Does higher alcohol consumption affect attitudes towards alcohol control measures in Estonia?

Objectives

To analyze whether higher alcohol consumption is associated with negative attitudes towards stricter alcohol control policy measures in Estonia.

Study design

Cross-sectional analysis of nationally representative data from 2022 (n = 2059).

Methods

Attitudes towards seven alcohol control measures and their association with high-risk alcohol consumption (>140 g absolute alcohol for men and >70 g for women per week) were analyzed using used descriptive statistics and binary logistic regression using nationally representative data on Estonian 15-74-year-old population.

Results

In general, high-risk consumption associated with lower acceptance for alcohol control policies. Although men had higher prevalence of opposing alcohol control measure for every item considered, both men and women with high-risk alcohol consumption were significantly more likely to be against alcohol control measures in general even after accounting for the variation by demographic characteristics.

Conclusions

As public opinion is detrimental to the successful implementation of alcohol policies, these findings emphasize the need to communicate alcohol-related harms to the public in order to increase awareness and support for alcohol control policies.

SARS-CoV-2 infection during pregnancy and perinatal outcomes in Estonia in 2020 and 2021: A register-based study

INTRODUCTION

Data from different countries show partly controversial impact of SARS-CoV-2 infection on pregnancy outcomes. A nationwide register-based study was conducted in Estonia to assess the impact of SARS-CoV-2 infection at any time during pregnancy on stillbirth, perinatal mortality, Apgar score at 5 minutes, cesarean section rates, rates of preterm birth and preeclampsia.

MATERIAL AND METHODS

Data on all newborns and their mothers were obtained from the Estonian Medical Birth Registry, and data on SARS-CoV-2 testing dates, test results and vaccination dates against SARS-CoV-2 from the Estonian Health Information System. Altogether, 26 211 births in 2020 and 2021 in Estonia were included. All analyses were performed per newborn. Odds ratios with 95% confidence intervals (CI) were analyzed for all outcomes, adjusted for mother's place of residence, body mass index, age of mother at delivery and hypertension and for all the aforementioned variables together with mother's vaccination status using data from 2021 when vaccinations against SARS-CoV-2 became available. For studying the effect of a positive SARS-CoV-2 test during pregnancy on preeclampsia, hypertension was omitted from the models to avoid overadjustment.

RESULTS

SARS-CoV-2 infection during pregnancy was associated with an increased risk of stillbirth (adjusted odds ratio [aOR] 2.81; 95% CI 1.37-5.74) and perinatal mortality (aOR 2.34; 95% CI 1.20-4.56) but not with a lower Apgar score at 5 minutes, higher risk of cesarean section, preeclampsia or preterm birth. Vaccination slightly decreased the impact of SARS-CoV-2 infection during pregnancy on perinatal mortality.

CONCLUSIONS

A positive SARS-CoV-2 test during pregnancy was associated with higher rates of stillbirth and perinatal mortality in Estonia but was not associated with change in preeclampsia, cesarean section or preterm birth rates.

Estonian alcohol control legislation in 1990-2020: A narrative review

ISSUES

The aim of this narrative review is to provide a detailed, chronological overview on the development of Estonian alcohol control legislation during 1990-2020.

APPROACH

Qualitative document review focused on six legislative acts central to Estonian alcohol control policy. Distinguishing four policy areas (availability, advertising, taxation and drink-driving), the review identifies and describes significant changes in these legislative acts and their amendments from 1990 to 2020.

KEY FINDINGS

The review identified 51 significant changes in acts regulating either availability, advertising, taxation or drink-driving in Estonia. Majority of these changes (n = 36) relate to Alcohol Excise Duty Act and the Alcohol Act which regulate the taxation, production and sales of alcohol. Although all six key legislative acts were introduced during the 1990s, only a few significant changes to alcohol control policy were made in this decade. In contrast, the 2000s experienced an intense period of new legislation and amendments followed by 2010s when the main emphasis was on alcohol taxation and advertising.

IMPLICATIONS

During three decades, Estonian alcohol control legislation has gradually evolved to include most evidence-based measures to reduce the harmful use of alcohol, the effects of the policies on consumption and alcohol-related harms remain relatively modest.

CONCLUSION

The liberal and unregulated alcohol control measures in the 1990s have transitioned in the following two decades towards a coherent alcohol policy. While many of the World Health Organization's 'best buys' have been successfully implemented, there are still some recommendations which have not been targeted.

Parental Leave and Fertility: Individual-Level Responses in the Tempo and Quantum of Second and Third Births

Previous studies have documented varying fertility responses to changes in parental leave provisions. We contribute to this literature by investigating the effects on the transition to second and third births of a policy reform that introduced generous earnings-dependent parental leave benefit in Estonia in 2004. Our study employs a mixture cure model, a model with some useful properties that has been seldom applied in fertility research. The advantage of the cure model over conventional event history models is the ability to distinguish the effect of the covariates on the propensity to have a next child from their effect on the tempo of childbearing. The results show that the transition to next birth accelerated as parents responded to so-called speed premium, a feature that allowed them to avoid a reduction in benefits caused by a reduction of earned income between births, through the closer spacing of births. Furthermore, the findings suggest that the introduction of generous earning-related parental leave was associated with a substantial increase in the progression to both second and third births.

Cesarean section trends from 1992 to 2016 in Estonia and Finland: A registry-based study

INTRODUCTION

The number of cesarean sections (CSs) has grown steadily, but the underlying factors driving this increase remain unknown. Data from Medical Birth Registries were retrieved to analyze CS trends in Estonia and Finland during the period 1992-2016.

MATERIAL AND METHODS

All births in Estonia (n = 356 063) and Finland (n = 1 437 234) were included. The differences between Estonia and Finland in five-year time periods for the total CS rate, and rates in Robson 1, 2, and 5 groups (R1, R2, R5) were analyzed by logistic regression. Total CS rates were adjusted for birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, mother's age. R1; R2; R5 rates were adjusted for birthweight and mother's age.

RESULTS

In Estonia, the proportion of CSs increased from 6.5% to 21.0% and in Finland from 15.1% to 16.8% between 1992 and 2016. In 2016, Estonia and Finland remained within the target value with their R1 + 2 (Estonia 18%; Finland 16%) and R5 (Estonia 59%; Finland 42%) values.

CONCLUSIONS

Comparing Robson groups in different countries can shed light on divergent CS rates and to improve the quality of perinatal and obstetric care.

From UAV to PlanetScope: Upscaling fractional cover of an invasive species Rosa rugosa

Invasive plant species pose a direct threat to biodiversity and ecosystem services. Among these, Rosa rugosa has had a severe impact on Baltic coastal ecosystems in recent decades. Accurate mapping and monitoring tools are essential to quantify the location and spatial extent of invasive plant species to support eradication programs. In this paper we combined RGB images obtained using an Unoccupied Aerial Vehicle, with multispectral PlanetScope images to map the extent of R. rugosa at seven locations along the Estonian coastline. We used RGB-based vegetation indices and 3D canopy metrics in combination with a random forest algorithm to map R. rugosa thickets, obtaining high mapping accuracies (Sensitivity = 0.92, specificity = 0.96). We then used the R. rugosa presence/absence maps as a training dataset to predict the fractional cover based on multispectral vegetation indices derived from the PlanetScope constellation and an Extreme Gradient Boosting algorithm (XGBoost). The XGBoost algorithm yielded high fractional cover prediction accuracies (RMSE = 0.11, R² = 0.70). An in-depth accuracy assessment based on site-specific validations revealed notable differences in accuracy between study sites (highest R² = 0.74, lowest R² = 0.03). We attribute these differences to the various stages of R. rugosa invasion and the density of thickets. In conclusion, the combination of RGB UAV images and multispectral PlanetScope images is a cost-effective method to map R. rugosa in highly heterogeneous coastal ecosystems. We propose this approach as a valuable tool to extend the highly local geographical scope of UAV assessments into wider areas and regional evaluations.

Declining first-ever stroke incidence rates in 15- to 54-year-old residents of Tartu, Estonia, from 1991 to 2017

BACKGROUND

Having a stroke at a young age has a huge socioeconomic impact. Data on the trends of stroke incidence in young adults from prospective population-based studies are scarce.

AIMS

The aim of this study was to analyze the trends in stroke incidence in 15- to 54-year-old residents of Tartu, Estonia from 1991 to 2017.

METHODS

Three population-based studies with identical study protocols determining the incidence of first-ever stroke have previously been conducted in Tartu, Estonia (1991-1993, 2001-2003, and 2013-2017). All residents of Tartu with first-ever stroke (ischemic stroke, spontaneous intracerebral hemorrhage, and subarachnoid hemorrhage) who were hospitalized to the Department of Neurology, Tartu University Hospital in respective study periods were included prospectively. Overlapping data sources for case ascertainment were used to include both hospitalized and non-hospitalized cases. Trends in first-ever stroke incidence in 15- to 54-year-old residents of Tartu were calculated and compared using rate ratio (RR).

