Sociodemographic inequalities in mortality from drowning in the Baltic countries and Finland in 2000-2015: a register-based study.

BACKGROUND: Drowning is an important public health problem. Some evidence suggests that the risk of drowning is not distributed evenly across the general population. However, there has been comparatively little research on inequalities in drowning mortality. To address this deficit, this study examined trends and sociodemographic inequalities in mortality from unintentional drowning in the Baltic countries and Finland in 2000-2015. METHODS: Data for Estonia, Latvia and Lithuania came from longitudinal mortality follow-up studies of population censuses in 2000/2001 and 2011, while corresponding data for Finland were obtained from the longitudinal register-based population data file of Statistics Finland. Deaths from drowning (ICD-10 codes W65-W74) were obtained from national mortality registries. Information was also obtained on socioeconomic status (educational level) and urban-rural residence. Age-standardised mortality rates (ASMRs) per 100 000 person years and mortality rate ratios were calculated for adults aged 30-74 years old. Poisson regression analysis was performed to assess the independent effects of sex, urban-rural residence and education on drowning mortality. RESULTS: Drowning ASMRs were significantly higher in the Baltic countries than in Finland but declined by nearly 30% in all countries across the study period. There were large inequalities by sex, urban-rural residence and educational level in all countries during 2000-2015. Men, rural residents and low educated individuals had substantially higher drowning ASMRs compared to their counterparts. Absolute and relative inequalities were significantly larger in the Baltic countries than in Finland. Absolute inequalities in drowning mortality declined in all countries across the study period except between urban and rural residents in Finland. Changes in relative inequalities were more variable during 2000-2015. CONCLUSION: Despite a sharp reduction in deaths from drowning in the Baltic countries and Finland in 2000-2015, drowning mortality was still high in these countries at the end of the study period with a substantially larger risk of death seen among men, rural residents and low educated individuals. A concerted effort to prevent drowning mortality among those most at risk may reduce drownings considerably in the general population.

Educational inequalities in hypothermia mortality in the Baltic countries and Finland in 2000-15.

BACKGROUND: Despite an increased focus on cold-related mortality in recent years, there has been comparatively little research specifically on hypothermia mortality and its associated factors. METHODS: Educational inequalities in hypothermia mortality among individuals aged 30-74 in the Baltic countries (Estonia, Latvia, Lithuania) and Finland in 2000-15 were examined using data from longitudinal mortality follow-up studies of population censuses (the Baltics) and from a longitudinal register-based population data file (Finland). RESULTS: Age-standardized mortality rates (ASMRs) were much higher in the Baltic countries than in Finland across the study period. From 2000-07 to 2008-15, overall ASMRs declined in all countries except among Finnish women. Although a strong educational gradient was observed in hypothermia mortality in all countries in 2000-07, inequalities were larger in the Baltic countries. Between 2000-07 and 2008-15, ASMRs declined in all educational groups except for high-educated women in Finland and low-educated women in Lithuania; the changes however were not always statistically significant. The absolute mortality decline was often larger among the low educated resulting in narrowing absolute inequalities (excepting Lithuania), whereas a larger relative decline among the high educated (excepting Finnish women) resulted in a considerable widening of relative inequalities in hypothermia mortality by 2008-15. CONCLUSION: Although some reduction was observed in absolute educational inequalities in hypothermia mortality in 2000-15, substantial and widening relative inequalities highlight the need for further action in combatting factors behind deaths from excessive cold in socioeconomically disadvantaged groups, including risky alcohol consumption and homelessness.

Perinatal Health Inequalities in the Industrial Region of Estonia: A Birth Registry-Based Study.

