Educational inequalities in cervical cancer screening participation in 24 European countries.

OBJECTIVES: Cervical cancer screening (CCS) is an important public health measure for early detection of cervical cancer and prevents a large proportion of cervical cancer deaths. However, participation in CCS is relatively low and varies substantially by country and socio-economic position. This study aimed to provide up-to-date participation rates and estimates on educational inequalities in CCS participation in 24 European countries with population-based CCS programmes. STUDY DESIGN: This was a cross-sectional study. METHODS: Using data from the European Health Interview Survey (EHIS) conducted in 2019, 80,479 women aged 25-64 years were included in the analyses. First, standardized participation rates and standardized participation rates by educational attainment were calculated for all 24 countries based on each country-specific screening programme organization. Second, a series of generalized logistic models was applied to assess the effect of education on CCS participation. RESULTS: Screening participation rates ranged from 34.1% among low-educated women in Romania to 97.1% among high-educated women in Finland. We observed that lower-educated women were less likely to attend CCS than their higher-educated counterparts. Largest educational gaps were found in Sweden (odds ratio [OR] = 6.36, 95% confidence interval [CI] = 3.89-10.35) and Poland (odds ratio = 5.80, 95% CI = 4.34-7.75). CONCLUSION: Population-based screening initiatives have successfully reduced participation differences between women with medium and high educational attainment in some countries; however, persistent disparities still exist between women with low and high levels of education. There is an urgent need to increase participation rates of CCS, especially among lower-educated women.

Does educational mobility in mid-life affect mortality? A cohort study covering 1.3 million individuals in Sweden.

•Studies on how increased formal educational level in mid-life affects mortality is lacking.•We found that women who increased their educational level in mid-life had a reduced risk of mortality.•In men, mortality was reduced only for those who increased their education from a low level.

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.

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.

Regional disparities in incidence, handling and outcomes of patients with symptomatic and ruptured abdominal aortic aneurysms in Norway.

OBJECTIVES: To study incidence, handling and outcome of patients hospitalised with symptomatic and ruptured abdominal aortic aneurysm in Norway. DESIGN, MATERIAL AND METHODS: Retrospective study of 1291 patients, between January 2008 and August 2010 using the National Patient Registry and a regional vascular surgery registry. We applied a stepwise logistic regression model to detect differences in regional in-hospital mortality. RESULTS: 385/711 (54%) patients hospitalised for aneurysm rupture, rAAA (ICD-10: I71.3), died. The odds of dying varied with a factor 2.3 between the extreme regions. 475/711 (67%) underwent repair, 323 survived, giving an in-hospital mortality rate of 32% after surgery. Older patients were significantly less likely to be transported for surgery. The overall incidence for patients aged >50 was 16.6 rAAA per 100,000 person-years. There was remarkable variation across counties with rates between 7.7 and 26.8. A total of 580 patients were hospitalised with suspected symptomatic aneurysms (ICD-10:I71.4, acute admission); 224 (39%) were treated with aneurysm repair, 356 (61%) were discharged without repair without a significant difference across health regions. CONCLUSIONS: For rAAA, we found substantial geographical variations in incidence, surgery and patient outcome. These results highlight the need for increased awareness about the condition and suggest ways to improve care trajectories to reduce delay to surgery, thereby minimising rupture mortality.

The association between cycling to school and being overweight in Rotterdam (The Netherlands) and Kristiansand (Norway).

Active transportation is a behavior that might contribute to energy balance. However, no clear association between active commuting to school and weight status has been reported in the international literature. Also, new studies indicate that cycling to school might have a greater health potential than walking to school. The purpose of the present study is to assess the potential association between cycling to school and weight status in two European cities, Rotterdam and Kristiansand, where cycling to school remains common. Data from two studies, ENDORSE (Rotterdam) and Youth in Balance (Kristiansand), were used including, respectively, 1361 and 1197 adolescents with mean ages of 14.1 and 14.4 years. The adolescents were categorized as cyclist or non-cyclist based on questionnaires on the usual mode of transportation to school. A total of 25% and 18% were categorized as overweight, and 35% and 31% were categorized as cyclists, in Rotterdam and Kristiansand, respectively. In multilevel logistic analyses, after adjusting for potential moderators, the odds ratios for cyclists being overweight compared with non-cyclists were, respectively, 0.63 (95% CI=0.45-0.89) and 0.52 (95% CI=0.34-0.78) in Rotterdam and Kristiansand. The results presented clearly show a negative association between cycling to school and overweight among adolescents both in Rotterdam and in Kristiansand.

