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Abstract The impact of economic growth on health outcomes has generated various conflicting results in recent years, particularly with the emergence of cardiovascular disease as one of the most salient global health issues. This paper looks at the relationship between economic development and health outcomes. We first estimate an empirical model using data on annual cardiovascular disease mortality in a panel of 27 European countries, over the period 2003 to 2014, together with per capita GDP levels in each country. We also include a number of additional determinants of health outcomes as prescribed by the literature, including various socio-economic, lifestyle and contextual variables. The results show that there is a statistically-significant inverted U-shaped relationship, whereby as income increases mortality rates first rise, before declining at subsequent levels of development. This trajectory persists even after the inclusion of the other determinants of health, as well as other robustness checks. We then seek to explain the persistence of the inverted U-shaped income-mortality relationship using a microeconomic model of consumer choice, with our findings suggesting that this relationship is consistent with a scenario of increasing returns to scale from healthcare investment. The results emphasise the importance of investment in the latest healthcare technologies and continued improvements to public healthcare systems, particularly within developing countries, in conjunction with efforts to boost economic growth. Highlights • Inverted U-shaped relationship between cardiovascular mortality and GDP per capita. • Results robust to inclusion of various control variables and confounders. • Relationship consistent with increasing returns from healthcare spending. [ABSTRACT FROM AUTHOR]

The relationship between adverse individual socio-economic circumstances and suicidal behaviour is well established. However, the impact of adverse collective circumstances – such as the socio-economic context where people live - is less well understood. This systematic review explores the extent to which area-level socioeconomic disadvantage is associated with inequalities in suicidal behaviour and self-harm in Europe. We performed a systematic review (in MEDLINE, Embase, PsycINFO, EconLit and Social Sciences Citation Index) from 2005 to 2015. Observational studies were included if they were based in Europe and had a primary suicidal behaviour and self-harm outcome, compared at least two areas, included an area-level measure of socio-economic disadvantage and were published in the English language. The review followed The Joanna Briggs Institute guidelines for quality appraisal. We identified 27 studies (30 papers) from 14 different European countries. There was a significant association (in 25/27 studies, all of which were rated as of medium or high quality) between socioeconomic disadvantage and suicidal behaviour (and self-harm), particularly for men, and this was a consistent finding across a variety of European countries. Socio-economic disadvantage was found to have an independent effect in several studies whilst others found evidence of mediating contextual and compositional factors. There is strong evidence of an association between suicidal behaviours (and self-harm) and area-level socio-economic disadvantage in Europe, particularly for men. Suicide prevention strategies should take this into account. [ABSTRACT FROM AUTHOR]

Abstract: This paper provides a consolidated overview of public and healthcare professionals' attitudes towards vaccination in Europe by bringing together for the first time evidence across various vaccines, countries and populations. The paper relies on an extensive review of empirical literature published in English after 2009, as well as an analysis of unpublished market research data from member companies of Vaccines Europe. Our synthesis suggests that hesitant attitudes to vaccination are prevalent and may be increasing since the influenza pandemic of 2009. We define hesitancy as an expression of concern or doubt about the value or safety of vaccination. This means that hesitant attitudes are not confined only to those who refuse vaccination or those who encourage others to refuse vaccination. For many people, vaccination attitudes are shaped not just by healthcare professionals but also by an array of other information sources, including online and social media sources. We find that healthcare professionals report increasing challenges to building a trustful relationship with patients, through which they might otherwise allay concerns and reassure hesitant patients. We also find a range of reasons for vaccination attitudes, only some of which can be characterised as being related to lack of awareness or misinformation. Reasons that relate to issues of mistrust are cited more commonly in the literature than reasons that relate to information deficit. The importance of trust in the institutions involved with vaccination is discussed in terms of implications for researchers and policy-makers; we suggest that rebuilding this trust is a multi-stakeholder problem requiring a co-ordinated strategy. [Copyright &y& Elsevier]

