Background: The aim of this study was to investigate socio-economic inequalities in health care utilization from the 1980s and through the last 3 decades in a Norwegian county population. Methods: Altogether, 166 758 observations of 97 251 individuals during surveys in 1984–86 (83% eligible responses), 1995–97 (51% eligible responses) and 2006–08 (50% eligible responses) of the total population of adults (≥20 years) from Nord-Trøndelag county in Norway were included. Health care utilization was measured as at least one visit to general practitioner (GP), hospital outpatient services and inpatient care in the past year. Socio-economy was measured by both education and income and rescaled to measure relative indexes of inequality (RII). Relative and absolute inequalities were estimated from multilevel logistic regression. Estimates were adjusted for age, sex, municipality size and self-reported health. Results: GP utilization was higher among individuals with higher education in 1984–86. Among men the RII was 0.54 (CI: 0.48–0.62), and among women RII was 0.67 (CI: 0.58–0.77). In 2006–08, the corresponding RII was 1.31 (CI: 1.13–1.52) for men and 1.00 (CI: 0.85–1.18) for women, indicating higher or equal GP utilization among those with lower education, respectively. The corresponding RIIs for outpatient consultations were 0.58 (CI: 0.49–0.68) for men and 0.40 (CI: 0.34–0.46) for women in 1984–86, and 0.53 (CI: 0.46–0.62) for men and 0.47 (CI: 0.41–0.53) for women in 2006–08. Conclusion: Through the last 3 decades, the previous socio-economic differences in GP utilization have diminished. Despite this, highly educated people were more prone to utilize hospital outpatient consultations throughout the period 1984–2008.
Background: Available information about the association between education and physical fitness (PF) is scarce. The purpose of this study was to examine educational differences in PF in the working age population using different methods to assess PF. Methods: The Health 2000 Survey was carried out for adults aged ≥30 years (n = 8028) in Finland. For this study, 30–54-year-old men and women with data on PF and physical activity (PA) were selected (n = 3724). PF was assessed by self-estimated overall physical fitness and running ability, a physician’s estimation of a participant’s working capacity, the trunk extensors’ endurance and hand grip strength tests. The highest educational qualification taken by the participant was used as a measure of education. The analyses were adjusted for age, PA, BMI, smoking and chronic diseases. Results: PF was best in the high-educated men and women. The educational differences were minor in self-estimated overall PF. Adjusting for the covariates, the differences in self-estimated running ability and working capacity decreased. The educational differences in the trunk extensors’ endurance test were independent of covariates. PA and other health behaviours contributed most to the differences. Conclusion: People with high education had better PF irrespective of the method used to assess PF. A large amount of the educational differences could be explained by PA and other health behaviours. More research is needed to understand the determinants of educational differences in PF.
The larger than expected socio-economic inequalities in health in more egalitarian countries might be explained by a heightened social mobility in these countries. Therefore, the aim of this explorative study was to examine the associations between country-level social mobility, income inequality and socio-economic differences in all-cause mortality, using country-level secondary data from 12 European countries. Both income equality and social mobility were found to be associated with larger socio-economic differences in mortality, particularly in women. These findings suggest that social mobility and income equality, beside their shiny side of improving population health, might have a shady side of increasing socio-economic health inequalities.
Background: Whether middle-aged individuals are capable of employment continuation may be limited by poor memory. Subjective memory complaints may be used to identify those at risk of poor memory. Research questions, therefore, were (i) are prevalent memory complaints associated with relevantly poor memory performance and decline in 55 to 64-year-olds; (ii) are incident memory complaints associated with relevant memory decline; and (iii) do these associations differ between employed and not employed individuals? Methods: Participants of the Longitudinal Aging Study Amsterdam (LASA) were examined. Data were weighted by sex, age and region. To examine the association of prevalent memory complaints with relevantly poor learning ability (n = 903) and delayed recall (n = 897; both assessed with the Auditory Verbal Learning Test), subnormal (≤ mean – 1 SD) and impaired (≤ mean – 1.5 SD) memory performance were defined. To examine the association of prevalent and incident memory complaints with relevant decline after 3 years in learning ability (n = 774 and 611, respectively) and delayed recall (n = 768 and 603, respectively), above normal (≤ mean – 1 SD) and clinically relevant (≤ mean – 1.5 SD) memory decline were investigated. Logistic regression analyses were applied. Results: Adjusted for gender, education and age, individuals with memory complaints more often had impaired delayed recall and clinically relevant decline in learning ability. Incident memory complaints were borderline significantly associated with clinically relevant decline in learning in continuously employed individuals (paid job ≥1 h weekly), but not in continuously not employed individuals. Conclusion: Memory complaints may identify 55 to 64-year-olds at risk of memory impairment and decline. Our results provide hypotheses about the association between memory complaints and decline in employed 55 to 64-year-olds.
