Impact of health spending on hospitalization rates in Baltic countries: a comparative analysis.

INTRODUCTION: This study examines the association between healthcare indicators and hospitalization rates in three high-income European countries, namely Estonia, Latvia, and Lithuania, from 2015 to 2020. METHOD: We used a sex-stratified generalized additive model (GAM) to investigate the impact of select healthcare indicators on hospitalization rates, adjusted by general economic status-i.e., gross domestic product (GDP) per capita. RESULTS: Our findings indicate a consistent decline in hospitalization rates over time for all three countries. The proportion of health expenditure spent on hospitals, the number of physicians and nurses, and hospital beds were not statistically significantly associated with hospitalization rates. However, changes in the number of employed medical doctors per 10,000 population were statistically significantly associated with changes of hospitalization rates in the same direction, with the effect being stronger for males. Additionally, higher GDP per capita was associated with increased hospitalization rates for both males and females in all three countries and in all models. CONCLUSIONS: The relationship between healthcare spending and declining hospitalization rates was not statistically significant, suggesting that the healthcare systems may be shifting towards primary care, outpatient care, and on prevention efforts.

The Impact of Raising Alcohol Taxes on Government Tax Revenue: Insights from Five European Countries.

BACKGROUND AND OBJECTIVE: Reducing the affordability of alcoholic beverages by increasing alcohol excise taxation can lead to a reduction in alcohol consumption but the impact on government alcohol excise tax revenue is poorly understood. This study aimed to (a) describe cross-country tax revenue variations and (b) investigate how changes in taxation were related to changes in government tax revenue, using data from Estonia, Germany, Latvia, Lithuania and Poland. METHODS: For the population aged 15 years or older, we calculated the annual per capita alcohol excise tax revenue, total tax revenue, gross domestic product and alcohol consumption. In addition to descriptive analyses, joinpoint regressions were performed to identify whether changes in alcohol excise taxation were linked to changes in alcohol excise revenue since 1999. RESULTS: In 2022, the per capita alcohol excise tax revenue was lowest in Germany (€44.2) and highest in Estonia (€218.4). In all countries, the alcohol excise tax revenue was mostly determined by spirit sales (57-72% of total alcohol tax revenue). During 2010-20, inflation-adjusted per capita alcohol excise tax revenues have declined in Germany (- 22.9%), Poland (- 19.1%) and Estonia (- 4.2%) and increased in Latvia (+ 56.8%) and Lithuania (+ 49.3%). In periods of policy non-action, alcohol consumption and tax revenue showed similar trends, but tax level increases were accompanied by increased revenue and stagnant or decreased consumption. CONCLUSIONS: Increasing alcohol taxation was not linked to decreased but increased government revenue. Policymakers can increase revenue and reduce alcohol consumption and harm by increasing alcohol taxes.

A narrative review of alcohol control policies in Latvia between 1990 and 2020.

ISSUES: Latvia has one of the highest alcohol per capita consumption in Europe. This study provides a narrative review of all evidence-based population-level alcohol control policies implemented in Latvia during the past 30 years. APPROACH: A review of country-level alcohol control policies implemented in Latvia between 1990 and 2020 was conducted. The World Health Organization's "best buys" and other recommended interventions for alcohol control were used to guide the search. KEY FINDINGS: Alcohol control policies in Latvia have evolved significantly over the last three decades. The most changes to alcohol control policy occurred in the transitional period between regaining independence in 1991 and joining the European Union in 2004. A number of significant alcohol control policies have been implemented to reduce alcohol availability and affordability, to restrict alcohol marketing and to counter drunk-driving. However, since 2010, when an increasing trend of alcohol consumption was observed, there has been a reluctance to pursue national public health policy actions to reduce alcohol consumption, and few adjustments to legislation to increase alcohol control have been made. IMPLICATIONS: Despite the progress in alcohol control, Latvia still has considerable potential for strengthening alcohol control to reduce the high levels of alcohol consumption. CONCLUSION: Although several alcohol control policies have been established in Latvia, many of the planned activities to limit alcohol intake and related harm have not been executed. Public health goals rather than political and economic incentives should be prioritised to reduce high levels of alcohol consumption in Latvia.

Do alcohol control policies have the predicted effects on consumption? An analysis of the Baltic countries and Poland 2000-2020.

