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.

Excess mortality associated with the COVID-19 pandemic in Latvia: a population-level analysis of all-cause and noncommunicable disease deaths in 2020.

BACKGROUND: Age-standardised noncommunicable disease (NCD) mortality and the proportion of the elderly population in Latvia are high, while public health and health care systems are underresourced. The emerging COVID-19 pandemic raised concerns about its detrimental impact on all-cause and noncommunicable disease mortality in Latvia. We estimated the timing and number of excess all-cause and cause-specific deaths in 2020 in Latvia due to COVID-19 and selected noncommunicable diseases. METHODS: A time series analysis of all-cause and cause-specific weekly mortality from COVID-19, circulatory diseases, malignant neoplasms, diabetes mellitus, and chronic lower respiratory diseases from the National Causes of Death Database from 2015 to 2020 was used by applying generalised additive modelling (GAM) and joinpoint regression analysis. RESULTS: Between weeks 14 and 52 (from 1 April to 29 December) of 2020, a total of 3111 excess deaths (95% PI 1339 - 4832) were estimated in Latvia, resulting in 163.77 excess deaths per 100 000. Since September 30, with the outbreak of the second COVID-19 wave, 55% of all excess deaths have occurred. Altogether, COVID-19-related deaths accounted for only 28% of the estimated all-cause excess deaths. A significant increase in excess mortality was estimated for circulatory diseases (68.91 excess deaths per 100 000). Ischemic heart disease and cerebrovascular disease were listed as the underlying cause in almost 60% of COVID-19-contributing deaths. CONCLUSIONS: All-cause mortality and mortality from circulatory diseases significantly increased in Latvia during the first pandemic year. All-cause excess mortality substantially exceeded reported COVID-19-related deaths, implying COVID-19-related mortality during was significantly underestimated. Increasing mortality from circulatory diseases suggests a negative cumulative effect of COVID-19 exposure and reduced access to healthcare services for NCD patients.

A mixed-method study on the provision of remote consultations for non-communicable disease patients during the first wave of the COVID-19 pandemic in Latvia: lessons for the future.

BACKGROUND: The COVID-19 pandemic has challenged the ability of healthcare systems to ensure the continuity of health services for patients with non-communicable diseases (NCDs). The issue of remote consultations has emerged. Before the COVID-19 pandemic, remote consultations were not routinely provided or covered by public health funding in Latvia. This study aimed to describe the dynamics of consultations and the volume of remote consultations provided for patients with particular NCD and explore clinicians' experiences of providing remote consultations during the first wave of the COVID-19 pandemic in Latvia. METHODS: A mixed-method study focusing on the first wave of the COVID-19 pandemic in Latvia in Spring 2020 was conducted. Quantitative data from the National Health Services were analysed to assess the dynamics of consultations for patients with selected NCDs. Qualitative data were collected through 34 semi-structured interviews with general practitioners (GPs) and specialists and were analysed using an inductive thematic analysis. Purposive maximum variation sampling was used for participant selection. RESULTS: During the period with the strongest restrictions of scheduled on-site consultations, a decrease in the total number of consultations was observed for a variety of NCDs. A significant proportion of consultations in this period were provided remotely. GPs provided approximately one-third of cancer-related consultations and almost half of consultations for the other selected conditions remotely. Among specialists, endocrinologists had the highest proportion of remote consultations (up to 72.0%), while urologists had the lowest (16.4%). Thematic analysis of the semi-structured interviews revealed five themes: 1) Adjusting in a time of confusion and fear, 2) Remote consultations: safety versus availability, 3) Sacrifice and loss of privacy, 4) Advantages and disadvantages of communication technologies, and 5) Different form of communication and a health literacy challenge. CONCLUSIONS: During the first wave of the COVID-19 pandemic in Latvia, disruptions to health care services decreased the total number of consultations for patients with NCDs provided by both GPs and specialists. In this period, remote consultations proved to be an important instrument for ensuring the continuity of health care for patients with NCDs, and the necessity to develop a well-designed system for telemedicine in Latvia was highlighted.

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.

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.

Pain and Moderate to Vigorous Physical Activity in Adolescence: An International Population-Based Survey.

