Determinants of non-participation in a mass screening program for colorectal cancer in Finland.

BACKGROUND: For an effective colorectal cancer (CRC) screening program, high participation rate is essential. However, non-participation in CRC screening program has increased in Finland. MATERIAL AND METHODS: The study was based on a population-based nationwide cohort of persons invited for CRC screening in 2004-2011. Information on the first round of the CRC screening participation and related background factors was obtained from the Finnish Cancer Registry, and information about health behavior factors from the Health Behavior Survey (HBS) in 1978-1999. Non-participation in CRC screening was analyzed with Poisson regression as incidence rate ratios (IRR) with 95% confidence intervals (95% CI). RESULTS: Of all persons invited for CRC screening (79 871 men and 80 891 women) 35% of men and 21% of women refused. Of those invited for screening, 2456 men (3.1%) and 2507 women (3.1%) were also invited to the HBS. Persons, who declined HBS, were also more likely to refuse CRC screening (men IRR 1.40, 95% CI 1.26-1.56, women 1.75, 1.52-2.02) compared to HBS participants. Never married persons had about a 75% higher risk for refusing than married ones. The youngest age group (60 years) was more likely to refuse screening than the older age groups (62 or >64 years). Smoking was associated with non-participation in screening (current smokers, men: IRR 1.32, 95% CI 1.05-1.67, women: 2.10, 1.61-2.73). CONCLUSIONS: Participation in CRC screening was affected by gender, age, and marital status. Persons, who refused the HBS, were also more likely to refuse CRC screening. Smoking was a risk factor for non-participation in CRC screening.

Explaining educational differences in leisure-time physical activity in Europe: the contribution of work-related factors.

Although educational differences in leisure-time physical activity (LTPA) exist across Europe, the independent effect of educational level on leisure-time physical activity has rarely been explored. This study examines the relative contribution of occupational class, employment status, and educational level to LTPA across 12 European countries. The data were obtained from 12 European health surveys conducted at the turn of the century and identified in the EUROTHINE project. All information was self-reported. Logistic regression was applied and relative inequality index (RII) was calculated. Analyses were limited to those in the prime working-age (age 30-59; total N=137,646) men and women. In all 12 European countries, LTPA was more common in the high-educated than in the low-educated. The association between education and LTPA remained mostly unchanged after adjusting for marital status, urbanization, and self-rated health. After further adjusting for occupational class and employment status, the educational differences in LTPA were only slightly attenuated. An inverse association was found between educational level and LTPA across almost all 12 European countries. Occupational class and employment status had only a modest effect on educational differences in LTPA in most of the examined countries, suggesting that education remains an important predictor of LTPA.

Twenty-five year socioeconomic trends in leisure-time and commuting physical activity among employed Finns.

The trend of socioeconomic differences in physical activity is largely unknown in Finland. In this study, we examined socioeconomic trends in leisure-time and commuting physical activity among Finns in 1978-2002. Nationwide data were derived from an annually repeated cross-sectional Finnish Adult Health Behavior Survey. People under the age of 25, students, the unemployed, and retirees were excluded from the analysis. The final data set included 25 513 women and 25 302 men. Socioeconomic variables included education, occupation, and household income. Odds ratios for being physically active and 95% confidence intervals were calculated. People with the lowest income were less leisure-time and commuting physically active. Among women, low occupational status was associated with high commuting physical activity whereas among men such an association was not found. No educational differences among men in leisure-time and commuting physical activity over time were found. Some indications were found that educational differences in leisure-time physical activity among women might have been reversed. Our data suggest that socioeconomic differences in leisure-time and commuting physical activity are quite small and have remained similar between 1978 and 2002.

Trends of socioeconomic differences in daily vegetable consumption, 1979-2002.

