The association between socioeconomic position and vigorous physical activity among adolescents: a cross-sectional study in six European cities.

BACKGROUND: The relationship between socioeconomic position (SEP) and adolescent physical activity is uncertain, as most evidence is limited to specific settings and a restricted number of SEP indicators. This study aimed to assess the magnitude of socioeconomic differences in adolescent vigorous physical activity (VPA) across various European countries using a wide range of SEP indicators, including family-based (education, family affluence, perceived social standing, parents' employment, housing tenure) and adolescent-based (academic performance and pocket money) ones. METHODS: We used data from a survey among 10,510 students aged 14-17 from 50 schools in six European cities: Namur (BE), Tampere (FI), Hannover (DE), Latina (IT), Amersfoort (NL), Coimbra (PT). The questionnaire included socio-demographic characteristics and the amount of time spent in VPA. RESULTS: The mean time spent practicing VPA was 60.4 min per day, with lower values for Namur (BE) and Latina (IT), and higher values for Amersfoort (NL). In the multivariable analysis, both categories of SEP indicators (family-based and adolescent based indicators) were independently associated with VPA. For each SEP indicator, lower levels of VPA were recorded in lower socioeconomic groups. In the total sample, each additional category of low SEP was associated with a decrease in mean VPA of about 4 min per day. CONCLUSIONS: This study showed that across European cities adolescent VPA is positively related to both family-based SEP and adolescents' own SEP. When analysing socioeconomic differences in adolescent VPA, one should consider the use of multiple indicators of SEP.

Nicotine dependence among adolescents in the European Union: How many and who are affected?

BACKGROUND: Nicotine dependence during adolescence increases the risk of continuing smoking into adulthood. The magnitude of nicotine dependence among adolescents in the European Union (EU) has not been established. We aimed to estimate the number of nicotine dependent 15-year-old adolescents in the EU, and identify high-risk groups. METHODS: The number of nicotine dependent 15-year-olds in the EU was derived combining: (i) total number of 15-year-olds in the EU (2013 Eurostat), (ii) smoking prevalence among 15-year-olds (2013/2014 HBSC survey) and (iii) proportion of nicotine dependent 15-year-olds in six EU countries (2013 SILNE survey). Logistic regression analyses identified high-risk groups in the SILNE dataset. RESULTS: We estimated 172 636 15-year-olds were moderately to highly nicotine dependent (3.2% of all 15 years old; 35.3% of daily smokers). In the total population, risk of nicotine dependence was higher in males, adolescents with poor academic achievement, and those with smoking parents or friends. Among daily smokers, only lower academic achievement and younger age of smoking onset were associated with nicotine dependence. CONCLUSION: According to our conservative estimates, more than 172 000 15-year-old EU adolescents were nicotine dependent in 2013. Prevention of smoking initiation, especially among adolescents with poor academic performance, is necessary to prevent a similar number of adolescents getting addicted to nicotine each consecutive year.

The same or different psychiatrists for in- and out-patient treatment? A multi-country natural experiment.

AIMS: A core question in the debate about how to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or different psychiatrists (specialisation). The controversial debate drives costly organisational changes in several European countries, which have gone in opposing directions. The existing evidence is based on small and low-quality studies which tend to favour whatever the new experimental organisation is.We compared 1-year clinical outcomes of personal continuity and specialisation in routine care in a large scale study across five European countries. METHODS: This is a 1-year prospective natural experiment conducted in Belgium, England, Germany, Italy and Poland. In all these countries, both personal continuity and specialisation exist in routine care. Eligible patients were admitted for psychiatric in-patient treatment (18 years of age), and clinically diagnosed with a psychotic, mood or anxiety/somatisation disorder.Outcomes were assessed 1 year after the index admission. The primary outcome was re-hospitalisation and analysed for the full sample and subgroups defined by country, and different socio-demographic and clinical criteria. Secondary outcomes were total number of inpatient days, involuntary re-admissions, adverse events and patients' social situation. Outcomes were compared through mixed regression models in intention-to-treat analyses. The study is registered (ISRCTN40256812). RESULTS: We consecutively recruited 7302 patients; 6369 (87.2%) were followed-up. No statistically significant differences were found in re-hospitalisation, neither overall (adjusted percentages: 38.9% in personal continuity, 37.1% in specialisation; odds ratio = 1.08; confidence interval 0.94-1.25; p = 0.28) nor for any of the considered subgroups. There were no significant differences in any of the secondary outcomes. CONCLUSIONS: Whether the same or different psychiatrists provide in- and out-patient treatment appears to have no substantial impact on patient outcomes over a 1-year period. Initiatives to improve long-term outcomes of psychiatric patients may focus on aspects other than the organisation of personal continuity v. specialisation.