Despite the increasing number of studies on industrially contaminated sites (ICS) and their health effects, there are very few studies on perinatal health outcomes in ICSs. In the present study, we examined the perinatal health inequalities by comparing adverse birth outcomes (ABOs) in the oil shale industry region of Ida-Viru County in Estonia with national-level figures and investigated the effects of maternal environmental and sociodemographic factors. Based on the 208,313 birth records from 2004-2018, Ida-Viru ICS has a birth weight 124.5 g lower than the average of 3544 g in Estonia. A higher prevalence of preterm birth (4.3%) and low birth weight (4.8%) in Ida-Viru ICS is found compared to 3.3% on both indicators at the national level. Multiple logistic regression analysis shows the statistically significant association of ABOs with fine particle (PM2.5) air pollution, mother's ethnicity, and education throughout Estonia. However, in Ida-Viru ICS, the ABOs odds are remarkably higher in these characteristics except for the mother's ethnicity. Furthermore, the ABOs are associated with the residential proximity to ICS. Thus, the Ida-Viru ICS has unequally higher odds of adverse perinatal health across the environmental and sociodemographic factors. In addition to reducing the air pollutants, policy actions on social disparities are vital to address the country's unjustly higher perinatal health inequalities, especially in the Ida-Viru ICS.

Educational inequalities in epilepsy mortality in the Baltic countries and Finland in 2000-2015.

Little is known about socioeconomic differences in epilepsy mortality. This study examined educational inequalities in epilepsy mortality in the general population in the Baltic countries and Finland in 2000-2015. Education-specific mortality estimates for individuals aged 30-74 in Estonia, Latvia and Lithuania were obtained from census-linked mortality datasets while data for Finland came from the register-based population and death data file of Statistics Finland. Trends and educational inequalities in epilepsy mortality were assessed using age-standardised mortality rates (ASMRs) per 100,000 person years and age-adjusted mortality rate ratios (RRs) calculated using Poisson regression. ASMRs were higher in men than women in all countries. ASMRs reduced in 2000-2015 among all men and women except for Finnish women. Among men, an inverse educational gradient in epilepsy mortality in 2000-2007 widened in 2008-2015 with ASMRs falling among high and mid educated men in all countries but increasing among low educated men in three countries. An inverse educational gradient in female mortality remained in all countries throughout 2000-2015. Although epilepsy mortality fell in the Baltic countries and Finland (men only) in 2000-2015, this masked a clear inverse educational gradient in mortality that became steeper across the period.

Health impact assessment of transportation noise in two Estonian cities.

Transportation noise is a growing public health concern worldwide, especially in urban areas, causing annoyance, sleep disturbance, cardiovascular diseases and other health effects. Recently, European Commission (EC) has developed a mutual methodology for assessing health impacts of transportation noise in European Union using strategic noise mapping. Applying this methodology, our aim was to quantify the health effects of road, rail and aircraft noise in two Estonian cities, Tallinn and Tartu. We also aimed to assess sensitivity of this methodology, while implementing lower threshold values and employing additional health outcomes. The proportion of highly annoyed residents due to road traffic noise was 11.6% in Tallinn, and 9.2% in Tartu; around 2.5% residents in both cities could have high sleeping disturbances. As exposure to railway and aircraft noise was relatively low in both cities, people with high annoyance and high sleep disturbance caused by railway and aircraft noise was below 1%. Ischemic heart disease (IHD) cases attributable to road traffic noise was estimated to be 122.6 in Tallinn and 21.5 in Tartu. Altogether transportation noise was estimated to cause 1807 disability adjusted life years (DALYs) in Tallinn and 370 DALYs in Tartu. The health costs were calculated as €126.5 and €25.9 million annually, respectively in the two cities. When we included higher number of health outcomes (stroke incidence, IHD deaths) and lowered exposure threshold by 5 dB, the annual burden of disease was doubled. As the latest epidemiological studies showed transportation noise having larger number of effects on lower noise levels, the results with the currently applied European Commission health impact assessment (HIA) methodology were rather conservative. Despite of uncertainties associated to applied methodology, transportation noise, especially road traffic noise, is an important environmental risk factor, that leads to considerable loss of healthy life years and causes large health costs in urban areas.

Socio-economic and demographic patterns of mental health complaints among the employed adults in Estonia.