BACKGROUND: Studies from different time periods have shown that consumption of vegetables is more common in higher socioeconomic groups and among women. However, there are only few studies of changes of socioeconomic differences in vegetable consumption over time. Our aim was to determine whether socioeconomic differences, measured by educational level and household income, in daily vegetable consumption have increased, decreased or been stable over the last two decades among Finnish men and women. METHODS: Data on daily consumption of fresh vegetables were derived from repeated annual cross-sectional surveys performed among representative samples of Finnish working aged (15-64 years) population. Data from the years 1979-2002 were linked with data on education and household income from Statistics Finland. Those under 25 years and all students were excluded, giving a total of 69 383 respondents. The main analyses were conducted with logistic regression. RESULTS: Daily consumption of fresh vegetables became overall more prevalent during the study period. Daily consumption of fresh vegetables was more common among those with higher education and higher income during the whole study period. Both educational level and household income differences in daily vegetable consumption slightly narrowed since 1979 among men and women. CONCLUSIONS: Women with high socioeconomic position have been initial trend setters, but the prevalence of daily consumers of vegetables in these groups has not increased since the early 1990s. The prevalence of daily consumption of fresh vegetables has increased more in lower educational and income groups during the 1980s and 1990s along with narrowing socioeconomic differences.

Applying an equity lens to tobacco-control policies and their uptake in six Western-European countries.

We identified policies that may be effective in reducing smoking among socioeconomically disadvantaged groups, and examined trends in their level of application between 1985 and 2000 in six western-European countries (Sweden, Finland, the United Kingdom, the Netherlands, Germany, and Spain). We located studies from literature searches in major databases, and acquired policy data from international data banks and questionnaires distributed to tobacco policy organisations/researchers. Advertising bans, smoking bans in workplaces, removing barriers to smoking cessation therapies, and increasing the cost of cigarettes have the potential to reduce socioeconomic inequalities in smoking. Between 1985 and 2000, tobacco control policies in most countries have become more targeted to decrease the smoking behaviour of low-socioeconomic groups. Despite this, many national tobacco-control strategies in western-European countries still fall short of a comprehensive policy approach to addressing smoking inequalities.

Snuff use and smoking in Finnish olympic athletes.

This study aimed to assess the prevalence of smoking and snuff use in Finnish elite athletes. Of all the athletes (n = 494) financially supported by the National Olympic Committee, 446 completed a structured questionnaire (response rate 90.3 %) in 2002. A control group (n = 1504, response rate 80.2 %) comprised an age-matched sample from the population-based sample collected by the National Public Health Institute. Any smoking was reported by 11.4 % of the athletes (3.6 % daily and 7.8 % occasionally) and by 38.3 % of the controls (28.1 % and 10.2 %). After adjusting for age, sex, and education, OR (95 % CI) for any smoking was highest 0.42 (0.23 - 0.77) for athletes in skill-based events and lowest 0.06 (0.02 - 0.17) for endurance athletes as compared with controls. Snuff use was reported by 24.6 % of the athletes (9.6 % daily and 15.0 % occasionally) and by 3.7 % of the controls (1.8 % and 1.9 %). The adjusted OR (95 % CI) for any snuff use was highest 15.6 (9.55 - 25.6) for team-sport athletes and lowest 3.33 (1.54 - 7.21) for endurance athletes as compared with controls. Although snuff use in the general female population is rare, also female athletes did use snuff. Though prevalence of daily smoking among athletes was one-seventh of the respective figure for the general population, prevalence of daily snuff use was five-fold that of controls. Tobacco free elite athletes are valuable in health counselling because athletes are considered role models influencing their peers and the sport. Sport associations are challenged to ban all forms of tobacco.

Trends in smoking behaviour between 1985 and 2000 in nine European countries by education.