Background: We investigated the role of socio-economic status on diabetes prevalence, on mortality and hospitalization in a large population-based cohort enrolled in Rome, Italy. Methods: Diabetic residents aged ≥35 years in 2007 were identified using multiple data sources. The effect of the deprivation of the area of residence on diabetes prevalence and on mortality and hospitalization (years 2008–10) was investigated by multilevel regression models, both among diabetic and non-diabetic populations. Results: Prevalence of diabetes (8.3%) was directly related to the deprivation of the area of residence, especially for women. Diabetes increased the risk of mortality and hospitalization, mainly for cardiovascular complications, compared with non-diabetic subjects, with increasing relative risks in more deprived areas. The social gradients observed among diabetic patients are modest compared with non-diabetic subjects, both for some acute complications (myocardial infarction, stroke) and chronic complications (ischaemic heart disease, nephropathy, retinopathy and amputation). Conclusions: Prevalence of diabetes is directly related to deprivation, especially for women. Diabetes increases the risk of mortality and hospitalization for cardiovascular complications. However, similar to another study conducted in Northern Italy, we found that social differences in health outcomes do not differ between people with and without diabetes, suggesting that the care for diabetic patients living in Rome is provided without social disparities, and in some cases, it protects against the adverse effects of social inequalities. The Italian care system for diabetes deserves to be further investigated, as it could represent a model for the care of other chronic conditions and for contrasting social inequities in health.
Background: Lower educated people have a higher prevalence of metabolic risk factors (MRF), that is, high waist circumference (WC), high systolic blood pressure, low high-density lipoprotein cholesterol level, high triglycerides and high fasting glucose levels. Behavioural and psychosocial factors cannot fully explain this educational gradient. We aim to examine the possible role of genetic factors by estimating the extent to which education and MRF share a genetic basis and the extent to which the heritability of MRF varies across educational levels. Methods: We examined 388 twin pairs, aged 18–34 years, from the Belgian East Flanders Prospective Twin Survey. Using structural equation modelling, a Cholesky bivariate model was applied to assess the shared genetic basis between education and MRF. The heritability of MRF across education levels was estimated using a non-linear multivariate Gaussian regression. Results: Fifteen percent (P < 0.01) of the negative relation between education and WC was because of genes shared between these two traits. Furthermore, the heritability of WC was lower in the lowest educated group (65%) compared with the highest educated group (78%, P = 0.04). The lower heritabilities among the lower educated twins for the other MRF were not significant. The heritability of glucose was higher in the lowest education (80%) group compared with the high education group (67%, P = 0.01). Conclusion: Our findings suggest that genetic factors partly explain educational differences in WC. Furthermore, the lower heritability estimates in WC in the lower educated young adults suggest opportunities for environmental interventions to prevent the development of full-blown metabolic syndrome in middle and older age.
