Occupational class and educational level inequalities in major cardiovascular risk factors in Turkey: 2008-2016.

BACKGROUND: We aimed to investigate the magnitude of occupational class (OC) and educational level (EL) inequalities in cardiovascular risk factors in Turkey from 2008 to 2016 and compare these inequalities with neighbouring European countries. METHODS: We used the Turkey Health Survey among a representative sample of the Turkish population. We estimated relative index of inequality (RII) for four cardiovascular risk factors (obesity/overweight, hypertension, diabetes, smoking) by OC/EL with an interaction term for survey year and compared selected results with neighbouring countries. RESULTS: Men with lower OC and EL smoked more (e.g. RII for EL = 1.40 [1.26-1.55]); however, the remaining risk factors were mostly lower in these groups. Women in lower socio-economic groups smoked less (e.g. RII for EL = 0.36 [0.29-0.44]), however, had higher prevalence of the remaining risk factors. Significant interactions with survey year were only found in a few cases. The pattern of inequalities in Turkey is largely similar to neighbouring countries. CONCLUSIONS: Inequalities in cardiovascular risk factors are less systematic in Turkey than in most high-income countries, but ongoing trends suggest that this may change in the future.

Improving job strain might reduce inequalities in cardiovascular disease mortality in european men.

Unfavorable psychosocial working conditions can lead to cardiovascular disease (CVD) mortality. Lower-occupational groups typically experience unfavorable psychosocial working conditions as compared to higher-occupational groups. We investigate the extent to which CVD mortality inequalities might be reduced if psychosocial working conditions for manual workers are raised to the level experienced by non-manual workers (upward-leveling scenario). We also investigate what would occur if psychosocial working conditions among manual and non-manual workers are raised to better levels as observed in the 'ideal' region (best practice scenario). Individual-level CVD mortality data from 12 European countries were obtained from the EURO-GBD-SE project (1998-2007). Psychosocial working conditions data (i.e. job strain) were extracted from the European Working Conditions Survey (2005) and rate ratios from literature reviews. Population attributable fractions (PAF) and two counterfactual scenarios (namely, upward-leveling scenario and best-practice scenario) were developed to examine employed male non-manual and manual workers. Results appeared to show that CVD mortality might be reduced in men when unfavorable psychosocial working conditions are improved for manual workers (PAF = 7.7%, 95% CI: 6.5-10.0). The upward-leveling scenario seems to reduce CVD mortality inequalities for manual workers, by 13-74%. Best-practice scenario shows the largest reduction in CVD mortality in the Baltic region (87 deaths per 100,000 person years). Findings suggest that rendering job strain in manual workers to the level experienced by non-manual workers might substantially reduce CVD mortality inequalities in European men.

Amenable mortality in the EU-has the crisis changed its course?

Background: Did the global financial crisis and its aftermath impact upon the performance of health systems in Europe? We investigated trends in amenable and other mortality in the EU since 2000 across 28 EU countries. Methods: We use WHO detailed mortality files from 28 EU countries to calculate age-standardized deaths rates from amenable and other causes. We then use joinpoint regression to analyse trends in mortality before and after the onset of the economic crisis in Europe in 2008. Results: Amenable and other mortality have declined in the EU since 2000, albeit faster for amenable mortality. We observed increases in amenable mortality following the global financial crisis for females in Estonia [from -4.53 annual percentage change (APC) in 2005-12 to 0.03 APC in 2012-14] and Slovenia (from -4.22 APC in 2000-13 to 0.73 in 2013-15) as well as males and females in Greece(males: from -2.93 APC in 2000-10 to 0.01 APC in 2010-13; females: from -3.48 APC in 2000-10 to 0.06 APC in 2010-13). Other mortality continued to decline for these populations. Increases in deaths from infectious diseases before and after the crisis played a substantial part in reversals in Estonia, Slovenia and Greece. Conclusion: There is evidence that amenable mortality rose in Greece and, among females in Estonia and Slovenia. However, in most countries, trends in amenable mortality rates appeared to be unaffected by the crisis.

