Gender Equality and Gender Inequalities in Self-Reported Health: A Longitudinal Study of 27 European Countries 2004 to 2016

Significant gender-based health inequalities have been observed across Europe, with women reporting worse health than men. Still, there has been little examination of how the gender–health gap has changed over time, and how it has been shaped by societal gender equality. We used data from the Statistics on Income and Living Conditions Eurostat database (EU-SILC), involving 2,931,081 participants aged 25–64, for 27 European countries. Logistic regressions were performed to model the association between self-reported bad health and gender, in general and over time. Analyses were stratified by employment, education, and clusters of countries according to levels of Gender Equality Index (GEI). Adjusting for age, year, and country, bad health was 17% more likely among women, but this disadvantage ceased after accounting for education and employment. Gender–health inequalities were larger among countries with higher GEI scores and among low-educated groups. The gender–health gap did not reduce significantly between 2004 and 2016, in general and within subgroups. Although societies are becoming more equal, persistent inequalities in employment and income still lead to sustained health differences between men and women.

Smoking and school absenteeism among 15- to 16-year-old adolescents: a cross-section analysis on 36 European countries

Background

Schools have a crucial role to play in preventing youth smoking. However, the well-known long-term health consequences of youth smoking may be insufficient to convince education stakeholders to devote efforts to implement school-based programmes. However, if youth smoking were to have short-term consequences, this evidence could prompt education stakeholders’ action. In this article, we investigate the link between smoking and school absenteeism.

Methods

We used data from the 2011 wave of the European School Survey Project on Alcohol and Other Drugs, on adolescents aged 15–16. We applied logistic models to assess the risk of more than 3 missed school days, by cause, as function of smoking intensity, adjusting for age, sex, socioeconomic status, academic performance, parental involvement and other risk behaviours (alcohol and cannabis consumption). Consistency was assessed by replicating the analyses for each sex and age group and further adjusting for depression and self-esteem.

Results

Smoking more than five cigarettes per day was significantly linked to school absenteeism, with a 55% excess risk of missing more than 3 school days per month due to illness (OR = 1.55, 95% CI 1.46–1.64), and a more than two times excess risk due to skipping (OR = 2.29; 95% CI 2.16–2.43). These findings were consistent across age and sex groups.

Conclusion

We observed an association between smoking intensity and absenteeism among youth in Europe. This implies that, to the extent that this association is causal, school tobacco control policies may reduce the short-term consequences of smoking on adolescents’ education and health.

Health and finance in the post-austerity context: the Portuguese experience

In March 2018, a Mission Structure (EMSPOS) was created in Portugal, under supervision of both Ministries of Health and Finance, to analyze the economic situation of the National Health Service (NHS), and propose recommendations to ensure its financial sustainability. The main concern was the recurrent cycles of overdue debt of NHS hospitals, which reached, in September 2018, more than 1.3 billion euros. These debts cycles, mainly to the pharmaceutical industry, were viewed as a combination of (i) under-budgeting during and following the Great Recession; (ii) expenditure growth related to population aging and new technologies; and (iii) a hospital financing and governance model that provided few incentives towards adequate management.

Hospitals' overdue debts limit their autonomy to assume investment compromises, while they deteriorate the NHS negotiation power vis-à-vis suppliers/creditors. Also, these debts were paid through financial bailouts, which shifted from punctual to predictable and regular, constituting an “indebtment reward” that destroyed any incentive towards efficiency and cost containment.

The challenge faced by EMSPOS was to ensure better budgets and autonomy to hospitals, both indispensable to face growing needs (the health sector claim), while providing the right monitoring and incentives to avoid new cycles of debt, inefficiencies, and unsustainable expenditure growth (the Ministry of Finance claim). This last request was reinforced by the Post-Program Surveillance (PPS), by the European Commission and Central Bank, that “measure Portugal's capacity to repay its outstanding loans”.

The EMSPOS proposed a new governance model that included better budgets with an efficiency-related performance component, a new management contract for hospitals' executive boards, and a path towards more investment autonomy, through the approval of “Activity and Budget Plans”. We will discuss the details of this new models and the challenges of its implementation.

Key messages

Portuguese NHS hospitals have been facing regular cycles of overdue debt, related to under-budgeting and inadequate governance models. Better budgets and hospital autonomy are needed to face growing needs (MoH claim), and right incentives are needed, to avoid inefficiencies and unsustainable expenditure growth (MoF claim).