Governments across Europe are required to make decisions about how best to allocate scarce health care resources. There are legitimate arguments for eliciting societal vales in relation to health care resource allocation given the roles of the general public as payers and potential patients. However, relatively little is known about the views of the general public on general principles which could guide these decisions. In this paper we present five societal viewpoints on principles for health care resources allocation and develop a new approach, Q2S, designed to investigate the extent to which these views are held across a range of European countries. An online survey was developed, based on a previously completed study Q methodology, and delivered between November 2009 and February 2010 across nine countries to 33,515 respondents. The largest proportion of our respondents (44%), were found to most associate themselves with an egalitarian perspective. Differences in views were more strongly associated with countries than with socio-demographic characteristics. These results provide information which could be useful for decision makers in understanding the pluralistic context in which they are making health care resource allocation decisions and how different groups in society may respond to such decisions. [ABSTRACT FROM AUTHOR]

Abstract: The aim of this paper is to examine educational inequalities in the risk of non-employment among people with illnesses and how they vary between European countries with different welfare state characteristics. In doing so, the paper adds to the growing literature on welfare states and social inequalities in health by studying the often overlooked ‘sickness’-dimension of health, namely employment behaviour among people with illnesses. We use European Union Statistics on Income and Living Conditions (EU-SILC) data from 2005 covering 26 European countries linked to country characteristics derived from Eurostat and OECD that include spending on active labour market policies, benefit generosity, income inequality, and employment protection. Using multilevel techniques we find that comprehensive welfare states have lower absolute and relative social inequalities in sickness, as well as more favourable general rates of non-employment. Hence, regarding sickness, welfare resources appear to trump welfare disincentives. [Copyright &y& Elsevier]

Abstract: Using the Large Analysis and Review of European housing and health Status (LARES) survey, this paper investigates the influence of neighborhood physical disorder on smoking behaviors, and the extent to which it is mediated by perceptions of safety. Indicators of physical disorder: litter, graffiti, and the absence of vegetation on facades, balconies or windows, were directly observed by surveyors. The paper also considers whether the place effects on smoking are similar across the 7 European cities in the study. Results indicate that the odds of smoking are 64% higher for those living in an area rated high on neighborhood disorder compared to low. The effect is substantially greater for men than for women with men in areas rated high on disorder showing odds of smoking that are twice as high as those living in areas rated low. The association does not vary by city of residence. Only a small part of the effect of neighborhood disorder is mediated by perceptions of safety. The finding of a substantial neighborhood physical disorder effect on smoking across a range of cities in Europe adds to the evidence suggesting that environmental interventions are worth pursuing in conjunction with other approaches to smoking prevention. [Copyright &y& Elsevier]

European health reforms during the last decades have strengthened patient rights and introduced choice, competition and financial incentives in a sector that has typically been state-directed and centrally controlled. The marketisation of health care has also drawn out profit and introduced private provision. The main argument behind this trend is that market competition will improve service quality and deliver health services more efficiently. Such reforms often fall under the umbrella of New Public Management (NPM), and there is a lack of empirical research on their effects. The purpose of this paper is to investigate the association between healthcare marketisation and health system outcomes across European nations. In order to measure a country's degree of healthcare marketisation we employed indicators of healthcare decommodification. The concept refers to the extent to which an individual's access to healthcare is dependent upon their market position and the extent to which a country's provision of health is independent from the market. These indicators are three measures that assess the financing, provision and coverage of the private sector, and thus reflects the varied role of the market in a health care system: private health care expenditure as amount of GDP, private hospital beds as amount of total hospital bed stock, and public healthcare coverage. As indicator of health system outcome, we employed a measure that has not previously been investigated in the context of healthcare marketisation: satisfaction with health care system. We used multilevel analyses on five waves (2009–2017) of the biannual European Social Survey (ESS), with our final models including more than 120,000 individuals from 21 countries. Our methodological approach allowed us to study both cross-sectional and longitudinal relationships. The strongest substantial associations were between coverage and satisfaction, with high public healthcare coverage being associated with higher satisfaction. • We employ novel measures of healthcare recommodification in multilevel analyses of health system satisfaction. • Privatised provision (the share of hospital beds) was positively associated with satisfaction. • Privatised financing of services was associated with lower satisfaction. • High public healthcare coverage was associated with higher satisfaction. [ABSTRACT FROM AUTHOR]