BACKGROUND: Mental health problems follow a distinct socio-economic gradient and contribute to the health inequalities. The study aims to analyse the socio-economic and demographic factors of self-reported mental health complaints (stress, depressiveness, overtiredness, suicidal thoughts) among employed adult population in Estonia. METHODS: Data on 4041 employed respondents (2064 men and 1977 women) aged 20-64 years from nationally representative health surveys from years 2016 and 2018 in Estonia were used for the study. Dependent variables included self-reported stress, depressiveness, overtiredness, and suicidal thoughts. Descriptive statistics and both log-binomial and Poisson regression analysis were used to describe the socio-economic and demographic variations in these mental health complaints. RESULTS: More than half of the respondents had either stress, depressiveness, overtiredness or suicidal thoughts with 25% reporting two or more of mental health complaints. Lower personal income was associated with higher rates of all mental health complaints (stress, depressiveness, overtiredness, and suicidal thoughts) among employed adults in Estonia. Additionally, lower education was associated with higher prevalence of depressiveness and lower job skills predicted higher prevalence of suicidal thoughts. Higher prevalence ratios for depressiveness and overtiredness were found for women compared to men whereas Estonians had higher prevalence ratios for stress and suicidal thoughts compared to non-Estonians. All mental health complaints were more frequently reported at younger ages (compared to 50-64-year olds) and by not married or cohabiting respondents. CONCLUSION: High prevalence of mental health complaints and their socio-economic and demographic patterning refer to considerable inequalities in mental health among employed adults. Policy actions targeting especially younger adults and those with financial difficulties are needed to address these early manifestations of mental health problems.

Costs of multidrug-resistant TB treatment in Finland and Estonia affected by the 2019 WHO guidelines.

BACKGROUND: Multidrug-resistant TB (MDR-TB) is a growing problem in the effort to end the global TB epidemic. In 2019, the WHO adopted a new standardised regiment for MDR-TB, consisting of only oral medications.METHODS: We estimated the impact of the new guidelines on the costs of TB treatment in Estonia and Finland. For both countries, the costs of the two most common new drug regimens were calculated, including drug costs, as well as care- and monitoring-related costs.RESULTS: In Turku, Finland, treatment costs with the old regimen were €178,714; this could either increase by 10% or decrease by 18%, depending on the duration of bedaquiline use (6 months vs. 20 months). In Estonia, treatment costs with the old regimen were €33,664, whereas the new regimens were associated with a 40% increase in overall costs.CONCLUSIONS: The 2019 WHO guidelines have led to significant changes in the costs of MDR-TB treatment in Finland and Estonia. These changes depend mostly on the drug regimen administered and on care-related practices, with important differences between countries and even within the same country due to local practices.

Leisure Time Physical Activity and Associated Factors among Adults in Estonia 2000-2018.

In order to implement evidence-based strategies, there is a need to assess (1) time trend in leisure time physical activity (LTPA) and (2) the relationship between trend of LTPA and trend of potential explanatory factors in Estonia from 2000 to 2018. Data from 25-64-year-old adults (n = 16,903) were drawn from cross-sectional surveys of Health Behavior among Estonian Adult Population. Joinpoint regression analysis was used to calculate annual percentage changes (APCs) and to identify whether there was a significant change in trends of LTPA. Logistic regression analysis was used to assess associations of LTPA with socioeconomic, health-related and health-behavioral factors. Prevalence of LTPA increased from 26.2% to 44.1% among men and from 28.0% to 40.6% among women from 2000 to 2018 (p < 0.001). Average APC for men was 3.4% (95% CI 2.6-4.3) and for women 2.4% (95% CI 1.4-3.4). Adjusted logistic regression model showed that LTPA was statistically significantly associated with higher education and income, economic inactivity, at-least-good self-rated health (SRH) and non-smoking. Interaction of SRH with study year was significant indicating that the association of at-least-good SRH changed over time (p = 0.016). Health promotion activities should be addressed in particular to adults with lower levels of LTPA, paying attention to the factors associated with LTPA.