Combining jobs and motherhood: is it worse when growing children alone?

Background

Women combining paid job and motherhood may experience a poorer health status than those childless. This risk is expectedly higher among lone mothers due to their greater emotional, social, and economic vulnerability. This study aims to assess the impact of employment characteristics on the health of working mothers and to understand differences between lone and coupled mothers.

Methods

We used data from the 5th Portuguese National Health Survey from employed women (N = 1,649) aged 25-55 living with a child (<16). We modelled depression (assessed by the Personal Health Questionnaire-8) and less-than-good self-reported health as a function of employment variables (part-time job; self-employment; instable job situation; skill level and sector of activity) using logistic regressions, adjusting for age, family variables, socioeconomic status, and social support. Interaction terms assessed differences between lone and coupled mothers.

Results

Women in part-time (OR = 3.04, 95%CI=2.97-3.11), high-skilled jobs (OR = 3.57, 95%CI=1.30-1.38), and self-employed (OR = 1.34, 95%CI=1.30-1.38) had higher odds for depression, compared to those working in low-skilled, full time and not self-employed jobs. Less-than-good health was also more likely among those working part-time (OR = 1.34, 95%CI=1.31-1.36) and self-employed (OR = 1.34, 95%CI=1.31-1.37). Mothers' mental health disadvantage was amplified when alone regarding self-employment and part-time jobs.

Conclusions

Employed mothers' physical and mental health may be harmed by part-time jobs, self-employment, and working in more differentiated jobs. Employed lone mothers may experience greater risks than coupled mothers.

Key messages

Part-time, high-differentiated jobs or self-employment may harm the physical and mental health of working mothers. Lone mothers are disproportionately impacted by these employment characteristics.

Gender equality and inequalities in self-reported health in 27 European countries (2004 to 2016)

Background

Across Europe, women tend to report worse health than men, probably due to women's lower position in society. Although societal gender inequalities have decreased, differences persist regarding employment, income and use of time. This study aims to assess the evolution of gender-based inequalities in 27 European countries between 2004 and 2016, and to analyze the impact of societal gender equality in this evolution.

Methods

We used data from the Survey on Income and Living Conditions (EU-SILC), from subjects between 25 and 64 years old (N = 2,931,081) from 27 European countries. Logistic regressions were performed with bad self-reported health as dependent variable, first adjusted for age, country and year, and later also for education and employment. Interactions between gender and year were added to the models to assess changes over time. Countries were clustered according to their societal gender equality, based on their Gender Equality Index of 2005 and 2015 (GEI). Analyzes were stratified by education, employment and cluster of GEI.

Results

Women were 17% (OR = 1.17, 95%CI=1.15-1.19) more likely than men to report bad health. Considering education and employment, women were 3% less likely to report bad health (OR = 0.97, 95%CI=0.96-0.99). Gender-based inequalities were larger among the cluster with higher GEI (OR = 1.37, 95%CI=1.26-1.48) and those with lower education (OR = 1.21, 95%CI=1.18-1.24). Although the gender gap reduced from 26% (OR = 1.26, 95%CI=1.18-1.34) in 2004 to 16% (OR = 1.16, 95%CI=1.08-1.24) in 2016, the decrease was not significant. Differences between years were not significant when analyses were stratified for education, employment or cluster of GEI.

Conclusions

Gender-based inequalities persisted between 2014 and 2016 and were strongly related to differences in education and employment. The gender gap was larger among countries with greater societal gender equality.

Key messages

Women’s disadvantage in self-reported health persisted in 2016 and was connected to socioeconomic differences. The gender gap is not smaller in countries with greater societal gender equality.

Gender-related treatment gap in depression among the elderly: a study on 18 European countries

Background

Depression is largely unrecognized and untreated, particularly among men. Help-seeking behaviors are known to differ between genders, yet, these discrepancies are expected to vary along the socioeconomic distribution. This study assesses the gender-related treatment gap for depression and analyzes how it varies with the socioeconomic status.

Methods

We used data from the Wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) from 56,931 participants aged 50-80 from 18 European countries. Among those depressed (assessed by the EURO-D scale), we modelled previous diagnosis of an emotional problem by a doctor, as proxy for the treatment gap. First, a logistic regression with gender as the explanatory variable was performed, adjusting for age and country. Afterwards, employment and education were factored in and interacted with gender, to assess the differential association of these variables for men and women.