Background: Studies in the USA have shown ethnic inequalities in quality of hospital care, but in Europe, this has never been analysed. We explored variations in indicators of quality of hospital care by ethnicity in the Netherlands. Methods: We analysed unplanned readmissions and excess length of stay (LOS) across ethnic groups in a large population of hospitalized patients over an 11-year period by linking information from the national hospital discharge register, the Dutch population register and socio-economic data. Data were analysed with stepwise logistic regression. Results: Ethnic differences were most pronounced in older patients: all non-Western ethnic groups > 45 years had an increased risk for excess LOS compared with ethnic Dutch patients, with odds ratios (ORs) (adjusted for case mix) varying from 1.05 [95% confidence intervals (95% CI) 1.02–1.08] for other non-Western patients to 1.14 (95% CI 1.07–1.22) for Moroccan patients. The risk for unplanned readmission in patients >45 years was increased for Turkish (OR 1.24, 95% CI 1.18–1.30) and Surinamese patients (OR 1.11, 95% CI 1.07–1.16). These differences were explained partially, although not substantially, by differences in socio-economic status. Conclusion: We found significant ethnic variations in unplanned readmissions and excess LOS. These differences may be interpretable as shortcomings in the quality of hospital care delivered to ethnic minority patients, but exclusion of alternative explanations (such as differences in patient- and community-level factors, which are outside hospitals’ control) requires further research. To quantify potential ethnic inequities in hospital care in Europe, we need empirical prospective cohort studies with solid quality outcomes such as adverse event rates.
A study involving the presentation of 192 Belgian or Finnish prescriptions in pharmacies in five other member states was undertaken to assess whether, as envisaged by European Union law, prescriptions issued in one member state are dispensed by pharmacists in another and to identify factors that influence such decisions. Overall, pharmacists were willing to dispense in 108 cases. Detailed results show important differences depending on the country where prescriptions are presented and whether prescriptions were written by International Nonproprietary Name and in English, as opposed to prescriptions written by brand in a national language.
Background: We examine the influence of social circumstances early in life on changes in cognitive function from young adulthood to middle age, and we explore the impact of birth characteristics, childhood activities, education and adult social class on the expected relationship. Methods: A cohort of 11 532 men born in Copenhagen, Denmark in 1953—7906, 10 246 and 2483 participants—had completed assessments of cognitive function at ages 12, 18 and 57 years, respectively. Linear regression was used to investigate the association of early-life characteristics with cognitive test scores at these ages and with score changes from early to mid-adulthood. Results: The cognitive scores at age 57 years had high correlations with scores at ages 12 (r = 0.67) and 18 years (r = 0.70), and these two scores also showed bivariate correlation (r = 0.69). Having a father from the working class at birth was associated with lower cognitive function at ages 12, 18 and 57 years. The latter relation was attenuated when educational status at age 18 years and adult social class were adjusted for, while birth characteristics and childhood activities had minor influence. Having an unskilled father at birth, low education, few intellectual and many social activities in childhood as well as low adult social class were associated with decline in cognitive function. Conclusion: Adverse social circumstances early in life were associated with lower cognitive function at ages 12, 18 and 57 years, as well as with a decline between these ages. Educational status at age 18 years and adult social class seemed to account for most of the associations, whereas childhood activities were independent predictors that did not explain the social inequality.
Background: Socio-economic inequalities in health survey participation can jeopardize the extrapolation of the survey findings to the total population. Earlier research, based on aggregated data, showed that in Belgium less-educated people with poor health were less likely to participate in a health survey. In this article, the association by socio-economic status and household non-response in a health survey is examined. Methods: A linkage between the Belgian Health Survey 2001 with Census 2001 enabled us to evaluate the participation by socio-economic status. Results: We observed that the socio-economic position was a determinant of health survey participation: participation rate was significantly lower in households with a lower socio-economic profile. Conclusion: Socio-economic inequalities in participation can introduce a bias in the health survey findings. Strategies targeting improvement of the participation of lower socio-economic groups need to be considered.
