Occupational class and educational level inequalities in major cardiovascular risk factors in Turkey: 2008-2016.

BACKGROUND: We aimed to investigate the magnitude of occupational class (OC) and educational level (EL) inequalities in cardiovascular risk factors in Turkey from 2008 to 2016 and compare these inequalities with neighbouring European countries. METHODS: We used the Turkey Health Survey among a representative sample of the Turkish population. We estimated relative index of inequality (RII) for four cardiovascular risk factors (obesity/overweight, hypertension, diabetes, smoking) by OC/EL with an interaction term for survey year and compared selected results with neighbouring countries. RESULTS: Men with lower OC and EL smoked more (e.g. RII for EL = 1.40 [1.26-1.55]); however, the remaining risk factors were mostly lower in these groups. Women in lower socio-economic groups smoked less (e.g. RII for EL = 0.36 [0.29-0.44]), however, had higher prevalence of the remaining risk factors. Significant interactions with survey year were only found in a few cases. The pattern of inequalities in Turkey is largely similar to neighbouring countries. CONCLUSIONS: Inequalities in cardiovascular risk factors are less systematic in Turkey than in most high-income countries, but ongoing trends suggest that this may change in the future.

Amenable mortality in the EU-has the crisis changed its course?

Background: Did the global financial crisis and its aftermath impact upon the performance of health systems in Europe? We investigated trends in amenable and other mortality in the EU since 2000 across 28 EU countries. Methods: We use WHO detailed mortality files from 28 EU countries to calculate age-standardized deaths rates from amenable and other causes. We then use joinpoint regression to analyse trends in mortality before and after the onset of the economic crisis in Europe in 2008. Results: Amenable and other mortality have declined in the EU since 2000, albeit faster for amenable mortality. We observed increases in amenable mortality following the global financial crisis for females in Estonia [from -4.53 annual percentage change (APC) in 2005-12 to 0.03 APC in 2012-14] and Slovenia (from -4.22 APC in 2000-13 to 0.73 in 2013-15) as well as males and females in Greece(males: from -2.93 APC in 2000-10 to 0.01 APC in 2010-13; females: from -3.48 APC in 2000-10 to 0.06 APC in 2010-13). Other mortality continued to decline for these populations. Increases in deaths from infectious diseases before and after the crisis played a substantial part in reversals in Estonia, Slovenia and Greece. Conclusion: There is evidence that amenable mortality rose in Greece and, among females in Estonia and Slovenia. However, in most countries, trends in amenable mortality rates appeared to be unaffected by the crisis.

The turn of the gradient? Educational differences in breast cancer mortality in 18 European populations during the 2000s.

This study aims to investigate the association between educational level and breast cancer mortality in Europe in the 2000s. Unlike most other causes of death, breast cancer mortality tends to be positively related to education, with higher educated women showing higher mortality rates. Research has however shown that the association is changing from being positive over non-existent to negative in some countries. To investigate these patterns, data from national mortality registers and censuses were collected and harmonized for 18 European populations. The study population included all women aged 30-74. Age-standardized mortality rates, mortality rate ratios, and slope and relative indexes of inequality were computed by education. The population was stratified according to age (women aged 30-49 and women aged 50-74). The relation between educational level and breast cancer mortality was predominantly negative in women aged 30-49, mortality rates being lower among highly educated women and higher among low educated women, although few outcomes were statistically significant. Among women aged 50-74, the association was mostly positive and statistically significant in some populations. A comparison with earlier research in the 1990s revealed a changing pattern of breast cancer mortality. Positive educational differences that used to be significant in the 1990s were no longer significant in the 2000s, indicating that inequalities have decreased or disappeared. This evolution is in line with the "fundamental causes" theory which stipulates that whenever medical insights and treatment become available to combat a disease, a negative association with socio-economic position will arise, independently of the underlying risk factors.

Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990-2004.

BACKGROUND: Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990-1994 and 2000-2004 in 14 European countries. METHODS: We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990-1994 and 2000-2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method. RESULTS: In 2000-2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between -1% and 56% among women. Since 1990-1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women. CONCLUSIONS: In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.