This paper examines whether maternity leave policies have an effect on women's mental health in older age. We link data for women aged 50 years and above from countries in the Survey of Health, Ageing and Retirement in Europe (SHARE) to data on maternity leave legislation from 1960 onwards. We use a difference-in-differences approach that exploits changes over time within countries in the duration and compensation of maternity leave benefits, linked to the year women were giving birth to their first child at age 16 to 25. We compare late-life depressive symptom scores (measured with a 12-item version of the Euro-D scale) of mothers who were in employment in the period around the birth of their first child to depression scores of mothers who were not in employment in the period surrounding the birth of a first child, and therefore did not benefit directly from maternity leave benefits. Our findings suggest that a more generous maternity leave during the birth of a first child is associated with a reduced score of 0.38 points in the Euro-D depressive symptom scale in old age. [ABSTRACT FROM AUTHOR]

Self-rated health (SRH) is arguably the most widely used generic health measurement in survey research. However, SRH remains a black box for researchers. In our paper, we want to gain a better understanding of SRH by identifying its determinants, quantifying the contribution of different health domains to explain SRH, and by exploring the moderating role of gender, age groups, and the country of residence. Using data from 61,365 participants of the fifth wave (2013) of the Survey of Health, Ageing and Retirement in Europe (SHARE) living in fifteen European countries, we explain SRH via linear regression models. The independent variables are grouped into five health domains: functioning, diseases, pain, mental health, and behavior. Via dominance analysis, we focus on their individual contribution to explaining SRH and compare these contributions across gender, three age groups, and fifteen European countries. Our model explains SRH rather well (R2 =.51 for females/.48 for males) with functioning contributing most to the appraisal (.20/.18). Diseases were the second most relevant health dimension (.14/.16) followed by pain (.08/.07) and mental health (.07/.06). Health behavior (.02/.01) was less relevant for health ratings. This ranking held true for almost all countries with only little variance overall. A comparison of age groups indicated that the contribution of diseases and behavior to SRH decreased over the life-course while the contribution of functioning to R2 increased. Our paper demonstrates that SRH is largely based on diverse health information with functioning and diseases being most important. However, there is still room for idiosyncrasies or even bias. • Self-rated health (SRH) is explained via five dimensions of health information. • Amount of explained variance by dimension is compared by gender, age group, and country. • Functioning and diseases were the most important dimensions. • Only minor differences in importance were found by gender and country. • Importance of diseases/behavior decreased with age, increased for functioning. [ABSTRACT FROM AUTHOR]

Abstract: The persistence of socioeconomic inequalities in health, even in the highly developed ‘welfare states’ of Western Europe, is one of the great disappointments of public health. Health inequalities have not only persisted while welfare states were being built up, but on some measures have even widened, and are not smaller in European countries with more generous welfare arrangements. This paper attempts to identify potential explanations for this paradox, by reviewing nine modern ‘theories’ of the explanation of health inequalities. The theories reviewed are: mathematical artifact, fundamental causes, life course perspective, social selection, personal characteristics, neo-materialism, psychosocial factors, diffusion of innovations, and cultural capital. Based on these theories it is hypothesized that three circumstances may help to explain the persistence of health inequalities despite attenuation of inequalities in material conditions by the welfare state: (1) inequalities in access to material and immaterial resources have not been eliminated by the welfare state, and are still substantial; (2) due to greater intergenerational mobility, the composition of lower socioeconomic groups has become more homogeneous with regard to personal characteristics associated with ill-health; and (3) due to a change in epidemiological regime, in which consumption behavior became the most important determinant of ill-health, the marginal benefits of the immaterial resources to which a higher social position gives access have increased. Further research is necessary to test these hypotheses. If they are correct, the persistence of health inequalities in modern European welfare states can partly be seen as a failure of these welfare states to implement more radical redistribution measures, and partly as a form of ‘bad luck’ related to concurrent developments that have changed the composition of socioeconomic groups and made health inequalities more sensitive to immaterial factors. It is argued that normative evaluations of health inequalities should take these explanations into account, and that a direct attack on the personal, psychosocial and cultural determinants of health inequalities may be necessary to achieve a substantial reduction of health inequalities. [Copyright &y& Elsevier]