Welfare state regimes, unemployment and health: a comparative study of the relationship between unemployment and self-reported health in 23 European countries.

BACKGROUND: The relationship between unemployment and increased risk of morbidity and mortality is well established. However, what is less clear is whether this relationship varies between welfare states with differing levels of social protection for the unemployed. METHODS: The first (2002) and second (2004) waves of the representative cross-sectional European Social Survey (37 499 respondents, aged 25-60 years). Employment status was main activity in the last 7 days. Health variables were self-reported limiting long-standing illness (LI) and fair/poor general health (PH). Data are for 23 European countries classified into five welfare state regimes (Scandinavian, Anglo-Saxon, Bismarckian, Southern and Eastern). RESULTS: In all countries, unemployed people reported higher rates of poor health (LI, PH or both) than those in employment. There were also clear differences by welfare state regime: relative inequalities were largest in the Anglo-Saxon, Bismarckian and Scandinavian regimes. The negative health effect of unemployment was particularly strong for women, especially within the Anglo-Saxon (OR(LI) 2.73 and OR(PH) 2.78) and Scandinavian (OR(LI) 2.28 and OR(PH) 2.99) welfare state regimes. DISCUSSION: The negative relationship between unemployment and health is consistent across Europe but varies by welfare state regime, suggesting that levels of social protection may indeed have a moderating influence. The especially strong negative relationship among women may well be because unemployed women are likely to receive lower than average wage replacement rates. Policy-makers' attention therefore needs to be paid to income maintenance, and especially the extent to which the welfare state is able to support the needs of an increasingly feminised European workforce.

Welfare state regimes and income-related health inequalities: a comparison of 23 European countries.

OBJECTIVE: The objective of this study was to determine whether the magnitude of income-related health inequalities varies between welfare regimes (Scandinavian, Anglo-Saxon, Bismarckian, Southern and Eastern). Specifically, it examined whether the Scandinavian welfare state regime has smaller income-based health inequalities than the other welfare state regimes. METHODS: The first (2002) and second (2004) waves of the representative cross-sectional European Social Survey (ESS), which comprised more than 80 000 respondents, were used to analyse income inequalities (relative health difference between the first and third income tertile) in self-reported health (general health, limiting longstanding illness) amongst those aged 25 or more. Data related to 23 European countries classified into five welfare state regimes. The study controlled for age and adjusted for educational attainment. RESULTS: When comparing the health of the first income tertile with the third, the Scandinavian countries only seemed to hold an intermediate position: they did not have the smallest, or the largest, health inequalities. However, the Anglo-Saxon welfare states had the largest income-related health inequalities for both men and women, while countries with Bismarckian welfare states tended to demonstrate the smallest. This pattern was unchanged after controlling for educational attainment. However, education seemed to explain the largest part of income-related health inequalities in the Southern regime. CONCLUSION: This study shows that the magnitudes of income-related health inequalities indeed vary by welfare state regime. However, this variation was not always in the direction expected as the Scandinavian countries did not exhibit the smallest health inequalities.

Class-related health inequalities are not larger in the East: a comparison of four European regions using the new European socioeconomic classification.

BACKGROUND: The article investigates whether people in Eastern Europe have larger health inequalities than their counterparts in three West European regions (North, Central and the South). METHODS: Data were obtained for 63,754 individuals in 23 countries from the first (2002) and second (2004) waves of the European Social Survey. The health outcomes were self-reported limiting longstanding illness and fair/poor general health. Occupational class was defined according to the European Socioeconomic Classification (ESeC). The magnitude of absolute and relative inequalities according to nine occupational classes for men and women separately were identified, analysed and compared in all four regions of Europe. RESULTS: For both sexes and within all European regions, the higher and lower professionals, self-employed and higher service workers reported fewer cases of ill health than other occupational classes. In contrast, lower technical and routine workers reported the poorest health, excluding the relatively small number of farmers. Income and education did not explain more, or less, of the class-related health inequalities in the East compared with the other regions. CONCLUSIONS: Little evidence was found for the hypothesis that East European countries have larger class-related health inequalities than other European regions. People's income and educational attainment both contribute to occupational health inequalities in the East as well as in the West.

The welfare state: a glossary for public health.

Recently, there has been a surge in comparative social epidemiology, and a sizeable amount of this has examined the relation between different aspects of the welfare state and population health. Such research draws strongly, though usually implicitly, on welfare state theories and concepts. In this glossary, we explicitly define these concepts in order to enable more researchers, practitioners and policy-makers to engage with and contribute to this exciting and fruitful area of public health research.