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Background: Studies have shown constant or increasing health inequalities in adulthood in the last decades, but less is known about trends in health inequalities among adolescents. The aim is to analyse changes in socioeconomic differences in subjective health complaints from 1994 to 2010 among 11- to 15-year-olds in Europe, North America and Israel. Methods: Data were obtained from the international 'Health Behaviour in School-aged Children' (HBSC) survey. Analyses were based on the HBSC surveys conducted in 1994 (19 countries), 1998 (25 countries), 2002 (32 countries), 2006 (37 countries) and 2010 (36 countries) covering a time period of up to 16 years. Log binomial regression models were used to assess inequalities in multiple health complaints. Socioeconomic position was measured using perceived family wealth. Results: Inequalities in multiple health complaints emerged in almost all countries, in particular since 2002 (RR 1.1-1.7). Trend analyses showed stable (29 countries), increased (5 countries), decreased (one country) and no social inequalities (2 countries) in adolescent health complaints. Conclusion: In almost all countries, social inequalities in health complaints remained constant over a period of up to 16 years. Our findings suggest a need to intensify efforts in social and health policy to tackle existing inequalities. [ABSTRACT FROM AUTHOR]

Background: Internationally, in many healthcare systems financial pressure has led to the implementation of co-payments, private medical (extra) services and rationing. In Germany, members of statutory health insurances (SHIs) increasingly report the denial of medical services and the offer/demand of privately financed supplementary health services individual health services, (IHSs) in medical practices. The public discussion on both denial and IHSs is chequered, mainly critical, partly polemic. The present study aims to operationalize IHSs and denial and investigates their occurrence, socio-demographic determinants within two regional populations. Methods: Two postal surveys were conducted in 4898 German inhabitants of Lübeck (Northern Germany) and Freiburg (Southern Germany), aged 20–79 years. The survey focused on experiences with IHSs and denial of health services in medical practices among members of SHIs. Results: In all members of SHIs that had consulted a physician during the past 12 months (n =1899), the one-year-prevalence of IHSs and denial of medical services were 41.7 and 20.5%. About 40% were offered a denied medical service as an IHS later. Conclusion: The study presents population-based, quantitative data on IHSs and denial of medical services in German practices. The results partly confirm former findings on the occurrence of IHSs. Contrary to other studies, socio-demographics seemed to play a minor role in the offer/demand of IHSs. [ABSTRACT FROM PUBLISHER]

Background: While the graded relationship between socio-economic status (SES) and risk behaviour in adulthood has been the subject of intense research, far less is known about socio-economic differences in health-related behaviour among adolescents. The purpose of the present study is to examine socioeconomic differences in adolescent tobacco use in Germany as well as changes in the relationship between 1994 and 2002. Methods: Data were obtained from the 'Health Behaviour in School-aged Children' study conducted in the largest federal state of Germany, Northrhine-Westfalia, in 1994, 1998 and 2002. The analysis is based on 11.401 11- to 15-year old students. Socio-economic differences in regular smoking were studied in relation to both parental SES (family affluence) and students own SES (school type). Trends from 1994 to 2002 were analysed for each category of family affluence and school type separately. Results: Family affluence only had a weak effect on regular smoking while for type of school a strong social gradient for smoking was found for both the genders. Trend analyses within the different family affluence and school-type categories showed that smoking has generally increased in all socio-economic groups. The level of socio-economic differences remained virtually unchanged in girls and boys in the past 10 years in Germany. Conclusions: The same relationships of family affluence and school type with smoking have persisted for almost a decade in Germany. Students own SES affects adolescent smoking substantially. Prevention programmes should focus on the school setting in order to tackle current as well as future health inequalities. [ABSTRACT FROM AUTHOR]