BACKGROUND: Many population-based alcohol control policies are postulated to work via changes in adult alcohol per capita consumption (APC). However, since APC is usually assessed on a yearly basis, often there are not enough data to conduct interrupted time-series or other controlled analyses. The current dataset, with 21 years of observation from four countries (Estonia, Latvia, Lithuania, and Poland), had sufficient power to test for average effects and potential interactions of the World Health Organization's (WHO) three "best buys" for alcohol control: taxation increases leading to a decrease in affordability; reduced availability (via a decrease in opening hours of at least 20 %); and advertising and marketing restrictions. We postulated that the former two would have immediate effects, while the latter would have mid- to long-term effects. METHODS: Linear regression analysis. RESULTS: Taxation increases and availability reductions in all countries were associated with an average reduction in APC of 0.83 litres (ℓ) of pure alcohol per year (95 % confidence interval: -1.21 ℓ, -0.41 ℓ) in the same year, with no significant differences between countries. Restrictions on advertising and/or marketing had no significant immediate associations with APC (average effect 0.04 ℓ per year; 95 % confidence interval: -0.65 ℓ, 0.73 ℓ). Several sensitivity analyses corroborated these main results. CONCLUSIONS: The WHO "best buy" alcohol control policies of taxation increases and availability restrictions worked as postulated in these four northeastern European Union countries.

Socioeconomic inequalities in adolescent health complaints: A multilevel latent class analysis in 45 countries.

Our study evaluated the relationship between adolescent health complaints and socioeconomic position in 45 countries. Data are from the 2017/2018 international Health Behaviour in School-aged Children survey which used proportionate sampling among adolescents aged 11 to 15 years old (n=228,979). Multilevel, multinomial regression analysis assessed the association between the multilevel latent classes with socioeconomic status (SES; at the household and country level). Three distinct latent classes were identified: No Complaints, Psychological Complaints, and a Physical and Psychological Complaints class; where, low household SES was highest for the physical and psychological complaints class. The findings suggest that health promotion policies and interventions among adolescents should consider the specific needs of adolescents living with low household SES as they report more subjective health complaints.

After the bell: adolescents' organised leisure-time activities and well-being in the context of social and socioeconomic inequalities.

BACKGROUND: Previous research has linked adolescents' participation in organised leisure-time activities (OLTAs) to better health and well-being. It remains unclear whether these associations can be observed consistently across social and socioeconomic strata and countries. METHODS: The present study used nine nationally representative samples of adolescents aged 11, 13 and 15 years (total n=55 429) from the 2017/2018 Health Behaviour in School-aged Children survey from Europe and Canada. Regression models with mixed effects to account for nested nature of data were applied to estimate: (1) the associations of social and socioeconomic factors with OLTA participation; (2) strengths of the associations between breadth and pattern of OLTA participation with health and well-being indicators, after adjustment for the social and socioeconomic factors. RESULTS: Rates of OLTA participation varied by age, sex and country of adolescents. Participants from lower socioeconomic classes and non-nuclear families were less likely to participate in OLTAs across each of the nine countries. Moreover, breadth of OLTA participation was associated with higher well-being independent of socioeconomic status or family structure. All of the participation patterns were associated with higher life satisfaction, but sports (either alone or in combination with a non-sport OLTA) were also associated with fewer psychological complaints and excellent self-rated health. CONCLUSION: Adolescents' engagement in OLTAs was associated with adolescents' subjective well-being regardless of country, age, sex and variance in social and socioeconomic factors. Policies aimed at increasing adolescents' subjective well-being and OLTA participation should focus on adolescents from low socioeconomic classes and non-nuclear families.

How Are Adolescents Sleeping? Adolescent Sleep Patterns and Sociodemographic Differences in 24 European and North American Countries.

PURPOSE: Insufficient and poor sleep patterns are common among adolescents worldwide. Up to now, the evidence on adolescent sleep has been mostly informed by country-specific studies that used different measures and age groups, making direct comparisons difficult. Cross-national data on adolescent sleep that could inform nations and international discussions are lacking. We examined the sleep patterns of adolescents across 24 countries and by gender, age, and affluence groups. METHODS: We obtained sleep data on 165,793 adolescents (mean age 13.5 years; 50.5% girls) in 24 European and North American countries from the recent cross-sectional Health Behaviour in School-aged Children surveys (2013-2014 and 2017-2018). For each country, we calculated the age-standardized mean in sleep duration, timing, and consistency and the proportions meeting sleep recommendations on school and nonschool days from self-reported bedtimes and wake times. We conducted stratified analyses by gender, age, and family affluence group. RESULTS: Adolescent sleep patterns varied cross-nationally. The average sleep duration ranged between 7:47 and 9:07 hours on school days and between 9:31 and 10:22 hours on nonschool days, and the proportion of adolescents meeting sleep recommendations ranged between 32% and 86% on school days and between 79% and 92% on nonschool days. Sleep patterns by gender and affluence groups were largely similar, but older adolescents slept less and went to bed later on school days than younger adolescents in all countries. CONCLUSIONS: The sleep patterns of adolescents vary across countries and sociodemographic groups. Insufficient sleep on school days is common in many countries. Public health and policy efforts to promote healthy adolescent sleep are encouraged.

