The Semmelweis Study: a longitudinal occupational cohort study within the framework of the Semmelweis Caring University Model Program for supporting healthy aging.

The Semmelweis Study is a prospective occupational cohort study that seeks to enroll all employees of Semmelweis University (Budapest, Hungary) aged 25 years and older, with a population of 8866 people, 70.5% of whom are women. The study builds on the successful experiences of the Whitehall II study and aims to investigate the complex relationships between lifestyle, environmental, and occupational risk factors, and the development and progression of chronic age-associated diseases. An important goal of the Semmelweis Study is to identify groups of people who are aging unsuccessfully and therefore have an increased risk of developing age-associated diseases. To achieve this, the study takes a multidisciplinary approach, collecting economic, social, psychological, cognitive, health, and biological data. The Semmelweis Study comprises a baseline data collection with open healthcare data linkage, followed by repeated data collection waves every 5 years. Data are collected through computer-assisted self-completed questionnaires, followed by a physical health examination, physiological measurements, and the assessment of biomarkers. This article provides a comprehensive overview of the Semmelweis Study, including its origin, context, objectives, design, relevance, and expected contributions.

Health insurance and accessibility to health services among Roma in settlements in Belgrade, Serbia--the journey from data to policy making.

The Serbian constitution and health-related laws assert that citizens and residents are universally entitled to health care, provided that they hold health insurance. However, until 2010, persons who did not hold a national identification number (ID) were required to present a plethora of documents to be granted one. We assessed the relationship between citizenship, residency and possession of health insurance cards, together with utilization of health services, among Roma residing in disadvantaged settlements in Belgrade. The Roma Health and Nutrition Survey was conducted in 2009 to assess the social determinants of health among Roma. Data were analysed, using logistic regression, to examine health insurance status and utilization of services by citizenship and residency. Eighty-nine per cent of respondents said they were Serbian citizens. Approximately 11% were refugees, 7% internally displaced persons (IDPs) and remainder domicile. Multivariate analysis revealed that non-citizens were more likely to lack health insurance [odds ratio (OR) = 9.2, confidence interval (CI) (3.5, 24.1)], as were refugees and IDPs [OR = 3.1, CI (1.4, 6.9), OR = 4.0, CI (1.4, 11.5), respectively]. Having health insurance was a positive predictor for being seen by a physician [OR = 2.3, CI (1.3, 4.2), OR = 2.3, CI (1.3, 3.9)]. Data from this survey indicated that non-citizen Roma had limited access to health services. These findings led the Serbian Ministry of Health and National Health Insurance Fund to reduce the administrative and legislative hurdles in obtaining health insurance, to ensure the Roma rights to health care. This demonstration of data-driven policies on Roma health could serve as a model for other countries.

Risk factors for low vaccination coverage among Roma children in disadvantaged settlements in Belgrade, Serbia.

BACKGROUND: Full vaccination coverage for children under 59 months of age in Serbia is over 90%. This study assesses vaccination coverage and examines its association with birth registration among Roma children who resided in disadvantaged settlements in Belgrade, Serbia. METHODS: The First Roma Health and Nutrition Survey in Belgrade settlements, 2009, was conducted among households of 468 Roma children between the ages of 6-59 months. The 2005 WHO Immunization Coverage Cluster Survey sampling methodology was employed. Vaccinations were recorded using children's vaccination cards and through verification steps carried out in the Primary Health Care Centers. For those who had health records the information on vaccination was recorded. RESULTS: About 88% of children had vaccination cards. The mean rate of age appropriate full immunization was 16% for OPV and DTP and 14.3% for MMR. Multivariate analyses indicated that children whose births were registered with the civil authorities were more likely to have their vaccination cards [OR=6.1, CI (2.5, 15.0)] and to have their full, age appropriate, series vaccinations for DTP, OPV, MMR and HepB [OR=3.8, CI (1.5, 10.0), OR=3.2, CI (1.5, 6.6), OR=4.8, CI (1.1, 21.0), OR=5.4, CI (1.4, 21.6), respectively]. CONCLUSIONS: The immunization coverage among Roma children in settlements is far below the WHO/UNICEF MDG4 target in achieving prevention and control of vaccine preventable diseases. It demonstrates the need to include "invisible" populations into the health systems in continuous, integrated, comprehensive, accessible and sensitive modes.

Policies to improve the health and well-being of Roma people: the European experience.

