Occupation as a Proxy for Job Exposures? Routine Data Analysis Using the Example of Rehabilitation.

AIM OF THE STUDY: Job exposures are associated with health-related outcomes including sick leave and reduction in earning capacity. Rehabilitation of persons in working age aims primarily to secure or restore work capacity. Information concerning job exposures is, however, not directly available in routine data of healthcare payers. Since exposures relate to specific occupations and the current occupation is part of routine data, job exposures may be determined indirectly via job-exposure matrices (JEM). The aim of the study is to describe the possibilities and challenges of the representation of job exposures by the occupation according to routine data using the example of rehabilitation. METHODS: The Scientific Use File 'SUFRSDLV15B' of the German Pension Insurance was analysed. We used data from n=1 242 171 persons in work with at least one completed medical rehabilitation between 2008 and 2015 (dataset 1). The occupation is coded according to KldB 88 or KldB 2010 (German Classification of Occupations). In addition, data from a nationwide survey with 2530 rehabilitation patients was available (dataset 2). Job exposures are operationalized by the Job Exposure Index via JEM. The relationship to the return-to-work prognosis at the end of rehabilitation (dataset 1) and to patient reported outcome measures (dataset 2) is described. RESULTS: Information concerning the occupation is available for about 91% of rehabilitation measures of employed patients for the year prior to rehabilitation. At high levels of job exposures, the proportion of persons with a predicted working capacity in the last job of fewer than 3 h per day increased by a factor of 4 compared to low-level job exposures (23.5 vs. 6.1%). On the other hand, there is a low association only to reduced working capacity in the general labour market (2.9 vs. 2.4%). High-level job exposures are associated with self-reported, work-related impairments. CONCLUSION: The Job Exposure Index may offer a valid approach to depict occupation-related exposures. The index can be used in the analysis of routine data of the pension insurance and other social security funds, as well as in the linkage of individual assessment data with routine data containing the occupation, without any additional data collection effort. Due to its construction based on job classifications, it will not replace the assessment of individual burdens.

[Medical rehabilitation from a lifespan perspective]. / Medizinische Rehabilitation unter einer Lifespan-Perspektive.

Lifespan research investigates the development of individuals over the course of life. As medical rehabilitation deals with primary and secondary prophylaxis, treatment, and compensation of chronic illnesses, a lifespan perspective is needed for the classification and diagnosis of chronic disorders, the assessment of course modifying factors, the identification of vulnerable life periods and critical incidents, the implementation of preventive measures, the development of methods for the evaluation of prior treatments, the selection and prioritization of interventions, including specialized inpatient rehabilitation, the coordination of therapies and therapists, and for evaluations in social and forensic medicine. Due to the variety of individual risk constellations, illness courses and treatment situations across the lifespan, personalized medicine is especially important in the context of medical rehabilitation, which takes into consideration hindering and fostering factors alike.

Promoting patient self-management following cardiac rehabilitation using a web-based application: A pilot study.

Background: The use of health-related mobile apps has become an important component of healthcare. Patients can use a range of tools to strengthen their health literacy and promote disease management. The aim of the project was to develop a web-based application for use on smartphones, tablets and computers for patients with cardiovascular diseases (cardio-app). Methods: A semi-standardized written survey was conducted among rehabilitation patients with cardiovascular diseases (n = 158). The usability of the cardio-app was assessed using the System Usability Scale (SUS). The usage behaviour was conducted with a self-developed questionnaire. Results: The study enrolled 158 eligible rehabilitation patients. The SUS of the cardio-app determined was 74.4 (SD ± 17.4). For 86%, the menu navigation was self-explanatory and logical. The visual presentation appealed to 92% of respondents. The content of the texts used in the app was understandable for 95%, and 93% found the technical terms used in the glossary well explained. For 57%, the app was helpful in planning their physical activities. 83% of the rehabilitation patients would recommend the app to others. The main criticisms of the app were the lack of synchronization options with other apps. Of those who did not use the app, the following reasons for non-use were most frequently cited: too much effort (43%), lack of time (29%) and pandemic-related reasons (29%). Conclusions: The cardio-app revealed high agreement values. Whether the use of the app is associated with improved clinical state and outcome would have to be verified in further studies.