OBJECTIVE: To examine whether trends in smoking behaviour in Western Europe between 1985 and 2000 differed by education group. DESIGN: Data of smoking behaviour and education level were obtained from national cross sectional surveys conducted between 1985 and 2000 (a period characterised by intense tobacco control policies) and analysed for countries combined and each country separately. Annual trends in smoking prevalence and the quantity of cigarettes consumed by smokers were summarised for each education level. Education inequalities in smoking were examined at four time points. SETTING: Data were obtained from nine European countries: Norway, Sweden, Denmark, Finland, the United Kingdom, the Netherlands, Germany, Italy, and Spain. PARTICIPANTS: 451 386 non-institutionalised men and women 25-79 years old. MAIN OUTCOME MEASURES: Smoking status, daily quantity of cigarettes consumed by smokers. RESULTS: Combined country analyses showed greater declines in smoking and tobacco consumption among tertiary educated men and women compared with their less educated counterparts. In country specific analyses, elementary educated British men and women, and elementary educated Italian men showed greater declines in smoking than their more educated counterparts. Among Swedish, Finnish, Danish, German, Italian, and Spanish women, greater declines were seen among more educated groups. CONCLUSIONS: Widening education inequalities in smoking related diseases may be seen in several European countries in the future. More insight into effective strategies specifically targeting the smoking behaviour of low educated groups may be gained from examining the tobacco control policies of the UK and Italy over this period.

Disparities in food habits in Europe: systematic review of educational and occupational differences in the intake of fat.

BACKGROUND: A higher socio-economic level is associated with healthier dietary habits. Nevertheless, socio-economic differences in the intake of fat have not consistently been reported in Europe. The objective of our study was to systematically assess differences in total fat (TF) intake and saturated fat (SF) intake across social groups. METHODS: Representative samples from nine European countries were used to perform a meta-analysis of surveys between 1985-1999, including both published and nonpublished results. RESULTS: Because important heterogeneity was found and the estimates for TF from Spain and Estonia were different from all others, we calculated the differences in intake excluding these two countries. We found a lower TF intake in the highest (versus the lowest) occupational level both for men (difference: -1.1% of total energy intake; 95% CI: -1.3 to -0.8%) and women (difference: -0.9%; 95% CI: -1.2 to -0.6%) when Estonia and Spain were excluded. CONCLUSION: European surveys indicate that people in the lowest category of occupation consume more fat and SF than people in the highest category.

Income and health behaviours. Evidence from monitoring surveys among Finnish adults.

STUDY OBJECTIVE: To examine the associations of individual and household income with various health behaviours, before and after adjusting for educational attainment and occupational social class. DESIGN AND SETTING: Data from 19 982 respondents to nationwide health behaviour surveys from 1993 to 1999 (response rate 70%) were linked with socioeconomic information from population registers. MEASUREMENTS: The income measures were total individual income liable to taxation and household's monthly disposable income. Health behaviours included smoking, alcohol use, leisure time physical activity, use of vegetables, use of saturated fat on bread, and being overweight. MAIN RESULTS: In men, smoking and infrequent vegetable use were more common among those with lower individual and household income. However, adjusting for education and occupational class removed most of the differences. Use of saturated fat on bread increased with decreasing individual income, before and after the adjustments. In women, smoking, infrequent vegetable use and being overweight were more common among those with lower income, but the differences by both income measures were largely removed by the adjustments. Women with higher income more often also were high alcohol users and had less physical activity, in particular when income was measured by the respondents' individual income. CONCLUSIONS: Adjusting for education and occupation largely removed income differences in health behaviours, but for some behaviours some independent effect remained. The results suggest that income does not only reflect the available material resources, but works as a general socioeconomic indicator that is associated with health behaviours in much the same way as other socioeconomic indicators.

A systematic review of socioeconomic differences in food habits in Europe: consumption of cheese and milk.