Background: Efficient actions to fight elder abuse are highly dependent on reliable dimensions of the phenomenon. Accurate measures are nevertheless difficult to achieve owing to the sensitivity of the topic. Different research endeavours indicate varying prevalence rates, which are explained by different research designs and definitions used, but little is known about measurement errors such as item non-responses and how outcomes are affected by modes of administration. Methods: A multi-national study was developed to measure domestic abuse against home-dwelling older women (aged >60 years) in Europe. The measurement instrument covered six forms of abuse, adapted from the Conflict Tactics Scale. 2880 individuals were interviewed by three different data collection methods (i.e. postal, face-to-face, telephone). Results: Principal component analysis of missing values of 34 indicators of abuse showed various patterns of item non-response. Moreover, principal component analysis indicated several response patterns across different types of data collection. A binary logistic regression explained that item non-response and abuse prevalence is influenced by individual characteristics (social status, vulnerability), method effects such as content (sensitivity), the order of the questions (forms of abuse), by type of data collection and the presence of assistance in survey completion. Conclusion: The discussion revolves around how these findings could help improving measuring elder abuse. Advantages and disadvantages of the questionnaire and type of data collection methods are discussed in relation to three potential types of response errors: item positioning effect, acquiescence and social desirability.
Background: Portugal has one of the highest rates of childhood obesity in Europe. Few studies have explored the relationship between parents’ perceptions of their residential neighbourhood (safety concerns and amenities of the built environment) and their children’s weight status. This study aims to examine the associations between parents’ perceptions of their residential neighbourhood and overweight/obesity among their children. Methods: Anthropometric measures of height and weight were taken for 2690 children in preschools and elementary schools in Porto. Body mass index (kg/m2) was calculated, and the International Obesity Taskforce (IOTF) cut-offs were used. Parents completed the ‘Environmental Module’ standard questionnaire of the International Physical Activity Prevalence Study. Chi-square tests and the logistic regression model adjusted for age, gender, maternal education and school cluster were used to examine the associations between parents’ perceptions of their residential neighbourhood and overweight/obesity among their children. Results: In this sample, 31.8% of the children were overweight (including obese). Significant associations were found between child obesity and the following residential environmental characteristics: the odds of children being obese were lower if their parents believed that it was safe (low/no crime rate) to walk/cycle at night (OR = 0.65, 95% CI = 0.54–0.79) and during the day (OR = 0.70, 95% CI = 0.55–0.86) and that it was easy and pleasant (pedestrian safety) to walk in their neighbourhoods (OR = 0.73, 95% CI = 0.58–0.90) and when local sidewalks were well maintained and unobstructed (OR = 1.18, 95% CI = 1.01–1.40). Conclusion: Parental perceptions of neighbourhood safety and the quality of local sidewalks are significantly associated with obesity values.
Objectives: As tuberculosis (TB) infection in childhood contributes to the pool of individuals with latent tuberculosis infection (LTBI) from which future tuberculosis cases arise, this study aimed to determine the prevalence and risk factors associated with LTBI in schoolchildren and adolescents from Shanghai, China. Methods: In this cross-sectional study, we administered T-SPOT.TB and TB infection risk factor questionnaire to children and adolescents aged between 10 and 18 years in 2010 in Shanghai. LTBI cases were defined by positive T-SPOT.TB test results and X-ray confirmation. Results: A total of 1106 schoolchildren and adolescents were enrolled, of which 46.1% were male, and 91.8% were vaccinated with Bacille Calmette Guerin (BCG). Overall, 52 (4.7%) children had a positive T-SPOT.TB result, with significant increase in age distribution. However, none of the participants demonstrated TB-related abnormality on X-ray examination. Multivariate analysis showed that LTBI was associated with no BCG vaccination (odds ratio: 2.40; 95% confidence interval: 1.182–5.335) and a history of TB exposure (odds ratio: 6.89; 95% confidence interval: 3.095–15.35). For 46 children and adolescents with history of TB exposure, contact hours per week of TB cases were significantly associated with risk of LTBI. Conclusions: Prevalence of LTBI in schoolchildren and adolescents in Shanghai is relatively low compared with other high epidemic areas of TB. A higher risk of LTBI was observed among children with no BCG vaccination and those with a history of TB exposure, which suggests that the prevalence of LTBI among schoolchildren could be further reduced by strengthening BCG vaccination under the national immunization programme and enhancing contact investigation of active TB patients.
