Scandinavian Journal of Public Health recent issues

Health impact assessment: An aid to political decision-making

Kemm, J. — 2008-11-12

Screening tool development for health impact assessment of large administrative structural changes

2008-11-12

Aims: Screening is the first, extremely important step of health impact assessment (HIA) methodology. It contributes to the decision to conduct or not conduct a full assessment, and predefines the main fields of interest of the assessment. Methods: Although there are examples of screening tools available on the Internet and in the scientific literature, in many cases lack of access to those tools creates a barrier to the use of HIA. Results: Denmark is undergoing a major structural change in state administration, moving many responsibilities from the state to the local level. Newly constructed councils are faced with challenges regarding their responsibilities in health promotion and other fields, and this has opened a window for the introduction of HIA at a local level. Owing to the lack of experience with HIA in Denmark, screening tools are lacking and are frequently requested by councils. Conclusions: This article describes a newly constructed screening tool for use at the local level, and describes how we approached the construction of the tool.

Hopelessness -- novel facet of the metabolic syndrome in men

2008-11-12

Aims: Recent studies have shown that lack of hope is linked to cardiovascular morbidity and mortality. Little is known, however, about the relationship of hopelessness and the metabolic syndrome. The aim of this study is to examine the association of hopelessness and the metabolic syndrome. Methods: This cross-sectional study examines the relationship between hopelessness and the metabolic syndrome as defined by the National Cholesterol Education Program in a population-based cohort of 1743 non-diabetic men aged 42, 48, 54 and 60 years old at baseline (1984—89). Hopelessness was measured by one's expectations about the future and reaching goals. Results: In simple age-adjusted univariate analyses the prevalence of the metabolic syndrome, many of its components and other cardiovascular risk factors were more common in men with higher levels of hopelessness. In a logistic regression model adjusted for age, smoking, alcohol consumption, cardiovascular disease, adult socioeconomic status and physical activity, men in the highest third were 2.1 (95% CI 1.3—3.2) times more likely to have the metabolic syndrome than those in the lowest third. After further adjusting for body mass index and elevated depressive symptoms the respective figures were 1.9 (95% CI 1.2—3.1) and 2.1 (95% CI 1.4—3.4). Conclusions: Hopelessness was strongly associated with the metabolic syndrome in these middle-aged men, independent of other depressive symptoms and traditional cardiovascular risk factors. These findings suggest that hopelessness is very closely related to the metabolic syndrome. Therefore lifestyle management of the metabolic syndrome should also take into account patients' expectations more thoroughly than hitherto acknowledged.

Managerial leadership is associated with self-reported sickness absence and sickness presenteeism among Swedish men and women

Nyberg, A., Westerlund, H., Magnusson Hanson, L. L., Theorell, T. — 2008-11-12

Aims: The objective of this study was to investigate the relationship between managerial leadership and self-reported sickness absence/presenteeism among Swedish men and women. Methods: Five thousand one hundred and forty-one Swedish employees, 56% of the participants in a nationally representative sample of the Swedish working population, were included in this cross-sectional questionnaire study. The leadership dimensions measured were five subscales of a standardized leadership questionnaire (Global Leadership and Organizational Behaviour Effectiveness Programme): Integrity, Team integration, Inspirational leadership, Autocratic leadership, and Self-centred leadership. Multiple logistic regression analyses were conducted, adjusting for factors in private life, employment category, labour-market sector, working conditions, self-reported general health, and satisfaction with life in general. Results: Inspirational leadership was associated with a lower rate of short spells of sickness absence (<1 week) for both men and women. Autocratic leadership was related to a greater amount of total sick days taken by men. Sometimes showing integrity was associated with higher rate of sickness absence >1 week among men, and seldom showing integrity was associated with more sickness presenteeism among women. Managers performing Team integration were sometimes associated with women taking fewer short (<1 week) and long (>1 week) spells of sickness absence. Adjustment for self-reported general health did not alter these associations for men, but did so to some extent for women. Conclusions: Managerial leadership was found to be relevant for the understanding of sickness absence in the Swedish working population. There were distinctive gender differences.

Roadmap for patient safety research: approaches and roadforks

Hofoss, D., Deilkas, E. — 2008-11-12

Patient safety improvement is a healthcare priority worldwide. Pioneer research reports include the 1984 Harvard Medical Practice Study, and the 1999 report "To err is human''. Patient safety research is expanding rapidly. Among the Scandinavian countries, Denmark is the patient safety improvement leader, and Norway is the laggard, having only recently institutionalized safety research and then having started with industrial safety research, and only recently having expanded into patient safety research. Aims: To produce a roadmap for patient safety research, indicationg three main roadforks. Patient safety research can be conducted along a number of lines. To identify patient safety problems and come up with ideas for patient safety improvement one can investigate 1) particular cases of adverse events, 2) the design of healthcare delivery systems, or 3) the culture of the care-giving institutions. The study of safety culture can be subdivided into the study of organization culture in general (and in particular of leadership culture) and the study of patient safety culture. The article provides a number of references to existing instruments of patient safety research. Methods: Qualitative interpretation of the referenced literature. Results: Scrutinizing adverse events for errors is health care's traditional way of improving patient safety. The idea of rethinking the design of care delivery systems has been accompanied by claims of modernity. The study of patient safety culture is the most recent approach. The three approaches are discussed in separate sub-chapters. Conclusions: Although chronology suggests a developmental trend, the three approaches should not necessarily be seen as steps up the ladder of evolution. Each approach does have its merits.

Health service interventions targeting relatives of heart patients: A review of the literature

Nissen, N. K., Madsen, M., Olsen Zwisler, A.-D. — 2008-11-12

Aims: Relatives of heart patients experience anxiety, uncertainty, and low quality of life, and the hospitalization of a heart patient is associated with increased risk of death for the partner. Relatives' physical and mental problems may be rectified by activities established by the health services to support relatives and to enable them to handle the situation. This study systematically reviewed the literature on the latest health service interventions targeting relatives of heart patients. Methods: The literature about interventions targeting relatives of heart patients has been systematically reviewed to clarify what the health services do for relatives of heart patients and to assess the effects of interventions. We searched Medline, EMBASE, PsycINFO, CINAHL database, CSA and the Cochrane Library from January 2000 to March 2006. Results: Only six scientific articles reported on interventions testing health service activities for relatives of heart patients, and one literature review scrutinized earlier studies within the field. All the interventions indicate positive effects on patients' and/or relatives' health and well-being, in accordance with nurses' assessments. Nevertheless, the few studies and their questionable quality means that full evidence on the effects of the interventions is lacking. Conclusions: Future research should clarify the evidence for health service interventions and draw up guidelines for activities for the relatives of heart patients.

Are hospitals also for relatives? A survey of hospitals' activities regarding relatives of cardiac patients

Nissen, N. K., Madsen, M., Kjoller, M., Waldorff, S. B., Olsen Zwisler, A.-D. — 2008-11-12

Aim: Patients and their close relatives both feel the burden of cardiovascular disease. Relatives of heart patients experience lower quality of life and increased mortality than the general population and relatives of patients with other diseases. Nevertheless, knowledge on health services aimed at relatives of patients with cardiac diseases is sparse. This study aimed to survey the prevalence of health services for relatives of cardiac patients in Denmark. Methods: We surveyed activities offered by Danish hospitals to the relatives of cardiac patients. Data were obtained from an Internet-based survey and 50 of 55 invited hospital departments participated. Results: Almost all departments offer activities to relatives of cardiac patients, but only one-quarter have activities specifically aimed at supporting relatives. Large departments offer activities for relatives more often than smaller departments. Participation rates for relatives are generally low, and the departments experience numerous barriers in providing activities for relatives of heart patients. Conclusions: Danish hospitals focus very little on relatives of cardiac patients, and this seems to be due to several factors, including lack of resources, lack of interest and knowledge among staff, and practical and psychological barriers among patients and relatives. More research is needed on health services concerning relatives of cardiac patients, regarding both the prevalence of activities and barriers to these.