Abstract: Although it is widely believed that one of the key factors influencing whether an adolescent smokes or not is the smoking behaviour of his or her peers, empirical evidence on the magnitude of such peer effects, and even on their existence, is mixed. This existing evidence comes from a range of studies using a variety of country-specific data sources and a variety of identification strategies. This paper exploits a rich source of individual level, school-based, survey data on adolescent substance use across countries – the 2007 European Schools Survey Project on Alcohol and Other Drugs – to provide estimates of peer effects between classmates in adolescent smoking for 75,000 individuals across 26 European countries, using the same methods in each case. The results suggest statistically significant peer effects in almost all cases. These peer effects estimates are large: on average across countries, the probability that a ‘typical’ adolescent smokes increases by between.31 and.38 percentage points for a one percentage point increase in the proportion of classmates that smoke. Further, estimated peer effects in adolescent smoking are stronger intra-gender than inter-gender. They also vary across countries: in Belgium, for example, a one percentage point increase in reference group smoking is associated with a.16 to.27 percentage point increase in own smoking probability; in the Netherlands the corresponding increase is between.42 and.59 percentage points. [Copyright &y& Elsevier]

Abstract: Although the number of insecure jobs has increased considerably over the recent decades, relatively little is known about the health consequences of job insecurity, their international pattern, and factors that may modify them. In this paper, we investigated the association between job insecurity and self-rated health, and whether the relationship differs by country or individual-level characteristics. Cross-sectional data from 3 population-based studies on job insecurity, self-rated health, demographic, socioeconomic, work-related and behavioural factors and lifetime chronic diseases in 23,245 working subjects aged 45–70 years from 16 European countries were analysed using logistic regression and meta-analysis. In fully adjusted models, job insecurity was significantly associated with an increased risk of poor health in the Czech Republic, Denmark, Germany, Greece, Hungary, Israel, the Netherlands, Poland and Russia, with odds ratios ranging between 1.3 and 2.0. Similar, but not significant, associations were observed in Austria, France, Italy, Spain and Switzerland. We found no effect of job insecurity in Belgium and Sweden. In the pooled data, the odds ratio of poor health by job insecurity was 1.39. The association between job insecurity and health did not differ significantly by age, sex, education, and marital status. Persons with insecure jobs were at an increased risk of poor health in most of the countries included in the analysis. Given these results and trends towards increasing frequency of insecure jobs, attention needs to be paid to the public health consequences of job insecurity. [Copyright &y& Elsevier]

Abstract: Limited access to healthcare for vulnerable immigrant children in Europe and North America is increasingly worrisome as immigration policies harden. This paper analyzes the gap between States'' obligations under international human rights law and the disparate local implementations in diverse countries. Studies that are both multidisciplinary and incorporate micro and macro level indicators are needed to reveal discrepancies between entitlements and access. It is argued that the lack of available data on the magnitude of the problem and on its individual and public health consequences stems from the conflicting situation faced by health institutions required to simultaneously protect the best interest of each child and allocate limited resources. Collaboration in research is urgently needed to assist policy-makers and institutions make informed decisions. [Copyright &y& Elsevier]

Abstract: There are consistent reports of protective associations between attendance at religious services and better self-rated health but existing data rarely consider the social or individual context of religious behaviour. This paper investigates whether attendance at religious services is associated with better self-rated health in diverse countries across Europe. It also explores whether the association varies with either individual-level (gender, educational, social contact) or country-level characteristics (overall level of religious practice, corruption, GDP). Cross-sectional data from round 2 of the European Social Survey were used and 18,328 men and 21,373 women from 22 European countries were included in multilevel analyses, with country as higher level. Compared to men who attended religious services at least once a week, men who never attended were almost twice as likely to describe their health as poor, with an age and education adjusted odds ratio of 1.83 [95% CI, 1.49–2.26]. A similar but weaker effect was seen in women, with an age and education adjusted odds ratio of 1.38 [1.19–1.61]. The associations were reduced only marginally in men by controlling for health status, social contact and country-level variables, but weakened in women. The relationships were stronger in people with longstanding illness, less than university education and in more affluent countries with lower levels of corruption and higher levels of religious belief. These analyses confirm that an association between less frequent attendance at religious services and poor health exists across Europe, but emphasise the importance of taking individual and contextual factors into account. It remains unclear to what extent the observed associations reflect reverse causality or are due to differing perceptions of health. [Copyright &y& Elsevier]