Background: The Eastern border of the European Union (EU) consists of 10 countries after the expansion of the EU in 2004 and 2007. These 10 countries border to the East to countries with high tuberculosis (TB) notification rates. We analyzed the notification data of Europe to quantify the impact of cross-border TB at the Eastern border of the EU. Methods: We used TB surveillance data of 2010 submitted by 53 European Region countries to the European Centre for Disease Prevention and Control and the World Health Organization Regional Office for Europe. Notified TB cases were stratified by origin of the case (national/foreign). We calculated the contribution of foreign to overall TB notification. Results: In the 10 EU countries located at the EU Eastern border, 618 notified TB cases (1.7% of all notified TB cases) were of foreign origin. Of those 618 TB cases, 173 (28.0%) were from countries bordering the EU to the East. More specifically, 90 (52.0%) were from Russia, 33 (19.1%) from Belarus, 33 (19.1%) from Ukraine, 13 (7.5%) from Moldova and 4 (2.3%) from Turkey. Conclusions: Currently, migrants contribute little to TB notifications in the 10 EU countries at the Eastern border of the EU, but changes in migration patterns may result in an increasing contribution. Therefore, EU countries at the Eastern border of the EU should strive to provide prompt diagnostic services and adequate treatment of migrants.
Objectives: The aim was to summarize national prevention of mother-to-child transmission (PMTCT) guidelines across Europe and to identify differences between these. Methods: A survey was conducted using a structured questionnaire sent to experts in 25 European countries from January to March 2012, requesting a copy of the national guidelines. Responses were received from 23 countries. Results: Twenty-two (96%) countries supported a policy to recommend antenatal HIV screening for all pregnant women (15: opt-out strategy; 8: opt-in strategy). For HIV-positive women in whom the only indication for antiretroviral therapy (ART) was PMTCT, the recommended gestational age for commencing ART varied from 12 to 28 weeks: initiation before 19 weeks gestation was recommended in guidelines from nine countries; in France, the UK and the Netherlands, there was a wide range, from 14 to 24 weeks, whereas the Swiss and Ukrainian guidelines recommended starting at 24–28 weeks and the German/Austrian and Lithuanian at 28 weeks. Six national guidelines recommended inclusion of Zidovudine in antenatal ART regimens, and seven (37%) allowed continuation of Efavirenz for women conceiving on this drug. According to nine guidelines, zidovudine should always be used intrapartum. Eighteen national guidelines stated that HIV-positive women on successful ART can have a vaginal delivery. Viral load thresholds for vaginal delivery were <1000 copies/ml in 5 countries, <400 copies/ml in 3 and <50 copies/ml in 11 countries. Conclusion: There are important differences across Europe in national PMTCT guidelines, with most variation seen where the evidence-base remains limited. Such differences should be considered when interpreting research and surveillance findings.
Background: Having been vaccinated against the human papilloma virus (HPV) may affect other behaviours related to sexual health. This study assessed knowledge and behaviour relevant to the prevention of sexually transmitted infections (STIs) among girls/women aged 14–23 years in relation to their HPV vaccination status. Methods: From November 2008 to February 2009, 328 girls/women from the Rhône-Alpes region were recruited by general practitioners and completed a self-administered questionnaire. Results: In all, 316 of the 328 respondents provided information on their HPV vaccination status: 135 (42.7%) had been vaccinated (51.2% of girls aged 14–16 years, 44% of women aged 17–20 years and 18.9% of 21–23-year-olds). Knowledge about HPV and the Pap smear was poor overall but greater in those who had been vaccinated: vaccinated 14–16-year-olds were significantly more likely to know the aim of the Pap smear than those not vaccinated (72.7% vs. 41.3%, P < 0.001), and vaccinated 21–23-year-olds were more likely to know about the need to continue Pap smear screening, despite vaccination (60.0% vs. 25.6%, P = 0.06). Irrespective of vaccination status, >80% cited condoms as a means of STI prevention and >85% of those who were sexually active used them. No difference was observed between vaccinated and non-vaccinated groups regarding requests for HIV serology, history of abortions or emergency hormonal contraception. Conclusion: Knowledge about cervical cancer prevention was better among those who had been vaccinated against HPV than among those who had not. Knowledge and behaviour relevant to STI prevention seemed appropriate whatever the respondents’ vaccination status.