Background Subjective well-being (SWB) is an important indicator of quality of life, but prior research mostly analyzed adolescents' subjective well-being in cross-sectional studies. There is a lack of studies examining changes in subjective well-being throughout adolescence using longitudinal panel data. This study examined trajectories of subjective well-being of adolescents in Germany throughout secondary education and differences by socioeconomic position, gender and family structure. Methods We use the German National Educational Panel Study and combine data from annual survey waves of two of its cohorts. These were first surveyed in 2010 and cover 5th to 10th and 9th to 12th grade level. Using growth curve modelling based on multilevel models, differences in levels and trajectories of subjective well-being overall and differentiated by school type, parental education, household income, gender and family structure were identified. The analyses include 34 504 observations of 12 564 students. Results Subjective well-being decreased from 5th to 12th grade. Students attending lower track schools showed lower subjective well-being, but also a lesser decrease over time. Students living in low-income households or in single-parent or step-families showed lower subjective well-being. Female students showed higher subjective well-being than males in 5th grade, but also a higher decrease over time, leading to lower subjective well-being than males by 12th grade. Conclusion This study provides a comprehensive picture of subjective well-being throughout secondary education. Adolescents' subjective well-being is linked to social factors regarding family and living conditions as well as school features. Overall, disadvantaged adolescents experience longer periods of lower subjective well-being, thus accumulating the effects of worse psychosocial health opportunities over time. [ABSTRACT FROM AUTHOR]

Background To address social inequalities in adolescent substance use and consequent disparities in health, it is important to identify the mechanisms of the association between substance use and academic performance. We study the role of health literacy (HL) in the association between academic performance and weekly smoking, monthly alcohol use and cannabis ever-use among adolescents in Europe. Methods SILNE-R school survey data, which was collected in 2016–17 with paper-and-pencil-method from Hanover (GE), Amersfoort (NL) and Tampere (FI), were used (N  = 5088, age 13–19). Health Literacy for School-aged Children instrument was used to assess students' HL. Logistic regression analyzed the association of substance use with academic performance and HL, separately and in the same model. Linear and multinomial logistic regression analyzed the association between academic performance and HL. Results Poor academic performance compared with high was associated with smoking [odds ratio (OR) 3.94, 95% confidence interval (CI) 2.83–5.49], alcohol use (OR: 2.94, 95% CI: 2.34–3.68) and cannabis use (OR: 2.56, 95% CI: 1.89–3.48). Poor HL was also associated with each substance use (with ORs of 2.32, 1.85 and 1.29). HL was positively associated with academic performance (β = 1.04, 95% CI: 0.89–1.20). The associations between academic performance and substance use were only slightly attenuated after controlling for HL. Conclusions Academic performance and HL were both determinants of substance use, confirming their role in tackling the disparities in substance use. However, HL did not demonstrably mediate the association between academic performance and substance use. A wider set of factors needs to be tackled to address emerging social inequalities in adolescent substance use. [ABSTRACT FROM AUTHOR]

Background Studies on adolescent secondhand smoke exposure within the family often dichotomously operationalize migration background without paying attention to social and cultural diversity within migrant populations. As a result, little is known about variation within migrant groups in smoke-free family environments (SFFEs). This study analyses the association between SFFEs and parental migration from different world regions. Methods Data from 14- to 16-year-old adolescents (N  = 17 144) on SFFEs and parental migration were obtained from cross-sectional repeated SILNE-R surveys. A multivariable multinomial regression was applied, presenting relative risks (RRs) with 95% confidence intervals (CIs) for maternal or paternal tobacco smoking and home smoking bans. Variation in migration background was measured according to parental sex and place of birth. Results Approximately 18% of adolescents are exposed to maternal smoking, and 25% are exposed to paternal smoking. Almost half of the respondents do not live in SFFEs but are subject to permissive (5%) or partial (39%) smoking bans at home. We found that adolescents of Eastern European descent are at a higher risk of being exposed to both paternal and maternal smoking. A sex difference in parental smoking was found among Arabic/Islamic migrants, where mothers are less likely to be smokers. Maternal and paternal African origins are associated with prohibitive smoking bans at home. Eastern European mothers show higher odds of permissiveness and freely allowing smoking at home. Conclusion Notable within-differences according to parental sex and place of birth were found for SFFEs and should be taken into account when implementing equity-sensitive tobacco prevention programs. [ABSTRACT FROM AUTHOR]

