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6.
MODERATED POSTER SESSIONS: ABSTRACTS

Child and adolescent public health
Medicine use for headache and stomachache among
school-aged children in Europe
Inese Gobina
I Gobina1*, R Valimaa2, J Villberg2, A Villerusa1, B Holstein3
1
Department of Public Health and Epidemiology, Riga Stradins University,
Riga, Latvia
2
Department of Health Sciences, University of Jyvaskyla, Jyvaskyla, Finland
3
National Institute of Public Health, University of Southern Denmark,
Copenhagen, Denmark
*Contact details: inese.gobina@rsu.lv
Implementation of a parent-training programme for

indicated prevention of early-onset conduct problems
Paula Villar
P Villar*, E Romero, MA Luengo
Department of Personality, Assessment and Psychological treatment
*Contact details: paula.villar@usc.es
Background
Early-onset conduct problems are a common source of worry
for families, schools and health systems for their disturbing
effects, and they are also linked to the development of severe
patterns of behavioural dysfunctions. Theoretical models
Telemedicine in Armenia: lessons and challenges

Anna Poghosyan
A Poghosyan*, A Babloyan
Arabkir Joint Medical centre, Institute of Child and Adolescent Health,
Yerevan, Armenia
*Contact details: pannagos@yahoo.com
Issue/Problem
The main idea of a telemedicine conception is to provide
timely and cost-effective care with possibility of early
interventions through coordination of services provided by a
multidisciplinary team of professionals. This promising tool
offers long-distance consultation, follow up and continuous
medical education and training opportunities for health care
professionals. For developing countries having limited
resources and medical expertise as Armenia, telecommunication services might be a potential solution for improvement of
both quality and access to health care facilities regardless of
geography.
Problem description
In 2007, Arabkir JMC-ICAH in cooperation with Medical
Missions for Children and St. Joseph Childrens Hospital (New
Jersey, USA) set up a Telemedicine project. The objective of
the initiative was to improve health-care delivery through the
establishment of the sustainable system using telecommunications and to promote medical education for health care
Downloaded from http://eurpub.oxfordjournals.org/ by guest on April 3, 2016
Background
There is a lack of evidence-based information on medicine use
in school-aged children. Existing studies suggest that the
prevalence of medicine use for pains in school-age children is
high and increasing. Studies that investigated cross-national
patterns in adolescents medicine use practice are rare. This
study aims to investigate adolescents medicine use for
headache and stomach-ache in 18 countries or regions in
Europe and the association between medicine use and
frequency of corresponding health complaints.
Methods
A total of 89 715 adolescents from nationally representative
samples of adolescents (11-, 13, 15 year olds) from eighteen
countries and regions in Europe were studied using the Health
Behaviour in School-aged Children (HBSC) 2005/2006 survey.
The prevalence of medicine use by age and sex during the past
month was estimated and multilevel modelling was used to
investigate the relationships between medicine use and
corresponding weekly or monthly health complaint.
Results
The prevalence of medicine use for pains varied substantially
by country. The prevalence of medicine use for headache
ranged from 30% in the French speaking part of Belgium and
Switzerland to 48% in France, and medicine use for stomachache from 13% in Greece to 41% in France. Medicine use for
pains was significantly more common among girls than boys
(P < 0.001) in all countries.
Multilevel models for pooled samples revealed that both
individual factors and country of residence contributed
statistically significantly to the variation in medicine use
during the past month. Among individual factors, the
frequency of headache or stomachache was the most
important. On the average, the odds of medicine use for
pains increased twice for children with weekly pains compared
with monthly.
Conclusions
The findings suggest the medicine use for headache and
stomach-ache is common for school-age children in Europe
and there is strong association with the frequency of
corresponding health complaints. Therefore, medicine use
can be used as an indicator of school-aged children with
significant individual burden of subjective health complaints.
outlining the development of these problems agree in the

importance of ineffective parenting practices as explanatory
factors. In this line, the family component of the EmPeCemos
programme, a multi-component indicated intervention, was
developed following the research about risk/protection
mechanisms and empirically validated prevention experiences.
Since 2005, this weekly 12-session parent-training programme
has been delivered in 24 Spanish schools, with the aim of
intervening on parenting skills and breaking the cumulative
circle of impairments of early-onset disruptive children.
Objectives
In this study, the implementation of the EmPeCemos family
programme is evaluated in order to assess: (i) the degree of
integrity and fidelity of its administration, (ii) rates of
participation and dropouts, (iii) the degree of its social
validity.
Results
The results show, firstly, that the integrity of the programme
administration was high: The 88.2% of the proposed activities
were administered following the programme manual and
principles. Secondly, 153 participants were involved in the
intervention [i.e. 83% of selected parents 95% confidence
interval (CI) = 0.7760.884]; dropout rates were 8.2% (95%
CI = 0.790.85) Finally, 93.5% of the participants (95%
CI = 0.8980.972) reported being satisfied with the changes
in their children; 95.5% of parents (95% CI = 0.922-0.988)
reported that EmPeCemos will be useful to manage further
problems in the future; and 95.7% of parents (95% CI = 0.925
0.989) would recommend the programme to friends and
relatives.
Conclusions
In conclusion, the programme generated high degrees of
acceptance and satisfaction by participants, which support its
social validity. Despite further research around this project is
needed, our findings show that EmPeCemos is a theoretically
solid-based programme, feasible and useful to satisfy the
demands of families of disruptive children in European
societies.
3rd European Public Health Conference: Moderated Poster Sessions: Abstracts
professionals. Cases difficult to diagnose and/or manage were

presented and the use of Telemedicine services by professionals
and/or patients, overall satisfaction of involved parties and
cases outcomes were chosen as indicators for evaluation.
Results
Overall, 30 patients were consulted during 2 years and five
videoconferences for health care professionals were conducted.
Among all presented cases 30% constitute patients having
neurology, 19%gastroenterology, 15%cardiology and
8%dermatology and respiratory problems. Almost 20% of
children did not have any diagnosis at the moment of
presentation and which was defined during video sessions.
Success was achieved in 87% of cases, while three patients
passed away due to suddenly developed complications related
to the main pathology.
Lessons
The experience obtained has proved that the establishment of a
new system of integrated medical facilities successfully using
innovative modern technologies might extend the scope of
health care and provide opportunities for improvement
through fostering communication and information exchange
between health care professionals.
Sebastian Liersch
S Liersch1*, E Sterdt1, S Bisson1, V Henze2, M Roebl3, C Krauth1,
U Walter1
1
Institute for Epidemiology, Social Medicine and Health System Research,
Hannover Medical School, Hanover, Germany
2
General Sport Club Goettingen since 1846 (ASC 46 e.V.), Goettingen,
Germany
3
Centre for Child and Adolescent Health Goettingen, Georg-AugustUniversity Goettingen, Goettingen, Germany
*Contact details: liersch.sebastian@mh-hannover.de
Background
The intervention fit for pisa supplements the mandatory 2 h
of physical education per week for the entire school term
(classes 14) with another 3 h of physical education per week at
five primary schools in Goettingen. The evaluation gives
information about how daily sports lessons affect health status,
leisure activities and the education of students in the long run
during the intervention as well as after its completion. The
study is funded by the Federal Ministry of Education and
Research.
Methods
Besides the school entry examination, annual medical
anamnesis and examinations are carried out with the students,
e.g. examining the motor development by means of sports tests
since the school year 2003/4. At the end of the 5th class in the
longitudinal approach 216 students (Intervention group [IG]:
n = 103; Control group [CG]: n = 113) were asked about their
physical activity behaviour in physical education and leisure
time using a child questionnaire. According to the information
regarding frequency, duration and physical activity intensity
three index-categories were generated (high activity level,
medium activity level, low activity level). Moreover, the parent
questionnaire allows inferences on socio-demographic features
such as migration background and social state.
Results
One year after completion of the intervention, students of the
IG have an unaltered interest in sport. However, the interest of
students of the CG has significantly declined. The physical
activity in a sports club has significantly changed (controlled
for sex and social state). At both measuring times the IG is
significantly more often in a sports club. Physical activity in
leisure time has significantly decreased from fourth to the end
of fifth class (fourth class: IG = 71%, CG = 61%; fifth class:
IG = 15%, CG = 19%).
Conclusions
Daily physical education at primary school contributes to a
sustainable improvement of childrens activity level and also to
an active organization of students leisure time activity.

Interviews at the end of 6th class will show how the
intervention effects persist 2 years after completion of the
intervention. Especially, the effectiveness for children with
migration background and disadvantaged groups will be
discussed.
Prevalence of depression among the university

students and related factors, Erciyes University
Turkey
Osman Gunay
O Gunay*, F Akpnar, S Poyrazoglu, H Aslaner
Department of Public Health, Erciyes University Medical Faculty, Kayseri,
Turkey
*Contact details: gunayos@erciyes.edu.tr
Background
Depression is a major public health problem all over the world.
Unipolar depression is responsible from 5.4% of the total
burden of disease in the European Region. University students
are under high risk for depression because of their age and the
other characteristics. This investigation was carried out to
determine prevalence rate of depression among the students of
Erciyes University and its relations to some psychosocial,
demographic, educational and health-related factors.
Methods
A total of 1003 university students who study at the medical,
theology and engineering faculties of Erciyes University were
taken into the study. A questionnaire including 26 questions
about socio demographic and educational characteristics and
health condition of the students and Turkish version Beck
Depression Inventory (BDI) were filled by the students under
the supervision of the investigators. Unpaired t-test, one way
ANOVA (post hoc Scheffe), chi square test and binary logistic
regression method were used for statistical analyses.
Results
Mean BDI score was found 11.3 8.6 in the study group. Of
the study group, 29.9% have a BDI score between 10 and 16
and 21.2% have 17. Prevalence of depression was significantly higher among the students who report economic level of
their family as poor, who have any physical disease, who are
not satisfied body image and who are not satisfied the faculty
(P < 0.05). No significant effect of the age, gender, faculty,
grade and living arrangement of the students and residence of
the family were found on depression prevalence.
Conclusions
According to BDI scores, approximately onethird of the
university students have moderate and oneforth have serious
depression. Studying at a faculty which the student doesnt
satisfy is one of most important factors affecting depression
prevalence. The students should be better oriented while they
choose the faculty.
Does place count? Differences in smoking occurrence

among high school students according to their living
environment
Mate Adam Balazs
Mate Adam Balazs1*, BF Piko1, RM Page2
1
Department of Behavioral Sciences, University of Szeged, Faculty of
Medcine, Hungary
2
Department of Health Science, Brigham Young University, Utah, USA
*Contact details: balazsmateadam@hotmail.com
Background
Smoking is one of the most important public health problems
facing countries throughout the world. The adolescent
population is especially vulnerable in terms of initiation of
smoking. The primary goal of our study was to analyse
interrelationships among smoking behaviour, smoking-related
attitudes, and adolescents living environment. We hypothesized that among those adolescents who commute to school or
live in a student dormitory (that is, far from their parents) the
Sustainable effects of physical activity promotion

based on a school-related prevention programme
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162
European Journal of Public Health, Vol. 20, Supplement 1, 2010
Twenty-year trends in tobacco smoking and

physical activity among Siberian adolescents: a
population-based cross-sectional study (19892009)
Diana Denisova
D Denisova*, L Zavyalova
Institute of Internal Medicine SB RAMS, Novosibirsk, Russia
*Contact details: diana2000@rambler.ru
Background
Tobacco smoking and sedentary behaviour are the major
preventable causes of morbidity and mortality in the world.
Unhealthy lifestyle typically begins in adolescence, so control
of the risk factors at this age period may reduce cardiovascular
events in adulthood. No one population-based study of time
trends in adolescent smoking and physical activity were
performed during the past 20 years in Russia.
Methods
Five cross-sectional surveys of representative samples of school
children aged 1417 years in 1989, 1994, 1999, 2003 and 2009
were carried out in Novosibirsk. This time period included
years of Russian reforms. Total sample was 3311 (46% males)
with response rate 8892%. Self-reported smoking (one
cigarette a week and more), low physical activity (2 h/week
of exercises and less) and sedentary behaviour (weekly screen
time) were obtained.
Results
During the period (19892009), the prevalence of regular
weekly smoking among boys linearly declined from 45 to
18%, among girlsfrom 19 to 13%. Average amount of
cigarettes per week in girls-smokers significantly increased
since 1989, in boys it did not change. Adolescents-smokers
registered twice more often in smoking families than in nonsmoking families: 65% versus 35% (P < 0.05). Levels of low
physical activity were stably high during all period in boys
(4955%) and girls (8373%). Leisure-time physical activity
of adolescents rapidly declined during the computer era. In
2009 average amounts of weekly screen time (computer
games, Internet, TV, video) were 31 h in boys and 28 h in
girls. Physical inactivity rates were higher in smokers
(P < 0.05).
Conclusions
Data from the long-term population-based study indicate on
trends to decline in cigarette smoking among Siberian
adolescents. However, stably high levels of low physical activity
and rising prevalence of sedentary behaviour at adolescents
caused by using computer and viewing TV specify in a
maintenance mainstream of preventive actions among current
youth generation.
The relationship between eating habits and sleeping
habits
Gudrun Kristjansdottir
DB Sigurdardottir1,2, G Kristjansdottir1,2*, R Vilhjalmsson1
1
Faculty of Nursing, University of Iceland
2
Landspitali University Childrens Hospital, Reykjavik, Iceland
*Contact details: gkrist@hi.is
Background
Previous studies suggest that sleeping habits and eating habits
are associated with school childrens overall health and
academic performance. Less is known about how these habits
are related. The present study explores the relationship
between sleeping habits and eating habits in school children.
Method
The study is based on a national school-based random sample
of half of all Icelandic 9th and 10th grade students (mean age
14.7 years; response rate 91%; N = 3913). The study considered
socio-demographic background, self-reported average hours of
sleep, time of sleep, wake-up time, breakfast, lunchbox, lunch,
and dinner eating, snacks between meals, meals with family,
and overall regularity of meals, using descriptive as well as
bivariate and multivariate analysis.
Results
The results show that very few children eat breakfast with their
family (55.2% almost never; 26.6% three times or more often).
The majority eats breakfast almost every day (58.3%), but
21.7% eat breakfast two times or less per week. Most
participants sleep at least 8 h (41.4%), but 27.0% sleep <7 h
each night. The children that sleep at least 8 h are significantly
more likely to eat regularly and eat breakfast than those that
sleep <8 h (chi-square = 65.1; P 0.001).
Conclusions
Based on the findings, it is concluded that healthy sleeping
habits and eating habits go together in important ways in the
lives of school children. The findings suggest that much
research is needed to adequately predict the links between lifestyle factors in school children in order to strengthen the
grounds for health promotion in this population.
The International Study of Wheezing in Infants
(Eisler)
Ines Aguinaga Ontoso
I Aguinaga-Ontoso1*, F Guillen-Grima1,2, B Marin-Fernandez1,
C Lopez Morras3, A Garca Iriarte1, A Sanz4, J Hermoso de Mendoza4
1
Department of Health Sciences, Public University of Navarra, Pamplona,
Spain
2
Department of Preventive Medicine and Public Health, University of
Navarra Clinic, Pamplona, Spain
3
Navarra Health Service, Pamplona, Spain
4
Navarra Hospital, Pamplona, Spain
*Contact details: ines.aguinaga@unavarra.es
Background
The International Study of Wheezing in Infants (Eisler) is a
multicenter epidemiological study speaking countries in order
to determine the prevalence of wheezing and severity in
children during the first year of life and the risk factors that
may associated with familial, personal or environmental. The
study provides a framework for investigating the evolution of
the prevalence and etiology in relation to factors affecting this
disease such genetic, lifestyle, environmental and health care.
Methods
The study was done in the 22 Primary Health Cancer of the
Navarra Health Service in the Metropolitan area of Pamplona
prevalence of smoking was higher and the likelihood of

habituation was also bigger.
Methods
The sample was composed of 546 adolescents from elementary
and high schools of Mako, Hungary. The participants
consisted of 288 (52.7%) twelfth-grade and 258 (47.3%)
eighth-grade students; 49.5% of the sample was male and
50.5% female. The pupils were questioned anonymously in
September 2008 about their substance use habits, lifetime and
monthly prevalence of smoking, attitudes related to smoking
and socio-demographics. Cross-tabulations and chi-square
tests were used to test these relationships.
Results
We did not find any relationship between smoking behaviour
and gender or according to the type of residence (P > 0.05).
However, whether one commuted to school or not was
significantly associated with lifetime prevalence of smoking
(P < 0.01), monthly prevalence of smoking (P < 0.01) and daily
amount of cigarettes (P < 0.05). Positive smoking-related
attitudes and their future plan to smoke were significantly
higher for those commuted to school or lived in a dormitory
(P < 0.001) and the relationship with social attitudes was also
significant (P < 0.001).
Conclusions
Results suggest that prevention programme have to pay
attention to the vulnerable subpopulations of adolescents,
such as commuters or those living in a dormitory, since the
probability of habituation among them is higher. On the other
hand these findings provide strong evidence that parental
monitoring has an important role in the adolescents attitudes
and substance use.
Healthy food habits among adolescents in Europe:

does income inequality matter?
Gintare Petronyte
P Petronyte*
Kaunas University of Medicine, Kaunas, Lithuania
*Contact details: gintare888@yahoo.com
Background
Previous research on income inequality and health has rarely
focused on adolescents. In order to fill some gaps in existing
research and provide useful insights about socio-economic
inequalities in healthy food habits, the aim of this study was to
examine whether country-level income inequality is associated
with daily fruit and vegetables consumption among
adolescents.
Methods
This study was based on merged data consisting of the 2005/06
Health Behaviour in School-aged Children survey and
country-level data collected from the 2006 United Nations
Human Development Report. The sample consisted of 148 710
adolescents aged 11, 13 and 15 years from 26 European
countries. Countries were grouped into low, medium and high
income inequality based on Gini coefficients. Data were
analysed using multilevel logistic regression models.
Results
Daily consumption of fruit varied from 23.2% in Latvia to
43.8% in Portugal whereas daily vegetables consumption from
17.1% in Austria to 52.9% in Belgium. Income inequality was
not significantly associated with adolescents daily fruit and
vegetables consumption. There was no significant association
of income inequality with adolescents daily fruit and
vegetables consumption after controlling for individual-level
parental socio-economic status. Daily fruit and vegetables
consumption increased with parental socio-economic status in
all countries but no significant differences were found in
Austria, Switzerland, The Netherlands, and Sweden for fruit
and in Austria, Germany, Latvia, Romania, Slovakia and
Croatia for vegetable consumption.
Conclusions
Individual-level parental socio-economic status is a more
important factor of daily fruit and vegetables consumption
among adolescents than country-level inequality.
Exposure to cyber-bullying among 12- to 18-year-old

Finnish adolescents: a population-based study
Pirjo Lindfors
P Lindfors1*, R Kaltiala-Heino2, A Rimpela1
1
Tampere School of Public Health, University of Tampere, Finland
2
Medical School, University of Tampere, Finland
*Contact details: pirjo.lindfors@uta.fi
Background
Cyber-bullying, which occurs in different forms through
internet or cell phones, has emerged as a new form of bullying
in recent years. Cyber-bullying constitutes a new adolescent
health problem, which calls for additional research. We
examined to what extend adolescents were exposed to cyberbullying targeted to themselves, their friends, their school or
workplaces.
Methods
The study is part of the nationwide Adolescent Health and
Lifestyle Survey. Data was collected from a sample of 1218year-olds in 2009 (n = 5561, response rate 56%). Information
on cyber-bullying was gathered by mail. Respondents were
asked: (i) whether they have been bullied via cell phone or
Internet during the last year, and if yes, then how often and
how serious and disruptive bullying was, (ii) whether their
friends have been bullied and (iii) if their school, class or
working places have been bullied during the past year.
Results
The preliminary results show that the prevalence of cyberbullied on individual level during the last year was 11.2%, out
of which 1.2% were bullied once a week or more often. Of those
who were bullied, 22.7% considered bullying as very serious or
slightly serious whereas 77.3% considered it as not serious or
disruptive. 13.4% of the respondents were exposed to bullying
through their friends and 6.6% reported that their school, class
or working place were cyber bullied during the last year.
Conclusions
Our results show that exposure to cyber-bullying can come
from various directions and levels,
including both individual, social group and environmental
levels. More research is needed to get a comprehensive
understanding of this complex phenomenon and how these
different forms of cyber-bullying are related to other ways of
bullying and adolescents wellbeing.
Trends in weekly pains among Icelandic
schoolchildren
Gudrun Kristjansdottir1,2*
1
Faculty of Nursing, Universtiy of Iceland
2
Landspitali University Childrens Hospital, Reykjavik, Iceland
Background
Previous research shows that recurrent pains are prevalent in
children age 1116. Frequent and multiple pains in head, back
and stomach are inversely related to psychological well-being,
quality of life, and scholastic performance. This study
considered trends in the prevalence of headache, back pain,
and stomachache in Icelandic schoolchildren between 1989
and 2006.
Methods
The study is based on two national school-based surveys of 6th
and 10th grade students entitled Health Behaviour in
Schoolchildren (HBSC). The former survey includes 2073
respondents (response rate 91%), and the latter 5697
respondents (response rate 86%). The students were asked
howoften they had experienced headache, bach pain and
stomachache. Trends in prevalance rates were assessed by age
and gender.
Results
The results show that the prevalence of single pains has not
changed significantly in between 1989 and 2006 the 6th grade
(11- to 12-year olds), where headache is still the most prevalent
weekly pain
(Spain). A written questionnaire was completed by a sample of

1050 parents of children who were 12-15 months old when
they went to a scheduled paediatrician examination or to
receive MMR vaccination As the area of Pamplona is mixed
language area, two versions of the questionnaire in Spanish
and Basque were used. The questionnaire has a sensitivity of
81%, a specificity of 85%, a PPV of 86% and a NPV of 79%
over the diagnosis of the doctor. It provides a common and
validated methodology for comparing the results of the study
in Pamplona with those obtained in other Spanish and Latin
American cities. The questionnaire includes a food frequency
questionnaire about mothers nutrition during pregnancy.
Results
The prevalence of wheezing during the first year of life was
31.27 [95% cofidence interval (CI) 28.4934.14]. The prevalence of some symptom of severe wheezing was 17%. The
main risk factors were parents antecedent such as mother with
asthma odds ratio (OR) 1.90 (95% CI 1.093.30), and father
with asthma OR 2.09 (95% CI 1.143.83) or Atopic Dermatitis
OR 2.26 (95% CI 1.204.26). Smoking during the second
trimester of pregnancy OR 1.14 (95% CI 1.042.08),
paracetamol consumption during pregnancy at least one a
month OR 1.45 (95% CI 1.042.03), and high consumption of
industrial pastries (P = 0.017) and French fries (P = 0.049).
Going to kindergarten during first year of live was also a risk
factors OR = 1.83 (95% CI 1.402.40)
Conclusions
To avoid wheezing in infants, pregnant women should avoid
smoking. Nutrition and paracetamol use should be watched.
Early entrance in kindergarten appears as a risk factor.
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164
(89/06 = 25.0%/27.9%), stomach ache comes second (89/