OBJECTIVE: To evaluate whether individual types of pain (headache, stomach-ache, and backache) or multiple pains affect the odds of young people achieving the recommended 60 minutes of moderate to vigorous physical activity (MVPA) per day in a large representative sample. DESIGN: Multicenter cross-sectional survey. SETTING: Twenty-eight countries across Europe and North America. SUBJECTS: Adolescents (N = 242,103). METHODS: An analysis of data collected in two waves (2001/02 and 2005/06) of the health behavior in school-aged children (HBSC) study was performed. Survey questions included the HBSC symptoms checklist and the amount of regular physical activity. Multilevel logistic regression was used to account for clustering effect of MVPA within countries. Models investigated the relationship between pain and physical activity, adjusted for the HBSC study year. Six models were conducted separately for gender and age-group (11, 13, and 15 years) strata. RESULTS: In general, the presence of pain was associated with reduced physical activity. Headache alone was associated with reduced physical activity in all six strata (odd ratios 0.77-0.84), stomach-ache alone in five strata (0.77-0.92), and backache alone in four strata (0.86-0.96). In 11- and 13-year-old girls, headache, stomach-ache, and backache, individually and in combination, were associated with decreased odds of being physically active (odds ratios ranging from 0.73 to 0.91). Within the other four age and gender strata, the relationship was less consistent. CONCLUSION: Pain is associated with reduced physical activity in adolescents but this association varies according to gender, age, and the type of pain experienced.

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.

Adolescents' medicine use for headache: secular trends in 20 countries from 1986 to 2010.

BACKGROUND: This study reports secular trends in medicine use for headache among adolescents in 20 countries from 1986 to 2010. METHODS: The international Health Behaviour in School-aged Children (HBSC) survey includes self-reported data about medicine use for headaches among nationally representative samples of 11-, 13- and 15-year-olds. We included 20 countries with data from at least three data collection waves, with a total of 380 129 participants. RESULTS: The prevalence of medicine use for headaches varied from 16.5% among Hungarian boys in 1994 to 62.9% among girls in Wales in 1998. The prevalence was higher among girls than boys in every country and data collection year. The prevalence of medicine use for headaches increased in 12 of 20 countries, most notably in the Czech Republic, Poland, Russia, Sweden and Wales. CONCLUSION: The prevalence of medicine use for headaches among adolescents is high and increasing in many countries. As some medicines are toxic this may constitute a public health problem.

Trends in life satisfaction in European and North-American adolescents from 2002 to 2010 in over 30 countries.

BACKGROUND: Life satisfaction (LS) is an indicator which is widely used for assessing the perception of a child's feeling about his life. METHODS: LS is assessed in Health Behaviour in School-aged Children via the Cantril ladder with 10 steps indicating the worst and best possible life. This range of values (0-10) was dichotomized into 'low' (0-5) vs. 'high' (6-10). Countries, age groups and genders were compared based on the odds ratio (OR) of declaring a higher LS in 2010 with respect to 2002. RESULTS: Analyzing the difference between 2002 and 2010, six countries from Western Europe show decreasing LS: Austria, Canada, Switzerland, Denmark, Finland and Greenland. In contrast, a group of Eastern European Countries, that is, Estonia, Croatia, Lithuania, Latvia, Russia and Ukraine, show a significant increase in LS. Data on gender and age differences confirm the lower rating of LS in girls and a decreasing rating with age. CONCLUSION: The LS scale appears to be a tool capable of discriminating the level of wellbeing of adolescent population among countries.

Trends in multiple recurrent health complaints in 15-year-olds in 35 countries in Europe, North America and Israel from 1994 to 2010.

BACKGROUND: Health complaints are a good indicator of an individual's psychosocial health and well-being. Studies have shown that children and adolescents report health complaints which can cause significant individual burden. METHODS: Using data from the international Health Behaviour in School-aged Children study, this article describes trends in multiple recurrent health complaints (MHC) in 35 countries among N = 237 136 fifteen-year-olds from 1994 to 2010. MHC was defined as the presence of two or more health complaints at least once a week. Logistic regression analysis was performed to evaluate trends across the five survey cycles for each country. RESULTS: Lowest prevalence throughout the period 1994-2010 was 16.9% in 1998 in Austria and highest in 2006 in Israel (54.7%). Overall, six different trend patterns could be identified: No linear or quadratic trend (9 countries), linear decrease (7 countries), linear increase (5 countries), U-shape (4 countries), inverted U-shape (6 countries) and unstable (4 countries). CONCLUSION: Trend analyses are valuable in providing hints about developments in populations as well as for benchmarking and evaluation purposes. The high variation in health complaints between the countries requires further investigation, but may also reflect the subjective nature of health complaints.

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.

An international survey of pain in adolescents.

BACKGROUND: A common belief is that pain is uncommon and short lived in adolescents. However, the burden of pain in adolescents is unclear because of limitations in previous research. The aim of this study is to estimate the prevalence of headache, stomach-ache and backache in adolescents and to explore the extent to which these three forms of pain coexist based upon a representative sample of adolescents from 28 countries. METHODS: Data were analysed from three consecutive waves (1997/98, 2001/02 and 2005/06) of the Health Behavior in School-aged Children: WHO Collaborative Cross-National survey (HBSC). Prevalence estimates are based upon adolescents who reported experiencing headache, stomach-ache or backache at least monthly for the last 6 months. RESULTS: There were a total of 404,206 participants with a mean (±SD) age of 13.6 (±1.7) years (range 9.8 to 17.3 years). The prevalence of headache was 54.1%, stomach-ache 49.8%, backache 37%, and at least one of the three pains 74.4%. Girls had a higher prevalence of the three pains than boys and the prevalence of pain increased with age. Headache, stomach-ache and backache frequently coexist, for example, of those with headache: 21.2% had headache alone, 31% suffered from both headache and stomach-ache, 12.1% suffered from backache and headache, and 35.7% had all three pains. CONCLUSIONS: Somatic pain is very common in adolescents, more often coexisting than occurring in isolation. Our data supports the need for further research to improve the understanding of these pains in adolescents.