Results

Depression was more prevalent among women (35.5%) than men (19.8%). Among those depressed, women (18.9%) were more likely than men (13.9%) to have been previously diagnosed for an emotional problem (OR = 1.43, 95%CI=1.42-1.43). Compared to men, women had a lower likelihood of diagnosis among homemakers (OR = 0.50, 95%CI=0.49-0.52) and a higher likelihood when unemployed (OR = 2.18, 95%CI=2.16-2.20), employed (OR = 1.10, 95%CI=1.10-1.11), disabled (OR = 1.20, 95%CI=1.19-1.21) with low (OR = 1.26, 95%CI=1.25-1.27) or middle educational level (OR = 1.67, 95%CI=1.66-1.68).

Conclusions

Although depression is more frequent among women, results suggest a larger treatment gap among men. Low- and medium-educated men seem less likely to have been previously diagnosed, as well as those unemployed. Among women, those homemakers are less likely to have been diagnosed with depression.

Key messages

Depressed men are less likely to have been diagnosed, particularly those unemployed and less-educated. Among women, depression diagnosis is less frequent when they are homemakers.

Economic Evaluation of Five Tobacco Control Policies Across Seven European Countries

Introduction

Economic evaluations of tobacco control policies targeting adolescents are scarce. Few take into account real-world, large-scale implementation costs; few compare cost-effectiveness of different policies across different countries. We assessed the cost-effectiveness of five tobacco control policies (nonschool bans, including bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smoke-free bans, and school education programs), implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal.

Methods

Cost-effectiveness estimates were calculated per country and per policy, from the State perspective. Costs were collected by combining quantitative questionnaires with semi-structured interviews on how policies were implemented in each setting, in real practice. Short-term effectiveness was based on the literature, and long-term effectiveness was modeled using the DYNAMO-HIA tool. Discount rates of 3.5% were used for costs and effectiveness. Sensitivity analyses considered 1%–50% short-term effectiveness estimates, highest cost estimates, and undiscounted effectiveness.

Findings

Nonschool bans cost up to €253.23 per healthy life year, school smoking bans up to €91.87 per healthy life year, and school education programs up to €481.35 per healthy life year. Cost-effectiveness depended on the costs of implementation, short-term effectiveness, initial smoking rates, dimension of the target population, and weight of smoking in overall mortality and morbidity.

Conclusions

All five policies were highly cost-effective in all countries according to the World Health Organization thresholds for public health interventions. Cost-effectiveness was preserved even when using the highest costs and most conservative effectiveness estimates.

Implications

Economic evaluations using real-world data on tobacco control policies implemented at a large scale are scarce, especially considering nonschool bans targeting adolescents. We assessed the cost-effectiveness of five tobacco control policies implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. This study shows that all five policies were highly cost-effective considering the World Health Organization threshold, even when considering the highest costs and most conservative effectiveness estimates.

Change in the Prevalence and Social Patterning of First-and Second-Hand Smoking in PORTUGAL: A Repeated Cross-Sectional Study (2005 and 2014)

Between 2005 and 2007, important reinforcements of the tobacco legislation have been implemented in Portugal, which may have affected smoking patterns. The aim of this study was to measure the change in prevalence of first- and second-hand smoking (SHS) among adults, and its socio-demographic patterning in Portugal from 2005 to 2014. Data from the last two Portuguese National Health Interview Surveys (2005 and 2014) were used. The changes in daily smoking and SHS were measured using Poisson regressions, stratifying by sex and survey year. The inequalities were measured using relative inequality indexes (RII). From 2005 to 2014, there was a reduction in SHS (75%-54% among men, and 52%-38% among women), and a reduction in smoking among men (27%-26%), and an increase among women (9%-12%). SHS reduction was more marked among less privileged people. Among Portuguese men, inequalities in daily smoking have increased slightly, while among women the gap favoring low-educated reduced. Between 2005 and 2014, SHS decreased, but not daily smoking, particularly among women. Additionally, socioeconomic inequalities in smoking increased. Future policies should simultaneously tackle smoking and SHS prevalence, and their socioeconomic patterning. More comprehensive policies such as comprehensive national (non-partial) bans, combined with price increases could be more effective.