The turn of the gradient? Educational differences in breast cancer mortality in 18 European populations during the 2000s.

This study aims to investigate the association between educational level and breast cancer mortality in Europe in the 2000s. Unlike most other causes of death, breast cancer mortality tends to be positively related to education, with higher educated women showing higher mortality rates. Research has however shown that the association is changing from being positive over non-existent to negative in some countries. To investigate these patterns, data from national mortality registers and censuses were collected and harmonized for 18 European populations. The study population included all women aged 30-74. Age-standardized mortality rates, mortality rate ratios, and slope and relative indexes of inequality were computed by education. The population was stratified according to age (women aged 30-49 and women aged 50-74). The relation between educational level and breast cancer mortality was predominantly negative in women aged 30-49, mortality rates being lower among highly educated women and higher among low educated women, although few outcomes were statistically significant. Among women aged 50-74, the association was mostly positive and statistically significant in some populations. A comparison with earlier research in the 1990s revealed a changing pattern of breast cancer mortality. Positive educational differences that used to be significant in the 1990s were no longer significant in the 2000s, indicating that inequalities have decreased or disappeared. This evolution is in line with the "fundamental causes" theory which stipulates that whenever medical insights and treatment become available to combat a disease, a negative association with socio-economic position will arise, independently of the underlying risk factors.

[The effects of smoking on health: growth of knowledge reveals even grimmer picture]. / De gezondheidseffecten van roken.

- In this article we give a short overview of new insights into the effects of smoking on health, both on smokers themselves and on those who are exposed to other people's tobacco smoke.- The number of diseases and conditions that are known to be caused by active smoking has now risen to over thirty.- The risk of premature death is not, as previously thought, twice as high in smokers as in non-smokers, but actually three times as high.- Passive smoking too has been shown to have a whole range of negative effects on health.- Further, the causal mechanisms of, amongst other things, the development of cancer, ischaemic heart disease and nicotine dependence under the influence of smoking have been largely unravelled.- Various issues require further investigation; these include the effect of smoking on psychological health and the effects of 'third-hand' smoke. In the meantime, a concerted campaign against this consumer product with its deleterious effects of the health of the population is overdue.

Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990-2004.

BACKGROUND: Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990-1994 and 2000-2004 in 14 European countries. METHODS: We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990-1994 and 2000-2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method. RESULTS: In 2000-2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between -1% and 56% among women. Since 1990-1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women. CONCLUSIONS: In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.

Does the Impact of the Tobacco Epidemic Explain Structural Changes in the Decline of Mortality?

Since 1950, most developed countries have exhibited structural changes in mortality decline. This complicates extrapolative forecasts, such as the commonly used Lee-Carter model, that require the presence of a steady long-term trend. This study tests whether the impact of the tobacco epidemic explains the structural changes in mortality decline, as it is presumed in earlier studies. For this purpose, the time index of the Lee-Carter model in males was investigated in 20 developed countries between 1950 and 2011 for possible structural changes. It was found that removing the impact of smoking from mortality trends took away more than half of the 12 detected trend breaks. For the remaining trend breaks, adjusting for smoking attenuated the degree of change in mortality decline. Taking the tobacco epidemic into account should become standard procedure in mortality forecasts to avoid a misleading extrapolation of trends. Nevertheless, more research is needed to identify additional factors, such as health-care policies and innovations in medical treatment, to explain the remaining structural changes.

Inequalities in tuberculosis mortality: long-term trends in 11 European countries.