Examining the relationships between income inequalities and different dimensions of well-being in selected Central Eastern European (CEE) countries.

This article examines the relationships between different dimensions of well-being and income inequalities across selected Central Eastern European countries after joining the European Union in 2004. Regarding the multivariety of well-being concept, it explores its 5 dimensions (material dimension, health dimension, education dimension, environmental dimension, happiness). Accounting for the interactions between dimensions of well-being matters for the inequalities, we conducted an in-depth analysis by adopting PMG estimation and panel ARDL model to assess the short-run and long-run links between variables. The results of conducted analysis allowed us to identify the canals through which income inequalities are linked directly or indirectly with the particular dimensions of well-being. In the long run, all the dimensions of well-being significantly affected income inequalities, and income inequality shaped material dimension, health, education, natural environment, and happiness. However, in the short run, the only dimension that shaped income inequalities was education. Income inequalities directly affected both health dimension and happiness.

Changing effect of the numerator-denominator bias in unlinked data on mortality differentials by education: evidence from Estonia, 2000-2015.

BACKGROUND: This study highlights changing disagreement between census and death record information in the reporting of the education of the deceased and shows how these reporting differences influence a range of mortality inequality estimates. METHODS: This study uses a census-linked mortality data set for Estonia for the periods 2000-2003 and 2012-2015. The information on the education of the deceased was drawn from both the censuses and death records. Range-type, Gini-type and regression-based measures were applied to measure absolute and relative mortality inequality according to the two types of data on the education of the deceased. RESULTS: The study found a small effect of the numerator-denominator bias on unlinked mortality estimates for the period 2000-2003. The effect of this bias became sizeable in the period 2012-2015: in high education group, mortality was overestimated by 23-28%, whereas the middle education group showed notable underestimation of mortality. The same effect was small for the lowest education group. These biases led to substantial distortions in range-type inequality measures, whereas unlinked and linked Gini-type measures showed somewhat closer agreement. CONCLUSIONS: The changing distortions in the unlinked estimates reported in this study warn that this type of evidence cannot be readily used for monitoring changes in mortality inequalities.

Quantifying the social costs and benefits of tobacco in Estonia.

BACKGROUND: The tobacco cost literature has predominantly focused on estimating direct healthcare costs and productivity losses from morbidity and mortality. This study places a greater focus on the effects that arise through the fiscal system, illicit trade and fire accidents to estimate the social costs and benefits of tobacco use in Estonia in 2018. METHODS: A prevalence-based cost-of-illness approach was used, relying on data from the 2017-2018 period. Age-specific tobacco-attributable fractions were employed to estimate the costs and benefits of tobacco-related morbidity and mortality. Data on mortality, morbidity and healthcare costs were received from the National Institute of Health Development and the Estonian Health Insurance Fund. We used data for offences and fires from the Estonian Rescue Board and the Estonian Tax and Customs Board. RESULTS: It was estimated that the total social cost attributable to tobacco in Estonia in 2018 was €174 million, representing 0.67% of the nation's GDP. If future benefits are also considered, the net social cost is €78 million. While the greatest cost components are productivity losses from mortality and morbidity, the level of tobacco-related law enforcement costs are comparable to direct healthcare costs, both of which exceed €10 million annually. CONCLUSIONS: Despite the substantial social benefits arising through the fiscal system, tobacco-related costs outweighed these benefits in Estonia in 2018. In addition, a considerable portion of the economic burden of tobacco is associated with illicit trade. Therefore, the healthcare and law enforcement sectors would both benefit from effective tobacco control policies.

The prevalence and patterns of exposure to interpersonal violence among men and women in Estonia.