Background Studies comparing adolescent e-cigarette use in different countries are scarce. We study students' e-cigarette and conventional cigarette ever-use, their social correlates and e-liquid use in seven EU countries. Methods SILNE-R data (N =12 167, response rate 79.4%) of 14–17-year-olds from Amersfoort (NL), Coimbra (PT), Dublin (IR), Hanover (GE), Latina (IT), Namur (BE) and Tampere (FI) were used. E-cigarette and conventional cigarette ever-use, dual-use, type of e-liquid and social correlates were measured with a school survey and analyzed with cross-tabulations and multinomial logistic regression. Results About 34% had tried e-cigarettes, but the variation was large between the cities (Latina 50%; Hanover 23%). Of e-cigarette ever-users, 37% had used nicotine e-liquid, 43% exclusively non-nicotine liquid and 20% did not know the content. Nicotine e-liquid was more prevalent among monthly e-cigarette users and weekly smoking e-cigarette users. The social correlates were mainly the same for exclusive e-cigarette ever-use, exclusive conventional cigarette ever-use and dual-use. Boys had greater odds for exclusive e-cigarette and dual-use compared to girls. Of social correlates, low academic achievement and parental smoking were positively associated with all categories of use, but parental education and immigrant background were not. The strongest association was found between peer smoking (most/all best friends smoke) and dual-use (OR 34.29). Conclusions Students' e-cigarette ever-use varies greatly between EU countries. E-cigarettes seem not to be a substitute for conventional cigarettes but more a complementary product. Tobacco control policies might also prevent e-cigarette use but specific regulations on e-cigarettes are needed to prevent nicotine addiction originating from them. [ABSTRACT FROM AUTHOR]

Background Tobacco-control policies have been suggested to reduce smoking among adolescents. However, there is limited evidence on the real-world costs of implementation in different settings. In this study, we aimed at estimating the costs of school smoking bans, school prevention programmes and non-school bans (smoking bans in non-educational public settings, bans on sales to minors and bans on point-of-sale advertising), implemented in Finland, Ireland, the Netherlands, Belgium, Germany, Italy and Portugal, for 2016. Methods We retrospectively collected costs related to the inspection, monitoring and sanctioning activities related to bans and educational activities related to smoking prevention programmes. We used an 'ingredients-based' approach, identifying each resource used, quantity and unit value for one full year, under the state perspective. Costs were measured at national, regional, local and school-level and were informed by data on how these activities were performed in reality. Results Purchasing power parities adjusted-costs varied between €0.02 and €0.74 (average €0.24) per person (pp) for bans implemented outside schools. Mean costs of school smoking bans ranged from €3.31 to €34.76 (average €20.60), and mean costs of school educational programmes from €0.75 to €4.65 (average €2.92). Conclusions It is feasible to estimate costs of health policies as implemented in different settings. Costs of the tobacco control policies evaluated here depend mainly on the number of person-hours allocated to their implementation, and on the scale of intervention. Non-school bans presented the lowest costs, and the implementation of all policies cost up to €36 pp for 1 year. [ABSTRACT FROM AUTHOR]