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.

Adolescents perception of the COVID-19 pandemic restrictions and associated mental health and well-being: gender, age and socioeconomic differences in 22 countries.

BACKGROUND: The COVID-19-pandemic has had a profound impact on the lives of adolescents worldwide. This study examined the subjective perception of the COVID-19 pandemic measures and its association with mental health and well-being (i.e., loneliness, life satisfaction and multiple health complaints) among 13- and 15-years-old adolescents from 22 countries. METHODS: Data from the cross-national Health Behaviour in School-aged Children (HBSC) 2021/22 study were used from representative samples of 22 countries (N = 67,544; 51.9% girls). The self-perceived impact of COVID-19 measure comprised 10 items asking about the impact on several dimensions of adolescent lives (e.g., relationships with family and friends, health, or eating behaviours). Measures of loneliness, multiple health complaints, and life satisfaction were included as indicators of mental health and well-being. A non-parametric multilevel latent class analysis considering individual and country-levels was conducted to identify classes of self-perceived impact of the COVID-19 measures. Multilevel logistic regression models adjusted by age and socioeconomic status were applied to assess the association between COVID-19 measure impact classes and mental health. RESULTS: Three classes were identified on individual level encompassing a neutral (51%), positive (31%), or negative (18%) perception of COVID-19 measures. A third of the adolescents reported a positive impact of the pandemic measures. The distribution of classes was heterogeneous within and across countries. Within the positive COVID-19 measure impact class, social relationships were the most important dimension, whereas mental health problems were mostly represented within the negative COVID-19 measure impact class. Girls with a negative perception of pandemic measures showed higher levels of loneliness and multiple health complaints and lower life satisfaction. 15-year-old adolescents and those with a low socioeconomic status reported higher levels of loneliness and lower life satisfaction. CONCLUSIONS: The majority of adolescents perceived the pandemic measures as neutral or positive. Girls, 15-year-old adolescents, and those with low socioeconomic status were at higher risk of suffering from pandemic measures and associated problems of loneliness, multiple health complaints, and low life satisfaction. We conclude that adolescent's mental health and well-being should be considered in the decision-making process by ensuring that the unique challenges of adolescents are adequately addressed in policies.

Peer victimization and subjective health among students reporting disability or chronic illness in 11 Western countries.

BACKGROUND: To compare the strength of the association between peer victimization at school and subjective health according to the disability or chronic illness (D/CI) status of students across countries. METHODS: This study used data from 55 030 students aged 11, 13 and 15 years from 11 countries participating in the 2005-06 Health Behaviour in School-aged Children survey. Self-completed questionnaires were administered in classrooms. Multivariate models of logistic regression (controlled for confounding factors and countries) were used to investigate differences in the association between peer victimization and poor subjective health according to the D/CI status. RESULTS: Overall, 13.5% of the students reported having been bullied at least two or three times a month. The percentage of victims was significantly higher among those reporting D/CI than among others in all countries studied. Victims of bullying were more likely to report poor self-rated health, low life satisfaction and multiple health complaints. However, there were no differences in the associations between peer victimization and subjective health indicators according to the D/CI status. CONCLUSIONS: In all countries studied, students reporting D/CI were more likely to report being victims of bullying. Victims of bullying reported more negative subjective health outcomes regardless of their D/CI status. Although inclusive education is currently a major topic of educational policies in most countries, additional efforts should be made to improve the quality of the integration of students with D/CI.

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.

Alcohol control policies reduce all-cause mortality in Baltic Countries and Poland between 2001 and 2020.