[INTEGRATED APPROACH TO PREVENT FUNCTIONAL DECLINE IN HOSPITALIZED ELDERLY]. / Integrale interventie ter voorkoming van functieverlies bij ouderen tijdens ziekenhuisopname: het Zorgprogramma voor Preventie en Herstel.

BACKGROUND: Hospital related functional decline in older patients is an underestimated problem. Thirty-five procent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. This percentage increases considerably with age. METHODS/DESIGN: To address this issue, the Vlietland Ziekenhuis in The Netherlands has implemented the Prevention and Reactivation Care Programme (PReCaP), an innovative program aimed at reducing hospital related functional decline among elderly patients by offering interventions that are multidisciplinary, integrated and goal-oriented at the physical, social, and psychological domains of functional decline. DISCUSSION: This paper presents a detailed description of the intervention, which incorporates five distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment for a selected patient group at the prevention and Reactivation Centre; (3) Availability of multidisciplinary geriatric expertise; (4) Provision of support and consultation of relevant professionals to informal caregivers; (5) Intensive follow-up throughout the entire chain of care by a casemanager with geriatric expertise. Outcome and process evaluations are ongoing and results will be published in a series of forthcoming papers. This article is an edited translation of the previously published article 'Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP), BMC Geriatrics 2012;12:7, AJBM de Vos, KJE Asmus-Szepesi, TJEM Bakker, PL de Vreede, JDH van Wijngaarden, EW Steyerberg, JP Mackenbach, AP Nieboer.

The importance of multidisciplinary teamwork and team climate for relational coordination among teams delivering care to older patients.

AIM: To identify predictors of relational coordination among professionals delivering care to older patients. BACKGROUND: Relational coordination is known to enhance quality of care in hospitals. The underlying mechanisms, however, remain poorly understood. DESIGN: This cross-sectional study was part of a larger evaluation study examining the opportunity to prevent loss of function in older patients due to hospitalization in the Netherlands. METHODS: This study was performed in spring 2010 among team members delivering care to older hospitalized patients (192 respondents; 44% response rate) in one hospital. Relational coordination was measured by the Relational Coordination survey; team climate by the Team Climate Inventory and questions were asked about participation in multidisciplinary team meetings and disciplines represented in these meetings. To account for the hierarchical structure, a multilevel analysis was performed. RESULTS: Correlation analysis revealed a positive relationship among being female, being a nurse and relational coordination; medical specialists showed a negative relationship. The number of disciplines represented during multidisciplinary team meetings and team climate were positively related with relational coordination. The multilevel analysis showed a positive relationship between the number of disciplines represented during multidisciplinary team meetings and team climate with relational coordination. CONCLUSIONS: The enhancement of team climate and attendance of diverse professionals during multidisciplinary team meetings are expected to improve relational coordination. Furthermore, this study underscores the importance of enhancing relational coordination between medical specialists and other professionals.

Understanding older patients' self-management abilities: functional loss, self-management, and well-being.

PURPOSE: This study aimed to increase our understanding of self-management abilities and identify better self-managers among older individuals. METHODS: Our cross-sectional research was based on a pilot study of older people who had recently been admitted to a hospital. In the pilot study, all patients (>65 years of age) who were admitted to the Vlietland hospital between June and October 2010 were asked to participate, which led to the inclusion of 456 older patients at baseline. A total of 296 patients (65% response rate) were interviewed in their homes 3 months after admission. Measures included social, cognitive, and physical functioning, self-management abilities, and well-being. We used descriptive, correlations, and multiple regression analyses. In addition, we evaluated the mediation effect of self-management abilities on well-being. RESULTS: Social, cognitive, and physical functioning significantly correlated with self-management abilities and well-being (all p ≤ 0.001). After controlling for background characteristics, multiple regression analysis indicated that social, cognitive, and physical functioning still related to self-management abilities (ß = 0.17-0.25; all p ≤ 0.001). Older people with low levels of social, cognitive, and physical functioning were worse self-managers than were those with higher levels of functioning. CONCLUSIONS: Self-management abilities mediate the relationship between social, cognitive, and physical functioning and well-being. Interventions to improve self-management abilities may help older people better deal with function losses as they age further.