Background Socioeconomic position (SEP) in different life stages is related to health-related quality of life (HRQoL). Yet, research on the relevance of life course processes is scarce. This study aims to analyse the association between accumulation of disadvantages, social mobility and HRQoL. Methods Analyses were conducted using population-averaged panel-data models and are based on data from the German Socio-Economic Panel 2002–14, including retrospective biographical information, comprising 25 473 observations from 8666 persons. Intergenerational and intragenerational mobility included the occupational positions in childhood (parental position), first job and middle age. Accumulation of disadvantages was measured using an accumulation index. HRQoL was assessed using the Mental and Physical Component Summary Scores of the SF12v2. Results Accumulation of disadvantages was the main predictor for the Physical Component Summary in mid-age. Men and women in a stable low SEP or with a steep downward mobility showed the least favourable physical HRQoL. This holds for intergenerational and intragenerational mobility. Mental HRQoL did not seem to be associated with accumulation or social mobility. Conclusion The results show that physical HRQoL is related to social mobility and accumulation of (dis-)advantages. Further research is needed thoroughly analysing this association. [ABSTRACT FROM AUTHOR]

Background Schools are crucial settings for young people's development. Rare studies have examined the impact of perceived school-climate and academic well-being on young people's self-rated health in joint analyses. This study focuses on the role of perceived school-climate and academic well-being for young people's self-rated health and examines whether school climate is mediated by indicators of academic well-being. Methods Data were obtained from the German National Educational Panel Study, including seventh grade students (n = 6838) aged 11–12, nested in 710 classes within 277 schools. Indicators of school climate (teacher control, demands, autonomy, interaction, goal setting and orientation, teaching quality) and academic well-being (satisfaction with school, helplessness in major school subjects) were reported from students. Multilevel modelling was used to analyze the relative importance of perceived school-climate and academic well-being on school-aged children's self-rated health. Results Results showed that academic well-being is strongly related to self-rated health. The better students perceive their academic well-being, the lower the likelihood of poor self-rated health. In contrast, indicators of perceived school climate are only indirectly related to self-rated health, mediated by academic well-being or are not at all associated with self-rated health. Conclusions This study suggests that school climate is important for academic well-being but not as important for students' self-rated health as academic well-being. Health promotion initiatives in schools have to ensure that school climate serves to enhance students' academic well-being to avoid health problems in the long-run. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic inequalities in coronary heart disease (CHD)-related morbidity and mortality are well explored. However, less is known about the causes of inequalities in CHD treatment. In this qualitative study, we explored socioeconomic differences in the pathways to diagnosis of CHD. Methods: The data originated from 38 semi-structured interviews with older CHD patients, aged 59-80 years, conducted at the university hospital in Halle, Germany, between November 2014 and April 2015. We analysed the narratives related to the time before CHD was confirmed by coronary angiography electively or urgently. Transcripts were analysed following inductive qualitative content analysis and we identified socioeconomic differences by comparing and contrasting patients' narratives. Results: The patients interpreted their symptoms based on expectations, normalization, relief and obtaining help from third parties. For those experiencing chronic CHD symptoms, only patients with low socioeconomic status (SES) waited to seek healthcare until they suffered myocardial infarction. Mainly low-SES patients procrastinated in undergoing diagnostic procedures. We found no socioeconomic differences in the urgent pathway. However, along the elective pathway, only low-SES patients reported receiving assistance from a general practitioner in accessing a cardiologist. Conclusions: Socioeconomic differences in CHD diagnosis were mainly apparent before patients sought healthcare. These differences were more pronounced when CHD was electively diagnosed due to chronic symptoms rather than urgently diagnosed due to acute symptoms. To address socioeconomic differences, general practitioners should focus on any indication of symptoms and interpretation mentioned by low-SES patients, and coordinate these patients' pathways to diagnosis while emphasizing the seriousness of CHD. [ABSTRACT FROM AUTHOR]