Cultural competence and social relationships: a social network analysis.

AIM: This study investigated the role of social relationships in the sharing of cultural competence by testing two hypotheses: cultural competence is a socially shared behaviour; and central healthcare professionals are more culturally competent than non-central healthcare professionals. BACKGROUND: Sustaining cultural competence in healthcare services relies on the assumption that being culturally competent is a socially shared behaviour among health professionals. This assumption has never been tested. INTRODUCTION: Organizational aspects surrounding cultural competence are poorly considered. This therefore leads to a heterogeneous implementation of cultural competence - especially in continental Europe. METHODS: We carried out a social network analysis in 24 Belgian inpatient and outpatient health services. All healthcare professionals (ego) were requested to fill in a questionnaire (Survey on social relationships of health care professionals) on their level of cultural competence and to identify their professional relationships (alter). We fitted regression models to assess whether (1) at the dyadic level, ego cultural competence was associated with alter cultural competence, and (2) health professionals of greater centrality had greater cultural competence. RESULTS: At the dyadic level, no significant associations were found between ego cultural competence and alter cultural competence, with the exception of subjective exposure to intercultural situations. No significant associations were found between centrality and cultural competence, except for subjective exposure to intercultural situations. DISCUSSION: Being culturally competent is not a shared behaviour among health professionals. The most central healthcare professionals are not more culturally competent than less central health professionals. CONCLUSIONS AND IMPLICATIONS FOR HEALTH POLICIES: Culturally competent health care is not yet a norm in health services. Health care and training authorities should either make cultural competent health care a licensing criteria or reward culturally competent health care.

Users' and health professionals' values in relation to a psychiatric intervention: the case of psychiatric advance directives.

Although clinical and organisational benefits have been expected from Psychiatric Advance Directives (PADs), their take-up rates remain low and their evaluation disappointing. The endorsement of PADs by stakeholders is decisive for their use and understanding stakeholders' preferences for implementation is crucial. A Multinomial Discrete Choice analysis was carried out of options for designing, completing, and honouring PADs, with a view to enhancing user autonomy, therapeutic alliance, care coordination, and feasibility. Although autonomy underlies the whole process, the criteria determining options varied with the stage of the intervention. These criteria should be taken into account in future PAD intervention and evaluation processes.

Substantial use of primary health care by prisoners: epidemiological description and possible explanations.

OBJECTIVES: To describe the use of primary care services by a prisoner population so as to understand the great number of demands and therefore to plan services oriented to the specific needs of these patients. DESIGN: Retrospective cohort study of a sample of prisoners' medical records. SETTING: All Belgian prisons (n = 33). PATIENTS: 513 patients over a total of 182 patient years, 3328 general practitioner (GP) contacts, 3655 reasons for encounter. MAIN RESULTS: Prisoners consulted the GP 17 times a year on average (95%CI 15 to 19.4). It is 3.8 times more than a demographically equivalent population in the community. The most common reasons for encounter were administrative procedures (22%) followed by psychological (13.1%), respiratory (12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). Psychological reasons for consultations (n = 481) involved mainly (71%) feeling anxious, sleep disturbance, and prescription of psychoactive drugs. Many other visits concerned common problems that in other circumstances would not require any physician intervention. CONCLUSION: The most probable explanations for the substantial use of primary care in prison are the health status (many similarities noted between health problems at the admission and reasons for consultations during the prison term: mental health problems and health problems related to drug misuse), lack of access to informal health services (many contacts for common problems), prison rules (many consultations for administrative procedures), and mental health problems related to the difficulties of life in prison.