Self-Reported Health and Patterns of Romantic Love in Adolescents from Eight European Countries and Regions.

Purpose: Sexual minority youth (SMY) are at increased risk of poor health, but it remains unclear whether this phenomenon is universal. In this study, nationally representative samples of 15-year olds from eight European countries and regions were investigated to test if adolescents who have been in love with same- or both-gender partners report poorer health than those exclusively in love with opposite-gender partners or who have never been in love. Methods: A subsample of 13,674 adolescents participating in the 2014 Health Behaviour in School-aged Children (HBSC) study was used. We conducted binary logistic regression, adjusted for gender, region, and relative family affluence, to analyze associations between self-reported romantic love, multiple psychosomatic symptoms, and poor self-rated health. Results: Adolescents reporting same-gender love (adjusted odds ratio [aOR] = 1.50, 95% confidence interval [CI]: 1.11-2.02) and both-gender love (aOR = 3.57, 95% CI: 2.65-4.83) had significantly higher odds for multiple psychosomatic symptoms than those who reported opposite-gender love. Similarly, both SMY groups had higher odds of poor self-rated health (aOR = 2.95, 95% CI: 1.64-5.31 and aOR = 3.08, 95% CI: 1.79-5.31, respectively). Those who reported that they have never been in love had significantly lower odds for multiple symptoms. Adjustment for sociodemographic variables and stratifying by gender did not substantially change the odds ratios. Conclusion: Adolescents in love with same- and both-gender partners reported poorer subjective health outcomes than those in love with opposite-gender partners or who reported never being in love, suggesting that SMY health inequalities are found across various European countries and regions.

Semantics bias in cross-national comparative analyses: is it good or bad to have "fair" health?

The Health Behavior in School-aged Children is a cross-national study collecting data on social and health indicators on adolescents in 43 countries. The study provides comparable data on health behaviors and health outcomes through the use of a common protocol, which have been a back bone of the study sine its initiation in 1983. Recent years, researchers within the study have noticed a questionable comparability on the widely used item on self-rated health. One of the four response categories to the item "Would you say your health is….?" showed particular variation, as the response category "Fair" varied from 20 % in Latvia and Moldova to 3-4 % in Bulgaria and Macedonia. A qualitative mini-survey of the back-translations showed that the response category "Fair" had a negative slant in 25 countries, a positive slant in 10 countries and was considered neutral in 9 countries. This finding indicates that there are what may be called semantic issues affecting comparability in international studies, since the same original word (in an English original) is interpreted differently across countries and cultures. The paper test and discuss a few possible explanations to this, however, only leaving to future studies to hold a cautious approach to international comparisons if working with the self-rated health item with four response categories.

Trends in self-rated health in European and North-American adolescents from 2002 to 2010 in 32 countries.

BACKGROUND: Self-rated health (SRH) in adolescence is known to be associated with health outcomes in later life. We carried out a trend analysis on data coming from three waves of data collected in 32 countries (mostly European) from 2002 to 2010 coming from the Health Behaviour in School-Aged Children surveys. METHODS: SRH in adolescents was assessed using a Likert scale (excellent, good, fair and poor). Responses were dichotomized into 'excellent' vs. 'rest'. Country, age and gender groups were compared based on the odds ratio of declaring excellent SRH in 2010 with respect to 2002 and 2006. RESULTS: The trend for European adolescents indicates an improvement over the last decade, although, in the majority of countries, a higher proportion of adolescents rate their health as excellent during the period 2002-06 with respect to the second half of the decade (2006-10).Girls were found to constantly rate their health as poorer, compared to their male peers, in all countries. Age has also a very stable trend towards a decreasing rating of health with increasing age. CONCLUSION: Decreased rating of health in the period 2006-10 may be a signal of the socio-economic difficulties of Europe in the last part of this decade.

Trends in health complaints from 2002 to 2010 in 34 countries and their association with health behaviours and social context factors at individual and macro-level.