OBJECTIVE: To assess differences in cheese and milk consumption across socioeconomic groups in representative samples from several European countries. DESIGN: A meta-analysis of published and unpublished surveys of food habits performed in nine European countries between 1985 and 1999. Educational and occupational levels were used as indicators of socio-economic status. RESULTS: A higher socioeconomic status was associated with a greater consumption of cheese. The pooled estimate of the difference in cheese consumption between women in the highest vs the lowest educational level was 9.0 g/day (95% CI: 7.1 to 11.0). The parallel observation in men was 6.8 g/day (95% CI: 3.4 to 10.1). Similar results were obtained using occupation as an indicator of socioeconomic status. The pooled estimates of the higher cheese consumption among subjects belonging to the highest (vs the lowest) occupational level were 5.1 g/day (95% CI: 3.7 to 6.5) in women and 4.6 g/day (95% CI: 2.1 to 7.0) in men. No statistically significant associations were found for milk consumption concerning educational or occupational level. CONCLUSIONS: Our findings suggest that consumption of cheese is likely to be higher among subjects belonging to higher socioeconomic levels. We did not find enough evidence to support that milk intake is different according to educational or social levels.

Comparative analysis of nutrition data from national, household, and individual levels: results from a WHO-CINDI collaborative project in Canada, Finland, Poland, and Spain.

STUDY OBJECTIVE: This project determined to what extent data on diet and nutrition, which were collected in a non-uniform manner, could be harmonised and pooled for international and national comparison. DESIGN: Direct comparisons of dietary data between studies were made using food balance sheets (FBS), household budget surveys (HBS), and individual dietary data (IDS); comparisons were also made within countries. Differences in study design and methodological approaches were taken into consideration. Data from research projects from the following four World Health Organisation (WHO) Countrywide Integrated Noncommunicable Disease Intervention (CINDI) countries were included-Canada, Finland, Poland, and Spain. MAIN RESULTS: FBS overestimated food consumption and nutrient intake compared to IDS. Results between HBS and IDS were quite similar, except for fish, meat, pulses and vegetables, which were underestimated by HBS, and sugar and honey and cereals, which were overestimated. Percentages of energy from fat, carbohydrates and proteins were higher when estimated from FBS, HBS, and IDS respectively. CONCLUSIONS: Results suggest that estimations from these three sources of dietary data are difficult to compare because they are measuring different levels of dietary information. The understanding of their relations may be important in formulating and evaluating a nutrition policy.

Patterns of unhealthy behaviour in Finland.

BACKGROUND: The aim of the study was to examine associations between unhealthy behaviours among the Finnish adult population. METHODS: Data from a series of cross-sectional health behaviour surveys from the years 1991-1998 were pooled. Associations between smoking, alcohol consumption, lack of regular physical activity and unhealthy diet were examined among 22,745 respondents. The associations were first studied in terms of accumulation: the occurrence of each combination of unhealthy behaviours was compared to their expected appearance, assuming that the behaviours were independent from each other. The same associations were then analysed with log-linear models. RESULTS: Only 2.4% of men and 0.9% of women had all four unhealthy behaviours. Nevertheless, the occurrence of four unhealthy behaviours was about three times more common than expected under the assumption of independence of the behaviours. Also, most of the three-behaviour combinations showed accumulation. Among the pairwise combinations, smoking and alcohol consumption as well as physical inactivity and unhealthy diet showed strongest accumulation, whereas the combination of alcohol consumption and unhealthy diet was less prevalent than expected. The combination of four healthy behaviours appeared 1.3 times more often than expected. In log-linear analysis a model containing all pairwise associations and the three-behaviour interaction between smoking, alcohol consumption and physical inactivity, as well as that of alcohol consumption, physical inactivity and unhealthy diet for men, provided an acceptable fit. Most of the unhealthy behaviours were positively associated but the association between alcohol consumption and unhealthy diet was inverse. Other behaviours modified the strength of the associations. The direction of the association between alcohol consumption and physical inactivity depended on other behaviours. CONCLUSIONS: Unhealthy behaviours showed pairwise and multiple accumulation. No three-behaviour associations were reducible to pairwise associations. Smoking had the strongest and most consistent associations with other unhealthy behaviours. Differences between sociodemographic groups were small and the patterns of unhealthy behaviour were remarkably similar among men and women.

Men, masculinity and food: interviews with Finnish carpenters and engineers.