RESULTS

Altogether 259 strokes were identified. From 1991 to 2017, the proportion of women increased from 38.3% to 43.6%. Mean age at onset in women decreased from 46.9 (standard deviation (SD): 7.3) to 42.6 (SD: 8.9). Overall crude incidence rates per 100,000 decreased significantly from 1991 to 2003 (from 57.2 (95% confidence interval (CI): 46.9-69.1) to 35.7 (95% CI: 25.7-48.3)); RR: 0.62 (95% CI: 0.44-0.89). While also present in women, the decrease was most notable in 45- to 54-year-old men (RR: 0.55 (95% CI: 0.30-0.99)). In 35- to 44-year-old men, the incidence rates decreased significantly from 2001 to 2017 (RR: 0.37 (95% CI: 0.14-0.99)).

CONCLUSION

The overall first-ever stroke incidence rates decreased from 1991 to 2003 and remained stable thereafter.

How the EU Cohesion Policy targeted at R&D and innovation impacts the productivity, employment and exports of SMEs in Estonia

The aim of this empirical investigation is to assess how the support targeted at R&D and innovation in the European Union Cohesion Policy Programme 2014-2020 affects the labour productivity, employment and exports of small and medium-sized companies. We estimate the treatment effects of two R&D financial support activities using a semiparametric efficient estimator with over-identified moment conditions and inverse probability weighting. The impact assessment uses population data on small and medium-sized enterprises in Estonia, the European Union member state that benefits most per capita from Cohesion Fund allocations. We found that support for R&D and innovation from the Cohesion Policy had a positive short-term effect on labour productivity and employment over the estimation period 2014-2018, and that the size and robustness of the effect were strongest for labour productivity. The short-term effect on exporting was ambiguous.

30 years of primary health care reforms in Estonia: The role of financial incentives to achieve a multidisciplinary primary health care system

Estonia has a legacy of hospital-focused service provision, but since the 1990s, has introduced a series of reforms to strengthen primary health care (PHC). The recent PHC reforms have placed an increasing focus on multidisciplinary care, involving home nurses, midwives, and physiotherapists, and emphasize PHC centres over single physician practices. These incremental reforms, without a supporting legal basis nor explicitly defined timelines and targets, nonetheless demonstrated the ability of financial incentives to drive change. EU structural funds in particular provided essential funding for infrastructure investments in PHC. Yet not all stakeholders supported these initiatives, largely due to the uncertain sustainability of funding. The EHIF also adjusted contract and payment terms to support PHC reforms, with some concessions to PHC providers operating as single practitioners. Despite substantial progress over the last three decades to shift the focus to PHC, there are some important bottlenecks that hinder the progress. These include PHC providers' hesitance to give up their freedom as single practitioners, low interest from specialists to start working at the PHC level, and a lack of financial incentives and adequate funding for a broader scope of PHC services. This looks to become more challenging in the future, as nearly half of family physicians are 60 years old or older. The development of the new PHC strategy in 2023 is very timely to comprehensively address these bottlenecks and to set the vision for the future of PHC in Estonia.

Health behavior of young patients with ischemic stroke in Estonia: A score of five factors

BACKGROUND

Behavioral risk factors are common among young patients with stroke. This study aimed to compare the health behavior of patients and healthy controls and develop a combined risk score of health behavior.

METHODS

The health behavior of patients aged 18-54 years who suffered an ischemic stroke from 2013 to 2020 in Estonia was compared to the Health Behavior among Estonian Adult Population 2014 study sample. We chose five risk factors for comparison: smoking status, body mass index, physical exercise, diet (salt use and vegetable consumption), alcohol intake (quantity and frequency), and composed a summary score.

RESULTS

Comparing 342 patients and 1789 controls, daily smoking (49.0% vs. 22.7%), obesity (33.4% vs. 15.9%), low physical activity (< twice/week) (72.2% vs. 60.5%), excessive salt use (8.6% vs. 4.5%), and frequent alcohol use (≥ weekly) (39.9% vs. 34.0%) were more prevalent among patients. The differences in infrequent vegetable consumption (<6 days/week) and excessive alcohol consumption (7 days, >8 units/females, >16 units/males) were not significant. The observed differences were similar for age groups 18-44 years and 45-54 years. The average Health Behavior Stroke Risk Score (0-10) was 4.6 points (CI 4.4-4.8, SD ± 1.97) for patients and 3.5 points (CI 3.4-3.6, SD ± 1.90) for controls.

CONCLUSIONS

Before stroke, young patients displayed significantly worse health behavior than the general population. The largest differences were found for smoking and obesity, and a cumulation of risk factors was observed via the HBSR score.

Suicide and other causes of death among Chernobyl cleanup workers from Estonia, 1986 - 2020: an update

Mortality was studied in a cohort of 4831 men from Estonia who participated in the environmental cleanup of the radioactively contaminated areas around Chernobyl in 1986-1991. Their mortality in 1986-2020 was compared with the mortality in the Estonian male population. A total of 1503 deaths were registered among the 4812 traced men. The all-cause standardized mortality ratio (SMR) was 1.04 (95% CI 0.99-1.09). All-cancer mortality was elevated (SMR 1.16, 95% CI 1.03-1.28). Radiation-related cancers were in excess (SMR 1.20, 95% CI 1.03-1.36); however, the excesses could be attributed to tobacco and alcohol consumption. For smoking-related cancers, the SMR was 1.20 (95% CI 1.06-1.35) and for alcohol-related cancers the SMR was 1.56 (95% CI 1.26-1.86). Adjusted relative risks (ARR) of all-cause mortality were increased among workers who stayed in the Chernobyl area ≥ 92 days (ARR 1.20, 95% CI 1.08-1.34), were of non-Estonian ethnicity (ARR 1.33, 95% CI 1.19-1.47) or had lower (basic or less) education (ARR 1.63, 95% CI 1.45-1.83). Suicide mortality was increased (SMR 1.31, 95% CI 1.05-1.56), most notably among men with lower education (ARR 2.24, 95% CI 1.42-3.53). Our findings provide additional evidence that unhealthy behaviors such as alcohol and smoking play an important role in shaping cancer mortality patterns among Estonian Chernobyl cleanup workers. The excess number of suicides suggests long-term psychiatric and substance use problems tied to Chernobyl-related stressors, i.e., the psychosocial impact was greater than any direct carcinogenic effect of low-dose radiation.

'Well, the Child Can't Choose, Right?': Foster Children's Participation Experiences of Child Protection Removal Practices

According to the United Nations Convention on the Rights of the Child, children have the right to voice their opinions and participate in decision-making in matters affecting their lives. Furthermore, professionals working with children have the responsibility to always make the best interests of the child the priority when contemplating decisions that have an impact on the child, including by ensuring that the child's concerns are paid attention to and their opinion is taken into consideration. However, studies indicate that the opposite occurs in practice and that decision-making in child protection cases often excludes children's views, especially in alternative care. In this qualitative study, 31 foster children's perspectives were gathered through in-depth semi-structured and focus group interviews with the aim of exploring the children's participation and perspectives based on their lived experiences within the context of child protection removal practice in Estonia. Findings indicate several obstacles that hinder children's meaningful participation, including not receiving adequate or truthful information about their removal and placement. Furthermore, they had no trustworthy adult to talk to and, therefore, they lacked opportunities to discuss their views or concerns with someone capable of acting on them. These findings suggest that children's active and meaningful participation in alternative care requires more attention and implications in practice.

Did the pandemic bring new features to counter-urbanisation? Evidence from Estonia

This paper aims to shed new light on changes in counter-urbanisation over the past three decades. A specific focus will be placed on new features of domestic migration to non-metropolitan rural areas which have become apparent during the global coronavirus pandemic. We focus on the intensity, origins, and destinations of counter-urban moves, and on the individual characteristics of counter-urban movers. Based on a case study of Estonia, our main findings show, firstly, that urbanisation has been the predominant migration trend across the past thirty years, with the main destination of domestic migrants being the capital city and its urban region. Secondly, we find that counter-urban moves have gained importance over time and especially during the periods of economic bust. The most important new features of counter-urbanisation during the pandemic relate to the increased migration of families with children and people who have high-income occupations to non-metropolitan rural areas. These new features of domestic migration could serve to slow down or even reverse the long-term problem of population aging in the countryside and the loss of educated people there.

Developments in quality of stroke care in Estonia

Background

Monitoring and measuring different aspects of stroke care pathway is the cornerstone for improvement of quality. We aim to analyze and give an overview of improvements of stroke care quality in Estonia.

Patients and methods

National stroke care quality indicators are collected and reported using reimbursement data and include all adult stroke cases. In Estonia, five stroke-ready hospitals are participating in Registry of Stroke Care Quality (RES-Q), providing data on all stroke patients 1 month every year. Data from the national quality indicators and RES-Q from 2015 to 2021 are presented.