Academic Well-Being and Structural Characteristics of Peer Networks in School

Peer networks at school and students' position in these networks can influence their academic well-being. We study here individual students' network position (isolation, popularity, social activity) and peer network structures at the school level (centralization, density, clustering, school connectedness) and their relations to students' academic well-being (school burnout, SB; schoolwork engagement, SE). Classroom surveys for 14-16-year-olds (N = 11,015) were conducted in six European cities (SILNE survey). Students were asked to nominate up to five schoolmates with whom they preferred to do schoolwork. SB and SE correlated negatively (-0.32; p < 0.0001). Students had on average 3.4 incoming (popularity; range 0-5) and 3.4 outgoing (social activity; 0-5) social ties. Percentage of isolated students was 1.4. Students' network position was associated weakly with academic well-being-popular students had less SB and higher SE, and socially active students had higher SE. School-level peer networks showed high clustering and school connectedness, but low density and low centralization. Clustering was associated with higher SB. Low centralization and high school connectedness protected from SB. Dense networks supported SE as did high average school connectedness. Correlations between these network indicators and academic well-being were, however, low. Our study showed that both students' network position and network characteristics at the school level can influence adolescents' academic well-being.

Cost of youth tobacco-control policies in seven European countries

BACKGROUND

Tobacco-control policies have been suggested to reduce smoking among adolescents. However, there is limited evidence on the real-world costs of implementation in different settings. In this study, we aimed at estimating the costs of school smoking bans, school prevention programmes and non-school bans (smoking bans in non-educational public settings, bans on sales to minors and bans on point-of-sale advertising), implemented in Finland, Ireland, the Netherlands, Belgium, Germany, Italy and Portugal, for 2016.

METHODS

We retrospectively collected costs related to the inspection, monitoring and sanctioning activities related to bans and educational activities related to smoking prevention programmes. We used an 'ingredients-based' approach, identifying each resource used, quantity and unit value for one full year, under the state perspective. Costs were measured at national, regional, local and school-level and were informed by data on how these activities were performed in reality.

RESULTS

Purchasing power parities adjusted-costs varied between €0.02 and €0.74 (average €0.24) per person (pp) for bans implemented outside schools. Mean costs of school smoking bans ranged from €3.31 to €34.76 (average €20.60), and mean costs of school educational programmes from €0.75 to €4.65 (average €2.92).

CONCLUSIONS

It is feasible to estimate costs of health policies as implemented in different settings. Costs of the tobacco control policies evaluated here depend mainly on the number of person-hours allocated to their implementation, and on the scale of intervention. Non-school bans presented the lowest costs, and the implementation of all policies cost up to €36 pp for 1 year.

Environmental disasters and birth outcomes: Impact of a tailings dam breakage in Brazil

There is evidence of a relationship between in utero exposure to catastrophic events and adverse birth outcomes, usually attributed to heightened maternal stress. The objective of our work was to evaluate if the breakage of a dam containing wastefrom a mining cite in Brazil, in 2015, an environmental disaster popularly known as the Mariana Tragedy, affected the health of newborns exposed in utero. We used administrative data on birth records and reports on the Mariana Tragedy to identify all births from newborns exposed in utero and the intensity of that exposure, according to the mother's municipality of residence. Using a difference-in-differences framework, we estimated the impact of different intensities of exposure on birth outcomes. We found that being directly exposed in utero to the Tragedy resulted in 1.86 days shorter gestational age and 2.6 percentage points higher incidence of preterm birth (<37 weeks). We found no impact on birthweight related outcomes. The effect is larger than previously identified for other catastrophic events. We hypothesize that this is probably due to the Tragedy impacting birth outcomes not exclusively through heightened maternal stress, but also through depressed economic activity in directly affected municipalities.

Depression symptoms as mediators of inequalities in self-reported health: the case of Southern European elderly

Background

Inequalities in the distribution of self-reported health (SRH) have been widely reported. Its higher expressivity among women, elderly and least educated groups has been partly attributed to differences in their health perceptions. However, this subjectivity may be masking the burden of mental illness in these groups. Thus, we sought to understand if depression symptoms mediate inequalities in SRH.

Methods

SHARE waves 4 and 6, pertaining to Spain, Italy and Portugal, were used (n2011 = 8517, n2015 = 11 046). Inequalities in SRH were calculated, comparing the risk amongst education level, gender and age groups, adjusting for chronic diseases, functional limitations and country fixed effects. We then tested depression symptoms as mediators.

Results

Depression symptoms were associated with poor SRH (odds ratio (OR)2011 = 1.379, OR2015 = 1.384, P < 0.001). Their inclusion reduced the magnitude of the association between SRH and education, annulled the statistical significance for age, and reversed the gender effect. As expected, chronic diseases and functional limitations remained significant predictors of poor SRH.