This paper examines the relationship between family structure and smoking among 15-year-old adolescents in seven European countries. It also investigates the association between family structure and a number of known smoking risk factors including family socio-economic status, the adolescent''s disposable income, parental smoking and the presence of other smokers in the adolescent''s home. Findings are based on 1998 survey data from a cross-national study of health behaviours among children and adolescents. Family structure was found to be significantly associated with smoking among 15-year-olds in all countries, with smoking prevalence lowest among adolescents in intact families and highest among adolescents in stepfamilies. Multivariate analysis showed that several risk factors were associated with higher smoking prevalences in all countries, but that even after these other factors were taken into account, there was an increased likelihood of smoking among adolescents in stepfamilies. Further research is needed to determine the possible reasons for this association. [Copyright &y& Elsevier]

This paper provides a deeper understanding of the mechanisms underlying implementation strategies for integrated care. As part of the SELFIE project, 17 integrated care programmes addressing multi-morbidity from eight European countries were selected and studied. Data was extracted from 'thick descriptions' of the 17 programmes and analysed both inductively and deductively using implementation theory. The following ten mechanisms for successful implementation of integrated care were identified. With regards to service delivery , successful implementers (1) commonly adopted an incremental growth model rather than a disruptive innovation approach, and found (2) a balance between flexibility and formal structures of integration. For leadership & governance , they (3) applied collaborative governance by engaging all stakeholders, and (4) distributed leadership throughout all levels of the system. For the workforce , these implementers (5) were able to build a multidisciplinary team culture with mutual recognition of each other's roles, and (6) stimulated the development of new roles and competencies for integrated care. With respect to financing, (7) secured long-term funding and innovative payments were applied as means to overcome fragmented financing of health and social care. Implementers emphasised (8) the implementation of ICT that was specifically developed to support collaboration and communication rather than administrative procedures (technology & medical devices), and (9) created feedback loops and a continuous monitoring system (information & research). The overarching mechanism was that implementers (10) engaged in alignment work across the different components and levels of the health and social care system. These evidence-based mechanisms for implementation are applicable in different local, regional and national contexts. • Ten mechanisms for successful implementation were empirically obtained. • Alignment work is a prerequisite for successful implementation of integrated care. • Implementation work should align components and levels of health and social care. • Meso-level is the driving force of integration. [ABSTRACT FROM AUTHOR]

The friction cost approach (FCA) estimates the productivity costs of disease from an employer's perspective but the lack of estimates of friction periods in different countries limits its use. Our aim was to use labour market aggregates to generate two alternative estimates of the friction period for European countries and to apply the FCA to illustrate the impact on cancer-related lost productivity costs. We included thirty countries (EU 27 + the United Kingdom, Switzerland and Norway). Base-case Method 1 BC used annual Dutch vacancy stock and flow data (2001–2019) to estimate friction periods for this country. A regression model was employed using Dutch data and country-specific vacancy and unemployment rates to generate country-specific friction period estimates for the other 29 countries. Alternative Method 2 ALT used country-specific newly occupied jobs as a proxy vacancy flow variable and vacancy stock data to generate friction period estimates. These were applied, within the FCA, to premature cancer mortality data (from GLOBOCAN2018) for all cancers combined for Western European countries. Costs are in €2018. Method 1 BC estimated friction periods in 2018 ranged from 70.8 days for Greece to 145.9 days for the Czech Republic, with a mean duration of 95.3 days. Method 2 ALT produced a mean friction period of 80.0 days. On average, across countries, Method 2 ALT friction periods were 15.4 days (−18.5%) shorter than Method 1 BC estimates. Friction period estimates over the last decade were shorter than those for 2018 reflecting lower vacancy rates. Total cancer premature mortality costs according to FCA Method 1 BC amounted to €1.0 billion in 2018 for Western Europe compared to €0.99 billion for Method 2 ALT. We developed two alternative – and viable - methods to estimate country-specific friction periods. These approaches will enable researchers to apply the FCA to estimate the productivity cost of diseases across Europe from an employer's perspective. • Lack of country-specific friction periods limits use of the Friction Cost Approach. • Paper presents two new methods with data to estimate friction periods across Europe. • New methods can be applied to alternative settings and updated over time. • Resulting estimates valuable for researchers estimating productivity cost of diseases. [ABSTRACT FROM AUTHOR]