How important are individual counselling, expectancy beliefs and autonomy for the maintenance of exercise after cardiac rehabilitation?

Mildestvedt, T., Meland, E., Eide, G. E. — 2008-11-12

Aims: We examined whether autonomy supportive and self-efficacy enhancing individual lifestyle counselling was associated with improved maintenance of exercise and physical capacity compared with group based counselling. We also tested whether self-efficacy beliefs and autonomous motivation was associated with improved maintenance of exercise over time. Methods: Randomised controlled trial and longitudinal study of predictor variables. One hundred and seventy six (38 female) patients mainly with coronary heart disease were randomized to either have standard group based rehabilitation or to additionally receive the intervention. Patients were recruited from a 4-week cardiac rehabilitation programme with two years follow-up at Krokeide Centre in Bergen, Norway. Results: We found no statistically significant between-group differences. The groups showed an overall improvement of their self-evaluated physical capacity during the two years of the study, corresponding 7% change of score (p<0.001). The composite exercise score improved 6% during follow-up (p<0.001). Intensity of exercise activities improved 17% from inclusion to 24 months' follow-up (p<0.001). Self-efficacy for increased exercise, general expectancy and autonomous motivation were significant predictors of increased exercise and physical capacity. Controlled motivation hampered physical capacity improvement. Conclusions: Among this self-selected and motivated group of rehabilitation patients we found no additional effect of adding individual counselling to group-based interventions. Based on longitudinal documentation this cardiac rehabilitation programme improves long-term maintenance of exercise and physical capacity and this maintenance is related to autonomous motivation, general expectancy and self-efficacy.

Long-term fiscal implications of subsidizing in-vitro fertilization in Sweden: A lifetime tax perspective

Svensson, A., Connolly, M., Gallo, F., Hagglund, L. — 2008-11-12

Aims: In Sweden approximately 3% of annual births are conceived using assisted reproductive technologies (ART). In light of increasing use of ART in Sweden we estimate the lifetime future tax revenues of a child conceived by in-vitro fertilization (IVF) to establish whether public subsidy of IVF represents sound fiscal policy. Methods: A modified generational accounting model was developed to calculate the net present value (NPV) of average investment costs required to achieve an IVF-conceived child. The model simulates direct lifetime financial interactions between the child and the Swedish government. Within the model we assume average direct financial transfers are made to the individual (eg, child allowance, education, health care, pension, etc). In return, the individual transfers resources to the government through taxation based on anticipated average earnings. The difference between direct transfers and gross taxes paid equals the net-tax contribution. Individual tax contributions were held constant in the model. Results: Based on average life-expectancy an individual born in 2005 will pay an undiscounted 32.5 million SEK in taxes to the Swedish government and receive 20.9 million SEK in direct financial transfers over their lifetime. When these figures are discounted and IVF costs are included in the analysis we obtain a lifetime NPV of 254,000 SEK with a break-even point at age 41 (the age of achieving a positive NPV) for an individual conceived through IVF. Conclusions: Based on results presented here we conclude that State-funded IVF in Sweden does not negatively impact the long run fiscal budget. Conversely, over an average lifetime an IVF offspring returns a positive net value to the State.

Costs of heart disease and risk behaviour: Implications for expenditure on prevention

Kruse, M., Davidsen, M., Madsen, M., Gyrd-Hansen, D., Sorensen, J. — 2008-11-12

Aims: The objective of this paper is firstly to estimate the healthcare costs attributable to heart disease in Denmark using recently available data for 2002—05. Secondly, to estimate the attributable healthcare costs of lifestyle risk factors among heart patients, in order to inform decision making about prevention programmes specifically targeting patients with heart disease. Methods: For a cohort consisting of participants in a national representative health interview survey, register-based information about hospital diagnosis was used to identify patients with heart disease. Healthcare consumption during 2002— 05 among individuals developing heart disease during 2002—05 was compared with individuals free of heart disease. Healthcare costs attributable to heart disease were estimated by linear regression with adjustment for confounding factors. The attributable costs of excess drinking, physical inactivity and smoking among future heart patients were estimated with the same method. Results: Individuals with heart disease cost the healthcare system on average 3195 (p<0.0001) per person-year more than individuals without heart disease. The attributable cost of unhealthy lifestyle factors among individuals at risk of heart disease was about 11%—16% of the attributable cost of heart disease. Conclusions: Heart disease incurs significant additional costs to the healthcare sector, and more so if heart patients have a history of leading an unhealthy life. Consequently, strategies to prevent or cease unhealthy lifestyle may not only result in cost savings due to avoided heart disease. Additional cost savings may be obtained because heart patients who prior to the disease led a more healthy life consume fewer healthcare resources.

An apple a day keeps the doctor away: Interdisciplinary approaches to solving major public health threats

Medin, J., Krettek, A. — 2008-11-12

Encouraging the installation of rollover protective structures in New York State: the design of a social marketing intervention

2008-11-12

Aims: Increasing the percentage of rollover protective structure (ROPS) equipped tractors has been the focus of many agricultural safety campaigns. Traditionally efforts have attempted to persuade farmers through education or community awareness interventions. These efforts have lead to marginal change. In response, a social marketing approach was tested as a means for increasing interest in ROPS retrofitting in New York. Methods: An initial phone survey was conducted with a random sample of New York farmers to identify a potential target population. Following target selection, in-depth interviews were conducted to isolate barriers and motivators to retrofitting. This information was used to develop message prototypes which were tested in small focus group discussions. Selected and revised messages, as well as various other incentives developed in response to feedback from interviews, were then tested in a prospective, quasi-randomized controlled trial. Results: Small crop and livestock farms were selected as the intervention target since they represent 86% of New York farms with none or only one ROPS protected tractor. Barriers to retrofitting which were identified in interviews were: 1) constant exposures normalize risk, 2) risk is modeled by significant others and 3) safety in general and retrofitting in particular requires too much time and money. The piloting of ROPS incentives led to a marked increase in ROPS sales in New York. Conclusions: Social Marketing provides a promising framework for the design of agricultural injury prevention programs. The potential implications for other health initiatives seeking to promote behaviour change are also discussed.

Underreporting of external cause codes in the Finnish Hospital Discharge Register

Lunetta, P., Impinen, A., Lounamaa, A. — 2008-11-12

Background: Hospital discharge data (HDD) represent one of the most valuable information sources for injury prevention and control. Objectives: To investigate external code of injury (E-code) underreporting in the Finnish National Hospital Discharge Register from 1 January 1987 to 31 December 2004. Material and methods: HDD for discharges with an injury as the main diagnosis were extracted from the FNHDR. The selection was made using codes for nature of injury (1987—1995, ICD-9; 1996—2004, ICD-10). The proportion of injury discharges with a missing E-code was examined by sex, age, hospital districts, type of hospital, duration of hospitalization, and nature of injury. Results: In 432,549 (23.1%) of the recorded 1,868,519 discharges, an E-code was missing. The proportion of the discharges with a missing E-code varied among the above variables. During the period 1987—2004, the overall E-code underreporting decreased from 18.0% to 12.8%. The introduction of the ICD-10 in 1996 was followed by a dramatic increase (up to 57.5% of all discharges) in E-code underreporting. Conclusions: More attention ought to be dedicated to teaching and periodic training on the use of E-codes. Educational activities should specifically target the medical doctors, who, in Finland, are responsible for assigning the E-codes.