06 = 23.1%/24.5%), and back pain is third (89/06 = 15.3%/
15.5%). As for 10th grade students (15- to 16-year-olds),
weekly prevalence rates reveal striking increase during this
period headache has increased from 19.2 to 39.2%,
stomachache
from 14.1 to 29.9%, and backpain from 25.4 to 38.3%. The
prevalence of single weekly pains has increased from 40.4 to
55.5%, two joint weekly pains from 15.1 to 29.6%, and three
joint weekly pains from 4.7 to 12.8%. Other research indicates
similar development, although national data have been lacking.
However, no previous study has found such increase in weekly
pains in 15- to 16-year-olds.
Conclusions
The reported increase in prevalence of weekly pains
deserves further investigation. It suggests that school health
services should direct greater attention to recurrent pain
as a growing public health problem, especially in midadolescence.
Zuzana Katreniakova
Z Katreniakova1,2*, M Sarkova2,3, A Madarasova Geckova2,4, W Lok2,
JP van Dijk2,5, W van den Heuvel2, B Middel5,6
1
Department of Social Medicine, Institute of Public Health, Medical Faculty,
PJ Safarik University, Kosice, Slovakia
2
Kosice Institute for Society and Health, PJ Safarik University, Kosice,
Slovakia
3
Institute of Educational Psychology and Health Psychology, Faculty of Arts,
PJ Safarik University, Kosice, Slovakia
4
Department of Health Psychology, Institute of Public Health, Medical
Faculty, PJ Safarik University, Kosice, Slovakia
5
Department of Social Medicine, University Medical centre Groningen,
University of Groningen, Groningen, The Netherlands
6
Department of Oral Health and Clinical Epidemiology, University Medical
centre Groningen, University of Groningen, Groningen, The Netherlands
*Contact details: zuzana.katreniakova@upjs.sk
Background
The main aim of this longitudinal study was to explore
intra-individual change over time in psychological well-being
and self-esteem from early to middle adolescence and to
investigate the roles played by gender and parental education.
Methods
The sample consisted of 519 Slovak adolescents [mean age:
11.48 (SD 0.58) at baseline and 14.88 (SD 0.45) at followup]. Two dimensions (depression/anxiety, social dysfunction)
of the General Health Questionnaire-12 (GHQ) and two
components (negative and positive self-esteem) of the
Rosenberg Self-Esteem Scale (RSES) were measured. The
difference between proportions test was used to estimate
differences in the prevalence rates of improved, deteriorated or
stable GHQ and RSES scores across boys and girls, and
multiple logistic regression analysis was performed to analyse
associations between changes over time in the GHQ and RSES
across gender and parental education.
Results
Both genders significantly deteriorated statistically in depression/anxiety with a substantially higher change over time
among girls compared with boys (ES = 0.63 versus 0.25
respectively) and significantly improved statistically in overall
self-esteem and in negative self-esteem with a small ES.
Statistically, only girls deteriorated significantly in overall
psychological well-being. Both gender (girls) and educational
level (lower) of the mother were the strongest factors
associated with depression/anxiety at the age of 15 adjusted
for the baseline (depression/anxiety) scores.
Conclusions
Our findings challenge us to go deeper into relations of other
potential socio-economic factors associated with psychological
status and to study pathways between psychological well-being
and self-esteem from a domain-specific perspective in early to
middle adolescence.
Maria Gorbatova
MA Gorbatova1,2*, MU Pastbin1,2, LN Gorbatova2, TN Ushmanova3,
AM Grjibovski4,5
1
International School of Public Health, Northern State Medical University,
Arkhangelsk, Russia
2
Department of Pediatric Dentistry, Northern State Medical University,
Arkhangelsk, Russia
3
Department of Prosthetic Dentistry, Northern State Medical University,
Arkhangelsk, Russia
4
Norwegian Institute of Public Health, Oslo, Norway
5
Institute of Community Medicine, University of Troms, Norway
*Contact details: marigora@mail.ru
Background
Orphans in Russia have poorer general health and limited
access to professional health care than children with parents.
Dental examination using international assessment criteria in
orphans was never performed previously in Northwest of
Russia. The aim of the study was to assess dental caries
experience and levels of oral hygiene and knowledge in orphan
schoolchildren in Northwest Russia.
Methods
In 2010, all 102 orphans (boys60.8%) aged 1114 years
attending three randomly selected schools in Severodvinsk
were examined. Caries in permanent teeth was recorded as
recommended by the WHO at D3 level by two calibrated
examiners. Oral hygiene level was assessed using Simplified
Oral Hygiene Index (OHI-S). Decayed-Missing-Filled teeth
(DMFT) scores are presented as means and standard errors.
Pearsons chi-squared tests and MannWhitney tests were used
for proportions and numerical data, respectively. Altogether,
94 orphans completed a questionnaire on personal dental
hygiene knowledge. Independent association between childrens oral hygiene knowledge and practice and caries was
assessed by logistic regression.
Results
Altogether, caries prevalence in orphans was 73% (95%
confidence interval 6380) with their mean DMFT score of
2.83 0.26. The average numbers of decayed, missing and
filled teeth were 1.25 0.17, 0.11 0.05, and 1.47 0.2
respectively. The mean value for OHI-S was 1.4 0.5. Girls
had more filled teeth (2.3 0.4 versus 0.94 0.15, P = 0.03)
and lower OHI-S levels (1.22 0.5 versus 1.45 0.5, P = 0.01)
than boys. Tooth brushing once a day or less often was
reported by 18% of children. Altogether, 78% of children
reported not using dental floss. About 52% of children
reported visiting a dentist once a year or less frequently.
Neither the knowledge of oral hygiene nor practice was
associated with caries.
Conclusions
Dental caries prevalence among 10- to 14-year-old orphans in
Severodvinsk is alarmingly high. Many decayed and missing
teeth may reflect generally poor knowledge or practice of
oral hygiene or other factors. Low number of filled teeth may
reflect poor organization of dental services for this particular
group.
Comparison of the life quality of boarders and daystudents studying in the regional boardingschools in
Turkey
Osman Gunay
E Kucuk1, O Gunay2*
1
Division of Midwifery, Giresun University Faculty of Health Sciences,
Giresun, Turkey
2
Department of Public Health, Erciyes University Medical Faculty, Kayseri,
Turkey
*Contact details: gunayos@erciyes.edu.tr
Background
Primary education, during which self confidence and self
respect, social relationships and future plans of individuals are
developed, is a very important period. Most of the habits and
lifestyle started during these critical years continue throughout
Intra-individual change over time in psychological

well-being and self-esteem among early and middle
adolescents in Slovakia
Dental caries and levels of oral hygiene and

knowledge among 10- to 14-year-old orphans in
North-West Russia
Sleep patterns among adolescents in South Korea

Kyoung Ae Kong
Kyoung Ae Kong*, Yoonjung Kim, Sun Min Park, Yu Na Ji,
Young Taek Kim
Division of Chronic Disease Surveillance, Korea Centers for Disease Control
and Prevention, Seoul, South Korea
*Contact details: joywell@korea.kr
Background
Despite evidence of the health implications of insufficient
sleep, a large number of students in South Korea do not
routinely get optimal hours of sleep. This study analysed the
sleep patterns and the association between sleep duration and
health risk behaviours using data from the 200509 Korea
Youth Risk Behaviour Web-based Survey (KYRBS).
Methods
Approximately 80 000 middle- and high-school students
completed the anonymous self-administered web-based questionnaire at computer room in 800 sampled schools in 2005
09. Statistical analyses were conducted on weighted data using
SAS software to account for the complex sampling design.
Results
On a typical school day, waketime of students is around 6:46
am, regardless of grade in 2009. Bedtime is between 11:40 pm
and 12:18 am in middle school students, around midnight or
later in high school students. The amount of sleep tended to
get less sleep as they get older (from 7.4 h in 7th grade to 5.4 h
in 12th grade). Overall 26.2% of students got a sufficient
amount of sleep (7.0 h), and 40.4% got an insufficient amount
of sleep (5.9 h). The percentage of current smoking, current
drinking, obesity, felt stress, felt sad or hopeless and considered
attempting suicide were the highest among student who slept
less than 4 h, the lowest among student who slept 78 h in
200509.
Conclusions
South Korean students got less sleep as they get older and
students with having health risk behaviours got less sleep than
those who did not. But the causality cannot be determined
with cross-sectional data. Therefore, additional surveys are
needed to identify the causality of relationships.
Urbanrural and gender differences in the prevalence
of overweight and obesity among adolescents in
Northwest Russia
Svetlana Khasnutdinova
SL Khasnutdinova1, AM Grjibovski2,3,4*
1
Department of Physical Activity and Health Promotion, Northern State
Medical University, Arkhangelsk, Russia
2
Arkhangelsk, Russia
3
4
Institute of Community Medicine, University of Troms, Troms, Norway
*Contact details: andrei.grjibovski@fhi.no
Background
The prevalence of overweight and obesity in European
adolescents has increased during the last decades. Previous
suggested that it increased in almost doubled in the 2000s
compared with the 1990s in large cities. Information about
urbanrural differences is almost non-existent. Moreover,
most of the Russian studies do not apply international cutoffs complicating international comparisons. This study aims
to asses the prevalence of overweight and obesity among
adolescents from urban and rural areas in Northwest Russia by
using the WHO-2007 criteria.
Methods
All 9th11th grade students (mean age 15.6 years) from urban
and rural schools in the Velsk district were asked to participate.
Response rate was 87%. Height and weight were measured in
1066 adolescents (271 boys and 370 girls from urban and 174
boys and 241 girls from rural areas). Overweight+obesity and
obesity were defined by the WHO-2007 criteria. Proportions
were compared using chi-squared tests.
Results
The prevalence of overweight+obesity and obesity in urban
versus rural boys was 14.8% versus 8.6% (P = 0.055) and 7.7%
versus 3.4% (P = 0.064), respectively. The corresponding
proportions for urban versus rural girls were 6.5% versus
12.4% (P = 0.012) and 2.4% versus 5.6% (P = 0.042), respectively. Among urban adolescents the prevalence of overweight+obesity and obesity was higher among boys (14.8%
versus 6.5%, P = 0.001 and 7.7% versus 2.4%, P = 0.002). No
gender difference in the prevalence of overweight+obesity
(8.6% versus 12.4%, P = 0.224) and obesity (3.4% versus 5.6%,
P = 0.308) were observed in rural areas.
Conclusions
The prevalence of overweight and obesity in urban boys tended
to be higher than among rural boys. In contrast, rural girls
were more likely to be overweight and obese than urban girls.
In urban areas, the prevalence of overweight and obesity was
higher among boys, while no gender differences in the studied
outcomes were observed in rural areas.
Depressive symptoms and physical fighting among
adolescents
Slvia Fraga
S Fraga1*, E Ramos1, S Dias2, H Barros1
1
Institute of Public Health-University of Porto (ISPUP); Department of
Hygiene and Epidemiology-University of Porto Medical School, Porto,
Portugal
2
Public Health Department, Institute of Hygiene and Tropical Medicine, New
University of Lisbon, Lisbon, Portugal
*Contact details: silviafraga14@gmail.com
Background
Although depressive symptoms and physical fighting are
salient public health problems faced by adolescents, few
longitudinal studies examined the extent to which depressive
symptoms contribute to engage in physical fights.
life. In order to fulfill the basic education needs of children

belonging to poor families living in places with low and
nonuniform population in Turkey, regional boarding schools
have been established. In these schools, boarders and daystudents study together. This study is carried out to compare
the quality of life levels of boarders and daystudents studying
in these schools.
Methods
The research was conducted in nine regional boardingschools
in the Giresun province of Turkey during the 200809
education period. From each of the fourth to eighth grades
in each school, one class was randomly selected. These classes
were visited and a questionnaire form consisting of 49
questions regarding the socio-demographic characteristics
and health status of the students was distributed along with
the Paediatric Quality of Life Inventory. The questionnaires
were answered by the students under the supervision of the
researchers. A total of 1126 students, 634 boarders and
492 day-students, were included. The physical, emotional,
social and school function domains scores; physical and
psychosocial summary scores and total quality of life scores are
calculated. Unpaired t test and one way ANOVA test were used
for statistical analyses
Results
It was found that the average points of boarders are lower than
that of the day-students for all domains (P < 0.001). In both
groups, the physical, emotional and total quality of life points
of girls were found to be lower than that of the boys (P < 0.01).
It was observed that in terms of the physical and psychosocial
summary scores and total quality of life scores, there was a
difference among the grades and in general the points of the
eighth grade students are higher.
Conclusions
The quality of life points of boarders are lower than that of the
day-students. The points of the boarder girls are far lower. The
factors that negatively affect the quality of life of boarders
should be analysed and measures to increase the quality of life
of these students should be taken.
165
166
Objective
To evaluate in a life course approach the role of depressive
symptoms on being involved in physical fighting at 17 years old.
Methods
The EPITeen project was designed to study a populationbased cohort of urban adolescents. We included in the
analysis, 1596 adolescents evaluated when they were 13 years
old and 17 years old. Depressive symptoms were evaluated
using Beck Depressive Inventory II (BDI), and adolescents
were categorized as (i) score 13 in both assessments; (ii)
>13 only at baseline, (iii) >13 at the age of 17 years.
Physical fighting was defined as being involved in physical
fights in the previous year and it was measured at 17 years
old.
We used logistic regression odds ratio (OR) and 95% confidence intervals (CI) to estimate the magnitude of the
associations, adjusted to parents education and family history

of depression.
Results
During the past year, 29.5% of girls and 62.5% of boys who
had scored BDI>13 at 17 year old were involved in physical
fights. For those who scored >13 only at baseline the values
were 20.2 and 45.8%, respectively. After adjustment, the
association between a BDI score >13 at 13 years old and being
involved in physical fights were OR = 1.10 95% CI (0.512.36)
in girls and OR = 1.32 95% CI (0.483.62) in boys. Considering
the same BDI scores at 17 years old the association was
OR = 1.87 95% CI (1.043.37) among girls and OR = 2.43 95%
CI (0.926.38) among boys.
Conclusions
There is a positive association between depressive symptoms
and being involved in physical fighting.
Chronic diseases and elderly

Rachel Irwin
R Irwin*
London School of Hygiene and Tropical Medicine, London, UK
*Contact details: rachel.irwin@gmail.com
In the WHO Europe region, non-communicable diseases

account for 86% of deaths and 77% of disease burden, with
cardiovascular diseases alone accounting for more than half of
these deaths. Clearly, there is a significant need to prevent
chronic disease and this data begs the question of why England
continues to struggle in preventing chronic disease. This article
surveys chronic disease prevention infrastructure across
Europe, specifically how are public health bodies funded,
organized and governed and what prevention activities do they
undertake? The article then addresses the extent to which
experiences can be applied and the questions that must be
addressed in transferring models of public health infrastructure to other countries. Specifically, this article highlights the
national institute of public health model, found notably in
Sweden and in Finland, as well as in other countries. The
article argues that three aspects are necessary for effective
chronic disease prevention:
(i) At all levelslocal, regional, national and multinational
acknowledging the wider determinants of health and the effects
of non-health sectors on health is key; this includes successfully
integrating public health into non-health sectors.
(ii) Staff needs to understand what public health is and the
ethos behind their institutes work.
(iii) Appropriate coordination is necessary amongst various
levels to reduce redundancy in programmes and to use funding
sensibly.
(iv) Appropriate political autonomy allows these bodies to
effectively carry out their functions.
This article first maps the public health prevention arena. It
then examines the national institution of public health model,
focusing on the function of these bodies and on how they are
structured and governed. It also discusses characteristics of
effective and successful chronic disease prevention structures,
as well as hindrances to prevention and discusses the main
issues in transferring the national institute of public health
model to other countries.
2
Department of Family Medicine, Northern State Medical University,
Arkhangelsk,
3
4
Background
The prevalence and burden of chronic obstructive pulmonary
disease (COPD) are high in many countries; therefore screening of COPD is an important task of the primary health care
service. This study aims to assess diagnostic performance
of the electronic pocket spirometer PiKo-6 device for the
screening of COPD in primary health care in Northwest
Russia.
Methods
Altogether, 521 patients from one general practice in
Arkhangelsk filled out questionnaires (including smoking
status and typical symptoms of COPD). FEV6 and FEV1/
FEV6 ratio were measured with a PiKo-6 device. A
standardized pulmonary function test with bronchodilatator
for determination of bronchial obstruction were performed in
patients with FEV1/FEV6<80% (PiKo positive), smokers and
ex-smokers, and patients with symptoms.
Results
Mean age in the sample was 55.0 [95% confidence interval (CI)
38.069.0] years (52.8% of them were males). Almost a half of
them were current (27.0%) or ex-smokers (19.1%). The
average smoking history was 17.5 (95% CI 7.033.8) packyears. 141 patients (27.1%) were investigated by using both
PiKo-6 device and standard spirometry. 61 patients (11.7%)
were PiKo positive. COPD was detected in 20 patients (3.8%)
[COPD I: 3 (0.6%); COPD II: 11 (2.1%) and COPD III: 6
(1.2%)]. The cut-off point FEV1/FEV6<80% using Piko-6
had sensitivity, specificity, positive predictive value and
negative predictive value of 95.0, 65.3, 31.2 and 98.8%,
respectively.
Conclusions
The PiKo-6 device can be recommended for screening in
Russian primary care settings where a standardized pulmonary
function tests are often unavailable. Pros and cons of the
screening using PiKo-6 device will be discussed.
Determinants of poor self-rated health in recently
diagnosed rheumatoid arthritis patients
Iveta Nagyova
Screening optimization of chronic obstructive

pulmonary disease in primary health care using PiKo6 device
Elena Andreeva
EA Andreeva1,2*, N Sividova2, AM Grjibovski1,3,4
Arkhangelsk, Russia
I Nagyova1*, Z Macejova2, JP van Dijk1,3

Kosice Institute for Society and Health, Department of Public Health,
Faculty of Medicine, PJ Safarik University, Kosice, Slovakia
2
First Internal Clinic, Faculty of Medicine, PJ Safarik University, Kosice,
Slovakia
3
Department of Social Medicine, University Medical Centre Groningen,
University of Groningen, Groningen, The Netherlands
*Contact details: iveta.nagyova@upjs.sk
Chronic disease prevention and control: a survey of

methods and structures
Approaches to chronic care and disease management

in Denmark in 2009
Ramune Jacobsen
R Jacobsen*, A Frlich
Department of Integrated Healthcare, Bispebjerg Hospital, Copenhagen and
Section for Health Services Research, Department of Public Health, Faculty
of Health Sciences, University of Copenhagen, Copenhagen, Denmark
*Contact details: rjac0012@bbh.regionh.dk
Background
Developing and validating disease management evaluation
methods for European health care systems (DISMEVAL)
project aims to review approaches to chronic care and disease
management in Europe as well as test and validate possible
chronic care and disease management evaluation methods. The
current study is a part of the DISMEVAL work package two
and provides the overview of approaches to chronic care and
disease management in Denmark in 2009.
Methods
The study is a review of scientific literature and political
documents. In addition, face-to-face interviews as well as email correspondence with the experts in the field (national and
regional level politicians working with chronic disease management in Denmark; physicians, nurses and physiotherapists
involved in the programmes described) were carried out. A
template for data collection was elaborated by RAND Europe.
Results
Three principal approaches to chronic care in Denmark were
described. (i) The National Board of Health developed
integrated clinical pathways for 34 cancers and four heart
diseases in the period 200509. The aim of the pathways is to
assure fast and optimal disease management course without
unnecessary waiting time. (ii) In 2005 the National Board of
Health introduced disease management programmes (DMP)
in general concepts and terms. The focus of the DMP is
integrated care assured by cooperation between general
practice, hospital and municipality. In 2009 two regions in

Denmark developed and approved DMPs for diabetes and
chronic obstructive pulmonary disease (COPD). (iii)
Rehabilitation programmes in municipalities and hospitals.
Conclusions
The only one long-term approach to chronic care in Denmark
that has been implemented and evaluated in 2009 was a
rehabilitation programme for people with COPD, diabetes type
2, chronic heart diseases and balance problems in elderly carried
out in collaboration between the Municipality of Copenhagen,
Bispebjerg hospital and general practitioners in the local area.
Diabetes-related deaths and co-mortality in the
Brussels-Capital Region (200105)
Hadewijch Vandenheede
H Vandenheede*, P Deboosere
Interface Demography, Department of Social Research, Vrije Universiteit
Brussel, Brussels, Belgium
*Contact details: hadewijch.vandenheede@vub.ac.be
Background
Mortality statistics, based on the underlying cause of death,
underestimate diabetes-related mortality, as persons with
diabetes mellitus (DM) often die of one of the complications
associated with the disease and not from a cause solely
attributable to DM. The aim of this study is to determine the
actual public health burden of diabetes-related mortality. First,
mortality from DMboth as an underlying (UCOD) and
multiple (MCOD) cause of death (any mention of DM)is
quantified. Second, death certificates with and without
mention of DM are compared with give an integral picture
of CODs associated with (mortality from) DM.
Methods
The census-linked mortality data of the metropolitan BrusselsCapital Region (period 200105) are used. To estimate
mortality from DM, directly standardized age-standardized
mortality rates (ASMRs) are computed. To examine CODs
associated with DM, age-adjusted Poisson regression models
are performed with the respective COD as the dependent and
DM as the independent variable.
Results
The ASMR (UCOD) is 16.8 [95% confidence interval (CI)
14.219.4] per 100 000 person-years (PY) for men and 10.9
(95% CI 9.412.4) for women. When DM as MCOD is taken
into account, ASMRs are 83.9 (95% CI 78.389.6) for men and
47.5 (95% CI 44.550.6) per 100 000 PY for women. The most
commonly reported CODs on death certificates with mention
of DM are heart diseases, renal failure, infectious diseases and
hypertension. Compared with persons without DM on their
death certificate, persons with DM are at an increased risk for
dying of a range of causes, such as infectious diseases,
pancreatic cancer, lipidaemia, hypertension, ischaemic heart
disease, cerebrovascular disease, chronic obstructive pulmonary disease, glomerular disease, decubitus ulcers and osteomyelitis. Mortality rate ratios vary between 1.22 (95% CI 1.08
1.38) for cerebrovascular disease and 54.41 (95% CI 33.85
87.47) for glomerular disease.
Conclusions
Diabetes-related mortality is more than 4 times higher than
expected based on the UCOD. Excess mortality associated with
DM reflects both the occurrence of complications and the
clustering of abnormalities known as the metabolic syndrome.
To reduce mortality from DM and its complications, multifactorial health interventions are necessary.
Does altruism and reciprocity play a part in
participation in longitudinal health research
studies? Findings from the British Whitehall II study
Gill Mein
G Mein1*, C Seale2, A Tinker3, S Bhamra4, R Ashcroft5
1
Faculty of Health and Social Care Sciences, St Georges University of
London, London, UK
Background
Self-rated health is a strong predictor variable for a number of
important health outcomes such as mortality, morbidity or
utilization of health-care services. In spite of that, there still
remain questions concerning the mechanisms underlying the
process of evaluation of health. The aim of this study was to
shed more light on possible determinants of this powerful
construct.
Methods
A total of 160 patients with recently diagnosed rheumatoid
arthritis were followed up over a 4-year period (mean age
48.7 12.0 years, mean disease duration 22.2 15.9 months).
Patients filled in questionnaires on pain (NHP, RAI), disability
(GARS), psychological distress (GHQ-28), adjustment to
disease (GARA) and self-rated health (OEH). Multiple linear
regressions, controlling for relevant socio-demographic and
clinical variables, were used to analyse data.
Results
The first regression model consisting of basic socio-demographic variables (older age, female gender, lower education)
explained 19% of the variance of poor self-rated health. In the
next steps, entering relevant clinical variables (higher erythrocyte sedimentation rate and C-reactive protein as well as longer
disease duration) explained additional 5%, more pain 24%,
more disability 4%, and worse adjustment to disease another
6%. The total explained variance after entering all variables into
the equation was 51% (adjusted). In the final model only age,
education, pain and adjustment to disease remained significant.
Conclusions
The outcomes provide support for the hypothesized relationships between the variables under the study, even though the
non-significant association of psychological distress is to a
certain extant surprising. The findings also reveal interesting
implications for adjustment to disease (viewed as a result of a
coping process) as being one of the most important
determinants of self-rated health.
167
168
2
Centre for Health Sciences, Queen Mary, University of London, London,
UK
3
Institute of Gerontology, Kings College London, University of London,
London, UK
4
National Centre for Social Research, London, UK
5
School of Law, Queen Mary University of London, London, UK
*Contact details: g.mein@sgul.kingston.ac.uk
Tooth loss and edentulism in the Turkish elderly