Results

The proportion of intravenous thrombolysis for all Estonian hospitalized ischemic stroke cases increased from 16% (95% Confidence Interval, CI 15%-18%) in 2015 to 28% (95% CI 27%-30%) in 2021. Mechanical thrombectomy was provided to 9% (95% CI 8%-10%) in 2021. The 30-day mortality rate has decreased from 21% (95% CI 20%-23%) to 19% (95% CI 18%-20%). More than 90% of patients with cardioembolic stroke are prescribed anticoagulants at discharge, but only 50% are on anticoagulant treatment 1 year after stroke. Also, the availability of inpatient rehabilitation needs improvement, being 21% (95% CI 20%-23%) in 2021. A total of 848 patients are included in the RES-Q. The proportion of patients receiving recanalization therapies was comparable to the national stroke care quality indicators. All stroke-ready hospitals show good onset-to-door times.

Conclusion

The overall stroke care quality in Estonia is good, especially the availability of recanalization treatments. However, secondary prevention and the availability of rehabilitation services need improvement in the future.

Contradictions of hegemonic masculinity and the (hopeful) potential of old age and caring masculinity in Estonian society and in films A Friend of Mine (2011) and Tangerines (2013)

Despite having a significant impact on how we perceive ageing, cultural representations of old age, particularly depictions of old men, have received little attention. This is especially true regarding the cinemas of small nations and Eastern European film. Some authors claim that this gap in knowledge unintentionally repeats a widespread cultural assumption of associating masculinity with young and middle age men (Saxton & Cole, 2012, pp. 97-98). Old age has a complex relationship with the hegemonic variant of masculinity, which, as defined by R. W. Connell and James W. Messerschmidt, opposes itself to femininities and oppresses alternative forms of masculinities (Connell & Messerschmidt, 2005, p. 832). As hegemonic masculinity presupposes that one is physically and/or socioeconomically in their prime, old age appears to be inversely correlated with it, offering an opportunity to rethink masculinities. At the same time, as the films analysed in this article will show, becoming marginalised in old age, often due to hegemonic masculinity, does not necessarily lead one to abandon its principles. Caring masculinity has recently been discussed as a non-hierarchical alternative to hegemonic masculinity (Hanlon, 2012; Elliott, 2016; Ruby & Scholz, 2018; Chatzidakis et al., 2020; Hyvönen, 2021). So far, caring is socially constructed as feminine (see also Reskin, 1988). Despite the growing labour market participation of females, the gender care gap is not closing at the same speed and remains the chief source of the 'patriarchal dividend' (Connell, 1995). Men's changing relation to care, at least regarding one's own children, has been the focus of policy reform, but less so men's relation to care more broadly. Theories that aim to explain the gender inequality in care work usually do not engage with critical studies of men and masculinity along with the concept of hegemonic masculinity (Connell & Messerschmidt, 2005). Care's intersectionality with ageing and masculinities especially merits further study. This article will frame caring masculinity as well as the social context regarding care and old age in Estonia. Following this, the representation of these topics will be analysed in two Estonian films: A Friend of Mine (Kivastik, 2011) and Tangerines (Urushadze, 2013), in which such concerns are central.

The burden of mental health-related mortality in the Baltic States in 2007-2018

Background

The problem of underestimating the burden of mental health-related mortality is widely discussed in the public health literature. Relevant scientific evidence from societies experiencing the largest burden of mental health mortality is important for better understanding global and national mental health challenges and improving policies. Three Baltic States - Estonia, Lithuania, and Latvia - are countries in the Central and Eastern European region that experienced post-soviet transition trauma and showed among the highest suicide and alcohol-related mortality rates in Europe. This study aimed to examine the change in the burden of mental health-related mortality in three Baltic States in the context of consistent growth in life expectancy in 2007-2018.

Methods

We calculated age-standardized years of life lost due to specific mental health-related causes of death in three Baltic countries from 2007 to 2018. Four mental health-related causes of death groups were analyzed: (i) all mental and behavioural disorders; (ii) intentional self-harm; (iii) main substance use-related causes of death; and (iv) external causes of death. The number of deaths came from the WHO Mortality Database; population exposures were extracted from the Human Mortality Database.

Results

We found that the proportion of age-standardized years of life lost due to mental disorders was relatively low in all three countries. It varied from 0.2% for females in Lithuania in 2009 to 2.4% for males in Estonia in 2007. However, the proportion of age-standardized years of life lost from self-harm and substance use remained high. In 2018, the proportion of age-standardized years of life lost due to self-harm was highest among males in Lithuania (4.1%) while the highest proportion due to substance use-related causes of death was among males in Estonia (7.3%).

Conclusions

Our findings indicate that the burden of mental health-related mortality remained high and showed divergent temporal changes across the three countries. In the context of the Baltic States and other post-soviet countries, fractions of various external causes of death and alcohol-related causes of death should be considered in assessing the total burden of mental health-related mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14175-9.

Health-Related Quality of Life and Its Socio-Demographic and Behavioural Correlates during the COVID-19 Pandemic in Estonia

The aim of the study was to analyse health-related quality of life (HRQoL) among the Estonian general population and its socio-demographic and behavioural correlates during the COVID-19 pandemic. Longitudinal data on 1781 individuals from an Estonian rapid-assessment survey on COVID-19 were used. HRQoL was assessed with the EQ-5D-3L in June 2020 (baseline) and in May 2021 (follow-up). The HRQoL index score and its socio-demographic and behavioural variations were analysed using paired t-tests and Tobit regression modelling. Statistically significant declines in mean EQ-5D index scores were observed for all socio-demographic and behavioural variables considered. Most of these changes were due to increased reporting of problems in the pain/discomfort and anxiety/depression health domains. Older age, being unemployed or economically non-active and having financial difficulties were significantly associated with lower HRQoL in both baseline and follow-up measurements. In the follow-up data, women had significantly lower HRQoL compared to men, whereas higher education proved to be the only protective factor regarding HRQoL. Unhealthy dietary habits and low physical activity had a negative impact on the HRQoL score in the follow-up data. These results indicate that the COVID-19 pandemic has had a substantial impact on HRQoL in the Estonian population.

Long-term mortality following SARS-CoV-2 infection: A national cohort study from Estonia

BACKGROUND

The objective of this study was to describe 12-month mortality following SARS-CoV-2 infection compared with a reference population with no history of SARS-CoV-2.

METHODS

Nationwide cohort study using electronic health care data on SARS-CoV-2 RNA positive cases (n= 66,287) and reference group subjects (n=254,969) with linkage to SARS-CoV-2 testing and death records.

FINDINGS

People infected with SARS-COV-2 had more than three times the risk of dying over the following year compared with those who remained uninfected (aHR 3·1, 95%CI 2·9-3·3). Short-term mortality (up to 5 weeks post-infection) was significantly higher among COVID-19 group (1623·0/10 000) than in the reference group (118/10 000). For COVID-19 cases aged 60 years or older, increased mortality persisted until the end of the first year after infection, and was related to increased risk for cardiovascular (aHR 2·1, 95%CI 1·8-2·3), cancer (aHR 1·5, 95%CI 1·2-1·9), respiratory system diseases (aHR 1·9, 95%CI 1·2-3·0), and other causes of death (aHR 1·8, 95%CI 1·4-2·2).

INTERPRETATION

Increased risk of death from SARS-CoV-2 is not limited to the acute illness: SARS-CoV-2 infection carries a substantially increased mortality in the following 12 months. This excess death mainly occurs in older people and is driven by broad array of causes of death.

FUNDING

Research was carried out with the support of Estonian Research Council (grants PRG1197, PRG198), European Regional Development Fund (RITA 1/02-120) and European Social Fund via IT Academy program.

The voices of parents in child protective services: A qualitative analysis of families' struggles with COVID-19

The pandemic of the Coronavirus disease 2019 (COVID-19) has affected children and families worldwide, disrupting their daily lives and well-being. A small-scale study involving 13 parents in Child Protective Services in Estonia was conducted using in-depth, semi-structured interviews to explore parents' experiences with COVID-19 and its impact on their families' well-being. The findings indicated that one of the areas most impacted by the COVID-19 pandemic was schooling, as the implementation of remote schooling often created tensions and conflicts at home. Parents reported regression in daily functioning, attributing this to the lack of supportive services during lockdown and additional distress resulting from increased workload at home and problems with balancing home and work life. Parents were exhausted by the various problems caused by the pandemic and questioned their ability to provide their children the support they needed. Discontinuation of services intensified existing challenges for both parents and children. Furthermore, a lack of trust in Child Protective Services was identified, serving as a barrier to asking for help in times of crisis.

Identifying Potential Drug-Related Problems Among Geriatric Patients With Use of an Integrated Clinical Decision Support Tool

Background: Drug-related problems (DRPs) which arise from potentially inappropriate medications (PIMs) are a common problem in older people with multi-morbidity and polypharmacy.

Aim: To develop an integrated PIM clinical decision support tool for identification of DRPs in geriatric multi-morbid polypharmacy patients, using the EU(7)-PIM and EURO-FORTA lists, with a focus on high-risk medications.