Conclusions

Depression symptoms, together with chronic diseases and functional limitations, explain the poorer SRH of the least educated, female and older groups in the Southern European population. Therefore, tackling inequalities in SRH must require focusing on mental health issues, which disproportionately affect the most vulnerable groups.

Prevalence of home smoking bans in six European cities: a repeated cross-sectional study (2013-2016)

Background

Secondhand smoke exposure is responsible for over half a million premature deaths. With regulation now reducing smoking in most public enclosed spaces, one major source of indoor exposure remains the home environment. Home smoking bans (HSBs) are household rules that restrict smoking from certain (partial HSB) or all areas (complete HSB). Recent data suggest growing trends of HSB adoption over time, but it is not known whether time trends vary according to household characteristics.

Objectives

The aim of this study is to examine changes in the prevalence of HSB in six European cities between 2013 and 2016, according to socioeconomic characteristics of the household and smoking behavior of household members.

Methods

Data were collected in all schools participating in both waves of SILNE study in 6 European cities. A self-administered questionnaire was used, targeting students age 14 to 16 (n = 22,326). Students reported their parents’ smoking status and if there was a HSB at their home. Detailed information on socio-economic characteristics were collected as well.

Results

Between 2013 and 2016 the percentage of households with a complete HSB increased from 51.5% to 53.1%, while partial HSB increased from 30.7% to 32.1%. The prevalence of HSB increased in Hannover (G), Latina (I), Amersfoort (N) and Coimbra (P), whereas decreased in Namur (B) and Tampere (F). Socioeconomic differences in HSB were reduced, with larger increases in HSB in households with a lower parental educational level. Increases in HSB were observed among intact households, those without migration background and those with non-smoking parents.

Conclusions

The increase in the prevalence of HSB observed in most cities and throughout a variety of household types and characteristics between 2013 and 2016 may reflect the effect of smoking denormalization in different social contexts. Further actions of the tobacco control community should target the most vulnerable groups.

Key messages

The percentage of households with a complete HSB increased between 2013 and 2016 in 4 out of 6 European cities. Increases in the prevalence of HSB over time were observed across all socio-economic groups.

Adolescents' smoking environment under weak tobacco control: A mixed methods study for Portugal

INTRODUCTION

Bans on smoking in public places and on sales to minors have been widely implemented across the globe. However, many countries have either adopted non-comprehensive (i.e., partial) bans and/or weakly enforce those bans. Little is known, from the adolescents' perspective, how this affects their smoking-related perceptions and behaviors. We studied the case of Portugal, where bans are partial and/or weakly enforced. We sought to understand how the bans affect adolescents' access to cigarettes from commercial sources, the visibility of smoking in public places, and smoking locations.

MATERIAL AND METHODS

We used a mixed methods design on data gathered in 2016. Quantitative, cross-sectional surveys were conducted in six schools (n = 2,444) in Coimbra, Portugal. In two of these schools, qualitative data were collected in eight single-sex focus group interviews (n = 42).

RESULTS

Ninety-five percent of the adolescents who tried to buy cigarettes were able to do so from commercial sources, through vending machines, or directly from the vendor. Bans on smoking on school premises and at enclosed public places did not prevent these adolescents from observing smoking outside school gates (84.0%), in cafes and restaurants (97%), or from smoking at cafes, bars, or nightclubs (72.9%).

DISCUSSION

Partial and/or weakly enforced policies seem to not prevent adolescents from having access to cigarettes, frequently seeing smoking, and finding ample opportunities to smoke in public places. Adopting and enforcing comprehensive policies are necessary efforts to prevent unfavorable responses and more effectively reduce adolescents' smoking behavior.

Gender inequality in self-reported health and its evolution in Europe between 2004 and 2016

Background

That women generally have worse health than men has long been shown. Yet, the situation in Europe might have changed recently. Gender inequalities have decreased in access to education, employment, and political representation. However, women have increasingly adopted traditionally masculine unhealthy behaviors, such as smoking. Also, the Great Recession may have hurt women harder, due to their greater socioeconomic vulnerability. This study aims to analyze gender inequalities in 30 European countries, and its evolution over the 2004-2016 period.