Bahar Guciz Dogan
B Guciz Dogan1*, S Gokalp2
1
Department of Public Health, Hacettepe Univ. Faculty of Medicine, Ankara,
Turkey
2
Department of Conservative Dentistry, Hacettepe Univ. Faculty of
Dentistry, Ankara, Turkey
*Contact details: bdogan@hacettepe.edu.tr
Background
According to recent censuses, elderly population of Turkey is
also rapidly growing as it is all over the world. The natural
teeth retention and edentulism are the most significant indices
of dental health among elderly people. There is no nation-wide
information related to edentulism among 65- to 74-year-old
people in Turkey. The aim of this study was to evaluate partial
and complete tooth loss and some related demographic factors
and oral health behaviours among Turkish elderly.
Methods
In this nationwide representative cross-sectional study, 1545
subjects aged 6574 years were evaluated using the proportional stratified cluster sampling method. The data were
collected in 2004 via a structured, pre-tested face to face
administered questionnaire and an oral examination according
Selecting the more effective population interventions

to reduce cardiovascular morbidity and mortality in
Catalonia, Spain by 2020
Isaac Subirana
I Subirana1, C Medina2*, J Vila1, R Elosua1, R Tresserras2, M Grau1,
J Marrugat1
1
Program of Research in Inflammatory and Cardiovascular Disorders
(RICAD), Barcelona Biomedical Research Park
2
Planification and Evaluation Directorate, Ministry of Health, Catalonia,
Spain
*Contact details: camedina@catsalut.cat
Background
At the beginning of 21st-century health targets were defined in
the context of Catalan Health Plan by the year 2010 according
to WHO guidelines for Europe. Based on the evaluation of
these objectives new targets need to be defined for next decade
Objective
To set up a valid system to project myocardial infarction (MI)
incidence by the year 2020 to define feasible preventive
interventions to reduce cardiovascular disease in Catalonia.We
present an example with a population smoking prevalence
reduction of 10% compared with a mean total cholesterol shift
to the left of 10 mg dl1
Methods
Incidence projections for Northeastern Catalonia for period
200620 were estimated based on Cox models fit on data from
the population MI registry 19902006 from the
REGICOR(Registre Giron del Cor) Project. Cardiovascular
risk factors prevalence in 1995, 2000 and 2005 representative
population samples by sex and age groups (3574 years) were
obtained. Smoking prevalence, LDL > 160 mg/dl, total cholesterol > 250 mg/dl, diabetes and hypertension was used to
model MI incidence. Framingham function adapted for
Spanish population for hard end points (fatal and non-fatal
MI) was used to simulate risk factors prevalence. Also
demographic projections were used in the estimates.
Results
Predicted MI incidence (100 000 inhabitants) in 1995, 2000
and 2005 were 325.42, 322.88 and 242.30 in male 3574 years,
and 89.54, 88.59 and 62.45 in female of the area of REGICOR
Study. 95% confidence interval includes the observed rates
(318.13, 292.59 and 230.29, and 92.00, 76.45 and 48.06,
respectively). A total of 10% reduction in smoking prevalence
(both sexes) from 2005 to 2020 would result in a decrease in
MI incidence from 242.30 to 225.3 in men and from 62.45 to
56.65/100 000 in women, while with a mean total cholesterol
shift to the left of 10 mg/dlMI incidence would decrease from
Background
As the ageing population increases, it is becoming more
important to retain older participants in longitudinal health
research studies. If attrition is high then the sample is no
longer representative. This multidisciplinary, multi-method
research used data collected in 2004 and 2008 from the British
Whitehall II study. We identified factors that encourage and
discourage older people from participating in longitudinal
health-related studies.
Methods
This article combined interviews with staff and participants
collected in 2004 which investigated reasons why participants
participate in the study, with focus group data collected in
2008 which examined factors that might encourage participants to continue participating. We identified themes
associated with reciprocity and altruism.
Results
The focus groups demonstrated the altruistic motives and
reciprocity of participation felt by study participants and staff.
The benefits of participation identified included self-interest,
intergenerational, and interpersonal. Participants felt morally
indebted to reciprocate in return for the free medical
examination, time with qualified medical staff and a pleasant
experience. Obstacles to participation included certain medical
tests (particularly the cognitive ones), poor understanding of
the measurements, and dislike of the questionnaire.
Participation of older people in longitudinal studies is more
likely to continue if the balance between benefits and
reciprocity is maintained. Achieving this balance, as participants age and decline, is a challenge for researchers of all
longitudinal studies.
Factors which may encourage continued participation include
receiving regular medical examinations, enjoying the prestige
and loyalty of the study and giving something back. However,
to increase further understanding exit interviews should be
included in the original study design.
Conclusions
Recommendations
made
to
encourage
continued
participation:
continuing medical examinations,
increasing the sense of study loyalty,
providing exit interviews as participants withdraw.
to WHO 1997. Functional dentition was accepted as having

≥ 21 teeth. Statistical significance was evaluated with
Chi-square test and binary logistic regression analyses were
used to determine the significance of explanatory variables.
Results
The mean number of teeth present was 7.0 9.1 and 48.0% of
elderly were edentate. The mean DMF-T was found 25.8 8.5.
These values were significantly higher in women (P = 0.016),
older age (P < 0.001) and rural individuals (P < 0.001). The
values of M were the highest. Subjects with 21 or more teeth
cover only 12.4% of the subjects. Among the predisposing
factors, age, visiting dentist, and health security were associated
with edentulism. Molars were the most frequently removed
teeth on both jaws. Logistic regression analysis showed that
female sex [odds ratio (OR) = 1.37], 7074 age group
(OR = 2.08) and illiteracy (OR = 3.25) were the independent
factors of not having functional dentition. For attachment loss,
female sex (OR = 1.60), 7074 age group (OR = 1.68), rural
residence (OR = 1.36) and illiteracy (OR = 2.29) were the
independent factors.
Conclusions
A reduction in edentulism may be achieved by the implementation of community programmes promoting oral health
for the prevention and treatment.
242.30 to 219.51 in men and from 62.45 to 58.27/100 000 in

women.
Conclusions
Hard endpoints risk functions accurately predict MI incidence
in 19952005 period. Projections are useful for planning
strategies of intervention. In the example smoking cessation of
10% in the population seems to be more effective in women in
reducing MI incidence while a reduction in 10 mg/dl in
cholesterol would be more effective in men.
Assessing the needs of patients with type 2 diabetes
for health promotion activities
Bert Vrijhoef
HJM Vrijhoef1,2,3*, AN Van Dijk-de Vries1,4, IGP Duimel-Peeters1,2
1
Maastricht University Medical Centre (MUMC+), Department of Integrated
Care, The Netherlands
2
Maastricht University, School for Public Health and Primary Care CAPHRI,
The Netherlands
3
Tilburg University, TRANZO Scientific Centre for Care and Welfare, The
Netherlands
4
Beyaert Robuust Limburg Foundation, Maastricht, The Netherlands
*Contact details: b.vrijhoef@zw.unimaas.nl
Chronic disease management: the state of the art in

Italy
Luca Valerio
L Valerio1*, ML Specchia1, AG De Belvis1, M Maggini2, G Maciocco3,
W Ricciardi1
1
Institute of Hygiene, Catholic University, Rome
2
Istituto Superiore di Sanita`, Rome
3
Department of Public Health, Florence University
*Contact details: lucavalery@hotmail.it
Background
Chronic diseases account for the bulk of morbidity, mortality
and spending in Europe. Chronic disease management (CDM)
is a validated strategy for addressing them, but neither its
actual implementation in Italy nor the consistency of existing
projects with scientific literature have been studied yet. As part
of a European study coordinated by Cambridge University, we

reviewed the approaches to managing chronic disease in Italy
as of 2010, with specific reference to CDM, and analysed them
in size, scope and consistency with literature as summarized by
Wagners Chronic Care Model (CCM).
Methods
We identified and described the existing projects by reviewing
literature and contacting public authorities and those in charge
for the selected projects for first-hand information. To evaluate
consistency with literature, we collected all publications on the
CCM and developed a series of indicators. The outcome
measure was defined as the percentage of the indicators each
project satisfied.
Results
Four projects represent the state-of-the-art of Italian CDM: the
national project IGEA for diabetes; Tuscanys project for
Proactive Care; the private-public partnerships Leonardo in
Apulia for cardiovascular disease and Raffaello in MarcheAbruzzo for cardiovascular risk. Comparison in size showed
that the public projects involve a larger population than the
publicprivate partnerships (>1 000 000 versus 10002000),
while Tuscanys project outmatches all others in scope (six
diseases addressed). Consistency with the CCM was found to
be generally high: Tuscany leads the ranking with 80% of the
indicators satisfied followed by Raffaello (60%), IGEA and
Leonardo (56% each). Differences mainly stem from two areas:
Information Systems and Community Services.
Conclusions
Awareness of the efficacy of CDM appears to be well developed
in Italy. Yet, its adoption is still sparse, and in specific areas
consistency with literature is limited. This study identifies the
criticalities that should be tackled by further cooperation
between policy-makers and researchers to improve implementation of CDM.
The association between waist circumference and

mortality in elderly: a meta-analysis
Wanda Bemelmans
EL de Hollander1,2*, RP Bogers2, WJE Bemelmans2, LCPGM de Groot1
1
Wageningen University, Wageningen, The Netherlands
2
Institute for Public Health and the Environment, Bilthoven, The Netherlands
*Contact details: ellen.de.hollander@rivm.nl
Background
There are inconsistencies regarding the association between
waist circumference (WC) and mortality in elderly. This metaanalysis of 10 prospective cohorts examined in elderly of 6575
years old the association between WC as a continuous variable
and (cause specific) mortality and between combined WCBody Mass Index (BMI) categories and (cause specific)
mortality.
Methods
In 10 cohorts (N = 16 766), the age, smoking and BMI adjusted
relative risks (RRs) of mortality for WC as a continuous
variable were examined by means of a bivariate random effects
model (including the terms WC and WC2). The RRs of
mortality for each WC-BMI category were pooled by means of
a univariate random effects models in eight cohorts
(N = 16 066). The reference point of WC for women was
80 cm and for men 94 cm.
Results
There was a significant association between WC (continuous)
and total, cardiovascular disease (CVD) and cancer mortality.
In men, the RR was 0.17 [confidence interval (CI) 0.110.27]
at 80 cm and rose to 11.14 (95% CI = 6.5518.96) at 110 cm.
The RR of total mortality in women was 0.40 (95% CI = 0.25
0.63) at 70 cm and rose to 10.03 (95% CI = 3.9425.59) at
100 cm. The associations for CVD and cancer mortality were
similar, although the RRs at 110 cm and 100 cm were lower.
The univariate analyses indicated that elderly men as well as
elderly women with a small waist circumference combined
with underweight had a high RR of total mortality (RR = 2.64,
Background
Health promotion has to become an integral part of primary
health care for chronic patients. A practical instrument to
identify patient needs in health promotion will support
patient-centered health counselling. Objective of this study
was to develop and pilot test the health promotion diabetesinstrument (HEPRODIA) in order to identify diabetes
patients needs for health-promoting activities with regard to
their preferred lifestyle behaviour change.
Methods
Scale development of the instrument was guided by existing
insights and expert opinions. The internal consistency and
feasibility of the instrument were evaluated. Questionnaire
data were collected in a sample of patients (n = 221) from eight
primary care practices in the southern part of The Netherlands.
Internal consistency (Cronbachs alpha) of the instrument and
experiences of the practice nurses were evaluated.
Results
The instrument resulted in a fixed set of 14 items to make
patients conscious about their preferred lifestyle change plus a
variable set of 420 items concerning specific barriers and
support needs regarding the chosen topic. The instrument
provides a starting point for a discussion with the practice
nurse about healthy lifestyle changes. Cronbachs alpha of the
different scales ranged from 0.46 to 0.74. The tool is perceived
by practice nurses as a useful instrument in daily practice that
may be improved by further adjustment to patient segments.
Conclusions
The HEPRODIA-instrument is an aid to asses patient needs
concerning health-promoting activities and to facilitate health
counselling. Patients and practice nurses can benefit from
using the instrument for patient-orientated health promotion
counselling. The psychometric properties of the instrument
can be further improved.
169
170
95% CI = 1.714.07; RR = 3.04, 95% CI = 2.014.61). Similar

results were found for CVD and cancer mortality, except in
women in the analyses for CVD mortality. In the higher WCBMI categories no significant associations were found, except
for CVD mortality in men.
Conclusions
In elderly, a larger WC is associated with a higher mortality
risk. For the combined WC-BMI categories, a high mortality
risk seems to be most apparent in the lowest category.
Towards a European Diabetes Information System:
from St.Vincent Declaration to EUDIP, EUCID, BIRO
and EUBIROD. Are we getting closer?
Fred Storms
F Storms1*, F Carinci2, C De Beaufort3, M Massi Benedetti4, on behalf
of the EUBIROD consortium
1
CBO, The Netherlands
2
Centre Hopitalier de Luxembourg, Luxembourg
3
SERECTRIX
4
University of Perugia, Italy
*Contact details: stormdcb@wxs.nl
Predictors of social participation 1 year after kidney

transplantation
Lucia Prihodova
L Prihodova1,2*, J Rosenberger1,3,4,5, I Nagyova1,2, M Majernikova1,2,3,
R Roland3,4, JW Groothoff6, JP van Dijk1,6
1
Kosice Institute for Society and Health, PJ Safarik University, Kosice, Slovak
Republic
2
Institute of Public Health - Department of Social Medicine, Medical Faculty,
PJ Safarik University, Kosice, Slovak Republic
3
Nephrology and Dialysis Center Fresenius, Kosice, Slovak Republic
4
Transplantation Department, University Hospital L. Pasteur, Kosice, Slovak
Republic
5
1st Internal Clinic, Faculty of Medicine, PJ Safarik University, Kosice, Slovak
Republic
6
Department of Social Medicine, University Medical Center Groningen,
University of Groningen, The Netherlands
*Contact details: luciaprihodova@gmail.com
Secondary prevention of coronary heart disease:

patients sense of coherence and health-related
behaviour
Barbora Silarova
B Silarova1,2*, I Nagyova1,2, JP van Dijk1,3, J Rosenberger1,4,
M Studencan5, SA Reijneveld3
1
Republic
2
Institute of Public Health - Department of Social Medicine, Medical Faculty,
PJ Safarik University, Kosice, Slovak Republic
3
Department of Social Medicine, University Medical Center Groningen,
4
Slovak Republic
5
East Slovakian Institute for Cardiac and Vascular Diseases, Kosice, Slovak
Republic
*Contact details: barbora.silarova@upjs.sk
Background
Reducing mortality from coronary heart disease (CHD)
remains a public health priority with much of the emphasis
on prevention on determinants of CHD focusing not only on
those who are at high risk of developing such disease in the
future but also on those who have developed symptoms of
CHD. The aim of this study was to explore whether the sense
of coherence (SOC) is associated with health endangering
behaviour among patients with established CHD after
controlling for socio-demographic and medical variables.
Methods
The sample consisted of 243 consecutive patients with
established CHD (mean age 56.5 7, 21% female) from the
East Slovakian Institute for Cardiac and Vascular Diseases.
Medical and demographic data were obtained from medical
records. Self-report data about patients health behaviours
(smoking, exercise, diet and alcohol consumption)
were gathered via a structured interview. SOC was measured
with the 13-item Orientation to Life Questionnaire.
Issue
Chronic diseases are becoming a growing burden to the health
care systems all over the world and also in Europe. One of the
most prominent is Diabetes Mellitus. Health care planning and
prevention can only be performed on reliable information at
both the National and European level.
Description
Measuring performance in diabetes care requires standard
procedures and accurate information. The foundations were
laid in 1989 during the St. Vincent initiative. Standard
indicators were defined for the first time in this occasion.
The progress made in the last 20 years allow gathering national
data through country representatives and automatically
producing quality and outcomes indicators from existing
databases.
Results
During the past 10 years, the European Commission (DGSANCO) supported four projects to create a system for
diabetes reporting. Standard EU indicators were defined by
EUDIP (EUropean Diabetes Indicators Project). The EUCID
project (European Core Indicators in Diabetes) included 19
country representatives to collect national indicators for
international comparisons. This form of collection proved to
be laborious and time consuming. BIRO (Best Indicators
through Regional Outcomes) delivered a solution to automate
the process. The sequel EUBIROD (European Best Indicators
through Regional Outcomes Diabetes) will collect regional
data from 20 European countries, to produce a European
report for the first time ever. Almost all EUCID participants
joined the EUBIROD project, including the IDF.
Lessons
Reliable data can be collected using the BIRO system, a
standard approach that aims to safely connect medical records
in the EUBIROD Consortium from the local to the European
level.
Background
Although a number of studies exist exploring the social
participation of patients after kidney transplantation (KT),
only a few explore its association with medical and
psychological factors in a longitudinal study. We focused on
the role that side-effects of immunosuppressive treatment,
well-being and mastery 3 months after KT play in social
participation at 1 year after KT.
Methods
A total of 76 patients (53.9% male; average age 47.5 13 years)
in the third month (T1) and 1 year (T2) after KT provided
their socio-demographic (age) and medical data (Glomerular
function measured by the Cockcroft-Gault equation) and
completed the Social participation questionnaire (a = 0.84),
the End-Stage Renal Diseases Symptom ChecklistTransplantation Module (ESRD-SCL-TM) (a = 0.840.91),
the General Health Questionnaire (GHQ-28) (a = 0.670.94)
and the Pearlin Mastery Scale (a = 0.68). Linear regression was
used to identify the predictors of social participation at T2, and
age, glomerular function, ESRD-SCL-TM subscales, GHQ-28
subscales, mastery and social participation at T1 were set as
independent variables.
Results
The model consisting of low social participation ( = 0.79;
P 0.001), severe depression (GHQ-28) ( = 0.33; P 0.05)
and low mastery ( = 0.41; P 0.001) at T1 predicted lower
social participation at T2 and explained 75.6% of the variance.
Conclusions
Social participation 1 year after KT is predicted by lower
social participation, more depression and lower mastery in the
third month after KT. Earlier social participation and
psychological factors seem to play a more important role in
future social participation than kidney function and side
effects. This needs to be considered in programmes focused on
increasing the social participation of patients after kidney
transplantation.
The relationship between patients SOC and health behaviour

was examined using regression analyses.
Results
Patients with a higher level of SOC were more likely to be exsmokers compared with smokers [odds ratio (OR) 1.09; 95%
confidence interval (CI) 1.021.16; P < 0.05]. For exercising, a
higher level of SOC was associated with higher exercise scores
(OR 1.03; 95% CI 1.011.06; P < 0.05). SOC was not associated
with diet behaviour and alcohol consumption.
Conclusions
A higher level of SOC appears to be associated with being an
ex-smoker and with more exercise behaviour. The behaviours
under examination here, such as smoking, exercise, diet and
alcohol consumption, are determined by many factors which
need to be taken into account when designing a successful
intervention. The present study shows that CHD patients with
a low SOC need more attention regarding the improvement of
their health-related behaviour in order to reduce their risk of
recurrences.
Clare Jinks
C Jinks*, BN Ong
Arthritis Research UK National Primary Care Centre, Keele University, Keele,
UK
*Contact details: c.jinks@cphc.keele.ac.uk
Background
Osteoarthritis is common and a major cause of pain and
disability in older adults. Many epidemiological studies
examining risk factors exist, as do opportunities for prevention. Despite this, little has been done on primary prevention.
This study aimed to explore perceptions of prevention of
knee pain across UK agencies. We aimed to investigate
participants understanding of prevention, barriers to prevention and identify if and how prevention is embedded within
practice.
Methods
Twenty-five semi-structured interviews were undertaken with
agencies playing a role in prevention (e.g. health/social-care
professionals, community groups/charities, district council).
Participants first gave views on knee pain prevention. We then
employed an innovative approach using Dahlgren and
Whiteheads rainbow of health determinants to prompt
discussion. Interviews were digitally recorded and transcribed.
Thematic analysis was undertaken.
Results
Preliminary findings highlight a dominant theme of uncertainty. Participants were unsure about whether prevention was
possible and what form it should take. However, as interviews
progressed, most participants identified strategies for primary
and secondary prevention (joint protection, exercise, diet,
education and information). Different approaches to weight
loss advice existed, although the need for consistent messages
was outlined. Participants recognized the importance of
multidisciplinary working, the role of social and community
networks, living and working conditions and schools. Barriers
to prevention included lack of follow-up, limited time with
individuals, financial constraints, costs and poor access to
facilities. Responsibility for prevention was seen to rest with
individuals despite a seemingly incompatible view that older
adults do not prioritise joint conditions thus limiting
motivation and uptake of prevention.
Conclusions
Developing prevention strategies for joint pain in older people
needs to combine understanding of specific social determinants with a co-ordinated multi-agency approach to supporting people. This approach should be integrated with existing
public health campaigns and requires further action by policy
makers, researchers, clinicians and patients.
A casecontrol study on systemic hypertension and

risk of obstructive sleep apnoea syndrome conducted
in Yerevan, Armenia
Ruzan Udumyan
R Udumyan1,2*, V Petrosyan1, G Piligian3, P Zelveian4
College of Health Sciences, American University of Armenia, Yerevan,
Armenia
2
Department of Public Health and Primary Care, University of Cambridge,
Cambridge, UK
3
Mount Sinai School of Medicine, NY, USA
4
Institute of Cardiology, Yerevan, Armenia
*Contact details: ruzudumyan@gmail.com
1
Background
Several studies suggest that obstructive sleep apnoea syndrome
(OSAS) increases the risk of developing hypertension (HTN)
and can be as serious risk factor as diabetes. OSAS has been
recognized in the Western world as a public health burden, but
there have been no OSAS-related epidemiological studies
conducted in Armenia.
Methods
The study utilized a case-control design to examine the
association between systemic HTN (outcome measure) and
risk of OSAS in adult people living in Yerevan, the capital of
Armenia, considering all known confounders suggested by the
literature. The control variables of interest were: age, gender,
body mass index, neck circumference, waist circumference,
waist-to-height ratio, smoking status, weekly alcohol consumption, coffee consumption, weekly physical activity, and
presence of diabetes and/or renal diseases.
The study population (108 cases and 157 unmatched controls)
came from the sample population (170 hypertensives and 578
normotensives) of a population-based Hypertension Extended
Study in Armenia conducted in 2004 by the Armenian Medical
Association in Yerevan.
Blood pressure was measured in a standardized fashion using
conventional mercury sphygmomanometer and following
guidelines adopted by the European Society of Hypertension.
Risk of OSAS was evaluated by the Berlin Questionnaire.
Results
In a logistic regression model adjusted for age, neck
circumference and co-morbidities (diabetes and/or renal
disease), the odds of HTN in people with high risk of OSAS
was 2.17 times greater (95% CI = 1.024.63) than odds of HTN
in people with low risk of OSAS.
Conclusions
This case-control study found an independent positive
association between high risk of OSAS and systemic HTN.
The study identified fat deposition in the neck as an influential
determinant of HTN and OSAS risk. Other independent risk
factors for HTN included older age, development of diabetes
and/or renal disease.
The study recommended to increase population awareness of
OSAS risk factors, symptoms and consequences, as well as to
consider the OSAS when developing national clinical guidelines, particularly in those related to the management of HTN.
Self-rated health as an outcome predictor in patients
with chronic cardiopulmonary disease
Jerneja Farkas-Lainscak
J Farkas-Lainscak1*, L Zaletel-Kragelj1, M Kosnik2, M Lainscak3,4
1
Chair of Public Health, Faculty of Medicine, University of Ljubljana,
Ljubljana, Slovenia
2
University Clinic of Respiratory and Allergic Diseases Golnik, Golnik,
Slovenia
3
Division of Cardiology, University Clinic of Respiratory and Allergic Diseases
Golnik, Golnik, Slovenia
4
Division of Applied Cachexia Research, Department of Cardiology, Campus
Virchow Hospital, Charite, Berlin, Germany
*Contact details: jerneja.farkas@mf.uni-lj.si
Background
Self-rated health (SRH) predicts outcome in general population but such information remains limited for patients with
chronic cardiopulmonary disease. As the global population
ages, the burden of chronic heart failure (CHF) and chronic
How would you go about that? I dont know. A

qualitative study on perceptions of prevention of
knee pain and disability
171
172
Time trends in monitoring of screening activities in

primary health care between 1998 and 2008 in
Lithuania
Vilma Kriaucioniene
V Kriaucioniene*, J Petkeviciene, J Klumbiene
Institute for Biomedical Research, Kaunas University of Medicine, Kaunas,