SETTING: Previous studies in many countries have shown that mortality due to tuberculosis (TB) is higher among people of lower socio-economic status. OBJECTIVE: To assess the magnitude and direction of trends in educational inequalities in TB mortality in 11 European countries. DESIGN: Data on TB mortality between 1980 and 2011 were collected among persons aged 35-79 years. Age-standardised mortality rates by educational level were calculated. Inequalities were estimated using the relative and slope indices of inequality. RESULTS: In the first decade of the twenty-first century, educational inequalities in TB mortality occurred in all countries in this study. The largest absolute inequalities were observed in Lithuania, and the smallest in Denmark. In most countries, relative inequalities have remained stable since the 1980s or 1990s, while absolute inequalities remained stable or went down. In Lithuania and Estonia, however, absolute inequalities increased substantially. CONCLUSION: The reduction in absolute inequalities in TB mortality, as seen in many European countries, is a major achievement; however, inequalities persist and are still a major cause for concern in the twenty-first century. Interventions aimed at preventing TB disease and reducing TB case fatality in lower socio-economic groups should be intensified, especially in the Baltic countries.

A closer look at the role of healthcare in the recent mortality decline in the Netherlands: results of a record linkage study.

BACKGROUND: Since 2002, Dutch mortality rates decreased rapidly after decades of stagnation. On the basis of indirect evidence, previous research has suggested that this decline was due to a sudden expansion of healthcare. We tested two corollaries of this hypothesis--first, that the decline was concentrated among those with ill-health and second, that the decline can be statistically accounted for by increases in healthcare utilisation. METHODS: We linked the Dutch health interview survey to the mortality register and constructed two cohorts, consisting of 7691 persons interviewed in 2001/2002 and 8362 persons interviewed in 2007/2008, each with a 5-year mortality follow-up (659 deaths in total). The change in mortality between both cohorts was computed using Cox proportional hazard models. We estimated the change in mortality by severity of chronic conditions and with respect to the inclusion of indicators of healthcare utilisation. RESULTS: Between the two study cohorts, mortality declined by 15% (95% CI 2% to 29%), and mortality reduction was greatest for those suffering from fatal and non-fatal conditions with a decline of 58% (95% CI 35% to 78%). Even after adjustment for health status and risk factors, most indicators of healthcare utilisation were associated with higher instead of lower mortality and changes in healthcare utilisation did not explain the decline in mortality. CONCLUSIONS: Our results only partly confirm the hypothesis that an expansion of healthcare explains the recent mortality decline in the Netherlands. Owing to confounding by health status, it is difficult to reproduce the mortality-lowering effects of healthcare utilisation of individual level studies in the open population.

[INTEGRATED APPROACH TO PREVENT FUNCTIONAL DECLINE IN HOSPITALIZED ELDERLY]. / Integrale interventie ter voorkoming van functieverlies bij ouderen tijdens ziekenhuisopname: het Zorgprogramma voor Preventie en Herstel.

BACKGROUND: Hospital related functional decline in older patients is an underestimated problem. Thirty-five procent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. This percentage increases considerably with age. METHODS/DESIGN: To address this issue, the Vlietland Ziekenhuis in The Netherlands has implemented the Prevention and Reactivation Care Programme (PReCaP), an innovative program aimed at reducing hospital related functional decline among elderly patients by offering interventions that are multidisciplinary, integrated and goal-oriented at the physical, social, and psychological domains of functional decline. DISCUSSION: This paper presents a detailed description of the intervention, which incorporates five distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment for a selected patient group at the prevention and Reactivation Centre; (3) Availability of multidisciplinary geriatric expertise; (4) Provision of support and consultation of relevant professionals to informal caregivers; (5) Intensive follow-up throughout the entire chain of care by a casemanager with geriatric expertise. Outcome and process evaluations are ongoing and results will be published in a series of forthcoming papers. This article is an edited translation of the previously published article 'Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP), BMC Geriatrics 2012;12:7, AJBM de Vos, KJE Asmus-Szepesi, TJEM Bakker, PL de Vreede, JDH van Wijngaarden, EW Steyerberg, JP Mackenbach, AP Nieboer.

The effect of urban green on small-area (healthy) life expectancy.