Comparison of population health status in six european countries: results of a representative survey using the EQ-5D questionnaire.

BACKGROUND: The EQ-5D questionnaire is an instrument for describing and valuing health states. OBJECTIVES: To compare general population health status measured by the EQ-5D in 6 European countries. METHODS: In the European Study of the Epidemiology of Mental Disorders representative population samples in Belgium (n = 2411), France (n = 2892), Germany (n = 3552), Italy (n = 4709), the Netherlands (n = 2367), and Spain (n = 5473) completed the EQ-5D as part of personal computer-based home interviews in 2001 to 2003. RESULTS: Of all respondents, 35.1% reported problems in one or more EQ-5D dimensions, most frequently pain/discomfort (28.5%), followed by mobility (13.6%), usual activities (10.5%), anxiety/depression (8.0%), and self-care (3.6%). Proportions of respondents reporting any problems differed significantly between countries, ranging from 26.6% in Spain to 44.5% in France. Mean EQ VAS score was 77.1, ranging from 75.0 in Spain to 82.0 in the Netherlands. After adjusting for sociodemographic variables, the proportion of respondents reporting problems in any of the EQ-5D dimensions was significantly higher in France and lower in Spain and Italy than the grand mean. Even after controlling for reported EQ-5D health states, mean EQ VAS scores were significantly higher in the Netherlands and lower in Spain than the grand mean. Age, female gender, low educational level, lack of paid employment, and low income were associated with more problems in most of the EQ-5D dimensions and lower EQ VAS scores. CONCLUSIONS: Self-reported EQ-5D health status differed considerably between countries, calling for caution when making international comparisons of disease burden and health care effectiveness.

Comparison of different valuation methods for population health status measured by the EQ-5D in three European countries.

OBJECTIVE: The purpose of this study was to analyze and compare different valuation methods for population health status measured by the EuroQol-5D (EQ-5D) in three European countries. METHODS: A representative survey of the noninstitutionalized population aged 18 and above was conducted in three European countries (Germany, The Netherlands, and Spain). A total of 11,932 respondents were interviewed using the EQ-5D self-classifier. Health state values based on community preferences (EQ-5D index) were calculated for each country using four different value sets: national value sets based on the time trade-off (TTO) and the visual analogue scale (VAS), the UK TTO-based value set and the European VAS-based value set. Linear regression analysis was conducted to evaluate the factors associated with different EQ-5D index scores depending on the value set used. Loss of quality-adjusted life-years (QALYs) was calculated for each country using the four value sets by multiplying the age and gender-specific values with the respective population size. RESULTS: In all countries, means of all EQ-5D index scores were higher for men than women, and decreased with age. Index scores calculated using the national value set based on TTO were higher than those calculated using the UK TTO-based value set and, also, slightly higher than those calculated using the European VAS-based value set or the national value set based on the VAS. The mean loss of QALYs estimated for Germany per inhabitant varied between 0.062 (national value set based on TTO) and 0.094 (European VAS-based value set). In The Netherlands, the mean loss of QALYs per inhabitant ranged from 0.090 (national value set based on TTO) to 0.125 (national value set based on VAS). In Spain, the mean loss of QALYs per inhabitant ranged between 0.072 (national value set based on TTO) and 0.085 (European VAS-based value set). CONCLUSIONS: In general, the differences among countries and valuations were rather small; nevertheless, some important variations should be taken into account while applying different valuation methods to the EQ-5D descriptive system. The associations between sociodemographic variables and health state scores remained the same across countries regardless of which value sets were used. Using different valuation methods lead to different QALY losses. To overcome this problem in international surveys aimed to compare health state scores or QALYs, it is advisable to use a single valuation method, making these scores comparable.

Is it always the same? Variability of depressive symptoms across six European countries.

Using common diagnostic systems together with structured interviews to assess mental disorders has made it possible to compare diagnostic groups of mental disorders across countries. The implicit assumption is that the symptomatology of a particular disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) will not vary between different countries. However, it is conceivable that there will be some variability in the symptom patterns. The present study examines if differences in depressive symptom patterns across European countries can be found and if there are different associations between symptoms and the latent construct depression. Data from 4025 individuals of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project were analysed. Individuals were interviewed using the Composite International Diagnostic Interview (CIDI 3.0). Confirmatory factor analysis was used to examine the associations between depressive symptoms and the latent construct of depression in each country. The proportions of endorsed symptoms of depression showed only slight variation across European countries and only minor to moderate differences in the associations between depressive symptoms and the latent construct depression. The results demonstrated that in European countries using a fully structured and standardized interview based on European-American diagnostic concepts leads to similar results with regard to depressive symptom patterns.