Methods

We used data from the Survey on Income and Living Conditions (SILC), from people between 25 and 64 years old (N = 3,109,150). We modeled the probability of bad/very bad self-reported health as function of gender, adjusting for age, country and year, using logistic regressions. We further adjusted for education and employment. Then, we included interactions of gender and year to test changes in inequalities over time. Finally, we stratified the analysis according to countries grouped based on the Gender Development Index (GDI).

Results

Women were 16.8% more likely to report bad health (OR = 1.17, p &lt; 0.01). Considering education and employment, women were 2.6% less likely to report bad health (OR = 0.97, p &lt; 0.01). Over time, adjusting for age, the gender gap reduced from 81.1% (OR = 1.81, p &lt; 0.01) in 2004 to 16.4% in 2016 (OR = 1.16, p &lt; 0.01), and from 31.5% to 2.5% with socioeconomic adjustment. The reduction was larger in countries with a greater GDI.

Conclusions

Gender inequality has decreased, but was still present in 2016, in favor of men. This thinning is partly explained by the narrowing of inequalities in education and employment. A greater GDI has favored a larger improvement.

Key messages

Gender inequalities in self-reported health have narrowed over 2004-2006, following the narrowing of socioeconomic inequalities. A greater GDI has favored a larger improvement in gender inequalities.

The association between smoke-free school policies and adolescents' anti-smoking beliefs: Moderation by family smoking norms

BACKGROUND

Smoke-free school policies (SFSPs) may influence adolescents' smoking through the development of anti-smoking beliefs. We assessed which types of anti-smoking beliefs (health, social and societal) are associated with SFSPs and whether these associations were different for adolescents in smoking permissive versus prohibitive families.

METHODS

Survey data was collected in 2016-2017 from 10,980 adolescents between 14-16 years old and 315 staff in 55 schools from seven European cities. We separately measured adolescent-perceived SFSP and staff-reported SFSP at the school-level. Associations between SFSP and anti-smoking health, social and societal beliefs were studied using multi-level logistic regression, adjusting for demographics and school-level smoking prevalence. We tested for interactions between family norms and SFSP, and estimated associations for adolescents in permissive and prohibitive families, respectively.

RESULTS

Adolescent-perceived SFSP was not significantly associated with anti-smoking health (OR:1.08, 95%CI:0.94-1.25), social (OR:0.89, 95%CI:0.75-1.04) and societal beliefs (OR:1.15, 95%CI:0.99-1.33). Staff-reported SFSP were associated with anti-smoking health beliefs (OR:1.12, 95%CI:1.01-1.24), but not with social (OR:0.94, 95%CI:0.83-1.07) or societal beliefs (OR:1.02, 95%CI:0.90-1.14). Most results were comparable between adolescents in smoking prohibitive and permissive families. However, in smoking prohibitive families, adolescent-perceived SFSP were associated with societal beliefs (OR:1.24, 95%CI:1.06-1.46), but not in permissive families (OR:1.06, 95%CI:0.90-1.25). Also, in smoking permissive families, staff-reported SFSP were associated with more pro-smoking social beliefs (OR:0.83, 95%CI:0.72-0.96), but not in prohibitive families (OR:1.05, 95%CI:0.92-1.16).

CONCLUSIONS

We found evidence that SFSP are associated with some anti-smoking beliefs, but more so among adolescents from smoking prohibitive families than from permissive families.

Inequalities in adolescent self-rated health and smoking in Europe: comparing different indicators of socioeconomic status

Background

Although there is evidence for socioeconomic inequalities in health and health behaviour in adolescents, different indicators of socioeconomic status (SES) have rarely been compared within one data sample. We examined associations of five SES indicators with self-rated health (SRH) and smoking (ie, a leading cause of health inequalities) in Europe.

Methods

Data of adolescents aged 14–17 years old were obtained from the 2013 SILNE survey (smoking inequalities: learning from natural experiments), carried out in 50 schools in 6 European cities (N=10 900). Capturing subjective perceptions of relative SES and objective measures of education and wealth, we measured adolescents’ own SES (academic performance, pocket money), parental SES (parental educational level) and family SES (Family Affluence Scale, subjective social status (SSS)). Logistic regression models with SRH and smoking as dependent variables included all SES indicators, age and gender.

Results

Correlations between SES indicators were weak to moderate. Low academic performance (OR=1.96, 95% CI 1.53 to 2.51) and low SSS (OR=2.75, 95% CI 2.12 to 3.55) were the strongest indicators of poor SRH after adjusting for other SES-indicators. Results for SSS were consistent across countries, while associations with academic performance varied. Low academic performance (OR=5.71, 95% CI 4.63 to 7.06) and more pocket money (OR=0.21, 95% CI 0.18 to 0.26) were most strongly associated with smoking in all countries.

