participants aged 40–75 living in Southern Netherlands participated in The Maastricht Study starting from September 2010 to October 2020 and were followed up to 10 years with annual questionnaires. SEP (education, income, occupation), low control beliefs, inferiority beliefs, and (pre)diabetes by oral glucose tolerance test were measured at baseline. Incident T2DM was self-reported per annum. We analysed the mediating roles of poor psychosocial resources by using counterfactual mediation analysis. People with low SEP had more often prevalent and incident T2DM (e.g. low education: HR = 2.13, 95%CI: 1.53–2.97). Low control beliefs and high inferiority beliefs were more common among people with low SEP. Moreover, low control beliefs and high inferiority beliefs were risk factors for T2DM (e.g. low control beliefs: HR = 1.50, 95%CI: 1.08–2.09). The relationship between SEP and T2DM was partially mediated by control beliefs (8.0–13.6%) and inferiority beliefs (2.2–4.5%). We conclude that poor psychosocial resources are important in socioeconomic inequalities in diabetes. Researchers and practitioners should consider the psychosocial profile of people with lower SEP, as such a profile might interfere with the development, treatment, and prevention of T2DM. Further research should explore how poor psychosocial resources interact with chronic stress in relation to socioeconomic health inequalities.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>With the acceleration of population aging, disability in older adults is a growing public health problem; however, little is known about the role of specific leisure-time activities in affecting disability. This study prospectively examined the association of leisure-time activities with disability among the Chinese oldest old. A total of 14 039 adults aged 80 years or older (median age of 89.8 years) were enrolled from the Chinese Longitudinal Healthy Longevity Survey from 1998 to 2014. Disability was defined as the presence of concurrent impairment in activities of daily living and physical performance. Cox proportional hazards models were used to estimate the associations between leisure-time activities and disability. During a mean of 4.2 years (2.7 years) of follow-up, 4487 participants developed disability. Compared with participants who never engaged in leisure-time activities, participants who engaged in almost daily activities, including gardening, keeping domestic animals or pets, playing cards or mahjong, reading books or newspapers, and watching TV or listening to the radio had a lower risk of disability, with HRs of 0.78 (0.69–0.88), 0.64 (0.58–0.70), 0.74 (0.63–0.86), 0.74 (0.65–0.84), and 0.84 (0.77–0.90), respectively. Moreover, the risk of disability gradually decreased with participation in an increasing number of those leisure-time activities (<span style="font-style:italic;">P</span> for trend <0.001). Frequent engagement in leisure-time activities was associated with a lower risk of disability among the Chinese oldest old. This study highlights the importance of incorporating a broad range of leisure-time activities into the daily lives of older adults.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The integration of human, animal, and environmental health in the One Health framework is crucial for tackling complex health and environmental issues. Governance structures in One Health initiatives are essential for coordinating efforts, fostering partnerships, and establishing effective policy frameworks. This systematic review, registered with PROSPERO, aims to evaluate governance architectures in One Health initiatives. Searches in PubMed, Scopus, WoS, and Cochrane from 2000 to 2023 were conducted. Key terms focused on peer-reviewed articles, systematic reviews, and relevant grey literature. Nine eligible studies were selected based on inclusion criteria. Data synthesis aimed to assess governance mechanisms’ functionality and effectiveness. Among 1277 sources screened, nine studies across diverse regions were eligible. An adapted framework assessed implementation mechanisms of international agreements, categorizing them into Engagement, Coordination, Policies, and Financial domains. The findings highlight the importance of effective governance, stakeholder engagement, and collaborative approaches in addressing One Health’s challenges. Identified challenges include deficient intersectoral collaboration, funding constraints, and stakeholder conflicts. Robust governance frameworks are pivotal in One Health paradigms, emphasizing stakeholder engagement and collaboration. These insights guide policymakers, practitioners, and researchers in refining governance structures to enhance human-animal health and environmental sustainability. Acknowledging study limitations, such as methodological variations and limited geographical scope, underscores the importance of further research in this area.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Burden of disease (BoD) studies quantify the health impact of diseases and risk factors, which can support policymaking, particularly in the European Union (EU). This study aims to systematically analyse BoD studies, which address EU public policies to contribute to the understanding of its policy uptake. A systematic search of six electronic databases and two grey-literature registries was carried out for articles published between 1990 and 2023. The thematic area, type of legislation and the respective policymaking stage were extracted. A textual analysis of the discussion was conducted to assess the inclusion of specific EU policy implications. Overton was used to detect citations in policy documents. Out of the 2054 records screened, 83 were included. Most studies employed secondary data, with 37 utilizing GBD data. Disability-adjusted life year was present in most of the studies (<span style="font-style:italic;">n</span> = 53). The most common type of the EU legislation mentioned was the directive (<span style="font-style:italic;">n</span> = 47), and the most frequent topic was environment (<span style="font-style:italic;">n</span> = 34). Policy implications for EU laws were discussed in most papers (<span style="font-style:italic;">n</span> = 46, 55.4%), with only 8 conducting evaluation of EU policies. Forty-two articles have been cited at the EU-level, in a total of 86 EU policies. Despite increasing efforts in integrating EU legislation impact within BoD studies, these results denote a low consideration of the legal and policy changes. Greater efforts in directing research towards policy effectiveness evaluation might increase their uptake in EU policies.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The aim of this study was to analyze the associations between healthcare services utilization and flight-related characteristics of asylum seekers and refugees in Germany. The 2020 wave of the German Socio-Economic Panel’s Survey of Refugees was used to compile a sample of asylum seekers and refugees (<span style="font-style:italic;">n</span> = 3134). Healthcare services utilization was measured using the self-reported number of visits to primary care physicians and hospitalization. Only the feeling of being welcome and worries about not being able to stay in Germany were identified as potential flight-related determinants of healthcare services utilization.</span>