BACKGROUND: Several epidemiological studies have investigated the effect of the quantity of green space on health outcomes such as self-rated health, morbidity and mortality ratios. These studies have consistently found positive associations between the quantity of green and health. However, the impact of other aspects, such as the perceived quality and average distance to public green, and the effect of urban green on population health are still largely unknown. METHODS: Linear regression models were used to investigate the impact of three different measures of urban green on small-area life expectancy (LE) and healthy life expectancy (HLE) in The Netherlands. All regressions corrected for average neighbourhood household income, accommodated spatial autocorrelation, and took measurement uncertainty of LE, HLE as well as the quality of urban green into account. RESULTS: Both the quantity and the perceived quality of urban green are modestly related to small-area LE and HLE: an increase of 1 SD in the percentage of urban green space is associated with a 0.1-year higher LE, and, in the case of quality of green, with an approximately 0.3-year higher LE and HLE. The average distance to the nearest public green is unrelated to population health. CONCLUSIONS: The quantity and particularly quality of urban green are positively associated with small-area LE and HLE. This concurs with a growing body of evidence that urban green reduces stress, stimulates physical activity, improves the microclimate and reduces ambient air pollution. Accordingly, urban green development deserves a more prominent place in urban regeneration and neighbourhood renewal programmes.

The importance of multidisciplinary teamwork and team climate for relational coordination among teams delivering care to older patients.

AIM: To identify predictors of relational coordination among professionals delivering care to older patients. BACKGROUND: Relational coordination is known to enhance quality of care in hospitals. The underlying mechanisms, however, remain poorly understood. DESIGN: This cross-sectional study was part of a larger evaluation study examining the opportunity to prevent loss of function in older patients due to hospitalization in the Netherlands. METHODS: This study was performed in spring 2010 among team members delivering care to older hospitalized patients (192 respondents; 44% response rate) in one hospital. Relational coordination was measured by the Relational Coordination survey; team climate by the Team Climate Inventory and questions were asked about participation in multidisciplinary team meetings and disciplines represented in these meetings. To account for the hierarchical structure, a multilevel analysis was performed. RESULTS: Correlation analysis revealed a positive relationship among being female, being a nurse and relational coordination; medical specialists showed a negative relationship. The number of disciplines represented during multidisciplinary team meetings and team climate were positively related with relational coordination. The multilevel analysis showed a positive relationship between the number of disciplines represented during multidisciplinary team meetings and team climate with relational coordination. CONCLUSIONS: The enhancement of team climate and attendance of diverse professionals during multidisciplinary team meetings are expected to improve relational coordination. Furthermore, this study underscores the importance of enhancing relational coordination between medical specialists and other professionals.

Modelling obesity outcomes: reducing obesity risk in adulthood may have greater impact than reducing obesity prevalence in childhood.

A common policy response to the rise in obesity prevalence is to undertake interventions in childhood, but it is an open question whether this is more effective than reducing the risk of becoming obese during adulthood. In this paper, we model the effect on health outcomes of (i) reducing the prevalence of obesity when entering adulthood; (ii) reducing the risk of becoming obese throughout adult life; and (iii) combinations of both approaches. We found that, while all approaches reduce the prevalence of chronic diseases and improve life expectancy, a given percentage reduction in obesity prevalence achieved during childhood had a smaller effect than the same percentage reduction in the risk of becoming obese applied throughout adulthood. A small increase in the probability of becoming obese during adulthood offsets a substantial reduction in prevalence of overweight/obesity achieved during childhood, with the gains from a 50% reduction in child obesity prevalence offset by a 10% increase in the probability of becoming obese in adulthood. We conclude that both policy approaches can improve the health profile throughout the life course of a cohort, but they are not equivalent, and a large reduction in child obesity prevalence may be reversed by a small increase in the risk of becoming overweight or obese in adulthood.

Understanding older patients' self-management abilities: functional loss, self-management, and well-being.