A European comparative study of marital status and socio-economic inequalities in suicide.

We assess (i) whether being married is a protective factor against socio-economic inequalities in suicide, and (ii) whether any such buffering effect varies between countries. We used the data from a European cross-national comparison project, a prospective follow-up of several European population censuses matched with vital statistics. The data encompass 99.5 million person-years aged 30 and above and 25,476 suicides in Austria, Belgium, Denmark, Finland, Turin, Madrid, Norway and Switzerland. Standardised rates were computed and logistic regressions were used to assess educational inequalities. Among the non-married, the lower educational group had an increased risk of dying of suicide compared to the higher group (Odds Ratio (OR) = 1.45). Inequalities among the married were lower (OR = 1.29). In all countries or regions except Austria, the lower educational group had a higher risk of suicide mortality among the non-married than among the married. The buffering effect of being married was not observed for elderly individuals (65 and over). Among younger individuals, the buffering effect of being married on relative inequalities in suicide was stronger in Madrid, Denmark, Norway and Switzerland (but significant only for Denmark and Norway). There was no indication that countries with stronger welfare policies or lower divorce rate had a lower buffering effect. We conclude that being married protects against inequalities in suicide and that this protective effect is not affected by the level of social capital at the country level.

Socio-economic differences in psychiatric in-patient care.

OBJECTIVE: We seek to investigate socio-economic differences in psychiatric in-patient care regarding admission, treatment and outcome. METHOD: This study is undertaken on a comprehensive and exhaustive psychiatric case register of all psychiatric in-patient care carried out in Belgium in 1997 and 1998 (n=144 754). RESULTS: Lower socio-economic groups were more likely to be compulsorily admitted, to be cared for in a non-teaching or psychiatric hospital, to be admitted in a hospital with unexpectedly long average length of stay and to be admitted to a ward with a more severe case-mix. They were less likely to receive antidepressants and psychotherapies. The improvements in functioning and in symptoms were also less favourable for these groups. The lowest group had a higher risk of dying in the hospital. CONCLUSION: Psychiatric in-patient care is associated with moderate socio-economic differences in access, treatment and outcome. Further research is needed to clarify the causes of such disparities.

Socioeconomic inequalities in depression: a meta-analysis.

Low socioeconomic status (SES) is generally associated with high psychiatric morbidity, more disability, and poorer access to health care. Among psychiatric disorders, depression exhibits a more controversial association with SES. The authors carried out a meta-analysis to evaluate the magnitude, shape, and modifiers of such an association. The search found 51 prevalence studies, five incidence studies, and four persistence studies meeting the criteria. A random effects model was applied to the odds ratio of the lowest SES group compared with the highest, and meta-regression was used to assess the dose-response relation and the influence of covariates. Results indicated that low-SES individuals had higher odds of being depressed (odds ratio = 1.81, p < 0.001), but the odds of a new episode (odds ratio = 1.24, p = 0.004) were lower than the odds of persisting depression (odds ratio = 2.06, p < 0.001). A dose-response relation was observed for education and income. Socioeconomic inequality in depression is heterogeneous and varies according to the way psychiatric disorder is measured, to the definition and measurement of SES, and to contextual features such as region and time. Nonetheless, the authors found compelling evidence for socioeconomic inequality in depression. Strategies for tackling inequality in depression are needed, especially in relation to the course of the disorder.

Equity in prevention and health care.