Background Influenza and pneumococcal vaccines have been proved to be effective and safe in preventing and controlling infection among elderly, reducing morbidity and mortality. However, some evidences raised health concerns related to these vaccinations. This study aims to identify prevalence and outcomes related to influenza and pneumococcal vaccinations in a large European population of frail old people living in nursing homes (NHs). Methods We conducted a survival analysis of NH residents participating to the Services and Health for Elderly in Long-TERm project, a prospective cohort study collecting information on residents admitted to 57 NH in eight countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands and Israel). Clinical and demographical data were collected using the international resident assessement instrument for long-term care facilities. Incident mortality was recorded during 1-year follow-up. A shared-frailty Cox regression model was used to assess the impact of vaccination status on mortality. Results Mean age of 3510 participants was 84.6 years (SD = 7.7). In total, 81.7 and 27.0% received influenza and pneumococcal vaccination, respectively. Overall, 727 (20.7%) residents died during the follow-up period. After adjusting for potential confounders, which included age, sex, number of diseases, depression, cognitive and functional status, influenza (HR = 0.80; 95% CI 0.66-0.97) and the combination of influenza and pneumococcal vaccination (HR = 0.72; 95% CI 0.57-0.91), but not pneumococcal vaccination alone (HR = 0.52; 95% CI 0.25-1.06), were associated with a statistically significant reduction in mortality in respect of no vaccinations. Conclusion In a population of older adult living in NH influenza and the combination of influenza and pneumococcal vaccination were associated with a reduction in all-cause mortality respect to no vaccination. [ABSTRACT FROM AUTHOR]

Background: Tobacco-related heath inequalities are a major public health concern, with smoking being more prevalent among lower socioeconomic groups. The aim of this study is to investigate the mechanisms leading to socioeconomic inequalities in smoking among 15-year-old adolescents by examining the mediating role of psychosocial factors in the peer group, family and school environment. Methods: Data were derived from the international WHO-collaborative ‘Health Behaviour in School-aged Children (HBSC)' study 2005/2006, including 52 907 15-year-old students from 35 European and North American countries. Socioeconomic position was measured by the Family Affluence Scale. Multilevel logistic regression models were conducted to examine the contribution of family, school and peer factors in explaining the association between family affluence and weekly smoking. Results: Across countries, adolescents from low affluent families had an increased risk of weekly smoking (ORboys 1.14, confidence interval (CI) 1.05-1.23; ORgirls 1.36, CI 1.26-1.46) compared with adolescents from high affluent families. Family and school factors mediated the association between family affluence and smoking to a high extent up to 100% (boys) and 81% (girls) in joint analyses. The most important single factors were family structure, relationships with parents, academic achievement and school satisfaction. Peer factors did not mediate the association between family affluence and adolescent smoking. Conclusion: The association between socioeconomic status and adolescent weekly smoking can largely be explained by an unequal distribution of family- and school-related factors. Focusing on the parent-adolescent relationship and adolescent school achievement can help to better understand inequalities in adolescent smoking behaviour. [ABSTRACT FROM AUTHOR]

Background: This article describes trends and stability over time in health complaints in adolescents from 2002 to 2010 and investigates associations between health complaints, behavioural and social contextual factors at individual level and economic factors at macro-level. Methods: Comprising N= 510876 11-, 13- and 15-year-old children and adolescents in Europe, North America and Israel, data came from three survey cycles of the international Health Behaviour in School-aged Children (HBSC) study. Age- and gender-adjusted trends in health complaints were examined in each country by means of linear regression. By using the country as the random effects variable, we tested to what extent individual and contextual variables were associated with health complaints. Results: Significant associations are stronger for individual level determinants (e.g. being bullied, smoking) than for determinants at macro-level (e.g. GDP, Gini), as can be seen by the small effect sizes (less than 5% for different trends). Health complaints are fairly stable over time in most countries, and no clear international trend in health complaints can be observed between 2002 and 2010. The most prominent stable determinants were being female, being bullied, school pressure and smoking. Conclusion: Factors associated with health complaints are more related to the proximal environment than to distal macro-level factors. This points towards intensifying targeted interventions, (e.g. for bullying) and also targeting specific risk groups. The comparably small effect size at country-level indicates that country-level factors have an impact on health and should not be ignored. [ABSTRACT FROM AUTHOR]