Methods: The integrated PIM tool used the information on PIMs in both databases—the EU(7)-PIM and EURO-FORTA. PIMs were classified into four color groups based on risk profile: high-risk PIMs (should be avoided in older patients) as red, moderate-risk PIMs (require dose and/or treatment duration adjustment) as yellow, low-risk PIMs (low DRP risk) as green, and questionable PIMs (incomplete/missing information) as grey.

Results: The summarized list of the high-risk (red and some grey) PIMs contained 81 active substances and medication classes. According to the ATC classification, most of the high-risk PIMs (n = 60, 74.1%) belong to the A, C, and N medication groups and 50.6% (n = 41) of the high-risk PIMs have currently marketing authorization in Estonia. The preliminary list of the moderate- and low-risk (yellow, green, and other grey) PIMs contained 240 active substances and medication classes, but sub-classification of this category into one or another group depends mainly on an individual patient´s clinical characteristics in a concrete analyzed study sample and needs further research.

Conclusion: The integrated clinical decision support tool based on the EU(7)-PIM and EURO-FORTA criteria addresses the need for more efficient identification of DRPs. It can be applied to identify PIMs and geriatric prescribing problems in different health care settings, and also in a context of little clinical information available.

Experiences and Expectations of Ethnic Minorities and Majorities towards Community Pharmacy Medicines-Related Services in Estonia

The unique professional competence of pharmacists can support the safe and effective use of medicines by patients. Additionally, it is important to acknowledge and incorporate the needs of patients with various cultural and social backgrounds. The objective of this study was to assess and compare the experiences and expectations of Russian- and Estonian-speaking pharmacy customers about medicines-related services in Estonian community pharmacies. Cross-sectional study among pharmacy customers was conducted in Estonia 2018−2020. For data analysis, an Independent t-Test was used to compare experiences and expectations of respondents towards medicines-related services. The study involved 552 pharmacy customers: 58.5% (n = 323) Estonians and 41.5% (n = 229) Russians. The majority of the total sample (78.3%) considered the pharmacist competent to help. Medicines-related concerns were more common among Russians (p = 0.037), however, they sought less contact to consult a pharmacist than Estonians (p < 0.001). Furthermore, expectations about different medicines-related services in the future were higher among Estonians than among Russians (p < 0.001). Community pharmacists in Estonia should focus more on person-centered care to better meet the expectations and needs of different ethnic groups about medicines-related services. It is also important to reduce the language barrier and to increase the recognition of cultural traditions by health professionals.

Estonian Dental Students' Oral Health-Related Knowledge, Attitudes and Behaviours (KAB): National Survey-Based Study

The strategic plan for dentistry and oral health in Estonia of 2030 focuses on oral health promotion and disease prevention through undergraduate dental curricula and fostering public health-oriented research among students. The present study was designed as a descriptive cross-sectional study to evaluate oral health-related knowledge, attitudes, and behaviours (KAB) of dental students in Estonia. The study was carried out in the spring semester of 2020, and it used a modified version of the Hiroshima University Dental Behavioural Inventory (HU-DBI). A total of 129 students responded to the survey, constituting a response rate of 93.5% due to the total population sampling (census) technique used in this study and the small target population size. Out of the 124 students included in the final analysis, 79% were females, 62.1% were clinical students, 11.3% reported smoking tobacco at least once a week, and 86.3% reported problematic internet use. The present study found that mean HU-DBI score of Estonian dental students was 8.09 ± 1.22 which is so far the highest recorded HU-DBI score in Europe. There was no significant difference between female vs. male or preclinical vs. clinical students in terms of HU-DBI score. While clinical students reported less faulty oral hygiene practices, such as hard toothbrush use and aggressive toothbrushing, preclinical students reported a slightly higher mean HU-DBI score. Smoking behaviour was more common among male and clinical students, and it was also associated with alcohol drinking and worry about teeth colour and halitosis.

Homogenisation of Biocultural Diversity: Plant Ethnomedicine and Its Diachronic Change in Setomaa and Võromaa, Estonia, in the Last Century

Simple Summary

To understand how healing practices change over time, it is important to recognize the role and extent of external factors affecting the diversity of uses. Our exemplary case study is part of a larger project studying the influence of centralization on the use of medicinal plants. We examined the current and past plant use of two small communities that reside on the border with Russia and speak two dialects of Estonian, namely Seto and Võro. Our results show that within the lifetime of the people we interviewed, many earlier known uses were abandoned and new uses were strongly influenced by knowledge disseminated through centralized channels. Many such uses have also been recorded in geographically distant regions that once belonged to the Soviet Union. This demonstrates the homogenizing influence of centralized knowledge distribution, which has eroded place-based biocultural diversity. In order to secure the survival of knowledge on how to use locally grown plants, we suggest that more attention on the regional level needs to be given to preserving and supporting the distribution of such place-specific knowledge.

Abstract

When studying the evolution of the use of medicinal plants, it is important to identify what role, and to what extent, external factors and local biocultural diversities play in shaping cultural changes. We chose as a case study, which forms part of a larger project, a religiously and linguistically distinct group, the Seto, and compared their current and past plant use with that of the surrounding Võro. Ethnobotanical fieldwork was conducted in the summers of 2018 and 2019. Current uses of plants constituted 34% of the total registered use reports and 41% of those were used to treat general diseases or used as prophylactics. In total, the medicinal use of 86 taxa was recorded, and of these 48 were prevalent. Strong erosion (the abandonment of 43, mainly wild taxa used historically) and valorisation of the uses shared with neighboring as well as distant regions once part of the Soviet Union, were evident, signalling the potential influence of the centralised distribution of knowledge. The results clearly show that the plant medicine-related biocultural diversities of the two groups have been considerably homogenised, eroded and influenced by the knowledge spread through various means during the Soviet era and over the last 30 years.

Does Public Service Motivation Affect Teacher Satisfaction From the Perspective of Urban and Rural Dual Structure? Empirical Analysis Based on Estonia TALIS 2018 Data

In recent years, basic education in Estonia has achieved balanced development despite the imbalance of structure and regional factors, and this phenomenon has made the Estonian educational system a general interest of international scholars. Based on the data from the 2018 Teacher Teaching International Survey (TALIS) database, this research divides 3,004 respondents in Estonia into rural teachers and urban teachers and explores the impact of public service motivation on teacher satisfaction from the perspective of urban-rural dual structure through the grouping and comparison of ordered regression models. The study finds that the three dimensions of public service motivations in Estonia will positively affect teacher satisfaction and that the influence coefficient of contribute to the society and the tendency to participate in education policies on teacher satisfaction is higher in rural areas than in urban areas. In addition, the satisfaction of rural teachers in Estonia will decrease with the age of teachers, and the satisfaction of male teachers will be significantly lower than the satisfaction of female teachers, while the satisfaction of urban teachers will decrease with the improvement of academic qualifications. In terms of the implications, on the one hand, Estonia's education policy attempts to solve the imbalance between the regional and teacher structure through subsidies and incentives; on the other hand, Estonia's education policy uses measures such as multidimensional evaluation, multichannel feedback, and local democratization to increase the teacher's participation as well as their satisfaction.

Effects of a minimal-guided on-line intervention for alcohol misuse in Estonia: a randomized controlled trial

BACKGROUND AND AIMS

Estonia has one of the highest alcohol-attributable mortality rates within the European Union. The aim of this study was to estimate the efficacy of an on-line self-help intervention to reduce problem drinking at the population level.

DESIGN

On-line open randomized controlled trial with an 8-week intervention and an active control group (intervention n = 303, control n = 286). Assessments took place at baseline and at 6 months follow-up.

SETTING

On- and offline channels were used for population-based recruitment within a nation-wide prevention campaign in Estonia.

PARTICIPANTS

Inclusion criteria were age ≥ 18 years, heavy drinking [Alcohol Use Disorders Identification (AUDIT) test score ≥ 8], literacy in Estonian and at least weekly access to the internet; n = 589 participants were randomized (50% male, 1% other; mean age 37.86 years; 45% with higher level of education).

INTERVENTION AND COMPARATOR

The intervention consisted of 10 modules based on principles of cognitive-behavioral therapy and motivational interviewing. The active control group received access to a website with a self-test including personalized normative feedback and information for standard alcohol treatment.

MEASUREMENTS

The primary outcome was AUDIT scores at 6 months follow-up adjusted for baseline scores.

FINDINGS

Intention-to-treat analyses were applied. Missing data were addressed by using baseline observation carried forward (BOCF) and multiple imputation by chained equations (MI); 175 completed follow-up in the intervention group and 209 in the control group. AUDIT score at follow-up was significantly smaller in the intervention [BOCF mean = 13.91, standard deviation (SD) = 7.61, MI mean = 11.03, SD = 6.55] than control group (BOCF mean = 15.30, SD = 7.31; MI mean = 14.30, SD = 7.21), with a group difference of -1.38 [95% confidence interval (CI) = -2.58, -0.18], P = 0.02 for BOCF and -3.26 (95% CI = -2.01, -4.51), P < 0.001 for MI.

CONCLUSIONS

A randomized controlled trial has found that an on-line self-help intervention with minimal guidance was effective at reducing problem drinking in Estonia.