Direct medical mental health care costs of schizophrenia in France, Germany and the United Kingdom - findings from the European Schizophrenia Cohort (EuroSC).

OBJECTIVES: To quantify and compare the resource consumption and direct costs of medical mental health care of patients suffering from schizophrenia in France, Germany and the United Kingdom. METHODS: In the European Cohort Study of Schizophrenia, a naturalistic two-year follow-up study, patients were recruited in France (N=288), Germany (N=618), and the United Kingdom (N=302). Data about the use of services and medication were collected. Unit cost data were obtained and transformed into United States Dollar Purchasing Power Parities (USD-PPP). Mean service use and costs were estimated using between-effects regression models. RESULTS: In the French/German/UK sample estimated means for a six-month period were respectively 5.7, 7.5 and 6.4 inpatient days, and 11.0, 1.3, and 0.7 day-clinic days. After controlling for age, sex, number of former hospitalizations and psychopathology (CGI score), mean costs were 3700/2815/3352 USD-PPP. CONCLUSIONS: Service use and estimated costs varied considerably between countries. The greatest differences were related to day-clinic use. The use of services was not consistently higher in one country than in the others. Estimated costs did not necessarily reflect the quantity of service use, since unit costs for individual types of service varied considerably between countries.

Relationship between parental bonding and mood disorder in six European countries.

The linkage between adverse parental child-rearing styles and the occurrence of mood disorders in adulthood has been investigated in a number of studies from different countries and cultural backgrounds. However, as direct cross-cultural comparisons hardly exist, little is known about cultural variations of this relationship. The European Study of the Epidemiology of Mental Disorders (ESEMeD) is a cross-sectional study in a stratified multi-stage random sample of 21,425 adults (18 years or older) from the general population of six European countries (Belgium, France, Germany, Italy, Netherlands, and Spain). Parental child-rearing styles were measured by means of a short form of the Parental Bonding Instrument (PBI) in 8,232 of the respondents. Based on the extraction and confirmation of a three-factor model of the PBI in a previous study, the association between parental bonding and mood disorders was studied by computing hierarchical nested multiple logistic regression models. The relationship between parental child-rearing styles and mood disorders was mostly homogeneous across the six countries. The PBI dimensions maternal and paternal care had the strongest associations with mood disorders. A significant association of overprotection was observable only for the mother. There was no significant relationship between authoritarianism and the occurrence of mood disorders. In the European countries studied, the association between parental child-rearing styles and the occurrence of mood disorders appears not to be culture-dependent. It would be of interest to assess whether this also holds for the rest of Europe and non-European countries.

Empirical evidence for an invariant three-factor structure of the Parental Bonding Instrument in six European countries.

The objective of the present study was to test the Parental Bonding Instrument's (PBI) three-factor structure (care, overprotection, and authoritarianism) found by [Cox, B.J., Enns, M.W., Clara, I.P. 2000, The Parental Bonding Instrument: confirmatory evidence for a three-factor model in a psychiatric clinical sample and in the National Comorbidity Survey, Social Psychiatry and Psychiatric Epidemiology 35 (2000) 353-357.] on an eight-item short form of the scale. A total of 8813 respondents from the six European countries participating in the ESEMeD project (Belgium, France, Germany, Italy, The Netherlands, and Spain) completed either the PBI-paternal or the PBI-maternal scale. Maximum likelihood confirmatory factor analysis was used to compare the original factor model of Cox et al. with a three-factor solution that emerged from an exploration of the structure with principal component factor analysis. When gender and age subgroups, as well as different countries, were taken into account, the accuracy of the model was confirmed. The fit indices for the new model indicated a generally better model fit than the ones for the model originally developed by Cox et al. Further efforts should be directed to the modeling of the dimension authoritarianism. The results provide the opportunity to estimate the influence of the extracted factors on mental disorders in different countries. The application of the short form of the PBI seems suitable primarily for large epidemiological studies.