Explaining differences in birth outcomes in relation to maternal age: the Generation R Study.

OBJECTIVE: To examine the association between maternal age and birth outcomes, and to investigate the role of sociodemographic and lifestyle-related determinants. DESIGN: Population-based prospective cohort study from early pregnancy onwards. SETTING: Rotterdam, the Netherlands. POPULATION: A cohort of 8568 mothers and their children. METHODS: Maternal age was assessed at enrolment. Information about sociodemographic (height, weight, educational level, ethnicity, parity) and lifestyle-related determinants (alcohol consumption, smoking habits, folic acid supplement use, caffeine intake, daily energy intake) and birth outcomes was obtained from questionnaires and hospital records. Multivariate linear and logistic regression analyses were used. MAIN OUTCOMES MEASURES: Birthweight, preterm delivery, small-for-gestational-age, and large-for-gestational-age. RESULTS: As compared with mothers aged 30-34.9 years, no differences in risk of preterm delivery were found. Mothers younger than 20 years had the highest risk of delivering small-for-gestational-age babies(OR 1.6, 95% CI: 1.1-2.5); however, this increased risk disappeared after adjustment for sociodemographic and lifestyle-related determinants. Mothers older than 40 years had the highest risk of delivering large-for-gestational-age babies (OR 1.3, 95% CI: 0.8-2.4). The associations of maternal age with the risks of delivering large-for-gestational-age babies could not be explained by sociodemographic and lifestyle-related determinants. CONCLUSIONS: As compared with mothers aged 30-34.9 years, younger mothers have an increased risk of small-for-gestational-age babies, whereas older mothers have an increased risk of large-for-gestational-age babies. Sociodemographic and lifestyle-related determinants cannot fully explain these differences.

The effects of work-related maternal risk factors on time to pregnancy, preterm birth and birth weight: the Generation R Study.

OBJECTIVE: To investigate the influence of maternal working conditions on fertility and pregnancy outcomes. METHODS: 8880 women were enrolled in a large prospective birth cohort during early (76%), mid (21%) or late pregnancy (3%) (61% participation). Complete questionnaire information was available for 6302 women (71% response). Outcomes were prolonged time to pregnancy (TTP) (> 6 months), preterm birth (< 37 weeks) and decreased birth weight (< 3000 g). Self-reported exposure to chemical agents was based on a limited list of chemicals. Physical load questions concerned manual materials handling, prolonged sitting and long periods of standing. A job-exposure matrix (JEM) linked reported job title to workplace chemical exposure within jobs according to expert judgement. Associations between maternal occupational exposure and fertility and pregnancy outcomes, adjusted for age, education, minority, parity, smoking and alcohol use, were studied using logistic regression analysis. RESULTS: Women in jobs with regular handling of loads ≥ 5 kg had better fertility and pregnancy outcomes. No self-reported exposure to chemicals was associated with any outcomes and self-assessments had very low reliability compared with JEM-based assessments. JEM-based maternal occupational exposure to phthalates was associated with prolonged TTP (OR 2.16, 95% CI 1.02 to 4.57) and exposure to pesticides was associated with decreased birth weight (OR 2.42, 95% CI 1.10 to 5.34). The population attributable fractions were small at 0.7% for phthalates and 0.7% for pesticides. CONCLUSION: This birth cohort study presents evidence of health-based selection into the workforce and adverse effects of maternal occupational exposure to phthalates and pesticides on fertility and pregnancy outcomes.

Explaining ethnic differences in late antenatal care entry by predisposing, enabling and need factors in The Netherlands. The Generation R Study.