Seroprevalence and levels of IgG antibodies after COVID-19 infection or vaccination

BACKGROUND

In a country-wide seroprevalence study of COVID-19 in Estonia, we aimed to determine the seroprevalence and the dynamics of IgG against SARS-CoV-2 after vaccination or positive PCR-test.

METHODS

Leftover blood samples were selected between 8 February and 25 March 2021, by SYNLAB Estonia from all counties and age groups (0-9, 10-19, 20-59, 60-69, 70-79 and 80-100 years) proportionally to the whole Estonian population and tested for IgG against SARS-CoV-2 spike protein receptor-binding domain (anti-S-RBD IgG) using Abbott SARS-CoV-2 IgG II Quant assay. Antibody levels after positive PCR-test or vaccination were described by exponential increase-decrease models.

RESULTS

According to total of 2517 samples, overall seroprevalence (95% confidence interval [CI]) was 20.1% (18.5-21.7%), similar in all age groups, but varied between counties. If individuals vaccinated with the first dose at least 14 d before antibody measurement were assumed to be seronegative, the overall seroprevalence was 15.8% (14.4-17.3%), 4.0-fold larger than the proportion of PCR-confirmed COVID-19 cases. Of seropositive individuals (n = 506) 194 (38.3%; 33.8-43.1%) had not had positive PCR-test or been vaccinated. According to exponential increase-decrease model, the peak of anti-S-RBD IgG in a 52-year-old (median age of PCR-positive and/or vaccinated individuals) was significantly higher after vaccination compared with positive PCR-test (22,082 (12,897-26,875) vs. 6732 (2321-8243) AU/mL), but half-life was similar (26.5 (6.9-46.1) vs. 38.3 (8.2-68.5) d).

CONCLUSIONS

One year after the start of COVID-19 pandemic the actual prevalence of infection is still underestimated compared with PCR-confirmed COVID-19 cases. Older compared with younger individuals have lower anti-S-RBD IgG level after vaccination, but similar decline rate.

Angiostrongylus vasorum in Estonia: Multi-center study in dogs with clinical signs suggestive of canine angiostrongylosis, survey of potential risk behaviors among the dogs, and questionnaire survey of knowledge about the parasite among veterinarians

Angiostrongylus vasorum is a parasite that can cause life-threatening disease in dogs. In recent years, A. vasorum has been reported spreading into new areas, in particular towards northeastern Europe. Despite being detected in wildlife in Estonia, no studies have focused on A. vasorum in domestic dogs in the country. We conducted a multi-center study in 2018-2019: at eight small animal clinics, altogether 115 dogs that had clinical signs that could be suggestive of canine angiostrongylosis were enrolled for testing using a commercial A. vasorum antigen detection test. In addition, we collected information on potential risk behaviors for acquiring A. vasorum infection - eating potential intermediate hosts and paratenic hosts - among the dogs, using a questionnaire for dog owners. Moreover, we surveyed knowledge about A. vasorum among veterinarians authorized to work in Estonia. None (0.0%, 95% confidence interval 0.0-2.6) of the 114 dogs included in the study tested A. vasorum antigen positive. Two (2.0%) of the 102 dogs included in the risk behavior analysis had been seen to eat slugs and/or snails, and this behavior was considered possible for further 17 (16.7%) of the dogs. Four (3.9%) of the dogs had been seen to eat frogs, and this behavior was considered possible for further 14 (13.7%) of the dogs. Thirty-eight (90.5%) of the 42 veterinarians who participated in the questionnaire survey selected the correct host and 28 (66.7%) selected the correct vectors of the parasite, from the provided options. Our results indicate that A. vasorum was either not established or not common in dogs in Estonia in 2018-2019, but this needs to be interpreted with caution due to the limited sample size, possible false negative results in recently infected dogs and the limited sensitivity of the test applied. Most local veterinarians seemed to know the parasite, and this awareness and knowledge among veterinarians should be maintained and further improved. Taken the presence of the parasite in local wildlife, it is prudent to include A. vasorum infection in the list of differential diagnoses for dogs with clinical signs that could be suggestive of canine angiostrongylosis in Estonia.

Norovirus strains among children aged 0-18 years hospitalized with acute gastroenteritis in Estonia 2015-2016

Norovirus (NoV) is the leading cause of acute gastroenteritis (AGE) in many countries that have introduced universal rotavirus mass vaccination. This is the first study to report data on NoV strains in Estonia. We recruited 2249 children aged 0-18 years hospitalized for AGE in Estonian hospitals from February 1, 2015 to August 31, 2016. Norovirus gastroenteritis (NoVGE) was diagnosed in 14.5% (n = 325) cases. Stool sample for RNA extraction and genotyping was available in 86% (n = 280) of NoVGE cases (2015, n = 91; 2016, n = 189). Dominant capsid types detected in 75% (n = 210) samples were, GII.4 (63.8%, n = 134), GII.3 (15.2%, n = 32), GII.17 (6.7%, n = 14), and GII.6 (5.2%, n = 11). Prevailing RNA polymerase types found in 77% (n = 215) samples were GII.P31 (51.1%, n = 110), GII.P21 (17.7%, n = 38), GII.P4 (11.2%, n = 24), and GII.P7 (6.5%, n = 14). Both regions were typeable for 67% (n = 189) of samples. Most prevalent strains were GII.4Sydney_2012[P31] (48.7%, n = 92), GII.3[P21] (15.3%, n = 29), GII.4Sydney_2012[P4] (5.8%, n = 11) and GII.17[P17] (5.8%, n = 11). Simpson's diversity index showed a significant difference between the age groups 1-4 and 5-9 years: D 0.64 (95% confidence interval [CI]: 0.55-0.73) versus 0.83 (95% CI: 0.81-0.86), respectively (p = 0.03). An accurate understanding of NoV strain diversity is important for control and preventive measures, especially in the postrotavirus vaccine era.

An overview of Estonian woodlice (Isopoda, Oniscidea)

An overview of the Estonian terrestrial isopod fauna is given, based on literature data and material collected from 1984 to 2021. The identified material consisted of 10915 specimens belonging to 14 species and collected from 172 localities throughout Estonia. In combination with previous data from the literature data, there are now reliable records of 16 species of woodlice from Estonia. Two species, viz. Platyarthrushoffmannseggii Brandt, 1833 and Hyloniscusriparius (C. Koch, 1838), are new for the fauna. The latter has probably colonised Estonia recently and range expansions have been reported elsewhere. The data on Philosciamuscorum (Scopoli, 1763) are dubious, and this species is currently excluded from the Estonian list.

On the enigma of Palaenigma wrangeli (Schmidt), a conulariid with a partly non-mineralized skeleton

Palaenigma wrangeli (Schmidt) is a finger-sized fossil with a tetraradiate conical skeleton; it occurs as a rare component in fossiliferous Upper Ordovician strata of the eastern Baltic Basin and is known exclusively from north Estonia. The systematic affinities and palaeoecology of P. wrangeli remained questionable. Here, the available specimens of P. wrangeli have been reexamined using scanning electron microscopy and x-ray computed tomography (microCT). Additionally, the elemental composition of the skeletal elements has been checked using energy dispersive X-ray spectroscopy. The resulting 2D-, and 3D-scans reveal that P. wrangeli consists of an alternation of distinct calcium phosphate (apatite) lamellae and originally organic-rich inter-layers. The lamellae form four semicircular marginal pillars, which are connected by irregularly spaced transverse diaphragms. Marginally, the diaphragms and pillar lamellae are not connected to each other and thus do not form a closed periderm structure. A non-mineralized or poorly mineralized external periderm existed originally in P. wrangeli but is only rarely and fragmentary preserved. P. wrangeli often co-occurs with conulariids in fossil-rich limestone with mudstone–wackestone lithologies. Based on the new data, P. wrangeli can be best interpreted as a poorly mineralized conulariinid from an original soft bottom habitat. Here the new conulariinid family Palaenigmaidae fam. nov. is proposed as the monotypic taxon for P. wrangeli.

Mobility-based SIR model for complex networks: with case study Of COVID-19

In the last decade, humanity has faced many different pandemics such as SARS, H1N1, and presently novel coronavirus (COVID-19). On one side, scientists have developed vaccinations, and on the other side, there is a need to propose models that can help in understanding the spread of these pandemics as it can help governmental and other concerned agencies to be well prepared, especially for pandemics, which spreads faster like COVID-19. The main reason for some epidemic turning into pandemics is the connectivity among different regions of the world, which makes it easier to affect a wider geographical area, often worldwide. Also, the population distribution and social coherence in the different regions of the world are non-uniform. Thus, once the epidemic enters a region, then the local population distribution plays an important role. Inspired by these ideas, we propose two versions of our mobility-based SIR model, (i) fully mixed and (ii) for complex networks, which especially takes into account real-life interactions. To the best of our knowledge, this model is the first of its kind, which takes into account the population distribution, connectivity of different geographic locations across the globe, and individuals’ network connectivity information. In addition to presenting the mathematical proof of our models, we have performed extensive simulations using synthetic data to demonstrate the generalization capability of our models. Finally, to demonstrate the wider scope of our model, we applied our model to forecast the COVID-19 cases at county level (Estonia) and regional level (Rhône-Alpes region in France).