BACKGROUND: To understand better the total burden of interpersonal violence on society, it is useful to assess the prevalence of interpersonal violence among both, men and women. Exposure to multiple forms of interpersonal violence, referred to as polyvictimization, has been associated with more severe health consequences than exposure to any form separately. The aims of this study were to assess the prevalence of emotional, physical and sexual interpersonal violence in childhood, adulthood and at both childhood and adulthood among men and women in Estonia, analyze the patterns of interpersonal violence and socio-demographic correlates of polyvictimization in adulthood by gender. METHODS: The analysis was based on two population-based, cross-sectional, self-administered surveys carried out among men and women in Estonia in 2014. In both surveys, the NorVold Abuse questionnaire was used to measure exposure to interpersonal violence. Men and women aged 18-44 were included to the analysis. RESULTS: Among men 66.6% and among women 54.2% had been exposed to at least one form of interpersonal violence during lifetime. Men had been more often exposed to isolated physical interpersonal violence, among women the distribution of different forms of interpersonal violence was more even and exposure to sexual violence was more common. The prevalence of polyvictimization in adulthood was two times higher among women compared to men and more socio-demographic correlates, were associated with it. Exposure to violence in childhood was associated with polyvictimization in adulthood across gender. CONCLUSIONS: The prevalence of interpersonal violence in Estonia is high among men and women. The most prevalent forms and patterns of interpersonal violence, however, differ by gender, as do the socio-demographic correlates. Screening for interpersonal violence, in childhood and adulthood, and gender-specific interventions are needed, especially for high-risk groups identified in this study. Primary prevention of childhood violence should be a priority, as it was associated with higher risk for exposure to violence later in life across gender.

Estonia advances on SDG achievement by tackling high alcohol consumption through a multi-pronged approach.

Estonia has implemented a comprehensive, multipronged approach to the reduction of alcohol consumption in the population, comprising a series of successful policy responses. The Estonian alcohol strategy (2014) builds on the Global strategy to reduce the harmful use of alcohol and the European action plan to reduce the harmful use of alcohol 2012-2010. It aims to decrease the overall yearly consumption of alcohol among the adult population to less than 8 litres of absolute alcohol per capita. Gathering support across society from a range of stakeholders, including policy-makers, researchers, parents and advocates, has been one of the key elements in the implementation of the policy. High-level political commitment and strategic timing of efforts have maintained the issue of alcohol control on the political agenda and in the public's mind.

Association of FTO rs1421085 with obesity, diet, physical activity, and socioeconomic status: A longitudinal birth cohort study.

BACKGROUND AND AIMS: Fat mass and obesity-associated protein (FTO) variants are among genetic variants frequently associated with obesity. We analyzed the association between FTO rs1421085 polymorphism and obesity, dietary intake, cardiorespiratory fitness (CRF), physical activity, and socioeconomic status (SES) from the age of 9-25 years. METHODS AND RESULTS: The sample included both birth cohorts (originally n = 1176) of the Estonian Children Personality Behaviour and Health Study. The association between FTO rs1421085 and obesity, dietary intake, CRF, physical activity, and SES from the age of 15-25 years was assessed using linear mixed-effects regression models. Associations at ages 9 (younger cohort only), 15, 18, and 25 years were assessed by one-way ANOVA. Male C-allele carriers had significantly (p < 0.05) higher body mass index (BMI), sum of 5 skinfolds, body fat percentage, and hip circumference from the age of 15-25 years. Findings were similar at the age of 9 years. In female subjects, waist-to-hip ratio was significantly greater in CC homozygotes. Interestingly, female CC homozygotes had a greater decrease in the rate of change in daily energy intake and lipid intake per year and higher physical activity score at every fixed time point. Moreover, in females, an effect of FTO × SES interaction on measures of obesity was observed. CONCLUSION: The FTO rs1421085 polymorphism was associated with obesity and abdominal obesity from childhood to young adulthood in males, and with abdominal obesity from adolescence to young adulthood in females. This association is rather related to differences in adipocyte energy metabolism than lifestyle.

Survival and sex composition of offspring: Individual-level responses in the quantum and tempo of childbearing during the demographic transition.