The Roma constitute the largest ethnic minority in the European Region. The many policy initiatives designed over the past two decades to tackle their adverse social conditions in Central and South Eastern Europe, where the Roma population is concentrated, have had limited success. This paper reviews what is being done to improve the health and social situation of Roma communities in the Region and identifies factors that may limit the effectiveness of these policy initiatives. Strong political commitment, measures to overcome prejudices against Roma, inter-sectoral policy coordination, adequate budgets, evidence-based policies, and Roma involvement can be identified as key preconditions for improved health outcomes and well-being. However, developing a sound evidence-based approach to Roma inclusion requires removing obstacles to the collection of reliable data and improving analytical and evaluation capacity. Health policies seeking to reduce health inequalities for Roma people need to be aligned with education, economic, labour market, housing, environmental and territorial development policies and form part of comprehensive policy frameworks allowing for effective integration.

Addressing social determinants of health inequities: what can the state and civil society do?

In this Health Policy article, we selected and reviewed evidence synthesised by nine knowledge networks established by WHO to support the Commission on the Social Determinants of Health. We have indicated the part that national governments and civil society can play in reducing health inequity. Government action can take three forms: (1) as provider or guarantor of human rights and essential services; (2) as facilitator of policy frameworks that provide the basis for equitable health improvement; and (3) as gatherer and monitor of data about their populations in ways that generate health information about mortality and morbidity and data about health equity. We use examples from the knowledge networks to illustrate some of the options governments have in fulfilling this role. Civil society takes many forms: here, we have used examples of community groups and social movements. Governments and civil society can have important positive roles in addressing health inequity if political will exists.

Time trends in incidence of myocardial infarction in male and female dominated occupations in Stockholm, Sweden.

AIMS: To investigate time trends in first acute myocardial infarction (MI) incidence in male and female dominated occupations in Stockholm during 1977-1996. METHODS: Population-based case-control study, where all first events of acute MI among participants aged 40-69 in Stockholm 1977-1996 were identified, using registers of hospital discharges and deaths. Controls were selected randomly using national population registers. There were 16,531 male and 4382 female cases and 117,015 male and 102,083 female controls. In all, 222 female cases worked in male dominated occupations and 844 male cases worked in female dominated occupations. RESULTS: Both women and men in male dominated occupations showed an elevated relative risk of first MI compared to other employees during the study period. Between 1985-1996, when there was a general decline in MI incidence in Sweden, women in male dominated occupations tended to show an increasing trend. Women in female dominated high and intermediate occupations had a lower relative risk of MI compared to other women in the same socioeconomic group. In male dominated and non-manual female dominated occupations a decline in the incidence of MI was seen during 1985-1996 in men but not in women. CONCLUSIONS: Work in male dominated occupations appears to be associated with an increased risk of MI in both genders. There is a need to investigate possible work related or other factors that may be driving this elevated risk.

Window of opportunity for intersectoral health policy in Sweden--open, half-open or half-shut?

'Health in All Policies' (HiAP) is defined as a 'horizontal, complementary policy-related strategy with a high potential for contributing to population health'. To ensure that health impacts are highlighted across sectors, the support of actors in different sectors, not just the health sector, is needed. Public health, here defined as a universally important but a low prioritized politics area, needs to involve high politics areas to fulfil the HiAP strategy. This study aimed to analyse the agenda setting, formulation, initiation and implementation of the intersectoral public health policy and one tool of HiAP, health impact assessment (HIA), at the national and local level (exemplified by Stockholm County) in Sweden. A literature search was carried out of scientific and grey literature on intersectoral health policy and HIA in Sweden. The study was a policy analysis, using a content analysis method, and the theoretical framework of Kingdon where the results were examined through problem identification (why a window of opportunity opens for an intersectoral health policy and HIA), the factors and impact of politics (support for the formulation and implementation of policy) and policy (how best to solve the problem). The results showed that actors perceived the problems (the rationale) differently depending on their agenda and interest. Politicians and experts had a high impact on the formulation of the policy, agreeing on the policy goals. However, there was little focus on implementation plans implying that the political actors were not in agreement, and the experts sometimes showing conflicting evidence-based opinions on how to best ensure the policy. Without this in place, it is difficult to involve high politics areas, and vice versa, without the involvement of high politics, it is difficult to achieve the policy. However, this is a long-term process, where small steps need to be taken, leaving the policy window half-shut.

Gender and health promotion: a multisectoral policy approach.