Background: Knowledge about alcohol consumption patterns and alcohol problems among the Belgian elderly population is scarce. The aims of this study were to explore alcohol consumption patterns and alcohol problems among the Belgian elderly population aged ≥65 years living at home, and to determine their association with socio-demographic characteristics, health status and socio-economic status. Methods: In this cross-sectional study based on a representative sample of 4825 non-institutionalized Belgian elderly people (≥65 years) in the Belgian Health Interview Surveys 2001 and 2004, alcohol consumption patterns and alcohol problems were estimated according to age, gender, survey year, living situation, frequency of social contacts, smoking status, and socio-economic status. Results: In all, 50.4% of the sample were non- or occasional drinkers, 29.1% were moderate drinkers, 10.4% at-risk drinkers, 4.6% heavy drinkers and 5.5% problematic drinkers. In total, 20.5% of the Belgian elderly population drank in excess of the National Institute on Alcohol Abuse and Alcoholism guidelines, and 4.7% had an alcohol problem according to the CAGE. In addition, 81.3% of the elderly people who consume alcohol used prescribed medications in the past 2 weeks. After adjustment for risk factors we found that, compared with moderate drinking, unhealthy drinking was significantly associated with age, gender, frequency of social contacts, health status and socio-economic status. Conclusions: Belgian health policy should be aware of the high level of at-risk drinkers in the elderly population and the underdetection and misdiagnosis of alcohol problems in this age group. An increased attention in public health initiatives among the Belgian elderly population is needed.
Background: This study predicts the implications of under-reporting of alcohol consumption in England for alcohol consumption above Government drinking thresholds. Methods: Two nationally representative samples of private households in England were used: General LiFestyle survey (GLF) and Health Survey for England (HSE) 2008. Participants were 9608 adults with self-reported alcohol consumption on heaviest drinking day in the last week (HSE) and 12 490 adults with self-reported average weekly alcohol consumption (GLF). Alcohol consumption in both surveys was revised to account for under-reporting in three hypothetical scenarios. The prevalence of drinking more than UK Government guidelines of 21/14 (men/women) alcohol units a week, and 4/3 units per day, and the prevalence of binge drinking (>8/6 units) were investigated using logistic regression. Results: Among drinkers, mean weekly alcohol intake increases to 20.8 units and mean alcohol intake on heaviest drinking day in the last week increases to 10.6 units. Over one-third of adults are drinking above weekly guidelines and over three-quarters drank above daily limits on their heaviest drinking day in the last week. The revision changes some of the significant predictors of drinking above thresholds. In the revised scenario, women have similar odds to men of binge drinking and higher odds of drinking more than daily limits, compared with lower odds in the original survey. Conclusion: Revising alcohol consumption assuming equal under-reporting across the population does not have an equal effect on the proportion of adults drinking above weekly or daily thresholds. It is crucial that further research explores the population distribution of under-reporting.
Background: The national health and social care systems in Europe remain poorly integrated with regard to the care needs of older persons. The present study examined the range of health and social care services used by older people and their unmet care needs, across six European countries. Methods: Family carers of older people were recruited in six countries via a standard protocol. Those providing care for disabled older people (n = 2629) provided data on the older person’s service use over a 6-month period, and their current unmet care needs. An inventory of 21 services common to all six countries was developed. Analyses considered the relationship between older people’s service use and unmet care needs across countries. Results: Older people in Greece, Italy and Poland used mostly health-oriented services, used fewer services overall and also demonstrated a higher level of unmet care needs when compared with the other countries. Older people in the United Kingdom, Germany and Sweden used a more balanced profile of socio-medical services. A negative relationship was found between the number of different services used and the number of different areas of unmet care needs across countries. Conclusions: Unmet care needs in older people are particularly high in European countries where social service use is low, and where there is a lack of balance in the use of health and social care services. An expansion of social care services in these countries might be the most effective strategy for reducing unmet needs in disabled older people.