Communicable disease policy development in response to changing European political frontiers in Finland, Norway and Sweden

Bernitz, B. K. — 2008-11-12

Aims: The European Union (EU) enlargement of 2004 brings both opportunities and challenges for public health. It is believed that further integration will bring direct health benefits, mainly through improved socioeconomic conditions, but there are also risks associated with the EU expansion, in particular cross-border health risks, such as the impact of the internal EU market policy of free movement and migration on communicable disease patterns. Against this background, this article examines communicable disease policy development in Finland, Norway and Sweden in response to changing European political frontiers, in particular the EU accession of the Baltic States. The emphasis is on HIV/AIDS and tuberculosis. Methods: The study is based on a qualitative and quantitative approach, using two complementary methods: documentary analysis and stakeholder analysis. Results: The article identifies a distinct pattern in communicable disease policy development between 1990 and 2005. The turn of the new millennium saw a sharp increase in national attention and the priority assigned to communicable diseases in Finland, Norway and Sweden. The article argues that this development is likely to be related to the rising national, regional and European awareness of the public health challenges associated with communicable diseases in today's borderless Europe. It also shows that the Baltic health situation is a particular concern for Finland. Conclusions: Although there is increasing national and regional activity within the communicable disease area, there is a need for a more effective European approach to tackle the future communicable disease challenges that may follow in an increasingly interdependent and integrated Europe.

Parents' and teachers' communication about HIV and sex in relation to the timing of sexual initiation among young adolescents in Tanzania

Kawai, K., Kaaya, S. F., Kajula, L., Mbwambo, J., Kilonzo, G. P., Fawzi, W. W. — 2008-11-12

Aims: Early sexual debut is associated with increased HIV risk among young adolescents in sub-Saharan Africa. Our study examines parents' and teachers' communication about sexual matters in relation to the timing of sexual initiation among students aged 12—14 years old in Dar es Salaam, Tanzania. Methods: Virgin primary school students were followed prospectively for 6 months to assess sexual initiation. Socio-demographic, psychosocial, and behavioural factors were assessed with a structured questionnaire. Univariate and multivariate logistic regression analyses were performed. Results: Of 2477 adolescents, 26.9% of students reported communicating about HIV and sex with parents and 35.6% communicated with teachers. Communication with teachers about HIV and sex was associated with delayed sexual initiation among adolescents after adjusting for potential confounding factors (OR=0.59, 95%CI=0.40—0.89, p=0.01). However, parental communication was not associated with the timing of sexual initiation. The perception that most peers are sexually active was a significant predictor of early sexual debut (test for linear trend, p=0.002). Students who do not live with a biological mother were marginally more likely to initiate sex compared to those who live with a biological mother (OR=1.39, 95%CI=0.97—1.99, p=0.08). Conclusions: Teachers can play an effective role in discussing HIV and sex with young adolescents. Our study highlights the necessity of responsible adults discussing sexual matters with young adolescents in sub-Saharan Africa. More research is required to better understand the role of parental communication about sexual matters and strategies for improving the quality of parental communication.

Time trends in sleep-onset difficulties among Norwegian adolescents: 1983--2005

2008-11-12

Aims: To investigate trend data in the prevalence of sleep-onset difficulties among Norwegian adolescents covering the age groups 11, 13 and 15 years. Methods: Data were based on the Health Behaviour in School-aged Children — A WHO Cross-National Survey (HBSC) — and were collected on six occasions between 1983 and 2005. At each point in time data were obtained from representative samples comprising between 3402 and 5026 adolescents. Results: The prevalence of sleep-onset difficulties was higher among 11-year-old students compared to the 13- and 15-year-olds. Girls reported a higher prevalence than boys. A logistic regression analysis showed that the prevalence of sleep-onset difficulties overall had increased significantly since 1983, which constituted the reference year. When the analysis was broken down by age and gender, the same tendency was found in all groups. Conclusions: The prevalence of sleep-onset difficulties among adolescents has increased during the last decades. This development gives reason for concern and should receive more attention from teachers, parents and health professionals.

World Health Organization Commission on the Social Determinants of Health: Social injustice is killing people on a grand scale: First World Forum Against Drugs: 100 years of global drug prevention marked in Stockholm

2008-11-12

Public health information systems -- and EUPHIX

Kamper-Jorgensen, F. — 2008-08-29

European community health monitoring: the EUPHIX-model

Achterberg, P. W., Kramers, P. G.N., van Oers, H. A.M. — 2008-08-29

Aims: On 20 June 2008, the EUPHIX website (www.euphix.org) was officially launched. EUPHIX aims to provide policy relevant health information, data and knowledge for policy makers, public health experts and educated lay people in the European Union (EU). The project was carried out by a partnership of European health reporting experts. Methods: The conceptual structure of EUPHIX resembles the one used for the ECHI-indicator framework, but adds health policies. EUPHIX includes texts (EUphacts) next to indicator data, as well as links to organizations, data and literature. Other contributions, called EUphocus, address broader agenda issues, such as mental health and health inequalities. Some EUphocus contributions contain summarized outcomes of EU projects. In this sense, EUPHIX has a European platform function as well. Behind the surface of the EUPHIX website lies a complex internet application, including databases, i.e. for indicator data, for internal and external web links and for references and definitions. This back-office contains a Content Management System that guides an editorial process allowing the differentiation of the roles of authors, reviewers and content editors. User oriented functionalities include different ways to interactively manipulate data for personal presentation needs. Some EUphacts are linked to the Health-EU Portal. Results: EUPHIX is drawing increasing numbers of visitors and has the potential to become the nucleus of a health monitoring system for the EU. However, current financing practice puts serious limits to its sustainability. Conclusions: The conclusion is that the EUPHIX model launched in June 2008 is integrating data, information and knowledge into a new type of Health Information System. The EUPHIX model is proposed to be the future model for EU health reporting.

Norhealth: Norwegian Health Information System

Trewin, C., Strand, B. H., Groholt, E.-K. — 2008-08-29

Norhealth (www.norgeshelsa.no) is a web-based health information system that monitors health and health related conditions, including risk- and protective factors, over time. Norhealth was developed to create a knowledge base for health promotion and prevention strategies in Norway and is targeted at politicians, decision makers, media, students and health professionals. Norhealth has a Norwegian and English version.

Users of Norhealth can create their own tables, graphs, time series, maps and radar diagrams. Most Norhealth elements can be exported to PDF and tables can also be exported to Excel. Norhealth elements can also be pasted into Word or PowerPoint.

Norhealth has 40 health indicators, but aims to reach 70. The indicator list corresponds roughly to the European Community Health Indicators (ECHI) short list. Data is presented at the national and regional level and by age group and gender. Around 50 fact sheets are written in Norwegian.

Future developments include linking fact sheets to figures in Norhealth, writing annual health reports, translating fact sheets to English, improving user friendliness, adding more health indicators and monitoring social inequalities in health. Conclusions: Norhealth is an interactive web-based health information system that was developed to create a knowledge base for health promotion and prevention strategies in Norway.