Conclusions

Socioeconomic inequalities in adolescent health were largest according to SES indicators more closely related to the adolescent’s education as well as the adolescent’s perception of relative family SES, rather than objective indicators of parental education and material family affluence. For future studies on adolescent health inequalities, consideration of adolescent-related SES indicators was recommended.

Excess winter mortality and morbidity before, during, and after the Great Recession: the Portuguese case

Although winter mortality and morbidity are phenomena common to most European countries, their magnitude varies significantly from country to country. The geographical disparities among regions with similar climates are the result of several social, economic, demographic, and biological conditions that influence an individual's vulnerability to winter conditions. The impact of poor socioeconomic conditions may be of such magnitude that an economic recession may aggravate the seasonal mortality pattern. This paper aims to measure the seasonal winter mortality, morbidity, and their related costs during the Great Recession (2009-2012) in mainland Portugal and its Regional Health Administrations (RHAs) and to compare it with the periods preceding and following it. Monthly mortality and morbidity data were collected and clustered into three periods: Great Recession (2009-2012), Pre-Recession (2005-2008), and Post-Recession (2013-2016). The impact of seasonal winter mortality and morbidity during the Great Recession in Portugal and its Regional Health Administrations was measured through the assessment of age-standardized excess winter (EW) death and hospital admissions rate and index, expected life expectancy gains without EW deaths, EW rate of potential years of life lost, and EW rate of emergency hospital admission costs. Important increases of winter deaths and hospital admissions were identified, resulting in an important number of potential years of life lost (87 years of life lost per 100,000 inhabitants in 2009-2012), life expectancy loss (1 year in 2009-2012), and National Health Service costs with explicit temporal and spatial variations. These human and economic costs have decreased consistently during the analyzed periods, while no significant increase was found during the Great Recession. Despite its reduction, the winter excess morbidity and mortality highlight that Portugal still faces substantial challenges related to a highly vulnerable population, calling for investments in better social and health protection.

Challenges for psychosocial rehabilitation services in the Lisbon Metropolitan Area: A qualitative approach

In Portugal, a mental health reform process is in place aiming to redefine the model of service provision. In 2008, a National Mental Health Plan (NMHP) was approved to provide policy guidance over the transition period. The NMHP intended, among others, to develop community-based services, with a specific focus on rehabilitation and deinstitutionalization. This study aims to explore the perspectives of service managers of psychosocial rehabilitation services regarding the main challenges to support the community living of persons with severe mental illnesses (PWSMI) in the Lisbon Metropolitan Area (LMA). The paper also contextualises the provision of psychosocial services within the country's mental health reform process and characterises the profile of service users in socio-occupational units (SOUs) of the LMA. Semi-structured interviews were performed with all SOUs' managers of the LMA (n = 13). Information regarding service user characteristics was collected based on service records (n = 344). Interviews were analysed according to the framework methodology. The results of the interviews were triangulated using document analysis. Fieldwork took place between June and July 2016. The findings suggest that the development of the mental health reform ensured significant changes to service delivery. Community-based mental health organisations are an important actor for service provision. However, important asymmetries were identified in the provision of psychosocial care within the LMA. At the same time, family carers are perceived as responsible for ensuring a large part of the social needs of the PWSMI but there is an increasing concern with their own ageing processes. As a conclusion, it is highlighted the current inequality between services and the need to contemplate a life-course perspective that comprehends the ageing process of caregivers poses an emerging challenge for psychosocial rehabilitation. These findings are also important for other low- and middle-income countries passing through similar reforms.

Tobacco control policies and smoking among older adults: a longitudinal analysis of 10 European countries

BACKGROUND AND AIMS

The impact of tobacco control on European older adults has not been studied, despite evidence that smoking cessation at old age can bring significant life expectancy gains. Our aim was to evaluate the impact of tobacco control policies on smoking among older adults in Europe from 2004 to 2013.

DESIGN

We used longitudinal data from the Survey of Health, Ageing and Retirement in Europe (SHARE, aged 50+ years) from four waves from 2004 to 2013. We used logistic regression models with clustered standard errors to determine whether the implementation of tobacco control policies was associated with changes in smoking status. Furthermore, we studied whether these associations varied by socio-demographic characteristics. Regression coefficients were converted to changes the probability of smoking [marginal effects (ME)].