Previous studies have documented varying fertility responses to childhood mortality and to the sex composition of the surviving offspring during the demographic transition. We contribute to this literature by applying a mixture cure model to reproductive histories of Estonian women born 1850-99. This model, unlike standard event history models, is capable of separating the effect of the covariates on the propensity of having another birth from their effect on its timing. Child fatalities, not having sons, and to a smaller extent, not having daughters, increased the propensity to have another child and decreased the interval to it. The response was stronger among later cohorts, but only with respect to parity progression. By contrast, the accelerated childbearing response diminished over time. Our findings suggest that behavioural responses in the quantum and tempo of childbearing can occur relatively independently.

E-Cigarette Use by Smoking Status in Estonia, 2012-2018.

Abstract: Background: In the context of declining smoking rates in Estonia, this study aims to analyze the recent trends in e-cigarette use and its associations with smoking status and sociodemographic factors. Methods: Nationally representative data from biennial cross-sectional health surveys in 2012-2018 (n = 9988) were used to describe the prevalence of smoking and e-cigarette use by smoking status in Estonia. Multivariate logistic regression analysis was used to describe the sociodemographic patterns of e-cigarette use in three subgroups: the general population, smokers, and ex-smokers. Results: The prevalence of current smoking decreased from 45.4% in 2012 to 31.5% in 2018 among men and from 26.6% to 20.0% among women. At the same time, e-cigarette use in the general population had increased to 3.7% among men and to 1.2% among women. The increase in the prevalence of e-cigarette use was statistically significant among men in the general population, smokers, and ex-smokers, but non-significant among women. In addition to period effects, e-cigarette use was patterned by age, gender, and education. Conclusion: In 2002-2018, the e-cigarette use had increased but smoking had decreased in Estonia. A timely and targeted tobacco policy may alleviate the harm of e-cigarette use from the public health perspective.

Comparison of psychotropic medication use in the Baltic countries.

Purpose: While the pivotal role of pharmacotherapy in psychiatry is universal, significant regional differences exist in drug use patterns. Herewith we compare the use of ATC psychotropic drugs (N05, psycholeptics and N06A, antidepressants) in 2010-2015 in the three Baltic Countries with reference to the Nordic Countries.Methods: Data were obtained from the national authorities on medicines as expressed in DDD per 1000 inhabitants per day. A semi-structured questionnaire was used for expert statements on the rationale of current use of medicines.Results: During the observation period the use of antipsychotics, anxiolytics, hypnotics and sedatives, and antidepressants steadily increased, while the growth in use of anxiolytics stagnated in the more recent years. Antipsychotic use was the largest in Lithuania and the lowest in Estonia. The use on anxiolytics in Lithuania was more than twice of that in Estonia and Latvia. Conversely, the use of hypnotics and sedatives was about three times higher in Estonia than in Latvia or Lithuania. Antidepressant use was dominated by the selective serotonin reuptake inhibitors in all three countries, but overall was much lower in Latvia as compared to Lithuania and Estonia. As compared to the Nordic Countries in 2015, antidepressants are used at much lower level throughout Baltics, probably reflecting underdiagnostics of depression and anxiety disorders.Conclusion: While the health-care expenditures in Estonia, Latvia and Lithuania are largely similar, as is the cultural and recent political background of these EU member countries, the extent and the pattern of psychotropic drug use is remarkably variable.

The Cost-Effectiveness of Abdominal Aortic Aneurysm Screening in Estonia.