Despite compulsory health insurance in Europe, ethnic differences in access to health care exist. The objective of this study is to investigate how ethnic differences between Dutch and non-Dutch women with respect to late entry into antenatal care provided by community midwifes can be explained by need, predisposing and enabling factors. Data were obtained from the Generation R Study. The Generation R Study is a multi-ethnic population-based prospective cohort study conducted in the city of Rotterdam. In total, 2,093 pregnant women with a Dutch, Moroccan, Turkish, Cape Verdean, Antillean, Surinamese Creole and Surinamese Hindustani background were included in this study. We examined whether ethnic differences in late antenatal care entry could be explained by need, predisposing and enabling factors. Subsequently, logistic regression analysis was used to assess the independent role of explanatory variables in the timing of antenatal care entry. The main outcome measure was late entry into antenatal care (gestational age at first visit after 14 weeks). With the exception of Surinamese-Hindustani women, the percentage of mothers entering antenatal care late was higher in all non-Dutch compared to Dutch mothers. We could explain differences between Turkish (OR = 0.95, CI: 0.57-1.58), Cape Verdean (OR = 1.65. CI: 0.96-2.82) and Dutch women. Other differences diminished but remained significant (Moroccan: OR = 1,74, CI: 1.07-2.85; Dutch Antillean OR 1.80, CI: 1.04-3.13). We found that non-Dutch mothers were more likely to enter antenatal care later than Dutch mothers. Because we are unable to explain fully the differences regarding Moroccan, Surinamese-Creole and Antillean women, future research should focus on differences between 1st and 2nd generation migrants, as well as on language barriers that may hinder access to adequate information about the Dutch obstetric system.

Weight status, energy-balance behaviours and intentions in 9-12-year-old inner-city children.

BACKGROUND: Dutch youth health care promotes four so-called energy-balance behaviours for the prevention of obesity: increasing physical activity, reducing sedentary behaviour and sugar-containing drinks, and eating breakfast. However, data on the prevalence of these behaviours and intentions to engage in them among primary schoolchildren is limited, especially for multi-ethnic, inner-city populations. The present study aimed to provide these data and explore differences according to socio-demographic characteristics and weight status. METHODS: Data on behaviours and accompanying intentions were collected using classroom questionnaires. Stature and body weight were measured by trained staff. Twenty primary schools in Rotterdam participated. Data on 1095 9-12 year olds (81.7% response rate) were available for analysis. Multiple logistic regression analyses were conducted to determine associations between behaviours (favourable or unfavourable), intentions (positive or not), gender, age, ethnicity, neighbourhood income level and weight status. RESULTS: The prevalence of being overweight was 30.4%, including 9.0% obesity. Engagement in energy-balance behaviours varied from 58.6% for outdoor play (>1 h previous day) to 85.9% for active transportation to school (day of survey). The highest positive intentions were reported for taking part in sports (83.9%), and lowest for reducing computer time (41.3%). Small differences in behaviours and intentions according to socio-demographic characteristics were found, most notably a lower engagement in physical activity by girls. Skipping breakfast and total number of energy-balance behaviours were associated with being overweight. CONCLUSIONS: The prevalence of being overweight among Dutch inner-city schoolchildren is high. A general rather than a differentiated approach is needed to improve engagement in energy-balance behaviours among inner-city schoolchildren.

Improving job strain might reduce inequalities in cardiovascular disease mortality in european men.

Unfavorable psychosocial working conditions can lead to cardiovascular disease (CVD) mortality. Lower-occupational groups typically experience unfavorable psychosocial working conditions as compared to higher-occupational groups. We investigate the extent to which CVD mortality inequalities might be reduced if psychosocial working conditions for manual workers are raised to the level experienced by non-manual workers (upward-leveling scenario). We also investigate what would occur if psychosocial working conditions among manual and non-manual workers are raised to better levels as observed in the 'ideal' region (best practice scenario). Individual-level CVD mortality data from 12 European countries were obtained from the EURO-GBD-SE project (1998-2007). Psychosocial working conditions data (i.e. job strain) were extracted from the European Working Conditions Survey (2005) and rate ratios from literature reviews. Population attributable fractions (PAF) and two counterfactual scenarios (namely, upward-leveling scenario and best-practice scenario) were developed to examine employed male non-manual and manual workers. Results appeared to show that CVD mortality might be reduced in men when unfavorable psychosocial working conditions are improved for manual workers (PAF = 7.7%, 95% CI: 6.5-10.0). The upward-leveling scenario seems to reduce CVD mortality inequalities for manual workers, by 13-74%. Best-practice scenario shows the largest reduction in CVD mortality in the Baltic region (87 deaths per 100,000 person years). Findings suggest that rendering job strain in manual workers to the level experienced by non-manual workers might substantially reduce CVD mortality inequalities in European men.