Alcohol consumption in the Baltic countries and Poland is among the highest globally, causing high all-cause mortality rates. Contrary to Poland, the Baltic countries have adopted many alcohol control policies, including the World Health Organization (WHO) "best buys". The aim of this study was to evaluate the impact of these policies, which were implemented between 2001 and 2020, on all-cause mortality. Monthly mortality data for men and women aged 20+ years of age in Estonia, Latvia, Lithuania, and Poland were analysed for 2001 to 2020. A total of 19 alcohol control policies, fulfilling an a-priori defined definition, were implemented between 2001 and 2020 in the countries of interest, and 18 of them could be tested. Interrupted time-series analyses were conducted by employing a generalized additive mixed model (GAMM) for men and women separately. The age-standardized all-cause mortality rate was lowest in Poland and highest in Latvia and had decreased in all countries over the time period. Taxation increases and availability restrictions had short-term effects in all countries, on average reducing the age-standardized all-cause mortality rate among men significantly (a reduction of 2.31% (95% CI 0.71%, 3.93%; p = 0.0045)). All-cause mortality rates among women were not significantly reduced (a reduction of 1.09% (95% CI - 0.02%, 2.20%; p = 0.0554)). In conclusion, the alcohol control policies implemented between 2001 and 2020 reduced all-cause mortality among men 20+ years of age in Baltic countries and Poland, and thus, the practice should be continued.

Alcohol-attributable mortality and alcohol control policy in the Baltic Countries and Poland in 2001-2020: an interrupted time-series analysis.

BACKGROUND: The Baltic countries-Lithuania, Latvia and Estonia-are characterized by a high rate of fully alcohol-attributable mortality, compared with Poland. Alcohol control policy measures implemented since 2001 in the Baltic countries included a restriction on availability and an increase in excise taxation, among others. The aim of the current study was to evaluate the relationship between alcohol control policy implementation and alcohol-attributable mortality in the Baltic countries and Poland. METHODS: Alcohol-attributable mortality data for 2001-2020 was defined by codes 100% alcohol-attributable for persons aged 15 years and older in the Baltic countries and Poland. Alcohol control policies implemented between 2001 and 2020 were identified, and their impact on alcohol-attributable mortality was evaluated using an interrupted time-series methodology by employing a generalized additive model. RESULTS: Alcohol-attributable mortality was significantly higher in the Baltic countries, compared with Poland, for both males and females. In the final reduced model, alcohol control policy significantly reduced male alcohol-attributable mortality by 7.60% in the 12 months post-policy implementation. For females, the alcohol control policy mean-shift effect was higher, resulting in a significant reduction of alcohol-attributable mortality by 10.77% in the 12 months post-policy implementation. The interaction effects of countries and policy tested in the full model were not statistically significant, which indicated that the impact of alcohol control policy on alcohol-attributable mortality did not differ across countries for both males and females. CONCLUSIONS: Based on the findings of the current study, alcohol control policy in the form of reduced availability and increased taxation was associated with a reduction in alcohol-attributable mortality among both males and females.

Classifying alcohol control policies enacted between 2000 and 2020 in Poland and the Baltic countries to model potential impact.

AIMS: The study's aim is to identify and classify the most important alcohol control policies in the Baltic countries (Estonia, Latvia and Lithuania) and Poland between 2000 and 2020. METHODS: Policy analysis of Baltic countries and Poland, predicting potential policy impact on alcohol consumption, all-cause mortality and alcohol-attributable hospitalizations was discussed. RESULTS: All Baltic countries implemented stringent availability restrictions on off-premises trading hours and different degrees of taxation increases to reduce the affordability of alcoholic beverages, as well as various degrees of bans on alcohol marketing. In contrast, Poland implemented few excise taxation increases or availability restrictions and, in fact, reduced stipulations on prior marketing bans. CONCLUSIONS: This classification of alcohol control policies in the Baltic countries and Poland provides a basis for future modeling of the impact of implementing effective alcohol control policies (Baltic countries), as well as the effects of loosening such policies (Poland).

Adolescent use of social media and associations with sleep patterns across 18 European and North American countries.

OBJECTIVE: Over the past decade, concurrent with increasing social media use (SMU), there has been a shift toward poorer sleep among adolescents in many countries. The purpose of this study was to examine the cross-national associations between adolescent SMU and sleep patterns, by comparing 4 different categories of SMU (nonactive, active, intense, and problematic use). DESIGN, SETTING, AND PARTICIPANTS: Data were from 86,542 adolescents in 18 European and North American countries that participated in the 2017/18 Health Behaviour in School-aged study. MEASUREMENTS: Mixed-effects linear regression models were used to examine cross-national associations between 4 SMU categories and adolescent sleep duration, bedtime and social jetlag derived from self-reported data. RESULTS: For all countries combined, nonactive SMU was associated with longer sleep, earlier bedtimes, and less social jetlag, compared to active SMU, although the differences were minor. By comparison, intense and problematic SMU were associated with less sleep and later bedtimes on both school and nonschool days, and greater social jetlag, compared to active SMU. While findings were relatively consistent between countries, some differences were observed, suggesting that the national and cultural context may be important in interpreting results. CONCLUSIONS: These findings suggest that both intense and problematic SMU are associated with poorer sleep patterns in adolescents across most countries. Further research is needed to identify effective policies, programs, and messaging to promote the healthy use of social media and prevent potential negative impacts on adolescent sleep.