PURPOSE: This study aimed to increase our understanding of self-management abilities and identify better self-managers among older individuals. METHODS: Our cross-sectional research was based on a pilot study of older people who had recently been admitted to a hospital. In the pilot study, all patients (>65 years of age) who were admitted to the Vlietland hospital between June and October 2010 were asked to participate, which led to the inclusion of 456 older patients at baseline. A total of 296 patients (65% response rate) were interviewed in their homes 3 months after admission. Measures included social, cognitive, and physical functioning, self-management abilities, and well-being. We used descriptive, correlations, and multiple regression analyses. In addition, we evaluated the mediation effect of self-management abilities on well-being. RESULTS: Social, cognitive, and physical functioning significantly correlated with self-management abilities and well-being (all p ≤ 0.001). After controlling for background characteristics, multiple regression analysis indicated that social, cognitive, and physical functioning still related to self-management abilities (ß = 0.17-0.25; all p ≤ 0.001). Older people with low levels of social, cognitive, and physical functioning were worse self-managers than were those with higher levels of functioning. CONCLUSIONS: Self-management abilities mediate the relationship between social, cognitive, and physical functioning and well-being. Interventions to improve self-management abilities may help older people better deal with function losses as they age further.

The relationship between older adults' self-management abilities, well-being and depression.

This study aimed to identify the relationship between self-management abilities, well-being and depression. Our study was conducted among older adults (>65 years of age) who were vulnerable to loss of function after hospital discharge. Three months after hospital admission, 296/456 patients (65 % response rate) were interviewed in their homes. The 30-item Self-Management Ability Scale was used to measure six self-management abilities: taking initiative, investing in resources for long-term benefits, taking care of a variety of resources, taking care of resource multifunctionality, being self-efficacious and having a positive frame of mind. Well-being was measured with the Social Production Function (SPF) Instrument for the Level of Well-being (SPF-IL) and Cantril's ladder. The Geriatric Depression Scale was used to assess depression. Correlation analyses showed that all self-management abilities were strong indicators for well-being (p < 0.001 for all). Regression analyses revealed that investing in resources for long-term benefits, taking care of a variety of resources, taking care of resource multifunctionality and being self-efficacious were associated with well-being. While no significant relationship was found between well-being and having a positive frame of mind or taking initiative, regression analyses revealed that these self-management abilities were related to depression. Investing in resources for long-term benefits and taking care of a variety of resources were significantly related to depression. This research showed that self-management abilities are related to well-being and depression among older adults. In addition, this study identified key self-management abilities for older adults who had recently been discharged from a hospital.

Educational inequalities in tuberculosis mortality in sixteen European populations.

OBJECTIVE: To describe the magnitude of socioeconomic inequalities in tuberculosis (TB) mortality by level of education in male, female, urban and rural populations in several European countries. DESIGN: Data were obtained from the Eurothine Project, covering 16 populations between 1990 and 2003. Age- and sex-standardised mortality rates, the relative index of inequality and the slope index of inequality were used to assess educational inequalities. RESULTS: The number of TB deaths reported was 8530, with a death rate of 3 per 100 000 per year, of which 73% were males. Educational inequalities in TB mortality were present in all European populations. Inequalities in TB mortality were greater than in total mortality. Relative and absolute inequalities were large in Eastern European and Baltic countries but relatively small in Southern European countries and in Norway, Finland and Sweden. Inequalities in mortality were observed among both men and women, and in both rural and urban populations. CONCLUSIONS: Socio-economic inequalities in TB mortality exist in all European countries. Firm political commitment is required to reduce inequalities in the social determinants of TB incidence. Targeted public health measures are called for to improve access to treatment of vulnerable groups and thereby reduce TB mortality.

Ethics and prevention of overweight and obesity: an inventory.