This study explores how Finnish men from two occupational groups describe food in their everyday life. The concept of masculinity is used in interpreting men's food-related behaviours and beliefs. Data are drawn from semi-structured interviews in the 1990s with twenty carpenters and twenty engineers involved in the building trade. The paper presents analyses of the similarities and differences in how the men talked about meat; vegetables; beer and wine as parts of meals; food as energy, health and pleasure; and cooking. The results show variation both between and within occupational groups. The men did not stress the role of meat, but rather emphasised the role of vegetables. The carpenters tended to favour meat whereas the engineers had a more positive attitude to vegetables. Eating was described as an everyday routine needed to refuel the body and stay healthy. In addition, the engineers talked about the pleasures of eating. The men described cooking as optional or exceptional. The carpenters seemed to more actively embrace hegemonic masculinity and reject what is feminine than the engineers, who have reformulated their definition of masculinity to encompass concerns with health. This study suggests that both masculinity and occupational class play a role in male food-related practices and preferences.

Smoking and passive smoking in Estonia, Lithuania and Finland. Identifying target groups of tobacco policy.

BACKGROUND: The aim of this study was to identify population groups which are the most crucial as targets for anti-tobacco action. METHODS: A comparison was made of the prevalence and patterns of smoking and passive smoking in Estonia, Finland and Lithuania. RESULTS: Total exposure to smoking, both one's own and passive smoking, was more common in two Baltic countries than in Finland. In these Baltic countries passive smoking was notably common among women. In all countries the exposure was more prevalent among the younger and less educated, but no difference emerged between urban and rural areas. CONCLUSIONS: The following target groups were identified as priorities for anti-tobacco actions: i) men of all ages in Estonia and Lithuania to stop their already established tobacco use, ii) young women in all three countries to prevent their starting a career of tobacco use and iii) young and less educated women in Estonia and Lithuania to prevent passive smoking, i.e. their exposure to environmental tobacco smoke.

The consumption of rye bread and white bread as dimensions of health lifestyles in Finland.

OBJECTIVE: The aim of this research was to describe the variation in bread consumption within social classes and to link this consumption to health-related lifestyles in Finland from 1978 until 1998. DESIGN: A cross-sectional survey on health-related behaviour and socio-demographic factors has been conducted annually since 1978. SETTING: Mailed questionnaire. SUBJECTS: A random sample of 5000 Finns aged 15-64 years has been drawn annually. The response rate has varied from 84% to 68%. RESULTS: The consumption of rye bread decreased, but among the female population a slight increase appeared in the 1990s. The consumption of rye bread was associated with a low educational level and a rural place of residence. White bread was consumed less than was rye bread. White bread was consumed more frequently by the less educated in urban areas. Contrary to white bread, the consumption of rye bread was not associated with smoking, exercise or alcohol consumption. CONCLUSIONS: The traditional place of rye bread in the Finnish dietary pattern has remained rather constant. White bread consumption has been associated with an unhealthy lifestyle. As a result, those Finns who are concerned about their health avoid white bread but seem not to associate rye bread with a healthier lifestyle. In Finland, rye bread has a different image to the image of whole-grain or dark brown bread in many other western European countries.

Disparities in vegetable and fruit consumption: European cases from the north to the south.

OBJECTIVE: To present disparities in consumption of vegetables and fruits in Europe and to discuss how educational level, region and level of consumption influence the variation. DESIGN: A review of selected studies from 1985 to 1997. SETTING/SUBJECTS: 33 studies (13 dietary surveys, nine household budget surveys and 11 health behaviour surveys) representing 15 European countries were selected based on criteria developed as part of the study. Association between educational level and consumption of vegetables and fruits was registered for each study and common conclusions were identified. RESULTS: In the majority of the studies, with the exception of a few in southern and eastern Europe, consumption of vegetables and fruits was more common among those with higher education. The results suggest that in regions where consumption of vegetables and fruits is more common, the lower social classes tend to consume more of these than the higher social classes. CONCLUSIONS: The differences in the patterns of disparities in vegetable and fruit consumption between regions, as well as within populations, need to be considered when efforts to improve nutrition and health are planned.