Socioeconomic inequalities in lung cancer mortality in 16 European populations.

OBJECTIVES: This paper aims to describe socioeconomic inequalities in lung cancer mortality in Europe and to get further insight into socioeconomic inequalities in lung cancer mortality in different European populations by relating these to socioeconomic inequalities in overall mortality and smoking within the same or reference populations. Particular attention is paid to inequalities in Eastern European and Baltic countries. METHODS: Data were obtained from mortality registers, population censuses and health interview surveys in 16 European populations. Educational inequalities in lung cancer and total mortality were assessed by direct standardization and calculation of two indices of inequality: the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). SIIs were used to calculate the contribution of inequalities in lung cancer mortality to inequalities in total mortality. Indices of inequality in lung cancer mortality in the age group 40-59 years were compared with indices of inequalities in smoking taking into account a time lag of 20 years. RESULTS: The pattern of inequalities in Eastern European and Baltic countries is more or less similar as the one observed in the Northern countries. Among men educational inequalities are largest in the Eastern European and Baltic countries. Among women they are largest in Northern European countries. Whereas among Southern European women lung cancer mortality rates are still higher among the high educated, we observe a negative association between smoking and education among young female adults. The contribution of lung cancer mortality inequalities to total mortality inequalities is in most male populations more than 10%. Important smoking inequalities are observed among young adults in all populations. In Sweden, Hungary and the Czech Republic smoking inequalities among young adult women are larger than lung cancer mortality inequalities among women aged 20 years older. CONCLUSIONS: Important socioeconomic inequalities exist in lung cancer mortality in Europe. They are consistent with the geographical spread of the smoking epidemic. In the next decades socioeconomic inequalities in lung cancer mortality are likely to persist and even increase among women. In Southern European countries we may expect a reversal from a positive to a negative association between socioeconomic status and lung cancer mortality. Continuous efforts are necessary to tackle socioeconomic inequalities in lung cancer mortality in all European countries.

Maternal anthropometrics are associated with fetal size in different periods of pregnancy and at birth. The Generation R Study.

OBJECTIVE: We aimed to examine the associations of maternal anthropometrics with fetal weight measured in different periods of pregnancy and with birth outcomes. DESIGN: Population-based birth cohort study. SETTING: Data of pregnant women and their children in Rotterdam, the Netherlands. POPULATION: In 8541 mothers, height, prepregnancy body mass index (BMI) and gestational weight gain were available. METHODS: Fetal growth was measured by ultrasound in mid- and late pregnancy. Regression analyses were used to assess the impact of maternal anthropometrics on fetal weight and birth outcomes. MAIN OUTCOME MEASURES: Fetal weight and birth outcomes: weight (grams) and the risks of small (<5th percentile) and large (>95th percentile) size for gestational age at birth. RESULTS: Maternal BMI in pregnancy was positively associated with estimated fetal weight during pregnancy. The effect estimates increased with advancing gestational age. All maternal anthropometrics were positively associated with fetal size (P-values for trend <0.01). Mothers with both their prepregnancy BMI and gestational weight gain quartile in the lowest and highest quartiles showed the highest risks of having a small and large size for gestational age child at birth, respectively. The effect of prepregnancy BMI was strongly modified by gestational weight gain. CONCLUSIONS: Fetal growth is positively affected by maternal BMI during pregnancy. Maternal height, prepregnancy BMI and gestational weight gain are all associated with increased risks of small and large size for gestational age at birth in the offspring, with an increased effect when combined.

[Compression of morbidity: a promising approach to alleviate the societal consequences of population ageing?]. / Compressie van morbiditeit: een veelbelovende benadering om de maatschappelijke consequenties van vergrijzing te verlichten?