African Swine Fever Re-Emerging in Estonia: The Role of Seropositive Wild Boar from an Epidemiological Perspective

African swine fever (ASF) emerged in Estonia in 2014. From February 2019 to August 2020, no pigs or wild boar tested positive for ASF virus (ASFV), only ASFV-specific antibodies could be detected in shot wild boar. However, ASF recently re-emerged in wild boar. We tested three hypotheses that might explain the current situation: (i) ASFV may have been present throughout, but at a prevalence below the detection limit; (ii) seropositive wild boar may have remained infectious (i.e., virus-carriers) and kept the epidemic going; or (iii) ASF was gone for 1.5 years, but was recently re-introduced. Using Estonian surveillance data, the sensitivity of the surveillance system and the confidence in freedom from ASF were estimated. Furthermore, the detection probability was determined and cluster analyses were performed to investigate the role of serological positive wild boar. The results suggest that the surveillance system was not able to detect virus circulation at a design prevalence below 1%. With respect to the confidence in freedom from ASF, the results indicate that circulating virus should have been detected over time, if the prevalence was ≥2%. However, the decreasing wild boar population density and ongoing surveillance activities made ASFV circulation at a low prevalence unlikely. Cluster analyses provided no evidence for a significant accumulation of serologically positive wild boar in temporal connection to the re-emergence of ASFV. Further targeted research, such as long-term experimental studies and molecular epidemiology, is necessary to improve our knowledge on the epidemiology of ASF and to control the disease more effectively.

'The Pandemic Affected My Life in a Negative Way': The Experiences of Estonian Children in Child Protective Services During the Coronavirus Disease 2019 Pandemic

This study investigates children's experiences concerning the effect of the containment measures associated with coronavirus disease 2019 (COVID-19) on their daily lives. A small-scale study using in-depth, semi-structured interviews was conducted in Estonia with 10 children registered with Child Protective Services (CPS) as in need of assistance. The COVID-19 pandemic generally negatively affected the children, who struggled with e-schooling, social relationships and emotional well-being. Most of the children reported struggling with their emotional well-being, using words such as anxiety, tension, fear, sadness, and depressing. Not all of the children received the necessary support or assistance from the CPS. The children reported a few positive experiences during the COVID-19 pandemic, such as attaining a more personalised method and schedule for studying and receiving parental support during e-schooling.

Use of Face-to-Face Assessment Methods in E-Learning-An Example of an Objective Structured Clinical Examination (OSCE) Test

The spread of COVID-19 and social-distancing rules have increased the need for alternative learning environments with a focus on e-learning platforms. The objective of this study was to assess whether and to what extent the transition from traditional learning and assessment environment to the e-setting impacts the knowledge and skills acquired by students and their satisfaction with new e-solutions of taking the OSCE test. The study compared the results of three face-to-face (2018-2019) and one electronically conducted (2021) OSCE tests, as well as students' feedback on the content and organization of the tests. For data analysis the one-way ANOVA test and post hoc multiple comparisons were used. The results demonstrated the feasibility and effectiveness of and students' satisfaction with OSCE tests in the Zoom environment. However, more focus on communication techniques is required in a remote communication environment to better cover all patient health-related and drug communication aspects. There were identified differences between undergraduate students and practicing assistant pharmacists in assessing patients' health problems and providing corresponding counseling. This result points to the need to implement the continuous development of patient-centered counseling techniques in the lifelong learning of pharmacists and the need to use innovative digital solutions, if applicable.

salamandrivorans in wild and captive amphibian populations in Estonia and Latvia

The pathogenic chytrid fungi Batrachochytrium dendrobatidis (Bd) and B. salamandrivorans (Bsal) cause infections that have become primary drivers of amphibian biodiversity loss. While globally widespread, the distribution margins of Bd and Bsal have not been determined, and the presence of these pathogens has probably gone unnoticed in many areas, especially in northern Eurasia. To better understand the presence and distribution of both pathogens in the northern temperate and boreal forest biomes, 243 individuals were sampled from 8 native amphibian species across Estonia. Additionally, 68 amphibians were sampled from captive collections in Estonia and Latvia. Pathogen infection was assessed using metabarcoding of the ITS2 marker. No positive matches for Bsal infection were found. Bd was detected in 13 specimens, 3 of which were sampled at the Riga Zoo (with a prevalence of 5.2%) and 10 in natural environments in Estonia (3.3%). The infected wild individuals belonged to 6 amphibian species and were detected throughout the mainland of Estonia, but not on islands. Prevalence of infection with Bd ranged between 3.1 and 12.5% among native species. In addition, we found molecular evidence for a potentially new sister species to Bd in nature. Although outbreaks of chytridiomycosis have never been observed in Estonia, it cannot be excluded that the dynamics of local amphibian populations are affected by Bd infections. Therefore, further work, including capture-mark-recapture studies and long-term monitoring, are required to clarify the impact of Bd on amphibians in Northern Europe.

The impact of sociodemographic factors on the utilization of radiation therapy in breast cancer patients in Estonia: a register-based study

Background

Radiation therapy is an important part of multimodal breast cancer treatment. The aim was to examine the impact of sociodemographic factors on radiation therapy use in breast cancer (BC) patients in Estonia, linking cancer registry data to administrative databases.

Methods

Estonian Cancer Registry provided data on women diagnosed with BC in Estonia in 2007–2018, including TNM stage at diagnosis. Use of radiation therapy within 12 months of diagnosis was determined from Estonian Health Insurance Funds claims, and sociodemographic characteristics from population registry. Receipt of radiation therapy was evaluated over time and by clinical and sociodemographic factors. Poisson regression with robust variance was used to calculate univariate and multivariate prevalence rate ratios (PRR) with 95 % confidence intervals (CI) for receipt of radiation therapy among stage I–III BC patients age < 70 years who underwent primary surgery.

Results

Overall, of 8637 women included in the study, 4310 (50 %) received radiation therapy within 12 months of diagnosis. This proportion increased from 39 to 58 % from 2007 to 2009 to 2016–2018 (p < 0.001). Multivariate regression analysis showed that compared to women with stage I BC, those with more advanced stage were less likely to receive radiation therapy. Receipt of radiation therapy increased significantly over time and was nearly 40 % higher in 2016–2018 than in 2007–2009. Use of radiation therapy was significantly lower for women with the lowest level of education compared to those with a university degree (PRR 0.88, 95 % CI 0.80–0.97), and for divorced/widowed women (PRR 0.95, 95 % CI 0.91–0.99) and single women (PRR 0.92, 95 % CI 0.86–0.99), compared to married women. Age at diagnosis, nationality and place of residence were not associated with receipt of radiation therapy.

Conclusions

The study showed considerable increase in the use of radiation therapy in Estonia over the study period, which is in line with increases in available equipment. The lack of geographic variations suggests equal access to therapy for patients living in remote regions. However, educational level and marital status were significantly associated with receipt of radiation therapy, highlighting the importance of psychosocial support in ensuring equal access to care.

Profession Driven Improvement of the Quality of Pharmacy Practice-Implementation of Community Pharmacy Services Quality Guidelines in Estonia

Constant improvement of the quality of community pharmacy services is important in the development of contemporary patient care. A national and voluntary Community Pharmacy Services Quality Guidelines (CPSQG) was developed to formulate the principles of contemporary pharmacy services, including quality criteria for service provision. The purpose of this study was to identify the implementation of the CPSQG as a profession-driven initiative towards improving and harmonizing community pharmacy services in Estonia. Three cross-sectional electronic surveys were conducted among community pharmacies in Estonia in 2014 (N = 478 pharmacies), 2016 (N = 493), and 2019 (N = 494), and the CPSQG indicators were used for evaluation of the service quality. In this study, the aggregated data, collected in three study years were used to identify the implementation of guidelines into practice. For data analysis, the One-Way ANOVA test and Post-hoc multiple comparisons were used. The results demonstrated slow implementation of the CPSQG, but guidelines-based evaluation enabled a detailed overview of the community pharmacy activities and provided services. In order to develop community pharmacy services more efficiently, the use of implementation science principles, continuous introduction of the CPSQG to the pharmacists, and more active involvement of the state could be considered in the future.

Perceived Stress During the First Wave of COVID-19 Outbreak: Results From Nationwide Cross-Sectional Study in Estonia

Objective: To study the population-level mental health responses during the first wave of coronavirus disease 2019 (COVID-19) outbreak in Estonia and analyze its socio-demographic, behavioral, and health-related variations among general population. Methods: This study used nationally representative data on 4,606 individuals, aged 18-79 years from a rapid-response cross-sectional survey conducted in April 2020. Point prevalence and mutually adjusted prevalence rate ratios for perceived stress from log-binomial regression analysis were presented for socio-demographic, behavioral, and health-related variables. Results: This study found that 52.2% of population aged 18-79 reported elevated stress levels in relation to COVID-19 outbreak. Higher levels of perceived stress were found in women, in younger age groups, in Estonians, and in those with higher self-perceived infection risk, presence of respiratory symptoms, and less than optimal health, according to self-reports. Conclusion: Although, the potential long-term health effects of the current crisis are yet unknown, the alarmingly high stress levels among people indicate that the COVID-19 pandemic might have had a widespread effect on people's mental health.