A systematic review of socio-economic differences in food habits in Europe: consumption of fruit and vegetables.

OBJECTIVE: To evaluate the differences in the consumption of fruit and vegetables between groups with different socio-economic status (SES) in the adult population of European countries. DESIGN: A systematic review of published and unpublished surveys of food habits conducted between 1985 and 1999 in 15 European countries. Educational level and occupational status were used as indicators of SES. A pooled estimate of the mean difference between the highest and the lowest level of education and occupation was calculated separately for men and women, using DerSimonian and Laird's random effects model. SETTING: The inclusion criteria of studies were: use of a validated method for assessing intake at the individual level; selection of a nationwide sample or a representative sample of a region; and providing the mean and standard deviation of overall fruit and vegetable consumption for each level of education or occupation, and separately for men and women. SUBJECTS: Participants in the individual surveys had to be adults (18-85 y). RESULTS: Eleven studies from seven countries met the criteria for being included in the meta-analysis. A higher SES was associated with a greater consumption of both fruit and vegetables. The pooled estimate of the difference in the intake of fruit was 24.3 g/person/day (95% confidence interval (CI) 14.0-34.7) between men in the highest level of education and those in the lowest level of education. Similarly, this difference was 33.6 g/person/day for women (95% CI 22.5-44.8). The differences regarding vegetables were 17.0 g/person/day (95% CI 8.6-25.5) for men and 13.4 g/person/day (95% CI 7.1-19.7) for women. The results were in the same direction when occupation instead of education was used as an indicator of SES. CONCLUSIONS: Although we cannot exclude over-reporting of intake by those with highest SES, it is unlikely that this potential bias could fully explain the differences we have found. Our results suggest that an unhealthier nutrition pattern may exist among adults belonging to lower socio-economic levels in Europe. SPONSORSHIP: The present study was supported by the European Union's FAIR programme (FAIR-97-3096).

From regional ethnographies to interdisciplinary approaches-research on meals in Finland.

The paper reviews Finnish research on meals and meal patterns since the turn of the century. The main research traditions and cases representing various methodological approaches-qualitative interview, health behaviour questionnaire and dietary survey-are discussed. In line with studies undertaken in other industrialized countries, the Finnish studies show that meal patterns are related to socio-economic structure, work schedules, lifecourse, living conditions and food availability. Meal patterns vary by individual energy needs, and the nutrient contents of meals can be different from those of snacks. It is difficult to account for all determinants and characteristics of meals in a single study. The three cases shed light on the various aspects of the meal. When planning an empirical study on meals the researcher should ask herself/himself at least four questions: (1) who defines the meal?; (2) are meal patterns assumed to vary by time and between subgroups of the study population?; (3) is information on nutrient content of various eating occasions relevant to the study?; and (4) could information on meals be obtained from existing data sources?

Gender, socioeconomic status and family status as determinants of food behaviour.

This study examines social structural and family status factors as determinants of food behaviour. The data were derived from the FINMONICA Risk Factor Survey, collected in Finland in spring 1992. A multidimensional framework of the determinants of food behaviour was used, including social structural position, family status and gender. The associations between the determinants of food behaviour were estimated by multivariate logistic regression models, adjusted for age and regional differences. Food behaviour was measured by an index including six food items which were chosen based on Finnish dietary guidelines. In general, women's food behaviour was more in accordance with the dietary guidelines than that of men. The pattern of association between educational level and food behaviour was similar for both genders, but slightly stronger for men than women. Employment status was associated only with women's food behaviour, but the tendency was the same for men. Marital status was associated with men's as well as women's food behaviour. The food behaviour of married men and women was more in line with the dietary guidelines than the food behaviour of those who had been previously married. Parental status, however, was only associated with women's food behaviour, that is, the food behaviour of women with young children was more closely in line with the dietary guidelines than that of the rest of the women.