Lithuania
*Contact details: vilmabor@yahoo.co.uk
Background
General practice-based screening is a valuable and costeffective way of reducing cardiovascular and cancer mortality.
The aim of the study was to evaluate the screening activities in
primary health care services in 19982008.
Methods
From 1998 six health behaviour surveys was carried out in
Lithuania. For every survey the national random sample of
3000 Lithuanians aged 2064 was taken out of the National
Population Register. The data was collected trough postal
survey using standardized questionnaire. The response rates
varied from 59.2 to 74.4%.
Results
Since 1998, the proportion of persons seeing doctor at least
once a year increased from 68 to 82%. In 1998, blood
pressure (BP) during the last year was measured in 72% of
respondents, in 2008in 74%. Over 10 years the proportion
of persons having cholesterol measurement during the last
year increased from 18 to 37%. Older, better educated
respondents reported having the measurements more often
than younger and less educated did. Glucose and cholesterol
were measured more frequently in men with university
education compared with those with incomplete secondary
education [odds ratio (OR) = 1.84, confidence interval
(CI) = 1.083.12 and OR = 1.73, CI = 1.032.93 respectively).
Since 2004 cervical cancer screening programme has been
initiated in Lithuania. In 2008 more than a half (57%) of
Lithuanian women indicated that cervical smear test had been
taken within 3 years. No consistent trend was observed in the
cervical smear test during the study period. In 2008 one-third
of women indicated that they had mammography. Women
living in rural areas were less likely to be screened performing
mammography than living in cities (OR = 0.35, CI = 0.19
0.65).
Conclusions
Although, over the past decade the participation of population
in screening programmes has increased, health professionals
should be encouraged to strengthen their activities in disease
prevention.
Environment, health and safety

The impact of polycyclic aromatic hydrocarbons on
pregnancy outcome
Wojciech Hanke
W Hanke*, K Polanska, W Sobala, S Brzeznicki
Nofer Institute of Occupational Medicine, Lodz, Poland
*Contact details: wojt@imp.lodz.pl
Background
There is widespread concern over the impact of Polycyclic
Aromatic Hydrocarbon (PAHs) on pregnancy outcome.
Polycyclic aromatic hydrocarbons are a group of two or
more fused aromatic rings compounds that are formed as a
result of incomplete combustion of organic matter. Sources of
environmental contamination can be both industrial and
nonindustrial, with the most common sources being cigarette
smoke, coal-fired utilities, vehicle exhaust, wood-burning
ovens and smoked food. 1-hydroxypyrene (1-HP) is
considered as appropriate surrogate markers of total PAHs
exposure. The aim of the study was to examine the impact
of PAHs on foetal growth including birth weight, length,
head and chest circumference, ponderal and cephalization
indexes.
Methods
The prospective cohort study was performed in eight
regions of Poland. The study population consisted of 449
motherchild pairs. The women were interviewed three times

during pregnancy and once after delivery. From all women
included into the study the urine sample was collected two
times. Concentration of 1-HP in urine of women was analysed
using high performance liquid chromatography. Smoking
status darning pregnancy was assessed based on cotinine
level in saliva analysed by liquid chromatography with tandem
mass spectrometry (LC-MSMS).
Results
The mean 1-HP concentration in the urine of participating in
the study women was 0.37 ug/g creatinine with the range 0.03
10.2 g g1 creatinine. The exposure to PAHs significantly
decreased child birth weight ( = 158.3; P = 0.01) and chest
circumference ( = 0.7; P = 0.002) and increased cephalization index ( = 4.2; P = 0.001) after adjustment for child
gender, gestational age, pregnant women marital status,
educational level, season of LMP, pre-pregnancy BMI, and
weight gain in pregnancy. When the cotinine level in saliva was
included in the analysis all the results were not statistically
significant (P > 0.05).
Conclusions
The findings suggest that transplacental exposure to PAHs
from multiple environmental sources may negatively influence
foetal development.
obstructive pulmonary disease (COPD) will increase. We

aimed to investigate the distribution of SRH and to assess SRH
as an outcome predictor in patients with CHF and COPD.
Methods
In two prospective cohort studies, SRH was assessed with
question How would you rate your health in general? and
patients were followed for 2448 months thereafter. Student ttest, MannWhitney test, hi-square test, KaplanMeier curves
and Cox proportional hazard models were used for data analysis.
Results
The most frequent SRH in patients with CHF (N = 100,
71 11 years, 54% men) was average (N = 31). During followup of 1.005 507 days, 58 patients with CHF died. In Cox
proportional hazard model, adjusted for patient characteristics
and biomarkers, worse SRH predicted higher mortality [hazard
ratio (HR) 1.49, 95% confidence interval (CI) 1.151.90]. The
most frequent SRH in patients with COPD (N = 127, 64 8
years, 79% men) was fair (N = 76). During follow-up of
790 149 days, 10 patients with COPD died, 39 were
hospitalized, and 78 had acute exacerbations. KaplanMeier
curves demonstrated more acute exacerbations (P = 0.003) and
hospitalizations (P = 0.008). In Cox proportional hazard model,
adjusted for patient characteristics and performance, SRH
predicted acute exacerbations (HR 1.80, 95% CI 1.033.11) and
hospitalizations (HR 1.93, 95% CI 1.123.68) but not death.
Conclusions
SRH predicted acute exacerbations and hospitalizations in
COPD and mortality in patients with CHF. This suggests that
SRH, a simple, quick, and financially available instrument,
could be suitable for identification of patients at increased risk
for complications of chronic disease and for planning of
tailored preventive measures. Integration of simple public
health indicator into every day clinical practice should
therefore be encouraged.
Health risk perception of environmental factors in an

urban population in Northwest Russia
Tatiana Unguryanu
TN Unguryanu1,2, SM Novikov3, AM Grjibovski2,4,5*
1
Administration of the Federal Service for Surveillance on Consumer Rights
Protection and Human Wellbeing in the Arkhangelsk region, Arkhangelsk,
Russia
2
Arkhangelsk, Russia
3
A.N. Sysin Research Institute of Human Ecology and Environmental
Hygiene Moscow, Russia
4
5
The role of air pollution on human health in

Dresden 200305
Anja Zscheppang
A Zscheppang1*, S Richter2, W Kirch1
Research Association Public Health Saxony and Saxony-Anhalt, Institute of
Clinical Pharmacology, Technische Universitat Dresden, Germany
2
Professorship of Geoinformation Systems, Technische Universitat Dresden,
Germany
*Contact details: anja.zscheppang@tu-dresden.de
Background
Pollution is a major concern in Europe. Cities are differently
exposed to air pollution such as ozone and PM10. Air
pollution may lead to an increase in cardiovascular and
respiratory morbidity and mortality as underlined in national,
European and international research. A project titled ,,Health
Risk from Environmental Pollution Levels in Urban System
(HEREPLUS) aims at analysing the association between air
pollution and human health in four European cities (Rome,
Madrid, Athens, and Dresden).
Methods
Environmental and epidemiological data are needed to assess
the effect of air pollution on population and environmental
health in urban settings. Air pollution, meteorological, traffic
data, green area distribution as well as hospital admission data
are collected for the time period 200305. Prevalence rates and
relative risks are analysed to estimate population health risk
caused by high ozone and PM10 concentration as well as high
temperature.
Results
Dresden is one of the biggest and most polluted cities in the
federal state Saxony, Germany. Ozone and PM10 concentration are measured half-hourly on three measurement stations
located near main streets. The target value for ozone to protect
human health (120 mg/m3 maximum daily 8-h average not to
be exceeded on >25 days per year) was exceeded on 74 days in
Dresden Mitte in 2003. Ozone concentration was especially
high during summer 2003 compared with 2004 and 2005. 888
per 100 000 inhabitants were admitted to hospitals (Diagnose
ICD-X ischemic heart disease) in Saxony in 2003. The
average stay in hospitals was 7 days.
Conclusions
Until now there is really a lack of knowledge regarding the
influence of air pollution on population health in Dresden and
Saxony. Data about the importance of air pollution and
environmental conditions were not analysed before the
project. The estimated relative health risk may be used to
establish strategies for environmental and population health
protection.
Environmental Radon-222, lung cancer and chronic

bronchitis in West Georgia
David Tsereteli
D Tsereteli1*, G Melikadze2, K Gvinianidze1, W Field3, D Steck4,
A Amiranashvili5, T Chelidze5, N Tsereteli1, M Todadze2
1
National Centre for Disease Control and Public Health, Tbilisi, Georgia
2
Institute of Geophysics, Tbilisi, Georgia
3
Department of Occupational and Environmental Health, College of Public
Health, University of Iowa, Iowa City, Iowa, USA
4
Physics Department, St. Johns University, Minneapolis, Minnesota, USA
5
Institute of Geophysics, Tbilisi, Georgia
*Contact details: rabdato@yahoo.com
This study was the first investigation of radon-222 (radon)

exposure and health in Georgia as well as one of the first
studies in a former Soviet Union country.
To reveal possible association between environmental radon
and both lung cancer and chronic bronchitis in West Georgia,
we performed an ecological epidemiological study. Data for
new cases of lung cancer and prevalence of chronic bronchitis
were collected through the primary health care net, National
Cancer centre and National centre for Disease Control and
Public Health. When undertaking the survey of radon,
particular attention was paid to the multiple active zones of
faults and areas of elevated geo-chemical background of
radioactive elements in the rocks. The concentration of radon
was measured in several types of water sources (boreholes,
wells and springs) as well as in the soil aeration zone. We
performed radon mapping based on application of geochemical methods. Correlations between radon concentrations in
soil, water and adverse health outcomes (lung cancer, chronic
bronchitis) were analysed using geographic information
system technology.
In districts where the radon concentration was high in soil
(more than 25 KBq m3) and water (>20 Bq l1), we observed a
higher incidence of lung cancer (43 cases per 100 000
population) as compared with the other districts (36 cases
per 100,000 population). The prevalence of chronic bronchitis
was similar (9.6% for high radon area and 9.8% for lower
radon area) for both the low and high radon area.
Our research is in agreement with known associations between
radon exposure and lung cancer and lack of an established
association between radon exposure and chronic bronchitis.
Background
Risk perception of environmental factors is an important
public health issue. Health risk assessment is valuable when its
results are adequately communicated to public health and
environment professionals and are clear for mass media and
general population. The evidence on risk perception in Russia
is scarce. The aim of the study was to assess health risk
perception by gender, age, education, occupation and income
in an urban setting in Northwest Russia.
Methods
A cross-sectional study was performed in a town of
Novodvinsk (Northwest Russia) in 2008. Altogether, 695
randomly selected adults were asked to rank from highest to
lowest the perceived level of risk associated with radiological,
chemical, microbiological pollution, genetic, physical, climatic,
emergency, lifestyle factors and quality of life. Factors with
ranks 13 were considered having high level of risk. Data were
analysed using chi-squared test.
Results
Radiological [92.2%; 95% confidence interval (CI) 89.794.6],
chemical (91.6%; 95% CI: 88.994.3) and microbiological
(74.6%; 95% CI: 70.678.6) pollution of environment were
rated by majority of the respondents as associated with the
highest risk. Respondents aged 30 years or younger tended to
overestimate the hazard of chemical pollution of environment
compared with the respondents aged 45 years (91.1 versus
81.3%, P = 0.025). More responders with high education
(19.9%) and office workers (18.2%) related highest risks to
lifestyle than those with persons secondary education (10.7%,
P = 0.010) and workers (9.7%, P < 0.001). More responders
with low income attributed high risk to life quality compared
with those with high income (15.8 versus 4.1%, P < 0.001). No
difference in high risk perception was observed between men
and women.
Conclusions
Health risk perception of environment factors varies by age,
education, occupation and income. Reasons behind the
observed associations will be discussed. Risk communication
should be planned carefully and take into account demographic
and socio-economical characteristics of the population.
173
174
Exposure to pesticides among families working in

agriculture and their children
Wojciech Hanke
W Hanke*, J Jurewicz, W Sobala, D Ligocka
*Contact details: wojt@imp.lodz.pl
Temporal trends in benzo(a)pyrene pollution in Urban

territories of Upper Silesia Agglomeration 1980-2004
Justyna Kazmierczak
A Mozdzierz1, M Juszko-Piekut1, J Stojko1, Z Kolosza2,
J Kazmierczak1*
1
Medical University of Silesia, School of Pharmacy, Department of Hygiene,
Bioanalysis and Environmental Studies, Katowice, Poland
2
Maria Sklodowska-Curie Memorial Cancer centre and Institute of
Oncology, Gliwice Branch, Poland Department of Cancer Epidemiology
Gliwice, Poland
*Contact details: justynamichner@op.pl
Background
Industrialization and urbanization processes are the main
reason for the natural environment degradation. For many
years, Upper Silesia has been one of Polish regions emitting the
highest amount of gases and particulate matters.
Objectives
The aim of the study was to assess the level of benzo(a)pyrene
pollution in atmospheric air on the territory of Zabrze,
Myslowice, Gliwice and Chorzow, as well as to analyse the
variability of temporal trends in pollution in the period from
1980 until 2004.
Long-term exposure to traffic-related air pollution

and type 2 diabetes prevalence in a semi-rural area of
The Netherlands (19982000)
Sanne Mallant
SF Mallant1,2*, MBA Dijkema1,3, K Hurk van den2, M Alssema2,
U Gehring3, RT Strien van1, PH Fischer4, G Nijpels2, CDA Stehouwer5,
G Hoek6, JM Dekker2,6, B Brunekreef3,7
1
Department of Environmental Health, Municipal Health Service,
Amsterdam, The Netherlands
2
EMGO Institute for Health and Care Research, VU University Medical
centre, Amsterdam, The Netherlands
3
Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The
Netherlands
4
Centre for Environmental Health Research, National Institute for Public
Health and the Environment, Bilthoven, The Netherlands
5
Department of Internal Medicine and Cardiovascular Research Institute,
Maastricht University Medical Centre, Maastricht, The Netherlands
6
Department of Epidemiology and Biostatistics, VU University Medical
centre, Amsterdam, The Netherlands
7
Julius centre for Health Sciences and Primary Care, University Medical
centre Utrecht, Utrecht, The Netherlands all affiliations, The Netherlands
*Contact details: smallant@ggd.amsterdam.nl
Background
Air pollution may promote type 2 diabetes by increasing
adipose inflammation and insulin resistance. This study
examined the relation between long-term exposure to trafficrelated air pollution and prevalence of type 2 diabetes among
50- to 75-year-old subjects living in a semi-rural region of The
Netherlands.
Methods
Participants were recruited in a Diabetes Screening Study
conducted between 1998 and 2000. Exposure to traffic-related
air pollution was characterized at the six-position postcode
centroid of participants home-addresses. Indicators of exposure were modelled NO2 concentration, traffic intensity at the
nearest main road, distance to the nearest main road and total
traffic in a 250-m circular buffer. Crude and age-, gender- and
income adjusted associations were examined by logistic
regression analysis.
Results
Full data were available for 8031 participants, 620 subjects
(7.7%) had type 2 diabetes. Crude and adjusted analyses for
distance to the nearest main road in quartiles (Q14) suggest
an association with type 2 diabetes prevalence [adjusted
OR (95%CI): 1620221 m (reference); 221142 m: 1.32
Background
Pesticides have a significant public health benefit but on the
other hand, public concern has been raised about the potential
health effects of the exposure to pesticides. The objective of the
study was to assess the exposure to pesticides of member of
families working in agriculture.
Methods
Exposure assessments were conducted in Lodz district among
families working in agriculture. A total of 71 families were
recruited to participate in the study. The exposure assessment
methods were used to estimate mothers, fathers and their
children exposure to two pesticides: MCPA (52 families) and
2,4-D (19 families). To assess the exposure to pesticides
mother, father and their child had to collect the urine (in the
morning in spraying day, in the evening, on the next day). The
sample from homes window was also taken after spraying
session. Patches were used by the person who performed
spraying during the whole process of pesticide spraying.
Measurements of pesticide concentrations in biological
material and patches were performed with liquid chromatography and mass spectrometry.
Results
The results have confirmed that farmers, and also their wives
and children are exposed to pesticides during and after
spraying. The growing of pesticide concentration from
morning to next day was statistically significant in mothers
(P = 0.002) and fathers (P < 0.001). The concentration of
pesticides found on home window confirmed the existence
of environmental exposure. There was statistically significant
association between concentration of pesticides found on
home window and pesticide concentration in mothers
(P = 0.014) and childrens (P = 0.03) urine. No differences
was found between the levels of pesticides in fathers urine and
use of protective equipment, differences of active ingredients
used and amount of pesticides used. No differences was found
between the levels of pesticides in mothers urine and
differences of active ingredients used, amount of pesticides
used and the distance from the field.
Conclusion
The data provide an evidence of existing exposure of children
and their families to pesticides. Measures to minimize
exposure to pesticides of applicators and members of their
families should be more effectively applied.
Methods
Basing on base data of the provincial environmental monitoring unit annual mean benzo(a)pyrene concentrations were
calculated for the cities of Upper Silesia. Temporal trends in
BaP air pollution were assessed using joinpoint regression
model.
Results
Acceptable annual mean benzo(a)pyrene concentration was
exceeded significantly on the territories of all studied
administrative units. The highest benzo(a)pyrene levels were
observed in Chorzow (1984320.3 ng/m3) and Zabrze
(1980297.0 ng/m3). Also in other cities, especially in the
period of 198089 benzo(a)pyrene levels were very high (from
66.0 to 320.3 ng/m3). The lowest BaP level in the entire studied
period was observed in Gliwice (20048.4 ng/m3).
In Zabrze 11% decline (198091) followed by as much as 24%
annual increase of BaP concentrations (199194) were
observed. From 1984 on the territory of Myslowice three
successive declines were observed: 198495 decline of 6%;
199598 decline of 34% and in the period 19982004 decline
of 9%.
Conclusions
When assessing temporal trends in BaP air pollution using
jointpoint regression model, beneficial decline trends were
observed on the territories of all cities studied.
The trend persisted until the end of the studied period, the
annual mean concentration of BaP still exceeded the Polish
and European norm of 1 ng/m3.
(1.021.70); 14279 m: 1.23 (0.951.60); 791 m: 1.08 (0.82

1.41)]. Similar results were observed for total traffic in a 250 m
buffer. Type 2 diabetes was not associated with modelled NO2
levels or traffic intensity at the nearest main road.
Conclusions
This study suggests an association between indicators of
exposure to traffic-related air pollution and prevalence of type
2 diabetes, in absence of a clear exposure-response relation.
The impact of environmental and behavioural factors
on elevated blood pressure of Moscow children
Sergey Zhivin
IN Ilchenko1, SV Zhivin1*, MB Kotova1, IE Seregina2, SM Lyapunov3
1
Department of Public Health and Preventive Medicine, I.M. Sechenov
Moscow Medical Academy, Moscow, Russia
2
Chemical Faculty, Moscow State University, Moscow, Russia
3
Analytical laboratory, Geological Institute RAS, Moscow, Russia
*Contact details: vilnius1985@gmail.com
Contribution to risk assessment of chlorinated

polycyclic aromatic hydrocarbons associated with
drinking water chlorination: formation, occurrence
and genotoxic effects
Ana Sofia Cardoso
M1 Rebola3, MJ Silva1, H Louro1, AM Antunes2, SS Jose3, ZI Silva3,
AS Cardoso3*
1
Genetics Department, National Health Institute Dr. Ricardo Jorge (INSA),
Lisbon, Portugal
2
Centre for Structural Chemistry, Instituto Superior Tecnico, Technical
University of Lisbon, Lisbon, Portugal
3
Environmental Health Department, INSA, Lisbon, Portugal
*Contact details: ana.s.cardoso@insa.min-saude.pt
Chlorinated polycyclic aromatic hydrocarbons (Cl-PAHs) have

been detected in river sediments as urban and industrial
contaminants and in tap water as chlorination by-products.
The carcinogenic and mutagenic properties of PAHs are well
known and the few available studies revealed that Cl-PAHs
possess greater mutagenicity than the parents PAHs.
Considering that drinking water quality is of essential public
health concern, the identification of Cl-PAHs formed as
chlorination by-products, the characterization of human
exposure and the investigation of their potential hazard
seems to be highly relevant.
The objectives of this work were to synthesize and characterize
the major chlorinated derivatives of benzo[a]pyrene (BaP) and
fluoranthene (Fluo), to develop analytical methodologies for its
quantification in water samples and to evaluate the genotoxic
and potentially carcinogenic effects of 6-Cl-BaP. The genotoxic
effects of Fluo chlorinated derivatives are now under study.
Using a newly developed synthetic method, 6-Cl-BaP was
obtained as the major chlorination product of BaP, and 3-ClFluo and 1,3-Cl2-Fluo were obtained from Fluo. The
formation of these derivatives in water samples subjected to
water treatment plants (WTPs) chlorination conditions was
additionally demonstrated. The genotoxic effect of 6-Cl-BaP
was characterized in comparison to that of BaP, using the
alkaline comet assay in a human liver-derived cell line. It was
observed that equimolar non-cytotoxic doses of 6-Cl-BaP were
able to induce a significantly higher level of DNA damage than
BaP, suggestive of a more potent genotoxic effect.
Overall, our experimental data revealed that chlorinated
derivatives of PAHs can be formed during water disinfection
procedures by chlorination in WTPs. In addition, preliminary
data showed that the major chlorinated derivative of BaP, 6Cl-BaP, was a potent genotoxic compound, which may predict
a high carcinogenic potential. Considering the lifetime human
exposure to water contaminants, these findings are of major
public heath importance and should be further developed for
the purpose of risk assessment.
Health impact indicators on climate change in