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys.

CONTEXT: Little is known about the extent or severity of untreated mental disorders, especially in less-developed countries. OBJECTIVE: To estimate prevalence, severity, and treatment of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders in 14 countries (6 less developed, 8 developed) in the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative. DESIGN, SETTING, AND PARTICIPANTS: Face-to-face household surveys of 60 463 community adults conducted from 2001-2003 in 14 countries in the Americas, Europe, the Middle East, Africa, and Asia. MAIN OUTCOME MEASURES: The DSM-IV disorders, severity, and treatment were assessed with the WMH version of the WHO Composite International Diagnostic Interview (WMH-CIDI), a fully structured, lay-administered psychiatric diagnostic interview. RESULTS: The prevalence of having any WMH-CIDI/DSM-IV disorder in the prior year varied widely, from 4.3% in Shanghai to 26.4% in the United States, with an interquartile range (IQR) of 9.1%-16.9%. Between 33.1% (Colombia) and 80.9% (Nigeria) of 12-month cases were mild (IQR, 40.2%-53.3%). Serious disorders were associated with substantial role disability. Although disorder severity was correlated with probability of treatment in almost all countries, 35.5% to 50.3% of serious cases in developed countries and 76.3% to 85.4% in less-developed countries received no treatment in the 12 months before the interview. Due to the high prevalence of mild and subthreshold cases, the number of those who received treatment far exceeds the number of untreated serious cases in every country. CONCLUSIONS: Reallocation of treatment resources could substantially decrease the problem of unmet need for treatment of mental disorders among serious cases. Structural barriers exist to this reallocation. Careful consideration needs to be given to the value of treating some mild cases, especially those at risk for progressing to more serious disorders.

Perceived need for mental health care and service use among adults in Western Europe: results of the ESEMeD project.

OBJECTIVE: This study assessed prevalence and correlates of perceived need for mental health care and its role in help seeking. METHODS: Data were from general population surveys conducted for the European Study of the Epidemiology of Mental Disorders. The sample consisted of adults who screened positive for specific mood and anxiety symptoms in surveys conducted in Belgium, France, Germany, Italy, The Netherlands, and Spain (N=8,796). These individuals were further assessed for mental disorders with the Composite International Diagnostic Interview 3.0. Respondents who reported voluntary use of health services to address concerns with their "emotions or mental health" or who reported a need for services for mental health reasons were considered to have perceived need. RESULTS: Nine percent of the total sample perceived some need for mental health care in the past 12 months. Among those who had a mental disorder in the past 12 months, 33% had perceived need. Psychiatric morbidity was the major determinant of perceived need. Among those with perceived need, older age, nonurban residence, and residence in Germany were positively associated with use of services. CONCLUSIONS: Only a third of those with a 12-month mental disorder perceived need for mental health care. Psychiatric morbidity was the main determinant of perceived need; however, other factors (being female and being older) were associated with use of health services among those with perceived need. Among those with perceived need, it is important to increase access to care for the youngest and those living in urban areas.

Adverse parenting as a risk factor in the occurrence of anxiety disorders : a study in six European countries.

OBJECTIVE: The aim of the study was to test the homogeneity of the association between adverse parenting and anxiety disorders within these disorders as well as among six European countries. METHOD: Based on data from 8,232 respondents (part II sample) originating from the European study of the epidemiology of mental disorders (ESEMeD), we examined the association between three dimensions of parental rearing (care, overprotection, authoritarianism) measured by a short form of the parental bonding instrument (PBI) and anxiety disorders by computing one logistic regression model per disorder. RESULTS: A similar pattern of recalled parenting behaviour across the four anxiety disorders assessed was found, with care and overprotection having the strongest associations. There were only minor country-specific variations of this pattern. CONCLUSION: Our results suggest an association between adverse parenting and the risk of anxiety disorders in particular as well as psychiatric disorders in general that is rather non-disorder specific.

The relation between body mass index, mental health, and functional disability: a European population perspective.