OBJECTIVE: To assess the cost-effectiveness of population-based abdominal aortic aneurysm (AAA) screening in Estonia. METHODS: A Markov cohort model was used to evaluate the cost-effectiveness of population-based AAA screening compared with no screening. A hypothetical cohort of 6000 men aged 65 was followed for 35 years. Data for disease transition probabilities and quality of life outcomes were obtained from published literature; costs were calculated based on Estonian data. Analysis followed the healthcare payer's perspective using an annual discount rate of 5% for costs and effects. The model evaluated the number of avoidable AAA ruptures and AAA-related deaths and the differences in costs and quality-adjusted life-years (QALYs). RESULTS: The AAA screening would have prevented 10 AAA ruptures and 6 AAA-related deaths among the cohort of 6000 men, resulting in 23 QALYs gained (0.000378 QALYs per individual). The additional cost of the screening and treatment was €39 429 (€65.4 per individual) with the incremental cost-effectiveness ratio for screening compared with no screening being €17 303 per QALY gained. Although results were sensitive to assumptions regarding health-related quality of life and the models' time horizon, screening was found to be cost-effective with a 99% probability at a willingness-to-pay threshold of €30 000 per QALY. CONCLUSION: Population-based AAA screening of elderly men is likely to be a cost-effective measure in reducing the AAA-related disease burden. Given the increase in the overall costs, the actual policy decisions regarding implementing an AAA screening program in Estonia are likely to be influenced by availability of resources as well.

Alcohol consumption and alcohol policy in Estonia 2000-2017 in the context of Baltic and Nordic countries.

INTRODUCTION AND AIMS: Alcohol consumption has become a global health threat and there is need for an evidence-based global alcohol policy. This study aimed to describe alcohol consumption in parallel with alcohol policy in 2000-2017 in Estonia in the context of Baltic and Nordic countries. DESIGN AND METHODS: A review of routine statistics concerning alcohol consumption and the pertinent legislation in Estonia was performed. The measures used to assess the effects of alcohol policy were adult (15 and older) pure alcohol per capita consumption (APC) in litres, alcohol outlet densities and opening hours, taxes and the price of alcoholic beverages. RESULTS: Adult domestic APC in Estonia increased from 9.3 to 14.8 in 2000-2007 and thereafter decreased to 10.2 in 2016 (10.3 in 2017). Adult APC in Estonia was lower than that in Latvia and Lithuania but higher than that in Nordic countries. Since 2010, beer has been the most prevalent alcoholic beverage in Estonia. The density and opening hours of alcohol retail shops were much higher in Estonia and other Baltic countries than in Nordic countries. The alcohol retail price increased twice from 2006 to 2017 in Estonia, resulting in a double price difference with Latvia. DISCUSSION AND CONCLUSIONS: Evidence-based comprehensive alcohol policy should continue in Estonia. Based on the example of Nordic countries, more attention should be paid to the physical availability of alcohol in Estonia. In terms of economic availability, it is important to focus on the cross-border alcohol trade to achieve improvements in public health.

Economic fluctuations and long-term trends in depression: a repeated cross-sectional study in Estonia 2004-2016.

BACKGROUND: In the 2000s, the Baltic countries experienced unprecedented credit-driven economic growth that was followed by a deep recession. This study examined the impact of profound macroeconomic changes on population mental health in Estonia in 2004-2016. METHODS: Data on 17 794 individuals in the 20-64 age group were obtained from seven nationally representative cross-sectional surveys. The prevalence of past 30-day depression was calculated for men and women further stratified by sociodemographic characteristics. Multivariable regression analysis was used to assess whether these characteristics were associated with the yearly variation in depression. RESULTS: In 2006, the adjusted prevalence ratio for depression was 0.77 (95% CI 0.64 to 0.93) for men and 0.85 (95% CI 0.74 to 0.97) for women as compared with 2004; in 2010, the prevalence ratio as compared with 2008 for both men and women was 1.22 (95% CIs 1.04 to 1.43 and 1.09 to 1.37, respectively). Among men, the increase in the prevalence of depression in 2008-2010 was statistically significant for 35-64 year olds, ethnic Estonians, those who were married, mid-educated or were employed, whereas among women, a significant increase was observed in 50-64 year olds, Estonians and non-Estonians, those who were not-married, were highly educated or mid-educated, in the mid-income group or were employed. CONCLUSIONS: Population mental health is responsive to macroeconomic changes. In less wealthy high-income countries, the greater impact of recession on depression among advantaged groups may relate to a higher debt burden coupled with job insecurity.