Slovakiaa pilot study on data availability
Zuzana Klochanova
Z Klochanova*
Department of Public Health, School of Health Care and Social Work,
Trnava University, Trnava, Slovakia
*Contact details: zklochan@gmail.com
Background
Science evaluated the climate changes as real. But their
potential impacts are ranked as controversial. System able to
monitor appropriate indicators and to forecast potential health
threats is necessary. There is challenge to improve communication between different sectors. And public health organizations have high potential for this role. The aim of this article is
to evaluate data availability for potential indicators of the
health impact of climate change in Slovakia.
Methods
They were conducted two studies focused on identification of
heatwaves impact on human health in Slovak city Trnava. First
study evaluated diagnosis-based mortality during heatwaves in
period 200608 monitored by Unit of urgent medicine. While
second study designed on previous assessment evaluated
number of diagnosis-based health emergencies in 2009
monitored by Emergency centre.
Results
The results presented availability of all appropriate data from
division of meteorology as well as urgent medicine, but also
limitations in availability of appropriate data monitored by
division of health emergency. Analysis showed increase in
mortality on cardiovascular diseases in relation to increase of
Background
In few studies on adults was demonstrated that the level of
nickel, lead, cerium in biosamples were significantly higher in
hypertensive patients. Passive smoking is an important source
of exposure to toxic elements also. But the mechanisms behind
this relations are not well understood in children. Thus, it has
been suggested that environmental exposures and behavioural
factors increase the risk of high blood pressure (BP) in
children.
Methods
In a cross sectional study, conducted in central okrug of
Moscow in 2008, was examined a random stratified sample of
211 7- to 9-year-old children drawn from three schools located
from 0.5 to 2 km from heavy road traffic (response rate was
60%). Information on behavioural and social factors was
collected via parental questionnaire. Information on childrens
health was collected by standard examination. Childrens BP
was measured in accordance with national recommendations
for children, 2003. Exposure assessment was based on the levels
of scalp hair nickel, cerium and lead, blood lead using method
of inductively coupled plasma mass spectrometry (ICP-MS).
Multiple logistic regression analysis was done with the
adjustment for confounders.
Results
Age-adjusted level of BP was strongly and significantly
correlated for the tertile rank of hair nickel distribution.
Levels of systolic and diastolic BP in children were also
significantly correlated with the smoking behaviour of parents
in the family. Odds ratio (OR) for elevated systolic BP due to
nickel was 2.6 [95% confidence interval (CI) = 1.25.8,
P < 0.021]; due to smoking of parents at home-1.7
(95%CI = 0.83.6, P < 0.179). Diastolic BP has shown stronger
associations with the levels of hair nickel (OR 6.9;
95%CI = 2.618.4, P < 0.001), smoking in the family (OR 2.1;
95%CI = 0.94.7, P < 0.07). There was a tendency towards
higher risks due to levels of hair cerium, good living conditions
and higher level of mothers education.
Conclusions
The impact of investigated environmental biomarkers on
childrens BP is different. The hair nickel impact is the most
meaningful, higher for diastolic BP, might be mediated by
behavioural family risks. The level of hair nickel is an adequate
indicator in the assessment of low degree air pollution and
combined effects of passive smoking.
175
176
air temperature, but also lack of the rest of health data. Using
of different definitions of heatwaves caused recognition only of
two summer heatwaves in 2009.
Conclusions
A well designed and analysed set of indicators of the health
impact of climate change is crucial. But assessed studies warn
that using of diagnosis-based mortality and number of health
emergencies as indicator in Slovakia needs in the first step exact
definition of heatwaves. Next, it is necessary the monitoring of
detailed health data from emergency centre in daily frequency.
Community orientation and promotion of children
falls at home among Arab minority In Israel
Subhi Badarni
S Badarni*
Sakhnin College for Teacher Education
*Contact details: sobhe5@bezeqint.net
The effect of Lithuanias year of sobriety (2008) on

losses due to alcohol-related injuries
Skirmante Starkuviene
S Starkuviene*, J Petrauskiene, R Kalediene
Department of Health Management, Kaunas University of Medicine,
Kaunas, Lithuania
*Contact details: smante@centras.lt
Best practices on road safety: what can european

countries learn from each-other?
Angelique Grosser
A Grosser*, G Burazeri, K Michelsen, P Schroder-Back
Maastricht University, Faculty of Health, Medicine and Life Sciences,
Department of International Health, Maastricht, The Netherlands
*Contact details: angelique_grosser@hotmail.de
Background
Road traffic crashes leading to death and injury are a serious
public health problem which can and should be prevented.
At a European level, this issue has gained attention in the
field of public health only recently. The aim of this desk review
was twofold: (i) to assess the change in mortality and
morbidity related to road traffic accidents in the European
region and; (ii) to identify European countries which have
implemented effective preventive programs in order to
disseminate such best practices thorough the European
region.
Methods
All countries of the European Union were included in this
analysis. Mortality and morbidity indicators for selected years
were retrieved from the WHO-HFA database, OECD, CARE
and UNECE. Furthermore, a literature search was conducted
in order to identify the European countries which have
implemented effective preventive programs related to road
safety measures.
Results
Overall, there is a decrease in mortality rates (44% from year
1991 to year 2007) and injury rates (11.2% from year 1991 to
year 2007) related to road traffic accidents in the European
Region. However, this decrease is unevenly distributed with a
Home falls are the main cause of morbidity and mortality

among 114-year-old children. One of every four is hospitalized for an injury sustained at home. A survey in Nahariya
Hospital showed a hospitalization ratio of 1.7:1 of Arab to
Jewish children. A total of 72% hospitalizations were due to
falls and head injuries.
Objectives
1. To increase awareness regarding domestic hazards for
injuries.
2. To minimize home injuries among children.
3. To increase the implementation of safety measures at home.
Methodology
A questionnaire was constructed for the purpose of the study.
The questionnaire had filled in sample that was selected
randomly. The safety condition at homes was measured before
and after the intervention program.
Target Population are: parents, school and kindergarten
children.
The interventional activities of the programme were the
following:
Instruction and training for mothers of children under the
age of 13 years.
Training of schoolteachers in injury prevention.
Training of local authority staff and recruiting them to
become agents of change.
Working with the local authorities Planning and
Construction Committees to enforce building regulation
promoting safety.
Utilizing the local and national media to develop a video,
lesson plans and training slides on the subject of safety and
injury prevention.
Results and conclusions:
1. Injury prevention had become an integral part of nurses
and schoolteachers work.
2. The safety deficiencies were reduced from 35 to 23%.
3. Percentage of children mortality due to the home injuries
had decreased by 35% at the end of the intervention in
health promotion program.
4. Injuries due to falls remained high. Our hypothesis is that
this may be related to increased awareness levels among
professional health and medical staff as well as in the
community level, which led to increase reporting and
registration of childhood injuries
5. Local authorities have developed safety instruction for their
Planning and Construction Committees and enjoined to
Healthy Cities Network in the country.
The period of 200708 was the time for legislative work on

alcohol control policies in Lithuania and 2008 was designated
as The year of sobriety. Objective of the studyto evaluate
the changes in years of potential life lost due to alcohol-related
injuries in Lithuania for the Year of sobriety (2008) in
comparison to the years 2006 and 2007.
Methods
Data on mortality of the able-bodied population (1564 years
old) for the years 2006, 2007 and 2008 was obtained
from the Lithuanian Department of Statistics. Agestandardized rates of alcohol-related years of potential life
lost (YPLL) per 100 000 population due to injuries (ICD-10
codes V01-Y98) were calculated. The alcohol-attributable
fraction was based on results of the Lithuanian forensic
autopsies.
Results
Age-standardized YPLL/100 000 population due to alcoholrelated injuries in 2008 was 2284.9 (3999.9 for males, 646.1 for
females). One descendent lost in average 20.5 years of life due
to alcohol-related injuries (one male in average 21.0, one
female18.1) in 2008. Significant decline of 17.5% in YPLL/
100 000 was estimated throughout 200608. The leading cause
of YPLL among all alcohol-related injuries for males were
suicides and reached 1133.8/100 000 population in 2008.
However, since 2006 till 2008 it increased by 17.7%. The
second leading cause of YPLL for males and the first
leading cause for females were alcohol-related traffic accidents
(for males550.3 and for females 111.1/100 000 population
in 2008). YPLL/100 000 population due to alcohol-related
traffic accidents significantly declined during the period of
200608: for males by 33.4% and for females by 43.8%.
General decline was observed in YPLL due to other major
types of injuries both for males and females during the study
period.
Conclusions
The positive changes in YPLL due to alcohol-related injuries
indicate successful implementation of evidence-based alcohol
control measures, which are likely to result in significant
improvements in health of Lithuanian population.
significant decrease in (e.g. Belgium and The Netherlands) and

no change or even slight increase in some countries (e.g.
Bulgaria and Slovenia). Effective preventive programs were
mostly implemented in western and northern European
Countries such as The Netherlands, Belgium, the UK and
Denmark. Eastern European countries lag behind the implementation of such good practices.
Conclusion
In general, there is an improvement of mortality and
morbidity indicators related to road traffic accidents in the
European region. Nonetheless, there is a high burden of
road traffic crashes and a lack of implemented good practices
for the eastern European regions. Therefore, the existing
best practices pertinent to the western countries should
be transferred and implemented in eastern European
countries.
Integration of Injury Statistics at the European
Level
Mathilde Sengoelge
Injuries are the leading cause of death and disability in young

ages in the EU. The implementation of a prevention-oriented
injury surveillance in Europe is a major demand towards
Member States in the European Union Council
Recommendation on the prevention of injury and the
Resolution on prevention of injuries in the WHO European
Region. Yet no comprehensive injury surveillance exists for
coordination of injury prevention at EU level. Valid and
reliable indicators are needed for non-fatal injury circumstances, including resulting disabilities. A major drawback in
the use of current injury hospital data from hospital discharge
registers (HDR) for injury surveillance is the poor quality of
these data in the area of external causes of injuries (e.g.
mechanism of accident). Detailed data on external causes are
currently recorded within the European Injury Database
(IDB). The IDB represents a sample of hospitals in 12
Member States currently, covering all external causes for all
types of accidents and injuries.
The aim is to integrate these two existing data sourcesthe
IDB and HDR in order to combine external cause data with
ICD10 diagnostic information and provide projections of
population-based injury incidence. Also included is an
operationalized set of validated indicators for disabilities
from injuries based on the HDR medical information.
A demonstration project titled INTEGRIS is being implemented with 20 participating hospitals in 6 EU Member
States. A flexible interface was developed for receiving the
injury data from various types of hospital for online
transmission to a central INTEGRIS server on a quarterly
basis.
By 2011 an implementation plan will exist for a cost-efficient
injury surveillance system for all EU Member States that is
compatible with the European Statistical System and provides
timely access to European-wide injury data.
Building policy to prevent interpersonal violence in
Scotland and Brazil, 200010
Alison Gehring
A Gehring*, P Donnelly, A Butchart
The Bute Medical School, University of St Andrews, Scotland, UK
Violence and Injury Prevention and Disability, World Health Organization,
Geneva, Switzerland
*Contact details: am2449@st-andrews.ac.uk
Background
Violence is a leading cause of death and disability globally. The
prevalence of violent behaviour is a public and political
concern in a growing number of countries. The prevention of
interpersonal violence is supported by a strengthening
evidence base of effective interventions. The limited study of

violence prevention policy focuses on content and programme
evaluation; neglecting actors, context and processes of policy
development. However an understanding of the factors that
shape policy is necessary if we are to understand how to reform
policy.
Method
An international comparative case study employing qualitative
approaches, including in-depth interview, document review
and direct observation, this study examines the processes by
which the interpersonal violence prevention policy developed
in Scotland, UK and Diadema, Brazil, with the focus on nonstate policy networks. The study serves to test the policy
network theoretical model as well as providing important
lessons about decision-making, the policy cycle and complex
policy environment.
Results
Preliminary research findings indicate that multisectoral
collaboration enables the development of direct violence
prevention policy as well as supporting the integration of
preventative measures in indirect policies across sectors. A
significant contribution of non-state actors, including health
professional networks, in the policy process is also suggested
from initial analysis.
Conclusions
The analytical generation of an understanding of the policy
environment and an explanation of the factors directing policy
can provide replicable lessons to inform action to strengthen
future development of violence prevention policy. It proposes
that the public health professional network could be a catalyst
in changing policy and should be supported in championing
the prevention of violence.
Cost of adverse events for hospitalized patients

Jose Luis Navarro Espigares
JL Navarro Espigares1*, MA Fernandez Sierra2, MM Rodrguez del
Aguila2, E Hernandez Torres1, MA Padial Ortiz1
1
Management Control Department, University Hospital Virgen de las
Nieves, Granada, Spain
2
Preventive Medicine Department, University Hospital Virgen de las Nieves,
Granada, Spain
*Contact details: jnavarro@ugr.es
Introduction
According to the European Commission, between 8 and 12%
of patients admitted to hospitals suffer from an adverse event
(AE) while receiving health care. This equals more than 6.5
million patients a year in the EU.
Objectives
The objective of this work is to measure the economic impact
of adverse events in hospital care.
Methods
We considered the additional stays in hospital generated as a
consequence of adverse events as the unique cost driver to
evaluate the economic impact of these adverse events. The
measurement was carried out in the University Hospital
Virgen de las Nieves (Granada, Spain) during the year 2006. A
total of 365 hospitalized patients were evaluated in four clinical
departments (general surgery, internal medicine, oncology and
intensive care unit). The average cost of a hospital stay was
taken from the analytical accounting of the hospital.
Results
One or more AEs were observed in 59 patients (16.2%) with an
average age of 64.2 years. The number of AEs was 77. Within
this group of 59 patients, 50.8% were men and 49.2% women.
AEs caused 246 additional hospital stays, 23 in intensive care
unit. The total cost of additional stays generated by AEs was
E150 482. If we extend these results to the hospital as a whole,
the budgetary impact of AEs rises to E660 841, i.e. 0.27% of
2006 hospital budget.
Conclusions
While adverse events in hospital care have a great impact on
the health and safety of patients, they also have relevant
R Bauer, G Furian, M Sengoelge*

Austrian Road Safety Board/KfV
*Contact details: mathilde.sengoelge@kfv.at
177
178
economic consequences. Even in the case of Spain, which is

not one of the worse countries in terms of AEs predicted by
population, the economic repercussion of AEs is not a trivial
issue. The opportunity cost of resources dedicated to the
unnecessary care involved could be considered a margin for
efficiency improvement.
Trends in hospital admissions due to bicycle-related

injuries, 200508
Josep M Suelves
JM Suelves*, C Cabezas, A Plase`ncia
Direccio General de Salut Publica, Barcelona, Spain
*Contact details: josepmaria.suelves@gencat.cat
x-6 and x-3 in farmed fish: a gap of aquaculture

practice
Caterina Ledda
G Oliveri Conti, C Ledda, M Fiore, M Zuccarello, JA Maieli Diaz,
R Fallico, S Sciacca, M Ferrante*
Department GF Ingrassia, Sector of Hygiene and Public Health, Catania
University, Italy
*Contact details: marfer@unict.it
Effect of frying, grilling and steaming on amino-acid

composition of marine fishes
Nuray Erkan
O
zkan1, S Arif 2, O
Birhan1
E Nuray1*, O
Istanbul University, Faculty of Fisheries, Department of the Seafood
Processing and Quality Control. Laleli/ Istanbul, Turkey
2 _
TUBITAK Marmara Research Center, Food Institute, Gebze/Kocaeli, Turkey
*Contact details: nurerkan@istanbul.edu.tr
Background
Anchovy, Atlantic Bonito, small and medium bluefish, striped
red mullet, and hake species are commercially the most
important fish species in Turkey and the world. It is generally
consumed fresh. The aim of this study was to determine the
effects of different methods of cooking (frying, grilling and
steaming) on the amino acid and proximate compositions of
these fish species.
Methods
After the cooking process, for all methods, the bones and skins
of fish were removed. All fish in each lot were homogenized
using a kitchen blender and analysed to determine amino acid
and proximate compositions.
Results
The changes in amino acid and proximate content were found
to be significant for all cooking methods in all fish species.
Cooking did, in general, significantly increase the contents of
essential, semiessential, and other amino acids when compared with raw fish species. Moisture, fat, ash and carbohydrate contents of raw fish were ranged between 48.01 and
83.05, 0.87 and 30.48, 1.10 and 1.61, and 0.09 and 8.70%,
respectively. All fresh fish investigated were high in protein,
11.2017.14 g per 100 g. Wide variations in protein content,
18.1125.65 g per 100 g, between species and methods of
cooking was observed.
Conclusions
Fried fish had intermediate fat values, while grilled and
steamed fishes had a comparatively low value. Grilled Atlantic
Bonito, anchovy, bluefish and fried mullet and hake appeared
to be a more valuable fish dish for obtaining the officially
recommended appropriate daily intake of essential amino acids
for humans.
Background
Bicycle use is being promoted for environmental and
public health reasons. In 2008, a survey revealed that
17.59% of Spaniards aged 1279 years rode a bicycle at
least once a week, as percentage higher than that observed in
2006
Riding a bicycle is not a risk-free activity, as unintentional
injuries due to falls and road crashes involving pedestrians and
motor vehicles have been widely described, but there is a very
limited number of studies examining injuries among bicycle
users in Spain. The use of bike-helmets has been reported to
reduce bicycle-related head injuries in a 6388%. Some data,
however, suggest that enforcing the use of helmets could
discourage bicycle riding.
The main objectives of this study were to describe hospitalizations due to bicycle-related injuries in Catalonia,
Spain, and to examine trends in cases reported in a 4-year
period.
Methods
Among hospital discharges reported in Catalonia from 2005 to
2008, all cases with an ICD-9 external cause corresponding to
bicycle-related crashes were selected.
ICD-9 diagnostic codes were grouped according to the Barell
matrix. Injury Severity Scores (ISS) were estimated using
ICDMAP-90.
Results
A total of 1891 hospital admissions were reported in the
4 years studied. No consistent trends were observed in the
annual number of cases reported from 2005 to 2008.
Significant monthly variations were found, with the highest
proportion of admissions from July to September (36.6%,
P < 0.001).
Hospital admissions were much more frequent among males,
which accounted for 86.1% of all cases. A total of 30.0% cases
were children aged 14.
Patients dying after hospital admission (19 cases, 1.0%) were
older than survivors (27.3 versus19.3 years, P = 0.001). Deaths
were significantly more frequent among cases reported as
traffic crashes (4.2% versus0.6%, P < 0.001). Traumatic brain
injury was the main diagnosis of 89.5% of cases dead after
admission, contrasting with 26.4% among survivors
(P < 0.001)
Conclusions
Despite the reported increase in bicycle usage reported in
Spain, no parallel trends in hospital-admissions due to bicyclerelated injuries were observed.
Traumatic brain injury, a frequent diagnosis among cases
studied, is a preventable life threatening condition.
Background
Currently industrialized countries diets are very rich in fatty
acids !-6 and poor in !-3 with a relationship of 20:1.
Farmed fish is consumed in population of such countries more
and more, its quality strongly depends on the environmental
conditions in which alive and on healthy and nutritional state
of the feed.
Amount of !-3 in farmed fish is very lower than wild fish,
because it also feeds phytoplankton rich in !-3.
The aim of our study is to appraise how much level of fatty
acid !-6 and !-3 in feed can influence the quality of farmed
fish.
Methods
A total of 30 sea bass, 30 sea bream and 30 samples of feed used
during various stages of fish growth were sampled from a farm
located in eastern Sicily.
The fatty acids !-6 and !-3 was detected by soxhlet extraction,
methanolic potash esterification and GC-FID determination.
Results
Feed showed 78% of !6, 19% of !3 and 3% of !9.
Content of !-6, !-3 and !-9 respectively of 60, 24 and 16%
has been highlighted in fish with a level of !-3 less than what
usually is found in wild fish.
Its important to note that in farmed fish stands out the
content of fatty acids !-9 (Oleic and nervonic acid) of plant
origin (olive and flax oil).
Conclusions
Farmed fish is nutritionally safer but it is of lower quality and
it is proved that feed composition impact on fish quality.
Therefore, aquaculture practice shows at present a gap in
production food quality.
179
Gender and health

Awareness and concern to prevention and its health
as objectivesubjective health indicators for female
population 4564 years megapolice Western Siberia
(Novosibirsk city)
Igor Gagulin
I Gagulin, D Panov, V Gafarov*, E Gromova, A Gafarova
Siberian Branch of Russian Academy of Medical Sciences, Novosibirsk,
Russia
*Contact details: valery.gafarov@gmail.com
Oral contraceptives containing drospirenone and

venous thromboembolism
Iris Broman
I Broman1, M Leppee2*, J Culig2, M Maric-Bajs2, M Eric3
1
School of Medicine, Osijek Croatia
2
Department of Pharmacoepidemiology, Andrija Stampar Institute of Public
Health, Zagreb, Croatia
3
Department of Anatomy, School of Medicine, Novi Sad, Serbia
*Contact details: marcel.leppee@stampar.hr
Background
The use of oral contraceptives (OCs) increases the risk of
thromboembolism. This risk increases among older women. In
an effort to reduce this risk, newer combinations with lower
oestrogen dose and new progestin components were introduced. The most commonly side effects associated with OCs
use are nausea, vomiting and migraine.
Methods
The study was conducted in the City of Zagreb during the
200508 period, by using various data sources, i.e. data on
drug utilization from the City Pharmacy Zagreb, data on side
effects from the Agency for Drugs and Medicinal Products and
data on the causes of mortality.
Results
In Zagreb, the utilization of OCs increased from 174 841
packages issued in 2005 to 205 056 packages in 2008. There
were reported 24 side effects and complications associated with
drospirenone/ethinylestradiol (DRSP/EE); eight complications
Sexual and reproductive health of women in