Schoolchildren's health as judged by Swedish school nurses -- a national survey

Clausson, E. K., Kohler, L., Berg, A. — 2008-08-29

Aims: To use school nurses' knowledge and experience for a better understanding of schoolchildren's health problems and their association to socioeconomic background and gender. Methods: Mail questionnaires were sent to a nationally representative, random sample of Swedish school nurses (n=129). The questionnaire included structured and open-ended questions asking for school nurses' judgement of schoolchildren's health status; changes over the previous two years; estimation of schoolchildren's most common reasons for consulting the school nurse; and estimation of factors influencing schoolchildren's health. Results: Swedish school nurses judged schoolchildren's mental health to have deteriorated during the previous two years with increasing health complaints, especially among girls and in disadvantaged housing areas. Disturbed family relations were considered as one important explanatory factor. Girls were more inclined to consult school nurses with subjective health complaints. Boys more often consulted the nurses with physical injuries. Conclusions: School nurses work closely with the children and meet them continuously during the school age period. They have a genuine knowledge of schoolchildren's health, which should be used even more, both in research and practice. The results may be applicable in other countries with similarly organized school health systems.

Migration and self-rated health: a comparison between Finns living in Sweden and Finns living in Finland

Westman, J., Martelin, T., Harkanen, T., Koskinen, S., Sundquist, K. — 2008-08-29

Aims: There is a lack of studies comparing health among immigrant groups with health among the population in their country of origin. This study compared the prevalence of self-rated poor health between Finns living in Sweden and Finns living in Finland. Methods: Data were obtained from the Swedish Annual Level of Living Survey between 1996 and 2003 and the Finnish national survey "Health 2000''. Odds ratios (OR) of self-rated poor health were estimated adjusting for age, marital status, education, employment and smoking. The participants were 21,991 Swedes and 836 Finns living in Sweden, and 5,096 Finns living in Finland. Results: For Finnish women living in Sweden the odds of self-rated poor health was significantly higher (OR=1.25, 95% CI=1.02—1.54) than for Finnish women living in Finland. An opposite pattern appeared among men; Finnish men living in Finland tended to have higher odds of self-rated poor health than Finnish men living in Sweden, although not to a statistically significant extent. In addition, Finns in Finland and in Sweden rated their health poorer than Swedes. Conclusions: Migration may have a different effect on Finnish men's and women's self-rated health. Further studies are needed to investigate the complex pathways between country of residence and self-rated health among immigrants.

Incidence and recurrent work-related violence towards healthcare workers and subsequent health effects. A one-year follow-up study

Hogh, A., Sharipova, M., Borg, V. — 2008-08-29

Aims: The aim of the present study was to analyse the incidence of violence and threats of violence during the first year at work after graduating as a healthcare worker, the risk of re-exposure and health effects among respondents previously exposed to violence or threats. Methods: We analysed baseline data from 5,696 healthcare students and conducted prospective multinomial regression analyses following 2,847 respondents during their first year of employment. Results: At baseline we found that nearly a third of the respondents had been exposed to violence or threats of violence, 8.7% during trainee periods. At follow-up, we found that 24.6% of the healthcare workers had been exposed to violence and 33.4% to threats during the first year at work after graduation. Exposure to violence or threats during trainee periods was a strong predictor of violence (Odds ratio (OR)=3.3) and threats (OR=4.2) at follow-up. The results showed that violence or threats in previous jobs or at other places had a significant impact on the health of the victims at follow-up independent of gender, age, sense of coherence, self-efficacy and health at baseline. Exposure during trainee periods had a small but not quite significant (p=0.06) impact on the health of the victims at follow-up. Conclusions: The study shows a high risk of violence and threats of violence among healthcare workers during training and the first year at work after graduation, indicating a need for violence prevention planning involving both college and workplaces.

Determinants of sick-leave duration: A tool for managers?

Flach, P. A., Krol, B., Groothoff, J. W. — 2008-08-29

Aims: To provide managers with tools to manage episodes of sick-leave of their employees, the influence of factors such as age, gender, duration of tenure, working full-time or part-time, cause and history of sick-leave, salary and education on sick-leave duration was studied. Method: In a cross-sectional study, data derived from the 2005 sick-leave files of a Dutch university were examined. Odds ratios of the single risk factors were calculated for short spells (≤7 days), medium spells (8— 42 days), long spells (43—91 days) or extended spells (≥91 days) of sick-leave. Next, these factors were studied in multiple regression models. Results: Age, gender, duration of employment, cause and history of sick-leave, salary and membership of scientific staff, studied as single factors, have a significant influence on sick-leave duration. In multiple models, this influence remains for gender, salary, age, and history and cause of sick-leave. Only in medium or long spells and regarding the risk for a long or an extended spell do the predictive values of models consisting of psychological factors, work-related factors, salary and gender become reasonable. Conclusions: The predictive value of the risk factors used in this study is limited, and varies with the duration of the sick-leave spell. Only the risk for an extended spell of sick-leave as compared to a medium or long spell is reasonably predicted. Factors contributing to this risk may be used as tools in decision-making.

Physician-assisted suicide: a survey of attitudes among Swedish physicians

Lindblad, A., Lofmark, R., Lynoe, N. — 2008-08-29

Aims: To investigate the attitudes of Swedish physicians towards physician-assisted suicide. Design: A postal questionnaire on the respondent's opinion of physician-assisted suicide was sent to a randomly selected sample of physicians in Sweden. The respondents were given the opportunity of furnishing arguments of their own and of prioritizing arguments. They were also asked about possible influence on their own and patients' trust in the healthcare system if physician-assisted suicide was to be legally accepted. Participants: 1,200 physicians from six specialties, approximately 200 individuals each in: general practice, geriatrics, internal medicine, oncology, psychiatry and surgery. Setting: The study was commissioned by the Swedish Medical Society and its logo was printed on questionnaires and envelopes. Results: The total response rate was 74%, ranging between 63%—80% among the specialties. On average 34% were pro physician-assisted suicide, 39% against it and 25% were doubtful; 2% per cent did not respond to the question at all. Psychiatrists were significantly more accepting than oncologists, who were the most restrictive specialty. Older physicians (>50 years) provided a significantly more accepting attitude than younger ones (≤51 years). Conclusions: Despite the fact that the World Medical Association condemns physician-assisted suicide as unethical, the present survey indicates that there is no clear majority for or against physician-assisted suicide among Swedish physicians, and that significantly more elderly physicians have an accepting attitude towards physician-assisted suicide. There is a need for further research explaining the differences between the age groups as well as the variation between specialities.

Non-participation in a field survey with respect to psychiatric disorders

2008-08-29

Aims: Higher rates of psychiatric morbidity among non-participants may lead to biased estimates of prevalence and incidence in epidemiological studies of psychiatric disorders. We had a unique opportunity to explore psychiatric morbidity and non-participation in a large epidemiological survey including questionnaires and a clinical examination. Methods: Members of the Northern Finland 1966 Birth Cohort were included in the study. In phase I, a postal questionnaire was mailed to all those with a known address in 1997 (N=11,540). In phase II, all subjects living in northern Finland or the Helsinki area (N=8463) were invited to a clinical examination. In phase III, clinical examination participants were given a questionnaire with psychological subscales to be filled in at home and returned by mail. The data on hospital-treated psychiatric disorders were obtained from the Finnish Hospital Discharge Register. Educational level was obtained from Statistics Finland. Results: The participation rates were 76%, 71% and 61% in phases I, II and III, respectively. Subjects with any psychiatric disorder participated less actively than those without any psychiatric disorder in all phases, in both genders and at all educational levels. Participation was not found to vary across specific disorders. Gender or education did not explain the association of psychiatric disorders with participation. Conclusions: Owing to non-participation, the true prevalence of psychiatric disorders may be higher than the prevalence estimated from epidemiological field surveys.