BACKGROUND: This article describes trends and stability over time in health complaints in adolescents from 2002 to 2010 and investigates associations between health complaints, behavioural and social contextual factors at individual level and economic factors at macro-level. METHODS: Comprising N = 510 876 11-, 13- and 15-year-old children and adolescents in Europe, North America and Israel, data came from three survey cycles of the international Health Behaviour in School-aged Children (HBSC) study. Age- and gender-adjusted trends in health complaints were examined in each country by means of linear regression. By using the country as the random effects variable, we tested to what extent individual and contextual variables were associated with health complaints. RESULTS: Significant associations are stronger for individual level determinants (e.g. being bullied, smoking) than for determinants at macro-level (e.g. GDP, Gini), as can be seen by the small effect sizes (less than 5% for different trends). Health complaints are fairly stable over time in most countries, and no clear international trend in health complaints can be observed between 2002 and 2010. The most prominent stable determinants were being female, being bullied, school pressure and smoking. CONCLUSION: Factors associated with health complaints are more related to the proximal environment than to distal macro-level factors. This points towards intensifying targeted interventions, (e.g. for bullying) and also targeting specific risk groups. The comparably small effect size at country-level indicates that country-level factors have an impact on health and should not be ignored.

Health-behaviour inequalities among Russian and ethnic majority school-aged children in the Baltic countries.

AIMS: The main aim of this paper was to investigate whether ethnic heath inequalities exist in self-rated health and risk-taking behaviours (smoking, drunkenness, use of cannabis) between ethnic majority (Estonian, Latvian, Lithuanian) and minority (Russian) population groups of school-aged children in three Baltic countries. METHODS: Investigation was carried out in the framework of Health Behaviour in School-aged Children (HBSC) study. Randomly selected students aged 11, 13, and 15 years answered questionnaires in the classroom in 2006. In total, 14,354 questionnaire forms were selected for analysis. RESULTS: Russian boys were more likely (p<0.05) to evaluate their self-rated health positively in schools with Russian teaching language. Odd ratios for current smoking and drunkenness were significantly lower among Russian boys in the schools with Russian language of instruction (p<0.05) in comparison with the reference group. Russian girls did not differ significantly (the exceptions were smoking in Estonia and cannabis use in Latvia) from the majority population girls by self-rated health as well as by the risk of smoking, drunkenness, and use of cannabis. CONCLUSIONS: The study found some differences in self-rated health and in risk-taking behaviours between Russian minority and ethnic majority students as well as between students of schools with different language of instruction (majority language vs. Russian) in Estonia, Latvia, and Lithuania. Being a member of minority group was not related with poor self-rated health or involvement in risk-taking behaviours in school-aged children in the Baltic countries.

Socio-economic inequality in multiple health complaints among adolescents: international comparative study in 37 countries.

OBJECTIVES: To use comparable data from many countries to examine 1) socio-economic inequality in multiple health complaints among adolescents, 2) whether the countries' absolute wealth and economic inequality was associated with symptom load among adolescents, and 3) whether the countries' absolute wealth and economic inequality explained part of the individual level socio-economic variation in health complaints. METHODS: The Health Behaviour in School-aged Children (HBSC) international study from 2005/06 provided data on 204,534 11-, 13- and 15-year old students from nationally random samples of schools in 37 countries in Europe and North America. The outcome measure was prevalence of at least two daily health complaints, measured by the HBSC Symptom Check List. We included three independent variables at the individual level (sex, age group, family affluence measured by the Family Affluence Scale FAS) and two macro level measures on the country's economic situation: wealth measured by Gross National Product (GNP) and distribution of income measured by the Gini coefficient. RESULTS: There was a significant socio-economic variation in health complaints in 31 of the 37 countries. The overall OR (95 % CI) for 2+ daily health complaints for all countries was 1.31 (1.27-1.36) in the medium versus high FAS group and 2.07 (2.00-2.14) in the low versus high FAS group. This socio-economic gradient in health complaints attenuated somewhat in the multilevel models which included macro level data. There was no association between GNP and health complaints. The OR for high symptom load was 1.35 (1.08-1.69) per 10 % increase in Gini coefficient. The socio-economic gradient in health complaints at the individual level was somewhat attenuated in the multilevel models which included macro level data. CONCLUSIONS: There was a significant association between low FAS and high level of health complaints in 30 of 37 countries. Health complaints increased significantly by increasing income inequality in the country.

Bullying and subjective health among adolescents at schools in Latvia and Lithuania.

OBJECTIVES: To investigate the prevalence of bullying among adolescents in Latvia and Lithuania and to study its association with self-rated health, health complaints, and life satisfaction. METHODS: A total of 3417 students in Latvia and 5626 in Lithuania were surveyed using the Health Behaviour Study among School-aged Children 2001/2002 (HBSC) questionnaire and research protocol. RESULTS: Being a victim, bully, or bully/victim was reported by 30.1% adolescents in Latvia and 52.3% in Lithuania with the highest proportion reporting being a victim. Bullying was associated with poor subjective health and low life satisfaction. CONCLUSIONS: The factors explaining the difference of bullying prevalence between both countries should be studied to develop effective anti-bullying interventions relevant to local conditions.