There is an urgent need for strategies that alleviate the societal consequences of population ageing. A possible strategy is aiming for compression of morbidity. Some of the initial conditions for a compression of morbidity have been invalidated. This is, the life expectancy has shown a much stronger increase than was expected and the modal age at death has exceeded the age of 85. Additionally, trend studies have found no consistent evidence for a compression of morbidity. At the department of Public Health, we aim at identifying entry-points for a compression. For example, an analysis was performed on potential contributions of changes in exposure to life style factors (smoking, hypertension, physical inactivity and overweight/obesity) to compression of cardiovascular disease, using multi-state life tables with data from the Framingham Heart Study. It was shown that smoking and physical inactivity increased the incidence of cardiovascular disease, as well as mortality with and without cardiovascular disease. Hypertension and overweight mainly increased the incidence of cardiovascular disease and were associated with a shorter lifespan and more years with cardiovascular disease. Interventions on the latter risk factors will therefore increase the life expectancy, but will also result in a compression of morbidity. For policymakers and researchers it is important to find a mix of interventions that lead to a comparable overall effect.

Tracking and determinants of subcutaneous fat mass in early childhood: the Generation R Study.

OBJECTIVES: To examine the development and tracking of subcutaneous fat mass in the first 2 years of life and to examine which parental, fetal and postnatal characteristics are associated with subcutaneous fat mass. DESIGN: This study was embedded in the Generation R Study, a prospective cohort study from early fetal life onward. Subcutaneous fat mass was measured by skinfold thickness (biceps, triceps, suprailiacal, subscapular) at the ages of 1.5, 6 and 24 months in 1012 children. Information about parental, fetal and postnatal growth characteristics was collected by physical and fetal ultrasound examinations and questionnaires. RESULTS: Normal values of subcutaneous fat mass are presented. Total subcutaneous fat mass was higher in girls than in boys at the age of 24 months (P=0.01). Subjects in the lowest and highest quartiles at the age of 6 months tended to keep their position in the same quartile at the age of 24 months (odds ratios 1.86 (95% confidence interval (CI) 1.3, 2.7)) and 1.84 (95% CI: 1.3, 2.6), respectively). Maternal height and weight, paternal weight, fetal weight at 30 weeks, birth weight and weight at the age of 6 weeks were each inversely associated with subcutaneous fat mass at the age of 24 months after adjustment for current weight at 24 months. CONCLUSION: This study shows for the first time that subcutaneous fat mass tends to track in the first 2 years of life. Furthermore, the results suggest that an adverse fetal environment and growth are associated with increased subcutaneous fat mass at the age of 24 months. Further studies are needed to examine whether these associations persist in later life.

Effect of nationwide tobacco control policies on smoking cessation in high and low educated groups in 18 European countries.

BACKGROUND: Recently a scale was introduced to quantify the implementation of tobacco control policies at country level. Our study used this scale to examine the potential impact of these policies on quit ratios in European countries. Special attention was given to smoking cessation among lower educational groups. METHODS: Cross-sectional data were derived from national health surveys from 18 European countries. In the analyses we distinguished between country, sex, two age groups (25-39 and 40-59 years) and educational level. Age-standardised quit ratios were calculated as total former-smokers divided by total ever-smokers. In regression analyses we explored the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS). RESULTS: Quit ratios were especially high (>45%) in Sweden, England, The Netherlands, Belgium and France and relatively low (<30%) in Lithuania and Latvia. Higher educated smokers were more likely to have quit smoking than lower educated smokers in all age-sex groups in all countries. National score on the tobacco control scale was positively associated with quit ratios in all age-sex groups. The association of quit ratios with score on TCS did not show consistent differences between high and low education. Of all tobacco control policies of which the TCS is constructed, price policies showed the strongest association with quit ratios, followed by an advertising ban. CONCLUSION: Countries with more developed tobacco control policies have higher quit ratios than countries with less developed tobacco control policies. High and low educated smokers benefit about equally from the nationwide tobacco control policies.

Ethnic differences in outcomes of diabetes care and the role of self-management behavior.