Advances in Genomic Discovery and Implications for Personalized Prevention and Medicine: Estonia as Example

The current paradigm of personalized medicine envisages the use of genomic data to provide predictive information on the health course of an individual with the aim of prevention and individualized care. However, substantial efforts are required to realize the concept: enhanced genetic discoveries, translation into intervention strategies, and a systematic implementation in healthcare. Here we review how further genetic discoveries are improving personalized prediction and advance functional insights into the link between genetics and disease. In the second part we give our perspective on the way these advances in genomic research will transform the future of personalized prevention and medicine using Estonia as a primer.

Surveillance of the Second Wave of COVID-19 in Europe: Longitudinal Trend Analyses

BACKGROUND

The COVID-19 pandemic has severely impacted Europe, resulting in a high caseload and deaths that varied by country. The second wave of the COVID-19 pandemic has breached the borders of Europe. Public health surveillance is necessary to inform policy and guide leaders.

OBJECTIVE

This study aimed to provide advanced surveillance metrics for COVID-19 transmission that account for weekly shifts in the pandemic, speed, acceleration, jerk, and persistence, to better understand countries at risk for explosive growth and those that are managing the pandemic effectively.

METHODS

We performed a longitudinal trend analysis and extracted 62 days of COVID-19 data from public health registries. We used an empirical difference equation to measure the daily number of cases in Europe as a function of the prior number of cases, the level of testing, and weekly shift variables based on a dynamic panel model that was estimated using the generalized method of moments approach by implementing the Arellano-Bond estimator in R.

RESULTS

New COVID-19 cases slightly decreased from 158,741 (week 1, January 4-10, 2021) to 152,064 (week 2, January 11-17, 2021), and cumulative cases increased from 22,507,271 (week 1) to 23,890,761 (week 2), with a weekly increase of 1,383,490 between January 10 and January 17. France, Germany, Italy, Spain, and the United Kingdom had the largest 7-day moving averages for new cases during week 1. During week 2, the 7-day moving average for France and Spain increased. From week 1 to week 2, the speed decreased (37.72 to 33.02 per 100,000), acceleration decreased (0.39 to -0.16 per 100,000), and jerk increased (-1.30 to 1.37 per 100,000).

CONCLUSIONS

The United Kingdom, Spain, and Portugal, in particular, are at risk for a rapid expansion in COVID-19 transmission. An examination of the European region suggests that there was a decrease in the COVID-19 caseload between January 4 and January 17, 2021. Unfortunately, the rates of jerk, which were negative for Europe at the beginning of the month, reversed course and became positive, despite decreases in speed and acceleration. Finally, the 7-day persistence rate was higher during week 2 than during week 1. These measures indicate that the second wave of the pandemic may be subsiding, but some countries remain at risk for new outbreaks and increased transmission in the absence of rapid policy responses.

Friends in All the Green Spaces: Weather Dependent Changes in Urban Mosquito (Diptera: Culicidae) Abundance and Diversity

Simple Summary

Many female mosquitoes require vertebrate blood for egg production. Cities are becoming increasingly important points of contact between mosquitoes and their prey, as large-scale urbanization continues. Human settlements represent unique but fragmented habitats that are permanently warmer than rural areas. Because of this, there is a growing demand to better understand urban mosquito populations and the factors affecting them in various circumstances. The aim of this study was to investigate the weather conditions influencing mosquito species and abundance in a Northern European town. Thus, a three-year-long mosquito collection effort was undertaken in Estonia. Results indicated that the number of active mosquitoes decreased with wind and higher temperatures. Interestingly, there was a significant negative correlation between temperature and humidity. Furthermore, while mosquitoes belonging to the Culex pipiens/Culex torrentium group were consistently abundant during the end of the warm season, other dominant species varied considerably between the months and the three study years. Overall, springtime hydrological conditions seemed to greatly influence the mosquito season. Urbanization could generate both higher temperatures and drier environments, resulting in fewer mosquitoes in some areas. This study also revealed the mosquito species most likely to contribute to disease transmission in Estonian towns.

Abstract

Mosquitoes (Diptera: Culicidae) are universally recognized as troublesome pests and vectors of various pathogens and parasites. Understandably, the species makeup and diversity of individual populations depends on local and broad scale environmental trends, especially on temperature and hydrological variations. Anthropogenic landscapes make for unique habitats, but their effect on insects likely varies across climatic regions. The aim of this study was to investigate the diversity and seasonal patterns of urban mosquitoes in the boreal region. Specimens were collected with an insect net from May to September during three years and determined to species or species group level. Weather information was added to each data point and results analyzed using multivariate regression models. Fieldwork yielded 1890 mosquitoes from four genera. Both abundance and the effective number of species (ENS) significantly decreased during the study period. The number of collected mosquitoes had a negative correlation with wind speed and temperature, latter of which exhibited a negative association with humidity. Species succession followed predictable patterns, but with some variation between years. Still, Culex pipiens/Culex torrentium were the most abundant throughout the study. Importantly, all dominant species were known disease vectors. Our work showed that higher temperatures could result in fewer mosquitoes in boreal towns.

Primary health care policy and vision for community pharmacy and pharmacists in Estonia

Estonia, with a population of 1.3 million, is the smallest country in the three Baltic States. As a post-soviet country, Estonia over the past 30 years has built up a new health care system, including the pharmaceutical sector. The GDP allocated to cover health care costs is significantly lower in Estonia compared to the EU average. Despite this, Estonia has excelled in the development of digital e-services in healthcare at both the domestic and international levels. The development and integration of the Estonian community pharmacy sector into primary health care has been influenced and affected by the liberalization within pharmaceutical policy and the lack of cooperation with the rest of the health care sector. Community pharmacy ownership and location matters have been prevalent. The promotion of the pharmacy services has mostly taken place on the basis of a professional initiative, as cooperation with the state has not been active. Possibly the professional fragmentation of the pharmacy sector may have played a negative role. The community pharmacy network in Estonia, especially in cities, enables fast and convenient access to the pharmacy services. Community Pharmacy Service Quality Guidelines support the harmonization of the provided services and patient-centered concept to enhance the patient role and involvement in their care. In recent years, community pharmacies in Estonia have also offered various extended services that are more or less integrated with the primary health care system. New developments may be affected by frequent changes in legislation and a shortage of professional staff in community pharmacies. The ownership reform of pharmacies in 2020 has so far not had a significant impact on the operation of pharmacies or the quality of services provided.

Rapid point-of-care (POC) testing for Hepatitis C antibodies in a very high prevalence setting: persons injecting drugs in Tallinn, Estonia

BACKGROUND

Between December 2018 and January of 2019, we evaluated the accuracy of the point-of-care Hepatitis C (HCV) antibody test (POC; OraQuick HCV) used at a community-based needle and syringe exchange program serving persons who inject drugs in Tallinn, Estonia.

METHODS

We compared the results of screening for HCV antibodies by OraQuick (oral swab) and enzyme immunoassay (EIA; blood draw) and assessed test results implications in a high prevalence setting. Findings Of the 100 participants, 88 (88%) had reactive POC test results, and 93 were HCV antibody positive on EIA testing. Sensitivity, specificity and negative predictive value (NPV) for the POC assay with EIA as the relevant reference test were as follows: 94.6% (95% CI 90.0-99.2%), 100% and 58.3% (95% CI 30.4-86.2%). Of the 12 testing, HCV-negative with the POC only 7 (58.3%) were true negatives.

CONCLUSIONS

Oral swab rapid testing HCV screening in this nonclinical setting was sensitive and specific but had unacceptably low NPV. In high prevalence settings, POC tests with high sensitivity and that directly measure HCV RNA may be warranted.

High incidence of stroke in young adults in Tartu, Estonia, 2013 to 2017: A prospective population-based study

BACKGROUND AND PURPOSE

Previous studies conducted elsewhere in the world have demonstrated an increase in the incidence of ischemic stroke (IS) in younger ages. We sought to determine stroke incidence and 28-day case-fatality rates in 15- to 54-year-old residents of Tartu, Estonia from 2013 to 2017.

METHODS

All stroke cases that were the first ever in a lifetime (IS, nontraumatic intracerebral hemorrhage [ICH], and subarachnoid hemorrhage [SAH]) in 15- to 54-year-old residents of Tartu, Estonia were prospectively registered from January 1, 2013 to December 31, 2017. Several additional overlapping data sources were used for case ascertainment including other departments of the Tartu University Hospital and outpatient clinic, Estonian Cause of Death Registry, and the Estonian Electronic Health Record. All cases were thoroughly validated before inclusion.