OBJECTIVE: To examine the association between body mass, mental disorders, and functional disability in the general population of 6 European countries. METHOD: Data (n = 21 425) were derived from the European Study on the Epidemiology of Mental Disorders (ESEMeD). The third version of the Composite International Diagnostic Interview was administered to assess mental disorders (mood, anxiety, and alcohol disorders) according to the Diagnostic Statistical Manual of Mental Disorders-fourth edition, body mass index (BMI) (kg/m(2), based on self-reported height and weight), and functional disability in the previous 30 days, assessed with the World Health Organization Disablement Assessment Scale-second version. RESULTS: About 3% of the respondents were underweight (BMI < 18.5 kg/m(2)), 53% had normal weight (BMI 18.5 to 24.9 kg/m(2)), 33% were overweight (BMI 25 to 29.9 kg/m(2)), and the remaining 12% met criteria for obesity (BMI >or= 30.0 kg/m(2)). Compared with individuals of normal weight, obese individuals were more likely to have mood (OR 1.3; 95%CI, 1.0 to 1.8) or more than one mental disorder (OR 1.4; 95%CI, 1.0 to 2.2). BMI had no impact on work loss days, whereas mental disorders had a considerable effect on work loss days. CONCLUSIONS: This is the first cross-national study investigating the role between BMI, mental disorders, and functional disability in the general population. Being overweight or obese is a common condition in the 6 ESEMeD countries. Although there is a moderate association between obesity and mental disorders, BMI did not independently influence functional disability.

Parental bonding and suicidality in adulthood.

OBJECTIVE: The short-term effect of an adverse parental child rearing style on suicidality in adolescence has been extensively discussed. Nevertheless, little is known about the long-term effect of adverse parental child rearing on lifetime suicidality in adulthood. So the present study aims to examine the relation between parental bonding on the one hand and suicidality in adulthood on the other. METHOD: We used data from 7740 respondents of the European Study of Epidemiology of Mental Disorders project, a cross-sectional household survey carried out in six European countries. The data were assessed with the World Mental Health Composite International Diagnostic Interview, a comprehensive, fully structured psychiatric diagnostic interview. Suicidality was categorized as follows: 'no ideation', 'ideation', 'attempt'. Parental bonding was assessed by means of a three-factor ('care', 'overprotection', 'authoritarianism') short form of the Parental Bonding Instrument. Using a multinomial-logistic regression model to investigate the association between these two constructs, we also adjusted for mood disorders, anxiety disorders, alcohol abuse/dependence and possible country effects. RESULTS: We found associations between low maternal and paternal care on the one hand and suicidality on the other. Country-specific differences proved negligible. CONCLUSIONS: Prevention programs can help better equip parents in their child-rearing role to create a more caring parenting environment. This can be a protective factor for suicidality in adulthood. Nevertheless, more efforts are necessary to better describe the paths that lead from child-rearing behaviour to suicidality in adulthood.

[The burden of depressive disorders in Germany - results from the European Study of the Epidemiology of Mental Disorders (ESEMeD)]. / Die Krankheitslast von depressiven Erkrankungen in Deutschland - Ergebnisse aus dem Projekt European Study of the Epidemiology of Mental Disorders (ESEMeD).

OBJECTIVE: The purpose of this study was to estimate and compare the disease burden of depression in Germany using preference-based valuations of depressive health states. METHODS: The data came from the European Study of the Epidemiology of Mental Disorders (ESEMeD) in which a representative sample of 3555 non-institutionalised adults aged 18 years or older was interviewed in Germany. Computer assisted personal interviews included EQ-5D, SF-12, time trade-off (TTO) and contingent valuation (willingness-to-pay, WTP). Respondents in whom 12-month prevalence for a depressive disorder according to DSM-IV was identified, were compared to respondents without depressive disorders (controls). Disease burden was measured in terms of loss of quality-adjusted life years (QALYs) and loss of monetary benefit due to depression per year. Valuations of health-related quality of life (HRQL) were derived from EQ-5D (EQ VAS and EQ-5D Index), SF-12 (SF-6D Index) and TTO. Disease burden was estimated by calculating the difference between individual valuation of HRQL/WTP for full health of cases and mean valuation/WTP of controls matched by age and gender. Results were extrapolated to the total population. RESULTS: Depending on the valuation method, the loss of QALYs per year due to depression in Germany was 144,886 (TTO), 239,152 (EQ-5D Index VAS), 265,085 (EQ-5D Index TTO), 307,139 (EQ VAS) and 403,373 (SF-6D Index). The additional WTP for full health amounted to 4.3 billion Euro. CONCLUSIONS: Depressive disorders caused a substantial disease burden. Subjects affected by depression showed lower preference-based scores compared to subjects without depression. However, calculated QALY losses varied strongly by valuation method.