Demand, control and social climate as predictors of emotional exhaustion symptoms in working Swedish men and women

Magnusson Hanson, L. L., Theorell, T., Oxenstierna, G., Hyde, M., Westerlund, H. — 2008-08-29

Aims: Most studies on burnout have been cross-sectional and focused on specific occupations. In the present study we prospectively investigated the association between demands, control, support and conflicts as well as downsizing and emotional exhaustion in men and women derived from a representative sample of the working population in Sweden. Methods: The study comprised working men (1,511) and women (1,493), who participated in the Swedish Work Environment Survey (SWES) in 2003 and had no physical exhaustion and prior sick leave at baseline. These participants were followed up in 2006 as part of the Swedish Longitudinal Occupational Survey of Health (SLOSH). Demands, decision authority, support from fellow workers and superiors, conflicts with fellow workers and superiors, and downsizing were utilized as predictors and the Maslach Burnout Inventory subscale of emotional exhaustion as the outcome in multiple logistic regression analyses. Results: High demands were a highly significant predictor of symptoms of emotional exhaustion (≥75th percentile). Downsizing and lack of support from superiors were also independent predictors for men as well as lack of support from fellow workers and low decision authority for women. Conclusions: This study indicates that high demands, low decision authority, lack of support at work and downsizing could be important predictors of emotional exhaustion symptoms among working men and women.

Increased abdominal obesity, adverse psychosocial factors and shorter telomere length in subjects reporting early ageing; the MONICA Northern Sweden Study

Nordfjall, K., Eliasson, M., Stegmayr, B., Lundin, S., Roos, G., Nilsson, P.M. — 2008-08-29

Background: The rate of biological ageing is individual and represents the steady decrease in physiological and mental functions. Adverse social factors have been shown to influence this process. Self-perceived early ageing (SEA) might be a useful indicator of early biological ageing and increased mortality risk. The aim of this population-based study was to identify markers of SEA, including telomere length. Methods: We studied 1502 subjects (744 men, 758 women) from Northern Sweden. These subjects underwent a physical examination, blood sampling (including telomere length) and completed a self-administered questionnaire about their subjective age, social situation, lifestyle, and self-rated health (SRH). Age- and SRH-adjusted statistical analyses were made comparing SEA subjects with same-sex controls. Results: In all, 7.9% of men and 12.1% of women reported SEA. These subjects had significantly (p<0.0001) wider waist circumference and higher body mass index than controls. SEA men showed higher fasting glucose and SEA women showed higher total cholesterol levels than controls (p=0.020 and p=0.015, respectively). In addition, SEA women more often reported infrequent physical exercise (p=0.006), mental problems (p=0.064) and worse SRH (p=0.001) than controls. In a random sub-sample, telomere length was significantly shorter in SEA subjects (n=139) than controls (n=301; p=0.02), but not after full adjustment for BMI. Conclusions: Self-perceived early ageing is not uncommon and is associated with abdominal obesity, poor self-rated health, lower education, and shorter telomere length. This could link adverse social factors with features of the metabolic syndrome as well as with early biological ageing, of importance for targeting preventive programmes.

All-cause mortality trends in Dikgale, rural South Africa, 1996--2003

Cook, I., Alberts, M., Burger, S., Byass, P. — 2008-08-29

Aims: The Dikgale Demographic Surveillance System (DDSS) site, established in 1995, is one of three rural surveillance sites in South Africa. This paper describes detailed mortality patterns of a rural African population in the central region of Limpopo Province. Methods: These data were based on yearly household visits to collect data on vital events, covering 63, 873 person-years of observation over eight years. Results: Crude mortality was 7.5 per 1,000 person-years (females: 6.9, males: 8.1). Under-1 year and under-5 years mortality was 15.1 and 5.8 per 1,000 person-years, respectively. Life expectancy at birth was 64.3 years (females: 68.1, males: 60.0). For the two four-year periods (1996—9 and 2000—3) under-20 years mortality risk decreased (rate ratio=0.45, 95% CI: 0.25 to 0.80) while 20—49 years mortality risk increased (rate ratio=1.55, 95% CI: 1.10 to 2.20). Multivariate mortality risk for migrants remained relatively constant (0.71, 95% CI: 0.54 to 0.94) across the two four-year periods, but has increased 2.5-fold in all DDSS +50 year-old adults across the two four-year periods. Conclusions: The DDSS mortality estimates appear to have remained relatively constant while recent mortality estimates for the Agincourt Demographic and Health Surveillance System (ADHSS) site suggest that mortality risk is higher and life expectancy is lower in ADHSS residents. Moreover, DDSS mortality estimates are substantially more favourable compared with provincial and national mortality estimates.

Birthweight and perinatal mortality among singletons and twins in north-eastern Tanzania

2008-08-29

Background: Low birthweights as well as high perinatal mortality rates are common in most African populations. Little is known, however, about how low birthweight corresponds with higher mortality rates within African populations. Twins are known to have lower birthweights and higher perinatal mortality rates than singletons. If lower birthweights represent higher perinatal risk per se, small twins within a population with generally lower birthweights should have critically increased risks. Methods: In total, 15,255 births in a Tanzanian hospital during 1999—2006 were analysed to determine birthweight distribution and examine perinatal mortality rates (including stillbirths and neonatal deaths within 24 hours) by birthweight in twins and singletons. Referral births from outside the district where the hospital was situated were excluded from analysis. Results: The mean birthweight for births within an estimated normal distribution was 3172 g, with a standard deviation of 462 g. The overall perinatal mortality rate was 43.9 per 1000 births (95% confidence interval: 40.7—47.2). Perinatal mortality rates among twins and singletons were 91.0 and 41.1 per 1000 babies respectively, corresponding to a relative risk of 2.2 (95% confidence interval: 1.7—2.8). The birthweight distribution for twins was shifted to lower birthweights. Twins had a generally lower birthweight and an excess of extremely small births as compared to singletons. The increased mortality rate for twins appeared to be independent of birthweight. Conclusions: The two-fold increased risk of perinatal death for twins was observed across the whole birthweight distribution, and very small twins appeared to have an excess perinatal risk that was almost similar to that of larger twins.

Environmental factors as predictors of alcohol use among ninth-grade adolescents in Pitkaranta (Russian Karelia) and in eastern Finland

2008-08-29

Background: In Russia, tobacco and alcohol use by adolescents are serious problems. In Finland, as in many other European countries, alcohol use is a growing concern. Aims: This study aimed to find out whether similar environmental factors predict adolescents' alcohol use among 15-year old adolescents in two politically and economically different cultures: in the Pitkäranta district in Russian Karelia and in eastern Finland. Methods: Research data gathered by self-administered questionnaires from the second North Karelia Youth Study and the Pitkäranta Youth Study were analysed. Path models using the structural equation modelling (SEM) approach were constructed to test whether similar path structures fit for boys and girls in both countries, and to test whether regression coefficients are similar between the cultures and by gender. Results: The results showed that alcohol use by family members and best friend is positively related to adolescents' alcohol use both directly and indirectly. The best friend's alcohol use was the most important predictor of adolescents' own alcohol use in every sub-sample. When indirect influences were also identified, the significance of parents' and siblings' alcohol use, in addition to alcohol use by the best friends, was strongly supported. Conclusions: The results highlighted the importance of the process of peer selection for adolescents' choices, and the importance of offering support to the parents and to the health personnel working with children and adolescents.