Bulgaria: need for an integrated approach
Lora Georgieva
L Georgieva*, S Popova
Faculty of Public Health, Medical University of Varna, Varna, Bulgaria
*Contact details: lorahg@abv.bg
Background
Bulgarian population decrease due to an excess of deaths over
births. Although the number of abortions per 1000 live births
has decreased from 1490.9 (1992) to 470.9 (2008), this
indicator remains higher than in Europe. Protection of
reproductive health is an important part of efforts to cope
with negative demographic trends in the country.
Methods
Results from a study on sexual and reproductive health of
women in northeastern Bulgaria are presented. Sexual
behaviour was investigated among 700 women aged 1549,
who have had at least one sexual intercourse and were not
under treatment of sterility. Professional view on the topic was
studied among 123 specialists in obstetrics and gynaecology
(OG) in outpatient care. Information was obtained by semistructured questionnaires.
Results
Average age of first sexual intercourse of the studied women is
16 years (minimal 12, maximal 23). They consider the
protection from unwanted pregnancy as a more important
issue related to sex, than sexually transmitted diseases. Among
women without permanent partner (181): 48.1% usually use
condom during sex, 18.8% apply emergency oral contraception after intercourse, 33.1% have unprotected sex. Among
women with permanent partner (519): 51.1% practice
interrupted intercourse, 19.7% have intrauterine device,
17.1% use continuous oral contraception, 4.8% use condom,
7.3% have unprotected sex. Those with at least one abortion
present 23.9%. The main reported reason for the first abortion
is too early age. According to the specialists in OG, the large
number of abortions in the country is due to: womens
negligence to their own health (69.9%), low awareness of
contraception (17.1%), sex with accidental partners (13.0%).
Their suggestions for reproductive health improvement are:
more information in school (74.8%), more sexual health
promotion activities of public health institutions (20.3%),
inclusion of prophylactic check-ups in the package of
specialized OG outpatient care (4.9%).
Conclusions
There is a need for an integrated approach to protect the sexual
and reproductive health of women in Bulgaria, especially of
Background
To explore awareness and attitudes towards their health in
women aged 4564 years.
Methods
As part of screening programme HAPIEE in 200305 was
examined representative sample of women 4564 years.
Awareness and attitude toward their health were examined
using a questionnaire Knowledge and attitudes toward their
health, adapted to the study population.
Results
A total of 85% women say that they are not entirely healthy or
sick. Over 90% of women believe that not enough care of their
health and could care more. Almost 100% of women noted the
likelihood of contracting a serious disease for 510 years.
About 60% woman say that the success or failure of prevention
or treatment will depend on how the disease. The proportion
of regularly checking their health is very small and does not
exceed 6%. At the time of severe heart attack called for medical
help to about 70 and 12% did not return to the doctor, even
with severe pain. Only 20% of women rely on the doctor
opinion about the state of health, while 36% would not agree
with the opinion of the doctor after a general inspection and
expressed willingness to further examination. Overall satisfaction with medical care is present in 60% of respondents. A
positive attitude to preventive health checks is close to 100% in
both age groups.
Conclusions
Observed negative trends: in social and behavioural characteristics of the female population aged 4564 years old.
The study was funded by grants from the Wellcome Trust
(WT081081AIA).
of venous thromboembolism (VTE), four complications of

pulmonary embolism and one of basilar artery thrombosis
during the 200508 period. Side effects and complications
constantly increased from one in 2005 to 15 in 2008.
Conclusions
Considering the utilization of OCs in Zagreb, the number of
DRSP/EE packages issued during the 200508 period increased
4.4-fold. During the period of observation, the number of
packages of other hormonal contraceptives declined. We have
established a causal relationship between the increasing sales of
OCs containing drospirenone and pill-related thrombotic
complications. Considering prescribing methodology, the
logbook of private prescriptions kept at pharmacies should
be analysed. The physicians prescribing DRSP/EE and other
OCs should be directly warned of the possible risks and
benefits of these drugs of ever growing utilization. In addition,
promotional material issued by the companies distributing
OCs in Croatia should be surveyed to ensure they are
consistent with their registration certificates.
180
younger ones, that have to include the common activities of

school, public health and medical services.
Cardiovascular diseasesEuropean data and
information on womens health
Kerstin Thummler
K Thuemmler*, G Neumann, A Britton, W Kirch
Research Association Public Health Saxony and Saxony-Anhalt, Faculty of
Medicine, Technische Universitat Dresden, Dresden, Germany
*Contact details: kerstin.thuemmler@tu-dresden.de
What do we have in common, what makes us

unique? Reflections from a forum of observatories
focused on gender health inequities. Cantabria,
Spain. 200809
Angeles Cabria
A Cabria1*, A Lopez2
Public Health Observatory of Cantabria, Spain
2
National Gender and Reproductive Health Observatory, Uruguay
*Contact details: acabria.ospc@fmdv.org
Issue/problem
As increasing needs for relevant information on gender health
inequities come forward to support new health policy in Latin
America and the Iberian Peninsula, a range of observatories are
emerging from public health administrations, civil society and
academia. Beyond notable socio-political and economic
differences between countries, there are common interests,
strategies and lessons to be learned from the observatories
experiences.
Description of the problem
A consultation with 18 public health observatories from Latin
America, Spain and Portugal, resulted in a forum to: share best
practices, lessons learned, strategies, methodologies and tools;
reflect upon the impact of observatories on health policies, and
the strengthening of civil society; evaluate their contribution to
Implications of high smoking prevalence in pre and

postnatal women in Serbia on health policy
Snezana Simic
S Simic*, S Krstev, J Marinkovic, D Matijevic, A Kotevic
Public Health Association of Serbia, Belgrade, Republic of Serbia
*Contact details: snezanas@eunet.rs
Issue/problem
Public Health Association of Serbia (PHAS) with financial and
logistic support of Canadian Public Health Association
(CPHA) realized study on smoking prevalence in pre- and
post-natal women in Serbia in 200809. Motivation for such
study was a high level of smoking among women in Serbia
which was 29.9% according to the results of the National
health survey from 2006.
A third of all pregnant women smoke before pregnancy
(35.7%). However, with of the course of pregnancy percentage
of women who smoke decrease and in the third trimester of
pregnancy on average one-quarter of them smokes (26.2%).
More than a third of women (37%) ever smoked at some point
during the course of pregnancy, whether regularly (23.4%) or
occasionally (13.8%). At 3 and 6 months after delivery 32 and
31% respectively, smoke. Almost 6 of 10 women are exposed to
environmental tobacco smoke at their homes.
Results (effects/changes)
Based on results of this study training and education of the
whole families was included in already established PHAS and
city Public Health Institute in Belgrade programmes such as
Hello baby (open telephone line for advises of new parents by
patronage nurses) and parenting schools project organized
with UNICEF at primary health centres. Cooperation was
established with other project providing psychological preparation for delivery on SMS spell out advising. Dissemination
of study results was extensive by published facts sheet and
meetings with media.
Lessons
The results of the study indicate a great need for specific
programme of smoking prevention for pregnant women
developed with cooperation of governmental and nongovernmental sector. Health system is still resistant to such
initiatives due to high smoking prevalence between health
professionals and absence of total ban smoking in health-care
institutions. PHAS can help in mobilization of public health
professionals.
Problem
There are more men than women in Europe, with the
proportion of women increasing in older age categories.
Cardiovascular diseases (CVD) are a main cause of mortality,
disability and morbidity among European women in later stage
of life. CVD includes coronary heart disease (CHD) and
cerebrovascular disease (stroke).
Methods
The patterns of mortality, morbidity and health risk factors of
CVD among women aged 15 years in the EU member states
(EU-27) were examined including influence of demographic
trends and socio-economic factors.
The main sources were the Statistical Office of the European
Communities, the WHO and PubMed databases.
Results
CVD is major causes of death among women in the EU-27.
Overall, of 100 000 women of all ages in the in 2005, 213.7 died
of CVD. The single most common cause of death is CHD.
Over one in seven women and over one in six men die from
the disease. The mortality rate from CHD among women was
greater in Central and Eastern Europe.
Stroke is the second most common cause of death, over one in
eight women and 1 in 10 men die from this disease. Because
death rate increases with age, stroke mortality is highest among
elderly women. Among women <65 years of age, the highest
death rates were observed in Eastern European countries.
However there is a lack on availability of reliable and topical
data for EU-27 and the availability of data in a sex-specific
format.
Lessons
Womens health issues need to be considered in the
standardization efforts, particularly in areas where gendered
data are inconsistent or unavailable such as CVD data.
Adequate resources shall be made available to close existing
information gaps in the field of changing health risk factors
across different stages of womens life cycle.
the public debate nationally and internationally; and promote

collaborations between observatories.
Forum participants represented a diverse sample of observatories whose identifying characteristics can be grouped into
two basic profiles: those arising from civil society (LatinAmerica), whose main strength is their autonomy from the
State on decision-making issues, their weakness being their
sustainability and funding; and those created from public
administrations and academia (Portugal-Spain) which contribute with relevant information for policy-makers, but may
become excessively institutionalized and subject to political
instability.
Lessons
The consultation and forum opened new arenas of reflection
and debate regarding the observatories role, as political actors,
on the elimination of health inequities. Their legitimacy
depends on the coherence between their values and mission,
and the methods, rigour and impact of their work. However,
their sustainability is going to depend, in addition to
institutional and economic support, on the strength of their
alliances, and their capacity to interact with a wide range of
actors, all of whom are fundamental to their work. Therefore,
partnerships between observatories with common values and
interests, across sectors and borders, could represent an
important strategy for their continuity and growth.
Gender and diversity analysis of self-management

interventions for chronic diseases
Sue Mills
S Mills*
BC Centre of Excellence for Womens Health, Vancouver, Canada
*Contact details: smills@cw.bc.ca
Reasons for and acceptance of abortion in

South-West Romania
Cornelia Rada
C Rada1*, M Dragomir2, I Prejbeanu2, G Geana1, C Zugravu3
1
Romanian Academy, Institute of Anthropology, Bucharest
2
University of Medicine and Pharmacy of Craiova
3
University of Medicine and Pharmacy of Bucharest, Romania
*Contact details: corneliarada@yahoo.com
Background
Human reproductive behaviour has been a constant concern
for medical specialists and sociologists. Understanding
womens reasons for having abortions can inform public
debate and policy regarding abortion and unwanted pregnancy. In Romania demographic changes after 1989 highlight
the need for a reassessment of why people decide to have
abortions or having fewer children.
Methods
A study regarding the sexual and reproductive health of the
population has been running in Dolj County (south-western
Romania). We applied a questionnaire with 119 items on 600
people from rural areas, equally distributed by gender, age
groups and instruction level. This analysis refers to the items
regarding the acceptance of and reasons for abortion. The
research is financially supported by CNCSIS UEFISCSU,

project PN II IDEI cod 72/2008.
Results
We found statistically significant differences between the age
groups (P < 0.05) regarding the social and economic factors
that lead to the decision to end a pregnancy; the gender and
the instruction level do not discriminate the subjects in this
issue. The data show people who have the number of children
they desired do not accept any other children in their life and
consider it is better to have an abortion. More than 80% of the
respondents accept the abortion when mothers life/health is in
danger or the foetus is malformed; 50% agree to the abortion
when the woman is unmarried or the family does not desire/
afford a child. There were significant differences (P < 0.001)
among the subjects depending on the age groups (old people
being more permissive) and on the educational level (high
educated subjects accept abortion more frequently if the socioeconomic status of the woman/family is precarious).
Conclusions
The desire to postpone a birth or to stop childbearing is a very
common reason given by people when their family experiences
abortion. But the reasons leading to the end of a pregnancy are
often far more complex than simply not intending to have a
child; they are influenced by a diversity of factors: age,
education, income, cultural, biological and physiological
factors.
Assessing population perception on gender equity in

Romania; pilot study
Florentina Furtunescu
F Furtunescu*, D Janta, A Cucu, DG Minca, R Botez
Public Health Department, University of Medicine and Pharmacy Carol
Davila, Bucharest, Romania
*Contact details: furtunescu_florentina@yahoo.com
Issue
In Romania equity between genders was a political priority
from many years. However, there are still areas in which
probability of success is lower for women than for men.
A transversal survey was done among 302 subjects, in order to
evaluate their perception related to rights, norms and cultural
values specific by gender. Data collection took place in 2009 on
a non-probabilistic sample.
Results
A total of 59% from the respondents were females. The
respondents worked in private or public companies. The
educational level was quite high and almost all were orthodox.
Significantly different perceptions related to social equity was
shown by gender (51% of males in favour, compared with only
27% of females, P = 0.003). Males financial status was
perceived as higher than in females by both genders. The
women presence in leadership position was perceived as
weaker compared with males by the majority of respondents.
Males engaged at political level are representing partially the
females interests and rights following the opinion of 67% of
females and 40% of males. Most of women and half of men
believe that women are more often victims of sexual
harassment. Males and females think in the same proportion
that a young female needs to make compromises to be
employed at the beginning of her career. Most majority of the
responders still believe there are specific workplaces designates
to males or to females. Health services succeed to respond to
gender specific medical needs according half of the responders.
Lessons
This study showed different perceptions and expectations
related to women social and economical opportunities.
These results are meant to raise awareness of the political
level about still conservative perceptions related to gender
differences in Romania. Further policies have to be developed
to insure equal opportunities for both genders in various fields
of activity.
Background
It is increasingly understood that the process of self-managing
chronic disease is differentially shaped by socio-cultural
understandings on how women and men with diverse ethnicity
and economic circumstances should live with disease in
society. Extensive research has documented differences in
peoples approaches to managing chronic diseases related to
gender and diversity. Few studies have explicitly analysed
existing self-management (SM) interventions to see how they
have considered these differences. Understanding the relevance
of SM interventions for diverse groups of people is essential for
determining the potential impacts of these initiatives and the
degree to which they can make meaningful contributions to
the health of the chronic disease populations and address
health inequities
Methods
A sex, gender and diversity analysis (SGBA) was conducted on
two SM programmes (the Stanford Chronic Disease SelfManagement programme and a COPD program) to determine
how SM interventions consider and account for sex, gender
and diversity in the ways people manage their chronic diseases.
SGBA attends to the ways in which determinants such as
ethnicity, socio-economic status, disability, sexual orientation,
migration status, age and geography interact with sex and
gender.
Results
Findings illuminate language and context neutral interventions that obscure differences in the ways people manage
chronic diseases and dominant discourses around capacity,
responsibility, empowerment and control, and health outcomes (better health and quality of life and reduced resource
utilization) that fail to recognize differences in men and
womens life circumstances and capacities due to gendered
roles, ethnicity and socio-economic status.
Conclusions
The results suggest that these interventions do not adequately
consider and account for the experiences of women and men
managing illness in diverse circumstances and may inadequately serve the needs of people with gendered and diverse
disease experiences and life contexts. If broadly implemented
in their current form, CDSM interventions may have limited
potential to reduce health inequities.
181
182
Outdoor recreational physical activity and

parenthood in a gender perspectivea study from
south eastern part of Sweden
Katarina Sjogren
K Sjogren1*, , E Ekvall Hansson2, L Stjernberg3
1
Blekinge Institute of Technology, School of Health Science, Karlskrona
Sweden and Faculty of Medicine, Department of Clinical Sciences in
Malmo, General Practise, Lund University Sweden
2
Faculty of Medicine, Department of Clinical Sciences in Malmo, General
Practise, Lund University Sweden
3
Blekinge Institute of Technology, School of Health Science, Karlskrona
Sweden
*Contact details: katarina.sjogren@bth.se
Evaluation risk of abortion in a rural population in

Romania
Iuliana Manuela Dragomir
IM Dragomir1*, C Rada2, F Badulescu3, I Prejbeanu4, M Mihai4
1
University of Medicine and Pharmacy, Public Health Department, Craiova,
Romania
2
3
University of Medicine and Pharmacy, Oncology Department, Craiova,
Romania
4
University of Medicine and Pharmacy, Environmental Health Department,
Craiova, Romania
*Contact details: manueladragomir@yahoo.com
Background
Abortion is still a public health concern in Romania. Low
utilization of health services and low social status in southwestern Romania are reflected in the reproductive health status
of the population.
Methods
Our research, financially supported by CNCSIS UEFISCSU,
project PN II IDEI cod 72/2008, had in target the
reproductive health of the population in south-western
Romania. We applied a questionnaire with 119 items on 600
subjects living in rural areas, equally distributed by sex, age
groups and instruction level. We are presenting the results
Gender equality at work: health experiences of

employees in elder care
Sofia Elwer
S Elwer1,2,3*, , L Alex1,2,3, A Hammarstrom1,2,3
Department of Public Health and Clinical Medicine, Umea University,
Umea, Sweden
2
Department of Nursing, Umea University, Umea, Sweden
3
Department of Public Health and Clinical Medicine, Umea University,
Umea, Sweden
*Contact details: sofia.elwer@fammed.umu.se
1
Background
Gendered practices of working life create gender inequalities
through horizontal and vertical gender segregation in work
which may results in inequities in health between women and
men. Gender equality could therefore be a key element of
health equity in working life and needs to be further analysed.
Aim
Our aim is to analyse views and experiences of gender equality/
inequality at work and its relation to health experiences.
Method
All care giving staff at two workplaces in elder care within a
municipality in the north of Sweden where invited to
participate in the study during paid work time. A total of 46
employees participated. Eight focus group discussions were
performed and led by a moderator. Qualitative content
analysis was used to analyse the discussions.
Preliminary results
We identified two themes concerning experiences of gender
equality and health. The first theme, Gender equality as a
structural ideal, showed how gender equality/inequality was
seen as a structural issue at a distance from the participants
health experiences. The second theme, Justifying inequality
with differences showed how gender equality/inequality in the
work relations and work division affected health in a variety of
ways. Inequalities in work division were primarily understood
in terms of personality and interests and not in terms of
gender.
Conclusions
The health experience of the participants was affected by
gender equality/inequality in terms of a gendered work
division. However, the participants did not see the gendered
work division as a gender equality issue. Gender perspectives
are needed to improve the health of the employees at the
workplaces through shifting from individual to structural
solutions.
Background
The participation in physical activity (PA) can change during
the life time. Parenthood has been found to be a life event that
is associated with decreased PA, especially among women, but
studies in the field are sparse. The aim of this study was to
investigate performance of outdoor recreational PA, and
factors influencing participation among parents and nonparents from a gender perspective.
Methods
This study included 432 individuals, 224 women and 208 men,
from Karlskrona municipality in the south eastern part of
Sweden. Data collection was carried out during the years 2008
09. We measured the self-reported amount of outdoor
recreational PA performed during the last year and analysed
the dependency of the probability of performing this PA on 25
variables covering individual and socio-economic factors.
Results
A total of 76% of the women and 65% of the men had
performed outdoor recreational PA during the 12 months
before one month prior to pregnancy. Men were affected by a
greater number of factors than women. Performing PA indoors
and having dog or horse ownership emerged as the most
important factors associated with the probability of performing outdoor recreational PA.
Conclusions
Those active in PA were active independent of indoor or
outdoor activities, i.e. to be physical active seems to have a
special connection to the personality and lifestyle. Becoming a
parent is a life-changing event that affects participation in PA.
By offering family-oriented PA choices that involve both
parents and children, midwives and health promoters can
courage parents to be active and to support each other. The
promotion of outdoor recreational PA, which also has
restorative effects on well-being, needs to focus on activities
which are attractive and affordable for the majority of both
women and men.
referring to the evaluation of the health risks of abortion and

the post-abortion symptoms.
Results
People 1824 are more implicated emotionally, they think is
high risk for health abortion 61.9% and people over the age of
35 did not experience to much guilt, only 34.2% from people
35 to 49 admit there is a high risk when abortion is happen
(P < 0.001). There were no gender differences between women
and men regarding reasons who cause abortion. There were
significant differences concerning age educational levels,
people with higher levels reporting better acceptance for
keeping pregnancy. Educational differences in abortion risk
and contraceptive counselling were observed among higher
educated people. Regarding advice to use contraceptive
methods to prevent abortion 80% younger accept to
use contraceptives and only 38.8% of people aged 3549,
P < 0.001.
Conclusions
Abortion is a sensitive and contentious issue with moral,
cultural, educational and age dimensions. Limited access and
low utilizations of health services in Romania, especially by
people over the age of 35, show differences between
adults sexually active before and after 1990 (the year when
abortion was legally accepted); also indicate the necessity to
improve the sexual-reproductive education and the access to
health.
Domestic violence and some related sociodemographic factors among married women in a
district of Ankara-Turkey
Bahar Guciz Dogan
B Guciz Dogan*, M Yardim, MI Gulmez, E Gumeler, G Guner,
ZK Gurkan
Department of Public Health, Hacettepe Univ., Faculty of Medicine
*Contact details: bdogan@hacettepe.edu.tr
Doing masculinity, not doing health. A qualitative

study among Dutch male employees about male
ideologies, health beliefs and company exercise
Petra Verdonk
P Verdonk, H Seesing, A De Rijk
Maastricht University, FHML, School Caphri, Institute for Public Health
Genomics, Maastricht, The Netherlands
*Contact details: petra.verdonk@socmed.unimaas.nl
Background
Being female is a strong predictor of health promoting
behaviours. Workplaces show great promise for lifestyle
interventions, but such interventions hardly take the gendered
background of lifestyle behaviours into account. Moreover, a
male perspective is lacking. This study aims to explore mens
health beliefs and attitudes towards health promotion, in
particular company exercise, in relation to masculine ideals in
male employees.
Methods
Thirteen heterosexual, white Dutch male employees aged 23
56 years in a wide range of professions and sectors who were
offered company exercise were interviewed in the Fall of 2008.
Interviews lasted approximately one to one-and-a-half hour
and addressed the mens health situation, their health beliefs
and lifestyle behaviours, as well as their masculinity ideals.
After theoretical saturation was reached, no further interviews