Efforts to counter the rise in overweight and obesity, such as taxes on certain foods and beverages, limits to commercial advertising, a ban on chocolate drink at schools or compulsory physical exercise for obese employees, sometimes raise questions about what is considered ethically acceptable. There are obvious ethical incentives to these initiatives, such as improving individual and public health, enabling informed choice and diminishing societal costs. Whereas we consider these positive arguments to put considerable effort in the prevention of overweight indisputable, we focus on potential ethical objections against such an effort. Our intention is to structure the ethical issues that may occur in programmes to prevent overweight and/or obesity in order to encourage further debate. We selected 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluated their ethically relevant aspects. Our evaluation was completed by discussing them in two expert meetings. We found that currently proposed interventions or policies to prevent overweight or obesity may (next to the benefits they strive for) include the following potentially problematic aspects: effects on physical health are uncertain or unfavourable; there are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination; inequalities are aggravated; inadequate information is distributed; the social and cultural value of eating is disregarded; people's privacy is disrespected; the complexity of responsibilities regarding overweight is disregarded; and interventions infringe upon personal freedom regarding lifestyle choices and raising children, regarding freedom of private enterprise or regarding policy choices by schools and other organizations. The obvious ethical incentives to combat the overweight epidemic do not necessarily override the potential ethical constraints, and further debate is needed. An ethical framework to support decision makers in balancing potential ethical problems against the need to do something would be helpful. Developing programmes that are sound from an ethical point of view is not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a programme may hamper its effectiveness.

Displaying random variation in comparing hospital performance.

INTRODUCTION: The role of transparency in quality of care is becoming ever more important. Various indicators are used to assess hospital performance. Judging hospitals using rank order takes no account of disturbing factors such as random variation and case-mix differences. The purpose of this article is to compare displays for the influence of random variation on the apparent differences in the quality of care between the Dutch hospitals. METHOD: The authors analysed the official 2005 data of all 97 hospitals on the following performance indicators: pressure ulcer, cerebro-vascular accident and acute myocardial infarction. The authors calculated CIs of the point estimate and the simulated CIs of the ranks with bootstrap sampling, and visualised the influence of random variation with three modern graphical techniques: forest plot, funnel plot and rank plot. RESULTS: Statistically significant differences between hospitals were found for nearly all performance indicators (p<0.001). However, the CIs in the forest plot revealed that only a small number of hospitals performed significantly better or worse. The funnel plot provides a representation of differences between hospitals compared with a target value and allows for the uncertainty of these differences. The rank plot showed that ranking hospitals was very uncertain. CONCLUSION: Despite statistically significant differences between hospitals, random variation is a crucial factor that must be taken into account when judging individual hospitals. The funnel plot provides easily interpretable information on hospital performance, including the influence of random variation.

Explaining differences in birth outcomes in relation to maternal age: the Generation R Study.

OBJECTIVE: To examine the association between maternal age and birth outcomes, and to investigate the role of sociodemographic and lifestyle-related determinants. DESIGN: Population-based prospective cohort study from early pregnancy onwards. SETTING: Rotterdam, the Netherlands. POPULATION: A cohort of 8568 mothers and their children. METHODS: Maternal age was assessed at enrolment. Information about sociodemographic (height, weight, educational level, ethnicity, parity) and lifestyle-related determinants (alcohol consumption, smoking habits, folic acid supplement use, caffeine intake, daily energy intake) and birth outcomes was obtained from questionnaires and hospital records. Multivariate linear and logistic regression analyses were used. MAIN OUTCOMES MEASURES: Birthweight, preterm delivery, small-for-gestational-age, and large-for-gestational-age. RESULTS: As compared with mothers aged 30-34.9 years, no differences in risk of preterm delivery were found. Mothers younger than 20 years had the highest risk of delivering small-for-gestational-age babies(OR 1.6, 95% CI: 1.1-2.5); however, this increased risk disappeared after adjustment for sociodemographic and lifestyle-related determinants. Mothers older than 40 years had the highest risk of delivering large-for-gestational-age babies (OR 1.3, 95% CI: 0.8-2.4). The associations of maternal age with the risks of delivering large-for-gestational-age babies could not be explained by sociodemographic and lifestyle-related determinants. CONCLUSIONS: As compared with mothers aged 30-34.9 years, younger mothers have an increased risk of small-for-gestational-age babies, whereas older mothers have an increased risk of large-for-gestational-age babies. Sociodemographic and lifestyle-related determinants cannot fully explain these differences.