<span class="paragraphSection">Recent publications of the UN population projections as well as the Global Burden of Disease estimations [<a href="#ckae134-B1" class="reflinks">1</a>] have not attracted the world’s attention. While the total world population will be stabilized, the total fertility rate (TFR) will decline below the replacement level in most countries. Many countries with negative natural population growth soften the problem by immigration. But it is not acceptable in countries with strong anti-immigration standing of the government and society, like Russia.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Persons with intellectual disabilities (ID) face pronounced health disparities. The aim of this study was to describe premature mortality by causes of death and avoidable mortality among persons with ID compared to the general Danish population. This study is based on a Danish nationwide cohort of adults (aged 18–74 years) with ID (<span style="font-style:italic;">n</span> = 57 663) and an age- and sex-matched reference cohort (<span style="font-style:italic;">n</span> = 607 097) which was established by linkage between several registers. The cohorts were followed in the Register of Causes of Death between 2000 and 2020. Causes of death were categorized into preventable, treatable, or unavoidable deaths using the OECD/Eurostat classification and furthermore categorized into specific interventions. We compared the observed and expected number of deaths by calculating standardized mortality ratio (SMR). Among persons with ID the number of deaths was 9400 whereof 5437 (58%) were avoidable. SMR for preventable deaths, e.g. by reducing smoking and alcohol intake or by vaccination, was 2.62 (95% CI, 2.51–2.73), and SMR for treatable deaths, e.g. by earlier diagnosis and treatment, was 6.00 (5.72–6.29). Unavoidable mortality was also six-fold increased (SMR = 6.03; 5.84–6.22). Preventable deaths were higher for persons with mild ID compared to severe ID, while treatable and unavoidable mortality were highest for persons with severe ID. The study confirmed that persons with ID have an amplified risk of mortality across all categories. There is a need for competence development of social care and healthcare personnel and reasonable adjustment of health promotion programs and healthcare services for people with ID.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>We studied the developmental trajectories of satisfaction with work–family reconciliation (WFS) and their associations with family—related factors and quality of life measures among municipal employees. The study was based on the Helsinki Health Study of municipal employees of the City of Helsinki in 2001–02 and its follow-up surveys in 2007, 2012, and 2017. Employees aged 40–50 at baseline and working at all timepoints were analysed (<span style="font-style:italic;">n</span> = 1681, 84% women). Growth Mixture Models were applied to identify trajectories of WFS (dissatisfied vs. satisfied). Associations of family-related and quality-of-life factors (physical functioning and emotional well-being) with the WFS trajectories were studied using log-binomial regression models, adjusting for sociodemographic and lifestyle variables. Two WFS trajectories, low (women 45%; men 53%) and high were identified. In a fully adjusted model among women, having ≥1 children aged 0–6 years was associated with increased odds of belonging to the low WFS trajectory (OR 1.52, 95% CI 1.19–1.95). Among men, having ≥1 children aged 7–18 was associated with decreased odds (0.39, 0.19–0.80). High emotional well-being was inversely associated with the low WFS trajectory among both genders (women 0.32, 0.23–0.45; men 0.20, 0.09-0.46). High physical functioning (0.59, 0.42–0.83) was inversely associated with the low WFS trajectory among women only. Less than half of the women and more than half of the men participants belonged to a low WFS trajectory, which associated with the age of children in the family and quality-of-life measures.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The objective of this study is to assess the impact of applying prevalences derived from a small-area model at a regional level on smoking-attributable mortality (SAM). A prevalence-dependent method was used to estimate SAM. Prevalences of tobacco use were derived from a small-area model. SAM and population attributable fraction (PAF) estimates were compared against those calculated by pooling data from three national health surveys conducted in Spain (2011–2014–2017). We calculated the relative changes between the two estimates and assessed the width of the 95% CI of the PAF. Applying surveys-based prevalences, tobacco use was estimated to cause 53 825 (95% CI: 53 182–54 342) deaths in Spain in 2017, a figure 3.8% lower obtained with the small-area model prevalences. The lowest relative change was observed in the Castile-La Mancha region (1.1%) and the highest in Navarre (14.1%). The median relative change between regions was higher for women (26.1%), population aged ≥65 years (6.6%), and cardiometabolic diseases (9.0%). The differences between PAF by cause of death were never greater than 2%. Overall, the differences between estimates of SAM, PAF, and confidence interval width are small when using prevalences from both sources. Having these data available by region will allow decision-makers to implement smoking control measures based on more accurate data.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Retention issues are widespread within the health workforce. This cross-sectional study used data collected from 1707 healthcare professionals in 2022–23 to identify with <span style="font-style:italic;">k</span>-means clustering groups of individuals sharing similar working experiences. These profiles were linked with varying levels of turnover intentions and a range of healthcare professions. While occupational therapists and paramedics reported in average better working conditions, registered nurses and intermediate caregivers reported the poorest experiences. In other clusters, salaries were high where work–life balance was low, and inversely. By learning from similarities and differences in the working conditions of diverse healthcare professionals, shared initiatives aimed at improving retention across professions can be facilitated.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Advertising for unhealthy foods adversely affects children’s food preferences and intake. The German government published plans to restrict such advertising in February 2023 and has revised them several times since. We assess the reach of the current draft from June 2023, and discuss its public health implications. We show that across 22 product categories covered by the current draft law, the median share of products permitted for marketing to children stands at 55%, with an interquartile range of 11–73%. Resistance from industry groups and from within government poses hurdles and leaves the prospects of the legislation uncertain.</span>
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