were held. Interviews are transcribed verbatim and thematic
analysis was used to analyse the data.
Results
We distinguished two categories. The ideal man is a winner:
Masculinity and competitiveness encompasses the mens
perception that the ideal man is competitive and noticed by
other men. Company exercise is associated with a particular
type of masculinityyoung, occupied with looks, and
interested in muscle building. A real man is not a whiner:
Masculinity and health issues entails that not feeling or
disclosing vulnerability is important for real men. Masculinity
norms are related to health beliefs and behaviours. Health
messages about alcohol intake are openly rejected and taking
care of health is feminine, hence, something to avoid.
Company exercise is hardly framed as a health measure and
is not related to the work role.
Conclusions
Competitiveness and nonchalant attitudes towards health play
a role in masculinity ideals. In particular, pursuing masculinity
seems often related to unhealthy behaviours while health
promotion is often related to femininity and hence, resisted.
Company exercise is connected to looks and resisting
competition with men or complying with other masculinity
norms motivates men to withdraw from company exercise. In
order to establish a greater reach among vulnerable employees
such as ageing men, worksite health promotion programmes
including company exercise may benefit from greater insight
in the tensions between health behaviours and masculinity
beliefs.
Protecting the right of women to affordable and
quality health care in Armenia: evaluation of the
obstetric care state certificate programme (OCSCP)
2010
Nune Truzyan
N Truzyan1*, R Grigoryan1, T Avetisyan2, B Crape1, V Petrosyan1
1
American University of Armenia, Yerevan, Armenia
2
Boston University, Boston, USA
*Contact details: nushik2000@yahoo.com
Issue/problem
Armenia has one of the highest-reported rates of out-of-pocket
health expenditures in the region. In 2008, the Armenian
government introduced a new OCSCP designed to curb
informal payments and assure that all women have access to
free, good quality services for delivery.
This study analysed the current maternal and child health
services within the scope of OCSCP through the review of
existing official documents in Armenia, assessed the functionality of the programme through a qualitative stakeholder
analysis, and provided recommendations according to the
study findings for further improvements. The study objectives
include (i) examination of the payment patterns and utilization of maternity-related health services in regard to the
OCSCP implementation, (ii) determination of the impact of
civil society activities in contributing to the effectiveness of the
programme and (iii) comparative analysis between the capital
city Yerevan and two regions of interest.
Overall 59 participants, including mothers, obstetrician
gynaecologists and administrators from regions and Yerevan
city participated in the stakeholder analysis. Programme
positive changes include lessening the frequency and the
amount of informal payments. Among shortcomings the lack
of transparency in computation of health providers salaries
and incomplete monitoring of financial flows in the maternity
hospitals increasing the risk of financial manipulations by
maternity hospital administrations and dissatisfaction of
doctors with their salaries. Expectant-mothers flow from
close to Yerevan regions to Yerevan is threatening the financial
viability of maternity hospitals in these regions.
Background
Any type of violence including domestic violence against
women seems as a big health and social problem in Turkey. It
could be said that there is social tolerance for violence against
women among workers in governmental establishments like
health centres, courts and police stations. Violence could be
related with the patriarchial family structure. Even women are
equal with men due to the civil law, they usually encounter
inequalities in civil and private life. The objectives of this study
were to evaluate the size of domestic violence and some related
socio-demographic factors.
Methods
In this descriptive study, the data was gathered via a structured
and pre-tested questionnaire from the women came to a
district health centre in Ankara (n = 103), the capital of Turkey
in three days in 2008. Index of Spouse Abuse (ISA) was used to
evaluate the type and degree of violence against women. Verbal
consent was obtained from the participants.
Results
The mean age of women was 30.5 7.6, and spouses was
35.3 8.6. About 52.4% of women and 33.0% of spouses were
primary school graduates. Only 6.8% of women and 9.7% of
spouses were university graduates. One-fourth of the subjects
were living in extended families. Only 22.3% of the couples
were relatives; 13.6% of the women were married unwillingly.
Among women, 7.8% exposed to physical, 6.8% exposed other
types of violence. With the increasing level of education, the
percent of violence decreased unsignificantly. Women <30 age
and women had a spouse <35 was exposed violence more. This
is similar for the subjects had passed the most of their life in
rural areas. Spouses who consumed alcohol regularly was
performed violence against their wives statistically more
(21.1%, P = 0.037) than never drinkers (4.8%). Subjects
married unwillingly (14.3%) and married younger than the
age of 19 (10.9%) was exposed violence more.
Conclusions
The level of education should be increased for both men and
women and marriage counselling should be expanded in all
primary and secondary health institutes in Turkey.
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Lessons
Dissatisfaction of maternity hospital providers with their
salaries may return the practice of informal payments.
Conclusions and recommendations address these obstacles
and challenges to further strengthen and enhance the
effectiveness and sustainability of the OCSCP. This unique
programme could serve as a model for reducing informal
payments in maternity care and other sectors in Former Soviet
Union countries.
Medically certified sickness absence with insurance
benefits in women with and without children
Birgitta Floderus
B Floderus1*, M Hagman1, G Aronsson2, S Marklund1, A Wikman1
1
Department of Clinical Neuroscience, Division of Insurance Medicine,
Karolinska Institutet, Stockholm, Sweden
2
Department of Psychology, Stockholm University, Stockholm, Sweden
*Contact details: birgitta.floderus@ki.se
Health promotion
A new perspective in measuring health.
The salutogenic approach
Goran Ejlertsson
G Ejlertsson*, HI Andersson, A Bringsen, P Nilsson
Centre of Public health, School of Health and Society, Kristianstad
University College, Kristianstad, Sweden
*Contact details: goran.ejlertsson@hkr.se
Background
Traditionally there has been a lack of instruments measuring
health in a salutogenic way. Current measures usually have
an ill-health perspective, which influences evaluation of
workplace health promotion activities. A salutogenic questionnaire has previously been developed at Kristianstad
University College. The purpose is to present the instruments ability to discriminate between different groups of
employees.
Methods
The SHIS, Salutogenic Health Indicator Scale, is built from
theoretical complexity but are still short, easy to handle and
have demonstrated good psychometric properties. The questions cover a 4-week period, and range from positive wording
to negative wording, e.g. Felt brisk to Felt tired, exhausted. The
SHIS index (Cronbachs alpha = 0.92) was standardized in
order to range from 0 to 100% (most negative to most positive
indicators of health).
The empirical data emanates from a Swedish web-based
hospital study among 770 health care staff (response rate
66%). In one of the comparisons WEMS, the Work Experience
Measurement Scale, was used. It was divided according to the
quartiles, from those with the worst to those with the best
work experiences. The analyses were done by means of
ANOVA.
Results
In relation to occupation SHIS ranged from 72 (nurses) to
62% (administration). SHIS was 65% in the ages <40, and 72%
>55. In different units SHIS ranged from 73% (surgery units)
to 58% (emergency ward). Finally in relation to work
experiences (WEMS), SHIS ranged from 55% in the lowest
quartile (worst work experiences) to 82% in the highest. All

differences were significant, P < 0.05.
Conclusions
The empirical findings have demonstrated SHIS ability to
discriminate between different groups when analysing their
health situation. This quality indicates the usefulness of the
salutogenic and holistic measure SHIS in different contexts
within the field of health promotion.
Determinants of health policy impact in local

contextsa study of politicians in four municipalities
in Finland
Nina Simonsen-Rehn
N Simonsen-Rehn1,2*, R Laamanen1,2, M Brommels1,3, S Suominen2,4
1
Hjelt-institute, Department of Public Health, University of Helsinki,
Finland
2
Folkhalsan Research Center, Helsinki, Finland
3
Medical Management Center, Karolinska Institutet, Stockholm, Sweden
4
Department of Public Health, University of Turku, Finland
*Contact details: nina.simonsen-rehn@helsinki.fi
Background
Local government has a decisive role in creating a supportive
environment for health promotion. However, we know little
about factors that are important for the output and outcome
in health promotion in municipalities as perceived by local
politicians. The aim of this study was to explore the
associations between perceived health policy impact and its
proposed determinants: health promotion goals, opportunities
given for community participation, and resources.
Furthermore, political engagement and experience were taken
into account.
Methods
A questionnaire survey to municipality politicians in four
Finnish municipalities with different forms of primary health
care provision, in 2004 (N = 195, response rate 52%). Data
were analysed by descriptive statistics and by multivariate
linear regression analysis.
Background
Female employees in European countries have more sickness
absence than men. In Sweden, around two-thirds of all days
with sickness benefits from the social insurance system can be
ascribed to women, and the reasons for the high level of
sickness absence is not fully understood. Most Swedish women
combine parenthood and work and are facing demands that
may contribute to impaired health and wellbeing. In a
population study we compared women with and without
children under different conditions, assuming increased
sickness absence in mothers, due to time- and strain-based

overload.
Methods
All women born in 196079 were followed from 19932003, in
total 1.2 million women. Information on children in the home
for each year of observation was related to medically certified
sickness absence with insurance benefits the year after. The
analyses were based on a modified version of the Cox
proportional hazard regression, and stratified on demographic
and socio-economic characteristics. Data were obtained from
national administrative registers.
Results
Sickness absence was higher in mothers than in women
without children, the relative risks decreased by age, with no
effect after age 35. In lone women an effect appeared in all age
groups, while in cohabiting women only for 2025 years of age.
Mothers had an increased sickness absence in all subgroups of
country of birth, education, income, and sector of employment. The relationship between number of children and
sickness absence was non-linear. In general, the highest risk
was found for mothers of one child. The upward trend of
sickness absence at the end of the 1990s was steeper for
mothers compare to women without children.
Conclusions
Despite the well-developed social security system and child
care services in Sweden, having children in the home predicts
increased sickness absence, particularly in young and lone
women.
Results
The politicians assessment of health promotion activities and
their effectiveness in the municipalities (i.e. health policy
impact) was moderate to fair. According to preliminary results,
three factors in a multivariate model explain nearly half of the
variance of health policy impact: emphasis on promotion of
health of older people, capacity of primary health care, and
capacity of care for older people. In a regression analysis done
separately for first-term and senior politicians some differences
emerge; emphasis on healthy and safe environments seem to
influence the first-term politicians assessment and emphasis
on healthy lifestyles the senior politicians assessment.
Conclusions
More attention on health promotion, also outside the health
care sector, still seems to be warranted on the local level in
Finland. However, the perceived significance of health services
in health promotion would be important to take into account
when deciding on different service arrangements. There did
not seem to be consensus on the local health promotion
policies among the politicians; the differences were mainly
related to time as member in the council.
Jane Schroeder
J Schroeder*, S Lochner, L Goltz, M Kosa, W Kirch
Institute of Clinical Pharmacology, Technische Universitat Dresden, Germany
(all authors)
*Contact details: jane.schroeder@mailbox.tu-dresden.de
Issue/problem
The German patient advice service Unabhangige
Patientenberatung Deutschland (UPD) provides independent
health information, advice and support. The offer includes
personal consultation in 22 advisory centres, free national
phone counselling, online counselling and information services
concerning specific health topics. The drug information service
of the UPD at the Institute of Clinical Pharmacology in
Dresden answers open questions about drugs and drug
therapy.
Socio-demographic characteristics, reasons for enquiry, kind
of drugs taken, and diseases of the patients who used the
service were recorded in a relational database. In the present
evaluation, all enquiries to the drug information service by
telephone, e-mail, letter or fax in 2009 were analysed
descriptively.
In the evaluated period, 1.946 patients contacted the drug
information service. Most enquiries were registered in
February and March. Patients mainly asked their questions
by telephone (87.4%). Women (63.0%) used the service more
frequently than men. The largest percentage of enquiries
originated from the age group 6079 years (56.6%). The
majority of questions concerned adverse drug reactions
(44.3%), drug interactions (27.2%) and drug therapy of a
certain disease (26.6%). Cardiovascular drugs (21.2%), drugs
for the nervous system (21.0%) and drugs acting on the
alimentary system and metabolism (11.5%) were the principal
drug groups causing consultation need.
Lessons
Especially people aged 6079 years feel insufficiently informed
about their drug therapy. The drug information service can
provide patients with detailed information about their
medication, possible side effects and interactions. It can help
to increase the knowledge about drugs in order to improve the
patients adherence to treatments.
Strengthening health promotion in The Netherlands
Mariken Leurs
M Leurs*, M Sturkenboom, K Witte, V Bos, H van Zoest, D van Dale
Centre for Healthy Living, National Institute for Public Health and the
Environment, Bilthoven, The Netherlands
*Contact details: mariken.leurs@rivm.nl
Issue
The Dutch Inspectorate for Health concluded in 2005 that
national health promotion (HP) support in The Netherlands
was fragmented. Additionally, they concluded that the quality
of HP at the local level did not meet required standards.
Description
HP in The Netherlands is largely unregulated: there are no
official quality standards for professionals; municipalities have
to produce a public health policy paper without a required
minimum impact or production level once every 4 years; and
almost every HP-theme has its own national institute
competing for local attention and national funds.
Results
The identified problem resulted in the decision by the Health
Ministry to create a national centre under public governance
focusing on strengthening (local) HP. By late 2008, the RIVM
Centre for Healthy Living was officially opened.
The Centre now promotes the adoption of recognized lifestyle
interventions by presenting those interventions in a clear and
concise manner on the website www.loketgezondleven.nl. The
Centre supports the recognition of interventions through an
assessment process focusing on quality, effectiveness and
cohesion.
Together with national and regional HP organizations the
Centre produces manuals for healthy schools (April 2010) and
healthy municipalities (November 2010). The process of
implementing the manuals includes facilitating collaboration
between professionals active in HP, education, primary care,
exercise promotion, and so on. This fits in with the
development of the Centres professional empowerment
programme.
Lessons
Starting a Centre partners have not asked for is challenging.
Moreover, financial pressures in the public sector have created
a need to promote efficient systems, knowledge sharing and
integrated data-bases and websites. These factors mean a
constructive and positive approach in working together with
partner organizations in the area of data collection, interpretation, dissemination and collaboration is vital to achieving
success.
Organizing and sharing desired overviews and manuals;
hosting regional meetings and a central website; and clearly
acknowledging the contribution of partners have been
important in achieving wider recognition of the role and
added value of the Centre for Healthy Living.
How to develop a culturally sensitive prevention
using the PEN-3 model: a case-analysis promoting
HIV/AIDS testing among Surinam and Antillean
communities in The Netherlands
Leonie van Egeraat
LCM Van Egeraat1*, MGBC Bertens1, AH Westmaas2
1
Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
2
GGD Rotterdam-Rijnmond, Department Infectious Disease Control,
Rotterdam, The Netherlands
*Contact details: lcm.van.egeraat@gmail.com
Introduction
It is important to take the cultural sensitivity of a program into
account, when developing evidence-based health promotion
interventions. Health promotion programs usually only target
behaviours and their underlying determinants that have a
negative impact on health. However, focusing on positive
cultural values, beliefs and behaviours can contribute to a high
level of cultural sensitivity. The PEN-3 model aims to achieve
cultural sensitivity in health promotion programs, joining
positive and negative cultural influences on health behaviour.
This study is a case study of the application, utilization and
interpretation of the PEN-3 model in the development of a
HIV/AIDS testing program for ethnic minority population in
Rotterdam, The Netherlands, by the Municipal Health Services
Rotterdam-Rijnmond.
Drug information needs of patients in Germany
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Integration of public health topics into continuous

education of school teachers: a way of promoting
health at schools
Elena Lunina
EY Lunina*, IS Petrukhin, AA Rodionov
Tver State Medical Academy, Tver, Russia
*Contact details: leyu@mail.ru
Background
Promoting the health of children through schools is an
important global goal. The recognition of education delivery,
together with health services and supportive environments, as
the means of health promotion at schools, makes a school
teacher to play a central role in this process.
Nevertheless school teachers in Russia often have poor
knowledge and skills in the field of evidence-based health
promotion and prevention. Therefore they seem to be unable
to play a part as actors in health promotion processes at
schools.
Objectives
In order to provide school teachers with basic concepts and
tools of evidence-based health promotion and encourage them
to apply and disseminate the acquired knowledge and skills at
school and communal levels an education programme was
developed by Tver School of Public Health (TSPH).
Results
The programme is designed for teachers working at primary
and secondary schools and is incorporated in the process of
continuous education of the teachers. It is comprised of 72
academic hours and includes such modules as Basic concepts
of health promotion and disease prevention, Health nutrition, Environmental and occupational health, Health
behaviour, Social inequalities and health, Infectious diseases, HIV/AIDS, sexually transmitted diseases. The programme is taught on a part-time basis and consists of two
sessions a week (two academic hours long each). In 200910
academic year twenty five school teachers have successfully
completed the program. By the end of the year the Department
of Education of Tver region initiated the establishment of
health centres at schools with the trained teachers to play a
leading role in their functioning.
Conclusions
Although the education programme for school teachers has
only recently started at TSPH, we believe that it can enable
teachers to serve as a high-quality source of information on
health promotion not only for pupils, but for parents, and the
community as a whole.
Analysis of bristle features in adult toothbrushes

Melek Turgut
MD Turgut1*, TI Keceli1, B Tezel1, ZC Cehreli1, A Dolgun2,
MU Tekcicek1
1
Department of Paediatric Dentistry, Hacettepe University, Faculty of
Dentistry, Ankara, Turkey
2
Department of Biostatistics, Hacettepe University, Faculty of Medicine,
Ankara, Turkey
*Contact details: melekturgut@yahoo.com
Background
Tooth brushing is a widely used oral hygiene method for
controlling dental plaque, cleaning the teeth and maintaining
gingival health. The design, length, number and end-rounding
quality of bristles affect the cleaning efficacy of a toothbrush.
In addition, unrounded bristle ends may cause irritations on
the soft tissues in the mouth. The aim of this study is to
evaluate bristle properties in proprietary manual adult
toothbrushes.
Methods
A total of 29 adult toothbrushes were obtained. The brushing
area length and head length were measured with a digital
calliper. The measurements were made by a calibrated single
operator and the mean of the three measurements for each
toothbrush was recorded. Bristle lengths were measured on
digital micrographs using open source image analysis software
(Image J). Bristles of the tufts from five regions were counted
and classified as acceptable and non-acceptable under a
stereomicroscope according to the end rounding morphology
by using Silverstone and Featherstone scale. The obtained data
was evaluated statistically with one-way ANOVA and chisquare tests.
Results
The mean brushing area length and head length were
26.48 2.24 and 31.36 2.75 mm, respectively. The mean
length of bristles ranged between 8.50 and 10.68 mm. There
was a statistically significant difference among the toothbrushes in regard to the mean number of bristles (P < 0.05).
Statistically significant differences were found with respect to
acceptable versus non-acceptable bristle ends in second, third,
fourth and fifth regions among toothbrushes (P < 0.05).
Conclusions
The present results demonstrated that there is a need for
improvement in the bristle features of toothbrushes.
Information regarding those features should be provided by
the manufacturers to raise the awareness of public on oral
health.
Economic assessment of health promotion in Finnish

municipalities
Pia Hakamaki
P Hakamaki*, T Stahl, K Perttila
National Institute for Health and Welfare (THL), Finland
*Contact details: pia.hakamaki@thl.fi
Issue
There is a considerable body of evidence concerning the
effectiveness of specific health promotion interventions.
However, little is known about their cost-effectiveness when
the interventions are implemented to the everyday work of
organizations. In Finnish municipalities, health promotion
belongs to the work of every administrative field. Information
is needed on health promotion measures in each sector.
Methods are also needed for producing comparable data on
costs, outputs and effects of health promotion, in order to
support planning and decision-making in municipalities.
Development work within four municipalities is co-ordinated
by THL (200812). The aim is to create an overall framework
for the economic assessment of health promotion in
municipalities and to develop practical tools for measuring
costs, outputs and effects of health promotion. The focus is
on services for children, young people and families with
children.
Methods
The case study encompasses: (1) interviews with the program
stakeholders and other PEN-3 researchers familiar with the
PEN-3 model in cultural health promotion interventions; (2)
document analysis and analyses of minutes of PEN-3 meetings;
and (3) and study of PEN-3 literature. Also, Prof. dr. C.O.
Airhihenbuwa, the developer of the PEN-3 model, will be
interviewed in this case study.
Results
Preliminary results show that the model, as described in the
literature, is too abstract for researchers to apply it in health
promotion program development. Furthermore, the PEN
acronyms in the model that are explained in the literature
are broadly interpreted and applied in diverse ways. The value
of PEN3 model and it is versatile application will be discussed.
Implications
This study contributes to the design of a PEN-3 manual in
which PEN-3 will be operationalized. This manual will
describe the utilization, application and interpretation of the
PEN-3 model in health promotion interventions. It will
integrate research practice to improve evidence-based public
health interventions, which can lead to the integration of new
knowledge, skills and competences in public health
professionals.
School development by using health management

Ulla Walter
U Walter1*, S Liersch1, S Bisson1, M Sayed1, I Windel2, T Altgeld2,
C Krauth1
1
Institut fur Epidemiologie, Sozialmedizin und Gesundheitssystemforschung,
Medizinische Hochschule Hannover, Germany
2
Landesvereinigung fur Gesundheit und Akademie fur Sozialmedizin
Niedersachsen e.V.
*Contact details: walter.ulla@mh-hannover.de
The development of organizations is essential for the

promotion of health in settings.
The goal of this explorative study is to give information about
to what extent the organization-referred intervention Learning
to Live Healthy (LLH), a national model project changes the
health promotion direction of schools and which costs result
from its implementation on a long-term basis. In addition this
research project will also evaluate to what extent a balanced
scorecard (BSC) is suited as a management and evaluation
instrument for schools. A Key Performance Indicator-Toolbox
will be developed to allow the schools to evaluate the
achievement of objectives, the implementation level of the
measures and the changes in the organization. The study is
funded by the Federal Ministry of Education and Research
(200912).
The explorative study develops and evaluates instruments and
methods, which schools can use within their health management to school development. Study part A develops a key
performance indicator-Toolbox to allow the schools to
evaluate the achievement of their objectives and support the
implementation and evaluation of the new measures. In
addition the necessary changes in the organization will also be
considered. Study part B proves and evaluates the Balanced
Scorecard as a strategic management instrument and the
intervention LLH. Moreover the analysis of costs not only
identifies, by dint of the process analysis, the achievement of
the intervention but also measures the consumption of the
associated resources and makes a monetary evaluation of these
ones.
The indicator-toolbox, which until now is missed for
Germany, will be available to schools e.g. as an integrative
component of the intervention LLH. As far as the BSCimplementation will prove satisfactory, schools could use
the BSC as an evaluated management instrument. An
evaluation of the costs makes possible to estimate the
suitability of the implementation of management approaches
into schools.
The results will be brought in terms of a political advice in
order to support the further development of the orientation
framework, school quality as well as into recommendations

for action of the National Association of Statutory Health
Insurance Funds.
The effect of physical activity intervention on
coronary heart disease risk in Izmir-Turkey: challanges
at the community level
Gul Gerceklioglu
G Gerceklioglu1*, G Ergor1, B Unal1, O Aslan2
1
Dokuz Eylul University, Department of Public Health, Izmir, Turkey
2
Dokuz Eylul University, Department of Cardiology, Izmir, Turkey
*Contact details: gul.saatli@deu.edu.tr
Background
Physical activity (PA) can reduce coronary heart disease
(CHD) risk by modifying risk factors. This study was aimed to
reduce CHD risk score and cardiovascular risk factors using a
structured PA intervention at the community level.
Methods
Participants of this study were age 30 years and who have
participated in the baseline study of Balcova Heart Project
(BAK) which is a health promotion project and aims to
estimate the CHD risk score using Framingham Equation.
Based on risk scores participants of this study were people who
had medium risk. Randomization was done based on the
streets which the people lived in. PA programme was planned
twice per week for 6 weeks. At the end of the programme 71
people in the intervention group (IG) and 93 people were
evaluated in the control group (CG). Cardiovascular risk
factors and CHD risk score were analysed using Wilcoxon Sign
Rank or Paired t-tests.
Results
Mean age of the participants was 59.8 7.5, 62.2% of them
were women. There was significant difference between the
baseline and end of the study in diastolic Blood Pressure (BP),
glucose, HDL and CHD risk score in both groups (P < 0.05).
Body weight was not changed in the IG whereas, increased in
the CG. Triglyceride level was decreased only in the IG
(P < 0.05). There was no difference in systolic BP, BMI, total
cholesterol and LDL cholesterol in both intervention and
control groups (P > 0.05).
Conclusions
Although there were significant changes in the IG for the CHD
risk factors, our study did not show significant differences
between the intervention and control groups. A 6-week PA
programme may be not enough to show major changes
between groups since the CG participants were also aware of
their CHD risk factors and may have been motivated to reduce
their risks through other ways.
Which integration of the cardiovascular health
promotion for health professionals?
Yves Coppieters
Y Coppieters*, A Leveque
Department of Epidemiology and Health Promotion, School of Public
Health, Universite Libre de Bruxelles (U.L.B.), Brussels, Belgium
*Contact details: yves.coppieters@ulb.ac.be
Issue/problem
Cardiovascular diseases are a priority of the 5-year programme
of health promotion of the French-speaking community of
Belgium. To determine the cardiovascular priority, a systemic,
participatory planning process has been introduced.
Results
A Cardiovascular Health Promotion Plan in the Frenchspeaking community has arisen from this process. One of the
priority objectives aims at strengthening the patients personal
resources. This comes into being through bolstering the skills
of health-care professionals and through patient self-reliance,
standardizing messages given to them, integration and the
recognition of one-on-one health promotion activities, the
implementation of a professional network and strengthened
multidisciplinary approaches. Another objective is aimed at
Results
As a first step, health promotion measures were operationalized in primary health care, social welfare and the education
sector. Based on this operationalization, the time used for
health promotion was then measured by monitoring working
hours, appointment books, client visits or procedures.
Preliminary results show that the operationalization and the
calculation of health promotion work, i.e. the staff involved
and the time used for it in municipal services, is a challenge.
The method used for measuring the proportion of health
promotion work depends on the type of service studied.
Testing of methods will require more pilots in different
municipalities and within different information systems. Cost
calculations based on this operationalization of health
promotion have recently started.
Lessons
Pilots in municipalities have shown that economic assessment
can provide new ways of supporting management and
monitoring of health promotion on a local level. By making
health promotion functions, outputs and effects visible within
comparable data, the information can be applied in steering
service management.
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A model of therapeutic education