RESULTS

We identified 110 cases (43.6% female) of first-ever stroke (IS 72.7%, ICH 12.7%, SAH 14.6%), out of which 85.5% were included prospectively. The mean age at onset was 44.3 ± 8.5 (SD) years. The mean age at onset was higher for men than for women (p = 0.046). The incidence of stroke standardized to the 1976 European standard population (EUR) was 46.1/100,000 (95% confidence interval [CI]: 37.4-54.8). IS incidence was 33.4/100,000 EUR (95% CI: 26-40.7). The total stroke incidence was higher in 45- to 54-year-old men than in women in the same age group (rate ratio, 2.24; 95% CI: 1.35-3.71). There were no more significant differences between sexes or age groups. The 28-day case-fatality rate was 10.9% for all strokes.

CONCLUSIONS

Our study shows higher crude incidence and case fatality of stroke in the young compared to studies from other high-income countries.

Leisure Time Physical Activity and Associated Factors among Adults in Estonia 2000-2018

In order to implement evidence-based strategies, there is a need to assess (1) time trend in leisure time physical activity (LTPA) and (2) the relationship between trend of LTPA and trend of potential explanatory factors in Estonia from 2000 to 2018. Data from 25−64-year-old adults (n = 16,903) were drawn from cross-sectional surveys of Health Behavior among Estonian Adult Population. Joinpoint regression analysis was used to calculate annual percentage changes (APCs) and to identify whether there was a significant change in trends of LTPA. Logistic regression analysis was used to assess associations of LTPA with socioeconomic, health-related and health-behavioral factors. Prevalence of LTPA increased from 26.2% to 44.1% among men and from 28.0% to 40.6% among women from 2000 to 2018 (p < 0.001). Average APC for men was 3.4% (95% CI 2.6−4.3) and for women 2.4% (95% CI 1.4−3.4). Adjusted logistic regression model showed that LTPA was statistically significantly associated with higher education and income, economic inactivity, at-least-good self-rated health (SRH) and non-smoking. Interaction of SRH with study year was significant indicating that the association of at-least-good SRH changed over time (p = 0.016). Health promotion activities should be addressed in particular to adults with lower levels of LTPA, paying attention to the factors associated with LTPA.

Students' Feedback on the Development of a Competency-Based Pharmacy Education (CBPE) at the University of Tartu, Estonia

Increasing need in society to provide collaborative and patient-centered pharmaceutical care has to be addressed in curriculum development. Principles of competency-based pharmacy education (CBPE) could be seen as one solution to the new professional challenges of pharmacists. At the University of Tartu (UT), the Pharmacy curriculum was updated in 2019 to introduce principles of CBPE. The aim of this study was to gather initial students’ feedback on the development of CBPE at the UT. The survey was conducted in the spring semester of the 2019/2020 academic year to collect feedback about all curricula at the UT. All 1st, 3rd, and 5th year pharmacy students (n = 67) were invited and 70.1% (N = 47) of them also participated in this study in order to evaluate the Pharmacy curriculum. Pharmacy students were more complacent with the content and less with the fixed structure of the Pharmacy curriculum. Students emphasized more theoretical knowledge and less practical and transferable skills of the competencies developed over the studies. Initial student feedback on the development of CBPE in Estonia demonstrated that theoretical knowledge needs to be more integrated with practice throughout the curriculum. In the future, more attention should be paid to the development of transferable skills, including digital skills.

A Multistage Process Model of How a Person Who Currently Injects Drugs Comes to Assist Persons Who Do not Inject with Their First Injections

Injecting drugs for the first time almost always requires assistance from an experienced person who injects drugs (PWID). While there has been moderate amount of research on PWID who assist with first injections, most of this research has focused on identifying characteristics of PWID who assist with first injections. We do not have a formal model that describes how the minority of PWID come to assist do so, while the majority never assist. Through comparison of persons who did or did not recently assist with first injections using data from PWID in Tallinn, Estonia (N = 286) and Staten Island, New York City (N = 101), we developed a formal multi-stage model of how PWID come to assist with first injections. The model had a primary pathway 1) of engaging in "injection promoting" behaviors, 2) being asked to assist, and 3) assisting. Statistical testing using odds ratios showed participation in each stage was strongly associated with participation in the next stage (all odds ratios >3.0) and the probabilities of assisting significantly increased with participation in the successive stages. We then used the model to compare engagement in the stages pre-vs. post participation in an intervention, and to compare persons who recently assisted to persons who had assisted in the past but had not recently assisted and to persons who had never assisted. Advantages of a formal model for how current PWID come to assist with first injections include: facilitating comparisons across different PWID populations and assessing strengths and limitations of interventions to reduce assisting with first injections.

Translation and cultural adaptation of IPOS (integrated palliative care outcome scale) in Estonia

BACKGROUND

Patient Reported Outcome Measures (PROMs) are questionnaires that could be used in palliative care (PC) to evaluate patient well-being and monitor their care. PROMs enable a focus on what is important to patients by putting the patient at the center of care. Adapting an existing PROM requires considering cultural differences, general usability and understandability of translated terms.

AIM

To translate and culturally adapt both the patient and staff three and seven day versions of the Integrated Palliative care Outcome Scale (IPOS) into Estonian. The IPOS consist of 10 questions (staff versions 9 questions) and 17 close ended items. The sub aim is to describe the differences and discrepancies found during the adaptation process and compare the results with previous research.

METHODS

The translation and adaptation process of IPOS was conducted using recommended guidelines consisting of six phases and included cognitive interviews with patients (n = 11) and palliative care multidisciplinary team members (n = 8). The study was conducted in two major Estonian hospitals.

RESULTS

The Estonian IPOS demonstrated face and content validity, acceptance by patients and staff. As a result of expert group review and cognitive interviews with patients and staff, 9 semantic changes were implemented.

CONCLUSIONS

Patient and staff versions of the IPOS with a recall of 3 or 7 days were translated and culturally adapted for Estonia. The Estonian IPOS four versions are ready for use in Estonia.

Factors associated with incidence of depressiveness among the middle-aged and older Estonian population

Objective:

Relatively scant research among older Estonian population describes factors associated with the incidence of depressive symptoms. This study identifies factors associated with the incidence of depressiveness among middle-aged and older Estonians over 2- and 4-year periods.

Method:

In this cross-sectional analysis, logistic regression models are used to identify the factors associated with the incidence of depressiveness over 2- and 4-year periods. The data were drawn from the Survey of Health, Ageing and Retirement in Europe (SHARE) 2011–2015 which included Estonian population aged 53 years and older in 2013. After excluding those younger than 53 years, not interviewed 2 years later, those with depressive symptoms at baseline in 2013, and missing values for depressiveness or other variables, our analytical sample comprised 2513 people.

Results:

Among those who were not depressive in 2013, 21.9% became depressive within 2 years; 16.1% of non-depressive individuals since 2011 became depressive by 2015. No age differences in incidence remained in adjusted models. Women have almost 50% higher odds of becoming depressive. A previous history of depressiveness and the presence of everyday activity limitations were important factors increasing the incidence of depression.

Discussion:

Changes related to the individual’s unique ageing experience are important explanatory factors related to the likelihood of developing depressive symptoms, rather than age itself. To diminish the incidence of depressive symptoms among older Estonian population, public health interventions should attempt to address factors which complicate existing health problems and facilitate continued independence and community involvement, both of which contribute to overall satisfaction with life.

Forest ditch maintenance impoverishes the fauna of aquatic invertebrates: Opportunities for mitigation

One of the main factors causing biodiversity loss in wetlands is drainage, nevertheless, even drained areas may provide habitat for aquatic fauna in the form of drainage ditches. Assemblages in ditches are regularly disturbed by ditch maintenance, but the extent of these disturbances and mitigation possibilities are poorly documented. We conducted an experimental study in three commercially managed forest plots in eastern Estonia, aiming to find out how ditch network maintenance (DNM) affects the diversity and assemblages of aquatic macroinvertebrates in ditches and remnant pools, and whether this effect can be alleviated by constructing mitigation waterbodies. For comparison we also collected data from natural pools in three undrained forest plots. Before DNM, ditches supported greater number of higher taxa compared to remnant and natural pools and more strictly aquatic taxa, whereas natural pools in undrained plots supported more Trichoptera shredders. After DNM, the diversity in remnant pools decreased. Moreover, majority of the pools dried out, which resulted in further reduction of the richness and abundance of macroinvertebrates. In ditches the diversity dropped immediately after DNM, but recovered in two to three years. Nevertheless, plot-scale richness and abundance did not completely recover. Assemblage shift in ditches took place right after DNM and remained distinct after the four year survey period. Mitigation pools provided habitat for several taxa (especially Odonata) uncommon in other waterbodies in drained and undrained plots. Our results show that DNM in forests substantially impoverishes habitat availability and reduces the abundance and diversity of aquatic macroinvertebrates. We recommend retaining uncleaned sections in ditches and constructing mitigation pools as tools for supporting wetland biodiversity in drained forests.