Global alcohol strategy: Sweden will host the first global World Health Organization conference on alcohol: HBSC report: Nordic teenagers have basically similar health behaviours

2008-08-29

Violence: News on a public health problem

Helweg-Larsen, K. — 2008-08-18

The influence of household work and of having children on sickness absence among publicly employed women in Sweden

2008-08-18

Aim: To investigate whether family obligations influence the risk of sickness absence among female municipal employees in Sweden. Methods: A 1-year prospective cohort study of 1464 female municipal employees <50 years of age in Sweden in 2000 was conducted using questionnaire responses and absence data from the employers' personnel records. The relative risk of having children <16 years of age in the home, marital status, household work, financial situation, working hours and work—family conflicts for repeated sick-leave spells (≥4 spells) and long-term sickness absence (≥28 days) were calculated by applying Poisson regression models. Results: Women reporting financial strain or work—family conflicts were at elevated risk for long-term sickness absence. Having children was not a risk factor for repeated sick-leave spells or long-term sickness absence among married/cohabiting women. Single women with children had a two-fold greater risk of repeated sick-leave spells than single women without children. Conclusions: The findings suggest that the combination of gainful employment and children does not influence the risk of repeated sick-leave spells or long-term sickness absence among married/cohabiting publicly employed women. However, this was not true for single women with children, which indicates that their circumstances are particularly strained.

Effects of age, period and cohort on stroke mortality among a middle-aged Lithuanian urban population from 1980 to 2004

2008-08-18

Aims: The main purpose of this paper was to assess the effect of age, period, and cohort on stroke mortality rates among a Lithuanian urban population aged 25—64 years (1041 men and 724 women) between 1980 and 2004. Methods: Routine stroke mortality data were obtained from official Kaunas region mortality register by codes 430—438 and I60—I69 in the 9th and in the 10th revisions of the International Classifications of Diseases (ICD), respectively. Mortality rates per 100,000 persons for men and women were age-adjusted using the age distribution of the European Standard Population. Age-specific mortality rates were analysed by sex, period, and birth cohort in eight 5-year age groups and five 5-year age groups. Goodness of fit of the Poisson regression models were evaluated using Pearson and Freeman-Tukey residuals. The age-period and age-period-cohort models provided a significantly better fit than a model with the factors ``age'' and ``cohort''. Results: During the study period, mortality rates decreased from 46.8 to 33.0 per 100,000 for men, and from 20.2 to 18.1 per 100,000 for women (average annual decrease of —1.3%, p<0.1 for men, and —1.6%, p<0.03 for women). An age effect was present in both sexes. The definite upward period effect was observed from 1990 to 1994 both among men and women, and was followed by a sharp fall during 2000—4. Cohort and period effects have contained relevant information which partially explained trends in stroke mortality among a 25—64 year-old Lithuanian urban population. Conclusions: During the period of 1980—2004, the mortality trend declined among women only. The period effect contains relevant information for the explanation of increasing mortality rates during 2000—4 among men and women. The Poisson regression models could be applied for the examination and explanation of the different causes of the population mortality.

Socio-demographic correlates of alcohol consumption in the Danish general population

Bloomfield, K., Grittner, U., Rasmussen, H. B., Petersen, H. C. — 2008-08-18

Aims: Little is known about specific Danish drinking patterns. This paper investigates how various socio-demographic factors are related to Danish alcohol consumption with special focus on age and sex. Methods: Data come from a national telephone survey of the Danish general population conducted in 2003 with a final sample size of 2,030 cases. Measures of beverage specific current drinking, overall drinking, daily drinking, heavy episodic drinking, mean consumption, volume per drinking occasion and frequency of drinking were analysed. Results: A little over 5% of the population are abstainers. Fourteen per cent of men and 9% of women are heavy drinkers; 38% of men and 18% of women are heavy episodic drinkers. Youth of both sexes drink heavily, and especially in a binge drinking style. Regular, more temperate drinking is associated with increasing age. Multivariate analyses suggest that other than age and sex, classical socioeconomic factors do not play a great a role in determining drinking patterns. Social integrative factors in particular influence women's drinking. Conclusions: With respect to the rest of Europe and North America, Danes consume high levels of alcohol with a large percentage of youth drinking in a binge pattern. Classical socioeconomic factors play a lesser role in determining drinking patterns compared to other Western countries. Longitudinal studies and studies of alcohol-related consequences in the Danish general population should be conducted to better formulate alcohol and public health policy.

Depression among women in rural Ethiopia as related to socioeconomic factors: A community-based study on women in reproductive age groups

Deyessa, N., Berhane, Y., Alem, A., Hogberg, U., Kullgren, G. — 2008-08-18

Background: Several previous studies have reported on socioeconomic and sociodemographic factors associated with depression among women, but knowledge in this area remains scarce regarding women living in extreme poverty in developing countries. Objective: The study was aimed at examining the 12-month prevalence of depressive episodes as related to socioeconomic and sociocultural conditions of women in the reproductive age group in rural Ethiopia. Methods: A community-based cross-sectional study was undertaken among 3016 randomly selected women in the age group 15—49 years. Cases of depression were identified using the Amharic version of the Composite International Diagnostic Interview. A standardized World Health Organization questionnaire was used to measure the socioeconomic status of the women and their spouses. Data were analysed among all women and then separately among currently married women. Results: The 12-month prevalence of depression among all women was 4.4%. After adjusting for common sociodemographic characteristics, only marital status showed a significant association with depressive episode in terms of higher odds ratios (ORs) for divorced/separated women and widowed women than for not-married women (4.05 and 4.24, respectively). Among currently married women, after adjusting for common sociodemographic characteristics, living in rural villages (OR=3.78), a frequent khat-chewing habit (OR=1.61), having a seasonal job (OR=2.94) and being relatively better off in terms of poverty (OR=0.48) were independently associated with depression. Conclusions: The prevalence of depression among women was in the lower range as compared to studies from high-income countries, but very poor economic conditions were associated with a higher prevalence of depression in this overall very poor setting. This further supports the notion that the relative level of poverty rather than the absolute level of poverty contributes to depression among women. Whether the association with khat chewing and depression is a causative effect or can be explained by self-medication remains unclear.

Does job strain mediate the effect of socioeconomic group on smoking behaviour? The impact of different health policies in Denmark and Sweden

2008-08-18

Aims: The aim was to compare the impact of socioeconomic groups (SEG) on the risk of being a daily smoker or quitter, and to investigate whether the potentially mediating effect of psychosocial working conditions was similar in the Danish and the Swedish populations. Methods: The study populations consisted of 10,049 employed participants, aged 18—64 years, 51% women, randomly selected from the general populations in the Oresund region, 1999—2000. Odds ratios (OR) for daily-smokers and "non-quitters'' were computed for two age-groups and two SEGs in gender specific models, stratified by country. The association between SEG, current smoking, quitting, and influence at work, job demand and jobstrain, respectively, was tested by means of logistic regression. Results: The contextual determinants defined by country had a different effect on smoking prevalence among men and women and among age groups. Low influence and job strain seemed to have an effect on smoking among Danish women, but not among Swedish women. The OR of being a daily smoker were higher in men than women among younger Danes, but higher in women than men among Swedes. The prevalence of low influence, high demand and job strain was higher and more socially skewed among the Swedes, but did not mediate the effect of SEG on smoking behaviour. Conclusions: The smoking prevalence was lower and the quit-rates higher among Swedes than Danes. Both countries had social differences in smoking that in absolute terms were rather similar, but in relative terms were higher in Sweden. The mediating effect of psychosocial working conditions was lacking. The determinants of smoking behaviours must be found somewhere else in the social and cultural context.