STUDY OBJECTIVE: There is an increasing body of evidence about socioeconomic inequality in preventive use, mostly for cancer screening. But as far as needs of prevention are unequally distributed, even equal use may not be fair. Moreover, prevention might be unequally used in the same way as health care in general. The objective of the paper is to assess inequity in prevention and to compare socioeconomic inequity in preventive medicine with that in health care. DESIGN: A cross sectional Health Interview Survey was carried out in 1997 by face to face interview and self administered questionnaire. Two types of health care utilisation were considered (contacts with GPs and with specialists) and four preventive care mostly delivered in a GP setting (flu vaccination, cholesterol screening) or in a specialty setting (mammography and pap smear). SETTING: Belgium. PARTICIPANTS: A representative sample of 7378 residents aged 25 years and over (participation rate: 61%). OUTCOME MEASURE: Socioeconomic inequity was measured by the HI(wvp) index, which is the difference between use inequality and needs inequality. Needs was computed as the expected use by the risk factors or target groups. MAIN RESULTS: There was significant inequity for all medical contacts and preventive medicine. Medical contacts showed inequity favouring the rich for specialist visits and inequity favouring the poor for contacts with GPs. Regarding preventive medicine, inequity was high and favoured the rich for mammography and cervical screening; inequity was lower for flu immunisation and cholesterol screening but still favoured the higher socioeconomic groups. In the general practice setting, inequity in prevention was higher than inequity in health care; in the specialty setting, inequity in prevention was not statistically different from inequity in health care, although it was higher than in the general practice setting. CONCLUSIONS: If inequity in preventive medicine is to be lowered, the role of the GP must be fostered and access to specialty medicine increased, especially for cancer screening.

Deprivation and mortality: the implications of spatial autocorrelation for health resources allocation.

This paper aims at investigating whether the relationship between mortality and socio-economic deprivation is affected by the spatial autocorrelation of ecological data. A simple model is used in which mortality (all-ages and premature) is the dependent variable, and deprivation, morbidity and other socio-economic indicators are the explanatory variables. Deprivation is measured by the Townsend index; the other socio-economic variables are the median income, unequal income distribution (Gini coefficient) and population density. Morbidity is estimated on the basis of hospital admission rates and overweight prevalence. Spatial autocorrelation is measured by the Moran's I coefficient. All mortality and morbidity variables have significant, positive, and moderate-to-high spatial autocorrelation. Two multivariate models are explored: a weighted least-squares model ignoring spatial autocorrelation and a simultaneous autoregressive model. The paper concludes that spatial autocorrelation has a significant impact on the relationship between mortality and socio-economic variables. Future ecological models intended to inform health resources allocation need to pay greater attention to the spatial dimension of the data used.

[Mortality socio-economic inequalities for small-areas in Belgium: assessing concentration]. / Inégalités socio-économiques de la mortalité dans les communes belges.

BACKGROUND: The reduction of socio-economic inequality in mortality is an important public health goal. Previous ecological studies aimed at studying the relationship between mortality rate and socio-economic factors have paid little attention to mortality causes avoidable by primary or secondary prevention. Furthermore, these studies do not make the distinction between, on the one hand, the strength of the relationship mortality/socio-economic deprivation and, on the other hand, the significance of the unequal distribution of mortality. The present work is aimed at measuring the strength of this relationship and the concentration of mortality in relation to socio-economic deprivation for both overall mortality and mortality avoidable by primary and secondary prevention. METHOD: Standardised mortality ratios were computed at the community level in Belgium (1985-93 period) for all causes and for 11 mortality causes avoidable by primary and secondary prevention. A deprivation index was elaborated using a factorial principal component analysis on 11 socio-economic indicators. The mortality/deprivation relationship was assessed by way of a standardised regression coefficient (B) while socio-economic concentration of mortality was estimated using the Concentration Illness Index (Cii) and the P90/P10 ratio. RESULTS: A strong positive relationship was found between mortality and deprivation for under 65 years all-causes mortality (B =0.71; CI [0.66; 0.76]), mortality for cirrhosis of the liver (B =0.56; CI [0.51; 0.62]), lung cancer (B =0.49; CI [0.42; 0. 56]), suicide (B =0.35; CI [0.29; 0.42]) and falls (B =0.34; CI [0. 28; 0.41]). However, the concentration of mortality was more limited: 14% (CI [11%-17%]) of cirrhosis of the liver mortality, 7% of fall (CI [5%-10%]) and suicide mortality (CI [4%-9%]), 6% (CI [5%-7%]) of lung cancer mortality is unequally distributed. CONCLUSION: Socio-economic deprivation is positively associated with mortality. This association is more pronounced for tobacco, alcohol and mental health related mortality. However, the strength of the relationship between socio-economic deprivation and mortality is not a good indicator of unequal distribution.