MEASUREMENTS

Smoking status was the dependent variable, and the Tobacco Control Scale (TCS) was the explanatory variable, overall and by its main policy components (pricing and smoke-free policies). Covariates included age, sex, education and country and wave fixed-effects.

FINDINGS

A 10-point increase in TCS was associated with a lower probability of smoking by 1.6 percentage points [95% confidence interval (CI) = -3.208, -0.056] for those aged 50-65, but not for older Europeans. Among those with primary school or no education, the associated drop was of 1.5 percentage points (95% CI = -2.751, -0.253). By contrast, no significant relation between TCS and smoking was observed among those with high education. Higher TCS scores for pricing (ME = -0.636, 95% CI = -0.998, -0.275) and smoke-free policies (ME = -0.243, 95% CI = -0.445, -0.041) were associated with a significantly lower probability of smoking (P = 0.001 and P = 0.018, respectively).

CONCLUSION

Increases in tobacco taxes and smoke-free policies are significantly related with a reduction in smoking among European older adults, suggesting potential health gains for this rising share of the population. These policies may be more effective among the lowest educated.

Income-related inequality and inequity in children's health care: A longitudinal analysis using data from Brazil

The Brazilian Unified Health System was created in the late 1980s to ensure free universal access to health care and was funded by taxes and social contributions. The persistent inequity in access to health services in favour of richer individuals in Brazil has been observed in the literature. However, to the best of our knowledge, no measurement of inequality in medicine use or private health insurance (PHI) among children has been performed with longitudinal data. This paper uses inequality indices and their decompositions to analyse the income-related inequalities/inequities in children's health care in the city of Pelotas, Brazil, using longitudinal data following children from 12 to 72 months of age. Our sample with data in all waves has between 1877 and 2638 children (varying according to outcome). We seek to answer three questions: i) How does the inequality/inequity in health care evolve as children grow up? ii) What are the main factors associated with inequality in children's health care? iii) How much of the change in inequality/inequity is explained by mobility in children's health care and income mobility? We found that inequities in health care have their beginnings in early childhood but that there was a reduction in inequity at 72 months of age. Ownership of children's PHI was associated with greater pro-rich inequity in health care. The reduction in inequality/inequity was linked to mobility in the sense that initially poorer children had greater gains in health care (a greater increase in PHI ownership and a lower reduction in medicine use). Despite this improvement among the poorest, apparently, the Brazilian public health service seems to fail to ensure equity in health care use among children, with possible long-term consequences on inequalities in health.

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The inequities in health care have their beginnings even in early childhood.

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Income and mother's education have a strong contribution in the inequalities.

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Private health insurance has strong contribution in inequalities of medicine use.

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There was reduction in inequity for children's health care in Pelotas/Brazil.

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This improvement for poorest children occurred when they reached 72 months.

Who wants to cross borders in the EU for healthcare? An analysis of the Eurobarometer data in 2007 and 2014

Background

The European Union (EU) Directive on Patients' Rights in Cross-border Healthcare clarified the entitlements to medical care in other EU Member states. However, little is known about whether EU citizens have been travelling or are willing to travel to receive care. This study aimed to measure the determinants of cross-border patient mobility and willingness to travel to receive medical care in the EU, before and after the adoption of the Directive.

Methods

We used individual data from the Eurobarometer 210 (2007) and 425 (2014). In the 2 years, 53 439 EU citizens were randomly selected. We performed a logistic regression on the cross-border patient mobility and willingness to travel to other EU countries to use healthcare services as a function of the year (2007 or 2014), adjusting for age, gender, education and country size.

Results

In 2007, 3.3% of citizens reported cross-border mobility and 4.6% in 2014. The odds of cross-border patients' mobility were 11% higher in 2014, compared with 2007 [odds ratio (OR) 1.11, 95% confidence interval (CI) 1.02-1.21]. Also, mobility was 19% higher in males (OR 1.19, 95% CI 1.08-1.30) and 20% higher amongst the more educated (OR 1.20, 95% CI 1.09-1.31). However, the odds decreased 11% per decade of age (OR 0.89 per decade, 95% CI 0.85-0.93) and country size. In 2014, the willingness to travel decreased by 20% compared with 2007.

Conclusions

Cross-border patient mobility is more likely amongst the younger, the more educated and those from smaller countries. The directive does not seem to have promoted mobility at a large scale among the neediest citizens.