The effects of family structure, parent--child relationship and parental monitoring on early sexual behaviour among adolescents in nine European countries

Lenciauskiene, I., Zaborskis, A. — 2008-08-18

Aims: To identify the influence of family structure, parent—child relationship and parental monitoring on adolescents' involvement in early sexual behaviour. Methods: The study was undertaken in the context of the World Health Organization collaborative Health Behaviour in School-Aged Children study. The representative samples were drawn from 10 European countries. A group of 14,287 (6716 boys and 7571 girls) 15-year-olds was surveyed. The data were collected by standardized questionnaires. Adolescents were asked about sexual behaviour, family structure, parent—child communication, and parental control. A logistic regression analysis was applied to assess the impact of determinants. Results: Greenlandic adolescents were predominantly engaged in early sexual behaviour. Intact family was a key protective factor for adolescents' early sexual behaviour. It significantly decreased both boys' and girls' involvement in early sexual behaviour. Close parent—adolescent relationships and a high level of parental monitoring were found to be less protective factors than family structure. Easy communication with parents, especially with the mother, was more significant for girls' than for boys' early sexual behaviour. A low level of maternal monitoring had a higher impact on boys' early sexual behaviour, while a low level of paternal monitoring had a higher impact on girls. For both maternal and paternal monitoring, the strongest relationship was observed among Hungarian adolescents, but among Greenlanders it was not statistically significant. Conclusions: Many 15-year-olds in European countries are engaged in early sexual behaviour. A close parent— child relationship and a high level of parental monitoring are not as important for adolescents' early sexual behaviour as an intact family.

Does intergenerational social mobility among men affect cardiovascular mortality? A population-based register study from Sweden

Tiikkaja, S., Hemstrom, O. — 2008-08-18

Background: Socioeconomic inequalities in cardiovascular mortality are well documented. The aim here is to examine the relation between childhood and adulthood class as well as the role of unique intergenerational social mobility trajectories in such mortality. Methods: Data were obtained from Swedish registries. Childhood and adulthood information were from the 1960 and 1990 censuses. Men born 1945—59 (809,199) were followed-up for four cardiovascular mortality outcomes 1990— 2002 (5533 deaths) by means of Cox regressions. Three different approaches were applied to study mobility between four main classes. Results: In mutually adjusted models, the effect of a manual adulthood class (compared with non-manuals) was clearly larger (hazard ratios (HR) were 1.56 for MI, 1.70 for stroke, 1.64 for other cardiovascular disease (CVD), 1.62 for all CVD) as for a manual childhood class (1.38, 1.17, 1.24 and 1.28, respectively). This also applied to unclassifiable, while there were few systematic findings for self-employed. When adjusting for education level, childhood class was still significant for MI, other and all CVD, but adulthood class was significant for all outcomes. Trajectory-specific analyses revealed that mobile men from non-manual to manual had significantly higher mortality than mobile from manual to non-manual and stable non-manuals, but not significantly lower than stable manuals. Conclusions: Cardiovascular mortality was clearly structured by adulthood class, but not as consistently structured by childhood class. The mediating role of education suggests that a major part of life-course disadvantages or advantages in relation to CVD was due to achieved education.

Self-reported chronic diseases and associated sociodemographic status and lifestyle risk factors among rural Vietnamese adults

Hoang Van Minh, , Dao Lan Huong, , Kim Bao Giang, — 2008-08-18

Aims: The fact that chronic diseases are leading causes of mortality and morbidity in hospitals in Vietnam was certified by yearly statistical information. However, population-based knowledge of chronic diseases is still largely lacking. This article examines the prevalence of major chronic diseases and their relationships with sociodemographic status and selected lifestyle risk factors among the adult population in a rural community in the north of Vietnam. Methods: A representative sample comprising 2500 adults aged 25—74 years was surveyed in 2005 using a structured questionnaire. Both descriptive and analytical statistical analyses were applied. Results: Thirty-nine per cent of the respondents had at least one of the studied chronic diseases. The prevalence of current smoking was 59% among men and 0.7% among women. The prevalence of at-risk alcohol drinking was 67% among men and 3% among women. Increasing age, low education and doing other jobs (small traders, temporary workers, housekeepers, handicraft makers and jobless), as well as tobacco use and at-risk alcohol drinking, were found to be associated with a higher probability of having at least one chronic disease of interest. Economic status was found to be inversely correlated with the probability of having at least one chronic disease among women only. Conclusions: The findings from this study indicated that chronic conditions and lifestyle risk factors were very common among the adult population in rural Vietnam. There is an association between chronic diseases and lower socioeconomic status and unhealthy lifestyle risk factors.

Social inequality in fetal and perinatal mortality in the Nordic countries

Jorgensen, T., Mortensen, L. H., Nybo Andersen, A.-M. — 2008-08-18

Aim: The aim of this study is to review the epidemiological literature from the past 27 years on social inequality in fetal and perinatal mortality in the Nordic countries in order to examine whether social inequalities in fetal and perinatal mortality exist, and whether there are differences between the countries. Methods: The databases MEDLINE and EMBASE were searched for Nordic epidemiological studies published between January 1980 and August 2007 about the association between social indicators and the outcomes spontaneous abortion, stillbirth or perinatal mortality. Thirty-five studies that fulfilled the inclusion criteria were identified for this review. Results: Social differences in stillbirth and perinatal mortality were found in all of the identified Finnish and Norwegian studies and in the majority of studies from Denmark, whereas in the Swedish studies the findings were less consistent. As only a small number of studies on spontaneous abortion were identified (n=3), no conclusions were drawn with regard to this outcome. Conclusions: There seems to be a reasonable body of evidence that social inequality in stillbirth and perinatal mortality exists in Norway, Finland and Denmark, whereas the conclusions regarding Sweden are more uncertain. A number of methodological problems complicate the comparison of the findings. Nordic collaborative analyses of social gradients in spontaneous abortion, stillbirth and perinatal mortality, which take these methodological concerns into account, are needed in order to draw inferences across countries.