Background: The recent economic recession, which began in 2007, has had a detrimental effect on the health of the adult population, but no study yet has investigated the impact of this downturn on adolescent health. This article uniquely examines the effect of the crisis on adolescents’ psychological health complaints in a cross-national comparison. Methods: Data came from the World Health Organization collaborative ‘Health Behaviour in School-aged Children’ study in 2005–06 and 2009–10. We measured change in psychological health complaints from before to during the recession in the context of changing adult and adolescent unemployment rates. Furthermore, we used logistic multilevel regression to model the impact of absolute unemployment in 2010 and its change rate between 2005–06 and 2009–10 on adolescents’ psychological health complaints in 2010. Results: Descriptive results showed that although youth and adult unemployment has increased during the economic crisis, rates of psychological health complaints among adolescents were unaffected in some countries and even decreased in others. Multilevel regression models support this finding and reveal that only youth unemployment in 2010 increased the likelihood of psychological health complaints, whereas its change rate in light of the recession as well as adult unemployment did not relate to levels of psychological health complaints. Conclusion: In contrast to recent findings, our study indicates that the negative shift of the recent recession on the employment market in several countries has not affected adolescents’ psychological health complaints. Adolescents’ well-being instead seems to be influenced by the current situation on the labour market that shapes their occupational outlook. [ABSTRACT FROM AUTHOR]

Background: Across Europe, tobacco use is more prevalent among secondary school students attending vocational tracks compared with students attending academic tracks. The purpose of the present study is to describe trends in social inequality in daily smoking among adolescents between 2002 and 2010 by addressing both absolute social inequality (prevalence difference between vocational and academic tracks) and relative social inequality (prevalence ratio) in seven European countries. Methods: Analyses were based on data from 15-year-olds who participated in the Health Behaviour in School-aged Children study in 2002, 2006 and 2010 in Belgium, Croatia, France, Germany, Hungary, Italy and The Netherlands (total N = 32 867). Results: Overall, daily smoking decreased between 2002 and 2010 in Belgium, France, Germany and The Netherlands, increased in Croatia and remained stable in Hungary and Italy. Considerable differences in daily smoking according to educational track existed in all countries. Absolute educational inequalities increased dramatically in Croatia and Italy, while relative inequalities showed a tendency to increase in all countries (significant in Belgium and The Netherlands). Conclusions: Conclusions on social inequality in adolescent smoking may appear differently when described by absolute and relative measures. Especially the large increase in absolute educational inequalities in daily smoking in Croatia and Italy are worrisome and warrant attention from the public health domain. The findings underline the need for appropriate smoking policies and interventions in vocational schools across Europe. [ABSTRACT FROM AUTHOR]

Background: Today, patient self-determination has become an issue in many western countries due to the widespread availability and use of technology, which makes it possible to prolong life often in spite of severe disability and poor quality of life. Many people fear an overzealous use of modern life-saving procedures which merely serve to prolong the dying process. As a first step towards autonomy and increasing self-determination, advance directives (living wills) have been introduced in some countries. Methods: To survey a general population's attitudes towards advance directives and self-determination a questionnaire was mailed to a representative sample of 600 citizens in northern Sweden. Issues regarding importance of control, concerns about own health care, treatment preferences and support for and use of advance directives were addressed. Results: There was a response rate of 80% and the great majority of respondents reported that it was extremely or very important to have a say in decisions about their health care (79.5%). A significant number of subjects were concerned about either being treated too aggressively or not aggressively enough. There was a variability in treatment preferences, depending on the reversibility of the condition. Conclusions: The results demonstrate a vital interest among the Swedish general public for greater self-determination in health care, which is also reflected by their support of advance directives. [ABSTRACT FROM AUTHOR]

Presents a study that evaluated general population's attitudes towards self-determination in health care in Northern Sweden. Fears regarding the use of life-saving procedures; Use of questionnaire on health care, treatment preferences and others; General support of advance directives.