Women and men are different as regards their biology, the roles and responsibilities that society assigns to them and their position in the family and community. These factors have a great influence on causes, consequences and management of diseases and ill-health and on the efficacy of health promotion policies and programmes. This is confirmed by evidence on male-female differences in cause-specific mortality and morbidity and exposure to risk factors. Health promoting interventions aimed at ensuring safe and supportive environments, healthy living conditions and lifestyles, community involvement and participation, access to essential facilities and to social and health services need to address these differences between women and men, boys and girls in an equitable manner in order to be effective. The aim of this paper is to (i) demonstrate that health promotion policies that take women's and men's differential biological and social vulnerability to health risks and the unequal power relationships between the sexes into account are more likely to be successful and effective compared to policies that are not concerned with such differences, and (ii) discuss what is required to build a multisectoral policy response to gender inequities in health through health promotion and disease prevention. The requirements discussed in the paper include i) the establishment of joint commitment for policy within society through setting objectives related to gender equality and equity in health as well as health promotion, ii) an assessment and analysis of gender inequalities affecting health and determinants of health, iii) the actions needed to tackle the main determinants of those inequalities and iv) documentation and dissemination of effective and gender sensitive policy interventions to promote health. In the discussion of these key policy elements, we use illustrative examples of good practices from different countries around the world.

Priorities for research to take forward the health equity policy agenda.

Despite impressive improvements in aggregate indicators of health globally over the past few decades, health inequities between and within countries have persisted, and in many regions and countries are widening. Our recommendations regarding research priorities for health equity are based on an assessment of what information is required to gain an understanding of how to make substantial reductions in health inequities. We recommend that highest priority be given to research in five general areas: (1) global factors and processes that affect health equity and/or constrain what countries can do to address health inequities within their own borders; (2) societal and political structures and relationships that differentially affect people's chances of being healthy within a given society; (3) interrelationships between factors at the individual level and within the social context that increase or decrease the likelihood of achieving and maintaining good health; (4) characteristics of the health care system that influence health equity and (5) effective policy interventions to reduce health inequity in the first four areas.

Using risk analysis in Health Impact Assessment: the impact of different relative risks for men and women in different socio-economic groups.

The aim of this study is to contribute to the emerging field of quantification of Health Impact Assessment (HIA), by analysing how different relative risks affect the burden of disease for various socio-economic groups (SES). Risk analysis, utilising attributable and impact fraction, raises several methodological considerations. The present study illustrates this by measuring the impact of changed distribution levels of smoking on lung cancer, ischemic heart disease (IHD), chronic obstructive lung disorder (COLD) and stroke for the highest and lowest socio-economic groups measured in disability adjusted life years (DALY). The material is based on relative risks obtained from various international studies, smoking prevalence (SP) data and the number of DALY based on data available for Sweden. The results show that if smoking would have been eliminated (attributable fraction, AF), the inequality between the highest and lowest socio-economic groups may decrease by 75% or increase by 21% depending on the size of the relative risk. Assuming the same smoking prevalence for the lowest socio-economic group as for the highest (impact fraction), then the inequality may decrease by 7-26%. Consequently, the size of the relative risk used may have a significant impact, leading to substantial biases and therefore should be taken into serious consideration in HIA.

Paying attention to gender and poverty in health research: content and process issues.

Despite the magnitude of the problem of health inequity within and between countries, little systematic research has been done on the social causes of ill-health. Health researchers have overwhelmingly focused on biomedical research at the level of individuals. Investigations into the health of groups and the determinants of health inequities that lie outside the control of the individual have received a much smaller share of research resources. Ignoring factors such as socioeconomic class, race and gender leads to biases in both the content and process of research. We use two such factors--poverty and gender--to illustrate how this occurs. There is a systematic imbalance in medical journals: research into diseases that predominate in the poorest regions of the world is less likely to be published. In addition, the slow recognition of women's health problems, misdirected and partial approaches to understanding women's and men's health, and the dearth of information on how gender interacts with other social determinants continue to limit the content of health research. In the research community these imbalances in content are linked to biases against researchers from poorer regions and women. Researchers from high-income countries benefit from better funding and infrastructure. Their publications dominate journals and citations, and these researchers also dominate advisory boards. The way to move forward is to correct biases against poverty and gender in research content and processes and provide increased funding and better career incentives to support equity-linked research. Journals need to address equity concerns in their published content and in the publishing process. Efforts to broaden access to research information need to be well resourced, publicized and expanded.