OBJECTIVE: Ethnic differences in outcomes of outpatient diabetic care and the role of self-management behavior and its determinants in explaining observed differences. METHODS: Face-to-face interviews were held with 102 Turkish or Moroccan, and 102 native Dutch diabetic patients to measure self-management behavior and determinants of self-management (as derived from the Attitudes-Social support self-Efficacy model, and Personal Models and Barriers). A medical record review was conducted to measure ethnic differences in outcomes of diabetes care. Data were analyzed using multiple linear regression. RESULTS: Outcomes differed significantly with ethnic minorities having higher levels of lipids (risk difference=RD=0.7%; CI: 0.3-1.2) and HbA1c (RD=0.9%; CI: 0.4-1.4) than native Dutch patients. Differences in self-management could not explain the ethnic differences in outcomes. Self-efficacy explained 18% of the ethnic differences in HbA1c. Beliefs about seriousness of diabetes and social support regarding diabetes management together explained 47% of the ethnic differences in lipids. CONCLUSION: This study provides evidence for ethnic differences in outcomes of diabetes care. Self-efficacy is the most important determinant in explaining the differences in HbA1c. PRACTICE IMPLICATIONS: For diabetes practice this suggests that strengthening patients' self-efficacy may improve the control of HbA1c and may result in a decrease of ethnic differences. The relationship between behavioral determinants like seriousness and social support and outcomes of diabetes care was differential by ethnic group, implying that caution is required when applying behavioral models to different ethnic groups.

[Male-female differences in health and healthcare are largely determined by social factors]. / Man-vrouwverschillen in gezondheid en zorg zijn voor een groot deel maatschappelijk bepaald.

Women are generally considered the 'weaker sex'. In relation to health issues, it is not as simple as that. One might even argue that, in this context, men are the weaker sex. Life expectancy, for example, is lower in men than in women due to the fact that men suffer more from chronic conditions and have higher mortality risks. Part of these differences in health can be attributed to biological factors, but social factors seem to play an even more important role. The health gap between men and women might evolve over time and differ between situations. This is illustrated by the decreasing difference in life expectancy between men and women, and by the relatively adverse cardiovascular risk profile of women in immigrant groups compared with the host populations. Within healthcare, differences between men and women are also partly due to social determinants. Examples include the underrepresentation of women in health research as well as in guidelines committees, thereby affecting the production and implementation of medical evidence.

[Variations in the pace of mortality decline in elderly in 7 Northwestern European countries between 1950-1999: the impact of smoking]. / Variaties in het tempo van sterftedaling onder ouderen in 7 Noordwest-Europese landen tussen 1950-1999: de rol van roken.

OBJECTIVE: Examination of the variations in the pace of old-age (80+) mortality decline in 7 Northwestern European countries for the period 1950-1999, and the impact of smoking DESIGN: Retrospective. METHOD: The population mortality data of 7 Northwestern European countries were collated according to year of death for a 50 year period (1950-1999), single year of age (60+ and 80+) and sex. Both all-cause and non-smoking-related mortality were analysed. In addition, a comparison was made with the pace of mortality decline at younger age among the same cohorts. Regression and correlation analyses were used. RESULTS: Marked variations in the pace of old-age mortality decline were found between countries, periods and sexes. While mortality declines were constantly strong in France and England and Wales, modest declines or even increases in mortality rate were observed in the 1950s in the Nordic countries, and since the 1980s in Denmark, The Netherlands, and (for men only) Norway. For non-smoking-related mortality, a high and consistent pace ofmortality decline was observed. The declines showed a clear cohort pattern, with the smallest declines or even increases for men born between 1890 and 1899, compared to an increased pace of mortality decline among women born between 1847 and 1937. Among men, but not women, the pace of old-age mortality decline correlated with the pace of mortality decline at ages 60-69 among the same cohorts. CONCLUSIONS: Variations in the pace of old-age mortality decline are strongly influenced by smoking and probably also by other factors originating earlier in life. For future decades, substantial further declines in old-age mortality may be expected, even though rates of change in specific countries and periods would be difficult to predict.