Burnout of caregivers: a comparison between partners of psychiatric patients and nurses.

Care of a person with mental illness involves multiple burdens, possibly leading to burnout. This study compares partners of persons with schizophrenia and depression with nursing staff based on dimensions of burnout. Nursing staff and partners of patients with schizophrenia or depression were consecutively recruited from psychiatric hospitals and interviewed with the Maslach Burnout Inventory. No significant differences were found in the three dimensions of burnout (emotional exhaustion, depersonalization, and personal accomplishment) for the two groups of caregivers. About one fourth of the respondents in both groups showed a high degree of burnout. Professional and nonprofessional caregivers face a similar degree of burden and need support to perform their caretaking tasks.

[Measuring preferences for depressive health states]. / Präferenzmasse bei depressiven Erkrankungen -- Ein Vergleich des EuroQol-Instruments, des Time-Trade-Off-Verfahrens und der Messung der Zahlungsbereitschaft.

OBJECTIVE: The purpose of this study was to analyse the construct validity and the concurrent validity of the EuroQol instrument (EQ-5D self-classifier, EQ VAS and EQ-5D indices), time trade-off (TTO) and contingent valuation (willingness-to-pay) for preference-based valuation of depressive health states. METHODS: A survey of a representative sample (N = 3522) of the non-institutionalised population aged 18 and above in Germany was conducted using the EQ-5D, TTO and contingent valuation as well as the SF-12 questionnaire. Construct validity was analysed by comparing 130 respondents in whom 12-month prevalence for major depression, minor depression, or dystimia according to DSM-IV was identified based on a version of the Composite International Diagnostic Interview (WMH-CIDI) to respondents without depressive disorders. Concurrent validity was analysed by assessing the correlation between these measures in the group with depressive disorders. RESULTS: In the group with depressive disorders, problems in all EuroQol dimension except for mobility were significantly more frequent, and mean values of all analysed preference measures except for willingness-to-pay were less favourable than in the group without depressive disorders (EQ VAS score 67 vs. 78; EQ-5D index [VAS] 83 vs. 94; EQ-5D index [TTO] 0.81 vs. 0.91; TTO 0.89 vs. 0.95; always p < 0.001). In the group with depressive disorders, EQ VAS score and EQ-5D indices were significantly correlated one with another (ranging from r = 0.63 to r = 0.92) as well as with the mental and the physical component scale of the SF-12 (ranging from r = 0.26 to r = 0.45) and with willingness-to-pay (ranging from r = - 0.20 to r = - 0.22); besides, willingness-to-pay was significantly correlated with TTO (r = - 0.46). CONCLUSIONS: The results of this study point to the construct validity and concurrent validity of preference measures in patients with depressive disorders.

[The direct costs of depressive disorders in Germany]. / Die direkten Kosten von depressiven Erkrankungen in Deutschland -- Ergebnisse aus dem European Study of the Epidemiology of Mental Disorders (ESEMeD) Projekt.

OBJECTIVE: The purpose of this study was to estimate the direct costs of depression in Germany from the social perspective. METHODS: The data came from the European Study of the Epidemiology of Mental Disorders (ESEMeD), in which a representative sample of 3555 non-institutionalised adults aged 18 years or older was interviewed in Germany. Using the most recent version of the Composite International Diagnostic Interview (WMH-CIDI), 131 persons with a 12-month prevalence of major depression, minor depression and dysthymia were identified. These patients reported their mental health care consumption of the last 12 months retrospectively, which was valued by prices of 2002. RESULTS: The average direct costs for treating depressive disorders were 686 EUR per patient and year. The total direct costs of depression in Germany was estimated at approximately 1.6 billion EUR. CONCLUSIONS: Because the sample was restricted to the non-institutionalised population, calculated costs may be underestimated. The costs per inhabitant in Germany exceed those reported by studies from the United Kingdom but are lower than those reported for the USA.