Health tests and health consultations reduced cardiovascular risk without psychological strain, increased healthcare utilization or increased costs: An overview of the results from a 5-year randomized trial in primary care. The Ebeltoft Health Promotion Project (EHPP)

Lauritzen, T., Ager Jensen, M. S., Thomsen, J. L., Christensen, B., Engberg, M. — 2008-08-18

Background: Few randomized controlled trials (RCT) have evaluated health tests and health consultations in primary care with a long follow-up period. The Ebeltoft Health Promotion Project (EHPP) evaluated health tests and health consultations over a period of 5 years in the frame of a health technology assessment. Objective: To review the results of EHPP. Design: RCT with a control group answering questionnaires and two intervention groups having questionnaires, a comprehensive health test with written advice followed by either a normal consultation on demand or a planned 45 minutes patient-centred consultation. Setting: Primary care. Participants: The target population was all 30—49 year old persons in the municipality of Ebeltoft, Denmark. Invitations were received by 2000 randomly selected persons. Intervention: A comprehensive biomedical health test including a cardiovascular risk score (CVRS) followed by written advice and health consultations. Main outcome measures: Biomedical measures, psychological measures, healthcare contacts, life years gained, direct and total health costs. Results: At baseline 75% participated. During the 5 years 85% participated at least once. Elevated CVRS was found in 19% in the control group compared to 10% in the intervention groups (p<0.01) after 5 years. There were no measurable long term psychological reactions. Numbers of contacts to the healthcare system were not increased. Significantly better life expectancy was found without extra direct and total costs. Conclusions: An offer of health tests and patient-centred health consultations to the middle-aged population can be cost-effective and may be considered in the fight against the increasing burden of lifestyle diseases.

Award: Nordic Public Health Award to professor of psychiatry: Children's teeth for research: Norway might be building the biggest milk teeth bank in the world: European network: A European public health law network is established: Conference premiere: First World Health Professions Conference on Regulation held in Geneva

2008-08-18

Global public health and gender theory: The need for integration

Ohman, A. — 2008-07-17

Young people's use of sports facilities: A Norwegian study on physical activity

Limstrand, T., Rehrer, N. J. — 2008-07-17

In recent years, sports facilities have fomed part of Norwegian public health policies to increase physical activity among children and adolescents. Despite large sums of public money being spent on such facilities, information on usage is limited. Aims: Our aim was to study the effects of gender, age and relative activity level on young people's use of sports facilities. Methods: We explored 662 young people's (age 6—16 years) usage of 19 different kinds of sports facilities. A questionnaire was administered to students and teachers, and situation plots of students at recess were made. Results: The findings indicate that sports facilities in general were less used by girls, adolescents (14—16 years) and the least active (physically active ≤ 1 times/week outside school) than by boys, children (6—13 years) and the most active (physically active ≥ 4 times/ week outside school). More general, multifunctional facilities were used to a greater extent than specialized facilities, particularly by the least active. Distance to facility was important for the use of common facilities. Conclusions: These results raise the question of whether sports facilities significantly increase physical activity among ``all'' young people, which is the government's stated goal. More research on sports facilities use and physical activity levels among males and females of all ages is warranted.

The potential migration effect of rural hospital closures: A Danish case study

Sorensen, J. F.L. — 2008-07-17

Aims: Rural hospital closures are high on the current healthcare agenda in Denmark. One concern raised is that rural hospital closures may further decrease population numbers in rural areas, as closures may induce some residents to move away from affected areas, i.e. closer to healthcare services elsewhere. The aim of this study was to investigate whether rural hospital closures may lead to out-migration in a Danish setting and to investigate which socioeconomic groups would be most likely to migrate. Methods: The island of Ærø was selected as the case study area. The island has one small hospital. By the use of fully structured telephone interviews, a representative sample of Ærø inhabitants (N=1000) was asked how important it was for them to live close to a hospital and whether they would consider moving away if their hospital was closed. Results: Forty-seven per cent found it very important to live close to a hospital, and 29% would consider moving away if their hospital was closed. Multiple regression analyses showed that families with children were most likely to consider moving away and elderly people were least likely to consider moving away. Conclusions: The study suggests that rural hospital closures may lead to out-migration, although the hypothetical method of questioning leaves uncertainty about the actual scale of out-migration. Families with children appear to be the most likely out-migrants. Elderly people may be hardest hit by a hospital closure, being most reliant on healthcare and least inclined to move away.

Job stress, sickness absence and sickness presenteeism in Nordic elderly care

Elstad, J. I., Vabo, M. — 2008-07-17

Aims: Nordic elderly care has been restructured to obtain more efficiency. Among workers caring for the elderly, levels of perceived job stress could vary, due to understaffing and resource scarcity. This study examines how sickness absence and sickness presenteeism are associated with perceived job stress. Methods: Data were obtained by posting questionnaires to lower-level care staff in Sweden (n=483), Denmark (n=704), Finland (n=597), and Norway (n=663). Self-reports about job stress (four items), sickness absence and sickness presenteeism were analysed by cross-tabulations and logistic regression. Results: Each item of job stress was associated with sickness absence and sickness presenteeism in the samples from all four countries. With low levels of job stress, levels of reported sickness absence and sickness presenteeism were relatively moderate. With increasing levels of job stress, the level of sickness presenteeism rose more sharply than that of sickness absence. Conclusions: The results can be interpreted in the light of features inherent in care work. Owing to professional norms and moral obligations, care workers could lower their thresholds for taking sick leave when care organizations are understaffed, because absences will be particularly critical for care recipients in such circumstances. Thus, while increasing job stress tends to be accompanied both by more sickness absence and by more sickness presenteeism, sickness presenteeism rises particularly in cases of high levels of job stress. Owing to cross-sectional data and self-reported information, conclusions are tentative.

Predictions by early indicators of the time and height of the peaks of yearly influenza outbreaks in Sweden

2008-07-17

Aims: Methods for prediction of the peak of the influenza from early observations are suggested. These predictions can be used for planning purposes. Methods: In this study, new robust methods are described and applied to weekly Swedish data on influenza-like illness (ILI) and weekly laboratory diagnoses of influenza (LDI). Both simple and advanced rules for how to predict the time and height of the peak of LDI are suggested. The predictions are made using covariates calculated from data in early LDI reports. The simple rules are based on the observed LDI values, while the advanced ones are based on smoothing by unimodal regression. The suggested predictors were evaluated by cross-validation and by application to the observed seasons. Results: The relationship between ILI and LDI was investigated, and it was found that the ILI variable is not a good proxy for the LDI variable. The advanced prediction rule regarding the time of the peak of LDI had a median error of 0.9 weeks, and the advanced prediction rule for the height of the peak had a median deviation of 28%. Conclusions: The statistical methods for predictions have practical usefulness.

Regional variations and determinants of direct psychiatric costs in Sweden

Tiainen, A., Edman, G., Flyckt, L., Tomson, G., Rehnberg, C. — 2008-07-17

Aim: The aim of the present study was to investigate socioeconomic and demographic determinants of direct costs for psychiatric disorders in Sweden. The cost categories were inpatient and outpatient costs, and costs for psychopharmacological drugs. Two consecutive years, 2001 and 2002, were chosen as the study period. Methods: The study included all costs for admissions, visits and prescribed drugs for adults aged ≥18 years in 2001 and 2002 in Sweden. These costs were aggregated and analysed at the county level. A multiple linear regression analysis was fitted to the data, and independent variables (i.e. predictors) were chosen on the basis of previous studies. All cost types (e.g. total, inpatient, outpatient and drug costs) were analysed separately in different models. Results: Large variations in total direct psychiatric costs were found between county councils (for example, the total costs varied between euro112 and euro195 per capita in 2001). The results indicate that psychiatric outpatient care is less utilized in rural than in urban areas, and drugs are more often prescribed in rural areas than in urban areas. Areas with a high proportion of women and people aged 65 years and over are strong predictors of mental healthcare costs, i.e. variables showing that the higher the proportion, the lower the direct costs. Conclusions: Factors such as urbanization, gender, age and number of immigrants are reasons for differences in psychiatric direct costs. On the basis of these findings, it seems plausible to conclude that women, older patients and immigrants may benefit from specialized psychiatry, but that such healthcare does not seem to be provided in all regions.