Gabriele Messina
M Piardi1, G Messina2, A Petraglia2, AM Gentile2, N Nante2*
1
Local Health Unit 1-Imperia, Bordighera Hospital, Italy
2
University of Siena, Dept. of Public Health, Health Services Research
Laboratory, Italy
*Contact details: nante@unisi.it
Introduction
Diabetes is a chronic disease with a very large spread. A report
by the World Health Organization in 2005 shows that over 2%
of deaths is due to diabetes. The impact of this disease on
quality of life and public health is strong. In recent years it
has established a fundamental role in the approach to diabetes,
not only of common behavioral and/or pharmacological
therapies, but also of health education programs, aimed at
patients and their families, by healthcare professionals
(doctors, nurses, dietitians).
Aim
To assess the effectiveness of a therapeutic education
structured programme (ETS) in improving knowledge and
clinical aspects of the disease in patients with type 2 diabetes.
Methods
The ETS programme was attended by a total of 28 people.
It included four meetings for 6 months last. At the beginning
and at the end of the study glycated haemoglobin and weight
were evaluated for each patient and GISED questionnaire
(a measure of diabetes knowledge) was administered.
Moreover, during each meeting, educational group lessons
have been taken about these issues: (i) instructions for use and
contract of care, (ii) diet, (iii) physical activity and medication;
(iv) complications. Pre-post data about weight and glycated
haemoglobin were analysed by paired T-test.
Results
Patients showed improvement in knowledge about the disease
(10% increase of right answers to questionnaire), weight loss
(P < 0.005) and reduction in glycated haemoglobin (P < 0.001).
The educational therapy sessions help to change some habits:
(i) food control; (ii) practice of physical activity; (iii) regularity
in taking drugs.
Conclusions
The programme showed not only an effect on the knowledge
of the disease but also on the clinical aspects of diabetes. The
results are indicative of how, by changing lifestyles, increasing
physical activity and following a balanced diet, patients can
improve metabolism.
A comprehensive approach for integrated HIV/STI

prevention among gay men in The Netherlands using
new media
Wim Zuilhof
W Zuilhof1*, P Van Empelen2, P Vriens3, U Davidovich4, R Koekenbier4
1
Schorer, Netherlands Institute for Homosexuality, Health and Well-being,
2
Erasmus Medical Centre, Department of Public Health, Rotterdam, The
Netherlands
3
Rotterdam-Rijnmond Public Health Service, Department of Infectious
Diseases, Rotterdam, The Netherlands
4
Amsterdam Public Health Service, Online Research & Prevention unit,
Department of Research, Infectious Diseases, Amsterdam, The Netherlands
*Contact details: w.zuilhof@schorernet.nl
Issue
Using a comprehensive approach to address high HIV/STI
figures among men who have sex with men (MSM).
Description
The approach, MAN tot MAN, was launched in 2008 to (i)
bundle HIV/STI prevention efforts online and offline, (ii)
increase access to primary prevention interventions and care,
(iii) stimulate MSM to take responsibility for their own health
and that of their sex partners. The approach entails a website
(mantotman.nl) that provides information on sexual health
and tailored interventions.
For evaluation a multi-method design involving successivesampling was used. Samples were based on Schorer Monitor
(annual MSM survey) data from 2007, 2008 and 2009 (i.e.
including the year before and after the launch) involving 3500
respondents (average age of 36). Evaluation outcomes
concerned STD/HIV-testing attitudes, intentions and behaviour and knowledge of PEP. Two other user surveys (N = 418
and N = 363) and Google Analytics provided additional data
on reach, recall, appreciation and delivery.
Results
Familiarity with mantotman.nl increased over time (from 6%
in 2008 to 31% in 2009). Significant differences in attitudes,
intentions and testing behaviour were found between
those MSM who were familiar with mantotman.nl and those
who were not. Of those unfamiliar with the site, 28% tested
for HIV/STD in 2007, 29% in 2008 and 37% in 2009. Of
those familiar with the site, 36% tested in 2008 and 46%
in 2009. Similarly positive effects were found for PEP
knowledge.
Analysis of the user surveys and Google Analytics showed
approval for the website and a positive evaluation of the sites
advisory tool for healthier sex. One-third of those thus advised
received suggestions for major improvements in their sexual
health. The recommendations were often followed: 51% tested
for HIV when advised to do so.
Conclusions
MAN tot MAN contributes to the formulated goals, reaches
the target populations, and stimulates individual action for
sexual-health improvement.
Smoke free workplacesa health promotion
intervention in Sibiu County, Romania, 200709
Eugenia Bratu
E Bratu1,2*, M Haratau1, T Haratau1, F Furtunescu2, S Berariu3
1
Romtens Foundation, Bucharest, Romania
2
Public Health Department, University of Medicine Carol Davila, Bucharest,
Romania
3
Public Health Department, Sibiu, Romania
*Contact details: ioneugenia@yahoo.com
Issue
People spend more than half of their active time at the
workplace, it seems obviously to pay attention to those factors
associated with the workplace which can influence the people
health. The workplace health promotion (WHP) activities
contribute to companies productivity and to societys smooth
functioning. Also, it is important to see how specialists can
work effectively to design interventions tailored to the target
population needs. This abstract presents the approach used to
patient access to infrastructure and social resources. All of this

will come about through very well-defined initiatives to be
introduced or strengthened for health-care professionals. For
example, in order to improve certain professional skills, the
main resource given to reach this objective is to strengthen
training and integration in some way (relationship with
patients, health education and promotion, screening and
treatment for cardiovascular risk factors) in the health-care
professional curriculum both in initial and continuing
training. Another strategy aims at improving awareness
of recommendations and guidelines among professionals,
thereby enabling them to provide optimal support for
patients with a patient education and health promotion
process. The strategies also stress the concepts of partnerships
and networks, institutional recognition of actions linked
to health promotion and patient education, adapting care to
each patient, etc.
Lessons
Such a plan requires resources, a good coordination of all
the parties involved and an ongoing consultation process
between the parties and the managers on the priorities
to be implemented, their monitoring and assessment methods.
Action on determining health factors is also a priority,
although this is a lesser direct concern of health-care
professionals and relate more to the creation of living
environments and lifestyles more conducive to good health.
Use of KAP study to estimate effects of a nationwide

communication pre-test directed to schoolchildren
parents about nutrition and physical activity, Italy
2009
Chiara Cattaneo
A Perra1, C Cattaneo1*, B Contoli2, G Cavallaro1, B De Mei1
1
National Centre for Epidemiology, Surveillance and Health Promotion,
Istituto Superiore di Sanita`, Rome
2
University of Tor Vergata, Rome
*Contact details: chiara.cattaneo@iss.it
Background
Following a nationwide test of a nutritional surveillance system
carried out in 45 590 8-year-old schoolchildren, the National
Public Health Institute has conducted a preliminary standardized communication session performed by health professionals with parents whose children class was randomized
selected for participating in the surveillance. The objective
was to evaluate, after a 3 months interval, to what extent
parents knowledge, attitudes and practices had been changed
for the different topics covered during the communication
session
Methods
Fifty-four classes were randomized selected among the 2610
participating in the nutritional surveillance. At least one
parental figure of each child was invited to participate in the
communication session, run during 1.5 h based on a
distribution of a pre-tested pamphlet and a standardized
computer guided presentation. A 41 item questionnaire was
administered before the session and 3 months later to
each participant. Changes for each item were tested using a
paired t-test and a multivariate analysis was performed to
identify individual characteristics, like age, socio-economic
situation, education level and employment status associated to
changes in knowledge, attitudes and practices
Results
Four hundred and twenty-one parents filled the first
questionnaire and 448 the second one, but only 199 paired
interview questionnaires were finally collected and analysed. A
general significant increase of parents knowledge has been
observed with little or variable changes in attitudes and
practices. Positive changes have globally been more
apparent for healthy nutrition than for physical activity
issues. Socio-economic situation, education level, age and

employment status are not significant change predictors
Conclusions
The KAP study conducted has proved to be a performing tool
to measure changes in communication activities. Particularly,
useful suggestions have been obtained about each subject to
improve the pamphlet and the framework of the communication session
Young people health educational action: prevention
of cardiovascular disease and cancers (Auvergne,
France, 200708)
Marie-Pierre Sauvant-Rochat
L Drotove1, E Caumon1, C Savanovitch1*, S Pruilhe`re-Vaquier2,
MP Sauvant-Rochat1
1
Auvergne University, Clermont-Ferrand, France, Auvergne
2
Cardiopneumology Clinic, Durtol, France
*Contact details: chantal.savanovitch@u-clermont1.fr
In the context of The Health By Heart, association for

primary prevention of cardiovascular disease and cancers,
schools of our area participated to an health educational action
to make sensitive young people in avoidable risk factors,
through three workshops: nutritional habits, physical activity
and addictions. The objective was to show if educative
messages provided during workshops can contribute to
modify youngs habits. Method: Questionnaires were administered to pupils before and after the action to can answer.
Results: So 754 subjects were included in the study among
whom 53% of schoolchildren and 47% of high school
students (72% in professional schools). Concerning nutritional habits, while our population possesses good knowledge
(8.0/10), national nutritional recommendations are not
reached by the majority: only 36% for fruits and vegetables,
47% for dairy products and 49% for starchy foods, except for
meats, fishes and eggs (87%). An increase of consumptions
was declared for respectively 34, 21, 16 and 13% of pupils
after the action. If the water constitutes the main drink, the
frequency of consumption of sweet drinks is worrisome,
particularly in second half of the day. Concerning physical
activity, the average score of knowledge is 7.2/10. Time of
practice seems to reach recommendations; <30% declares to
have increased it after the action. The time in front of a
screen is high (2 h/day); less than a third decreased it.
Concerning addictions, the knowledges are heterogeneous
(7.5/10 for the tobacco and 5.8/10 for the alcohol). A
consumption of tobacco and cannabis is declared by
respectively 35 and 17% of high school students (especially
in professional schools); whereas 45% consumes regularly
some alcohol. The consumption of cannabis is marginal.
Little modified their frequency of consumption of addictives
substances after the action. The majority of pupils appreciated
to participate and 81% wish to take part again in such an
action. Conclusion: The results have shown positive effects on
nutritional habits, physical activity and sedentarity but the
action needs to be improved concerning addictions
workshops.
Populations attitude toward tobacco control in
Georgia
George Bakhturidze
G Bakhturidze*, N Peikrishvili
Tobacco Control Alliance in Georgia
*Contact details: bakhtura@hotmail.com
Introduction
While the tobacco companies have been developing in Georgia
during last 15 years, no control or even comprehensive
study about social or economic aspects of smoking exists, as
well as any efforts of health improvement through tobacco
control. As a part of effective and comprehensive anti-smoking
policy it is important to enforce the tobacco legislation in
Georgia.
develop and implement a tobacco control WHP programme

in Sibiu.
In the project were used quantitative and qualitative research
methods to identify and evaluate the specific needs. The
educational approach to health promotion was used for
intervention: to provide information to help clients make
informed choices about their health behaviour. A series of
health information education sessions (IES) were provided by
a multidisciplinary team to the companies representatives and
employees in order to increase the level of information,
awareness and the ability to manage tobacco control and
health issues at workplaces level.
Results
The research show 32% of employees were smokers and the
information on the issue of passive smoking was missing. 2200
employees from 12 county companies have attended IES and
were informed about the adverse effects of active and passive
smoking. All companies have implemented tobacco control
policies (TCP). After attending IES, 53 smokers asked help to
stop smoking and they were being referred to the county
smoking cessation offices, 40 being still non smokers at the 3
months evaluation.
Lessons
Participation in meetings of this impressive number of people
made possible to succeed in implementing TCP in their
institutions and has attracted other representatives of institutions wishing to conduct WHP programmes in their institutions as well.
189
190
Interactive e-patients and public health: a content

analysis of online social networks focusing on
diseases
Umberto Gelatti
U Gelatti1*, G Orizio1, C Gasparotti1, L Caimi2, P Schulz3
1
Section of Hygiene, Epidemiology and Public Health, University of Brescia,
Italy
2
Quality and Technology Assessment, Governance and Communication
Strategies in Health Systems Study and Research Centre, University of
Brescia, Italy
3
Institute of Communication and Health, University of Lugano, Switzerland
*Contact details: gelatti@med.unibs.it
Background
As the participated web developed to create virtual worlds
and virtual communities, health institutions and activists
discovered Web 2.0 tools, in particular the creation of healthrelated online social networks. In order to analyse the existing
online social networks dedicated to health issues, we
performed an active search on the internet for such websites
and analysed their features according to the content analysis
method.
Methods
The study was performed in September and October 2009. We
analysed a sample of health social networks for patients,
selected using the Altavista, Bing, Google and Yahoo
search engines. A codebook was elaborated to investigate four
areas: general information; technical characteristics and
utilities; characteristics of the website and contents, both
general and related to the online community.
Results
The search led to a sample of 41 social networks. Twenty-three
websites (56.1%) were dedicated to several diseases, the others
to one only. Although the majority of the sample (87.8%)
provided a way to get in contact with the website, only five
(12.2%) showed the name of the author or operating
organization. Eight websites (19.5%) indicated one or more
sponsors, and 9 (22.0%) named one or more partners. It was
often hard to tell whether an institution mentioned was a
sponsor or a partner. Five websites (12.2%) enabled users to
buy health-related products online. Twelve websites (29.3%)
offered users the chance to search for doctors, and 12 (29.3%)
gave therapeutic information. Two websites (4.9%) published
aggregate statistical data about the patients registered with the
social network.
Conclusions
Our findings confirm the criticalities of online health social
networks, showing a lack of commitment by the public health
sector in this field. Strong involvement is required on the part
of the public health sector in this revolutionary and changing
era for information, and consequently for health, in order to
minimize risks and enhance the benefits of a process that
cannot be halted as long as patients are free to share their
experiences on the web.
Health services research

Cost-effectiveness analysis of total hip arthroplasty
with minimally invasive surgery
Jose Luis Navarro Espigares
JL Navarro Espigares1*, E Hernandez Torres1, P Gonzalez de la Flor2,
JL Ruiz Arranz3, MA Padial Ortiz1
1
Management Control, University Hospital Virgen de las Nieves, Granada,
Spain
2
Preventive Medicine Department, University General Hospital of Jaen, Jaen,
Spain
3
Orthopaedic Surgery and Traumatology Department, Hospital of Ronda,
Malaga, Spain
*Contact details: jnavarro@ugr.es
Total hip arthroplasty (THA) is the primary late-stage

treatment for many degenerative hip diseases. In recent
decades there has been growing interest in the development
of minimally invasive techniques which have revolutionized

hip surgery.
The main objective of this study is to evaluate the costeffectiveness of total hip arthroplasty through anterolateral
minimally invasive surgery (MIS) and compare it with the
traditional approach.
A study was conducted to compare traditional and minimally
invasive surgical techniques for total hip arthroplasty in a
population of 340 patients at two Spanish hospitals (the Virgen
de las Nieves University Hospital of Granada and the Serrana
de Ronda Hospital) during the year 2007. The design of the
study was a prospective stochastic cost-effectiveness analysis,
where effectiveness data were collected over a 1-year period at
individual patient levels and costs were gathered from the
Aim
This study is first multi-component survey, which gives us real
picture regarding smokers behaviour and populations
attitude toward the tobacco control policy in Georgia.
Tobacco control policy and appropriate survey is required in
order to learn public opinion on tobacco use and poverty,
attitudes regarding the tobacco tax, smoke-free areas and
employment, ban of sale to minors, ban of advertising and
promotion, etc. It would assist us to promote forming the
appropriate tobacco control policy in our Country.
Methods
For this study we use analyse of relevant theories, researches
and original study conducted by me and other researchers in
200809. The sample size for the whole territory of the country
was determined with the objective to ensure a rather high
statistical reliability of the estimates of various summary and
average indicators: the length of 95% confidence interval
should not exceed 1015% of the estimate. According to this
criterion, the sample size was determined as 1605 households.
Persons interviewed were 3279 (1494-Male and 1785-Female).
This is a descriptive study; hence we describe reported
population answers on our basic questions. Answers also will
be analysed according to the basic demographical data.
Results
Two out of three Georgian men (65%) and one out of five
Georgian women (19%) are current smokers. Men and women
in Georgia have different patterns of smoking. For both men
and women, smoking prevalence is the highest in 1340 age
groups and is lower in older age groups.
Majority of the population (87%) support (agree or strongly
agree) a ban on tobacco advertising in the printing media, on
billboards, sponsorship and other forms of advertisement; this
support is more frequently expressed by non-smokers, exsmokers, older age groups and poorer sections of the
population.
Nearly half of smokers (49%) think it is necessary to increase
tobacco taxes, 14% think there is no need to change current
taxes on tobacco products. Men smokers (26%) could be
expected to smoke much more cigarettes in response to a price
increase than women (12). Women smokers (48%) mostly
could be expected not change their habit after decreasing the
prices than men (26%).
Survey result shows that women mostly support strong
regulations and restrictions than men in Georgia. Average
knowledge regarding tobacco control legislation is 50%. It is
very interesting that majority of smokers attitude is to support
strong restriction measures of smoking restrictions or ban of
sale to minors. Majority of Georgian population61% (57%
of men and 64% of women) consider that current tobacco
control policy and regulations should include more restrictions
on smoking and increase the penalties for violations. Among
them are 57% smokers and 91% non-smokers.
Maternal outcomes by the accessibility to local

obstetric care in Korea
Younghyun Choi
YH Choi1*, BJ Na2, NG Lim3, JH Hwang2, JY Lee2
1
The Graduate School of Public Health and Welfare, Konyang University,
Daejeon, South Korea
2
Department of Preventive Medicine, College of Medicine, Konyang
University, Daejeon, South Korea
3
Department of Medical Administration, Daejeon Health Sciences College,
Daejeon, South Korea
*Contact details: medmis@hanmail.net
Pregnant women in rural areas cannot access sufficient

obstetric care in their own communities due to the shortage
of obstetricians. Therefore, most of them must seek health-care
providers outside of their communities. The purpose of this
study was to investigate the relationship between maternal
outcomes and the accessibility to local obstetric care in
Korea.
This study was an ecological study in which the unit of
analysis was an administrative district. Using Korea National
Health Insurance Corporation data, the total number of
deliveries and the delivery proportion within and outside of
the community were calculated for 245 administrative
districts from 2001 to 2008. Three outflow levels were
categorized based on each districts out-of-community
delivery proportion: high outflow (upper one-third), moderate outflow (middle one-third), and low outflow (lower
one-third). Also, abortion rate, eclampsia rate, and other
delivery-related complication rates were calculated for the
245 districts. One-way ANOVA test and multivariate linear
regression were used to evaluate maternal outcomes among
the three outflow levels.
The high outflow group had higher eclampsia and other
delivery-related complication rates than the low outflow group
(ANOVA, P < 0.05). However, there was no significant
difference in the abortion rates among the three groups.
Multivariate linear regression analysis showed that high
outflow levels and low local tax per capita were statistically
significant to increase eclampsia and other delivery-related
complication rates (P < 0.05).
These results indicate that poor accessibility to local obstetric
care can result in poor maternal health outcomes. Therefore,
the Korean government should consider new health-care
facility construction in the underserved areas and additional
financial support (i.e. reimbursing transportation and accommodation expenses) to pregnant women in the underserved
areas in order to increase accessibility to obstetric care.
Work environment and quality of care in public and

private service housing for elderly people
Anna-Mari Aalto
AM Aalto1*, , T Sinervo1, V Syrja1, A Noro1, H Finne-Soveri1,
H Taimio2, R Lilja2, J Pirttila2
1
Health and Social Services, National Institute for Wellfare and Health,
Helsinki, Finland
2
Labour Institute for Economic research, Helsinki, Finland
*Contact details: anna-mari.aalto@thl.fi
Background
Privatization of service production is an ongoing trend in the
Finnish social- and health care. The advantages of privately
produced services are thought to be better leadership, higher
job control and flatter organization as well as better quality, the
disadvantages being increased uncertainty, growing demands,
lay-offs, lower wages and higher turnover rates among
employees. The aim of the study is to examine the differences
between private-owned (profit and non-profit) and municipal
units in service housing for elderly people.
Methods
The factors studied are quality of care and management and
work environment. The study is based on data from personnel
surveys (N = 1500), resident assessments (2500) (quality of
care, patient structure) and data organizational structures and
bed-days in municipal and private-owned service houses (150
work units). The analyses were conducted on unit level taking
into account the patients-structure and staffing levels.
Results
The results show significant differences between private-owned
and municipal units in both quality of care indicators and
work environment factors. Taking into account the patientstructure and staffing levels the share of patients with nine or
more drugs in municipal services was higher than in privately
owned (profit and non-profit)services (P < 0.003), while the
use of tranquilizers was more common in private-owned nonprofit services (P < 0.04). Negative mood and pain among
patients were more common among municipal units (P < 0.01
and 0.001 respectively). Of work-related factors skill discretion
and procedural justice of management were lower in privately
owned for-profit units (P < 0.001 and 0.02, respectively)
compared with non-profit private or municipal units.
Conclusions
In summary, poorer quality of life among patients was found
in municipal units, but contrary to expectations poor working
environment were found particularly in private-owned forprofit services.
Association of process quality of care indicators with
patient outcomes in diabetes
Grigory Sidorenkov
G Sidorenkov1,2*, F Haaijer-Ruskamp1,2, D de Zeeuw1, P Denig1,2
1
Department of Clinical Pharmacology, University Medical Center
Groningen, University of Groningen, Groningen, The Netherlands
2
Graduate School of Medical Sciences, University Medical Center
Groningen, Groningen, The Netherlands
*Contact details: g.sidorenkov@med.umcg.nl
Background
For measuring quality of care, process of care quality
indicators is considered as important tools. Such measures
often focus on the recommended tests or examinations
conducted or medications prescribed by health care professionals. To be considered as valid measures, it is important that
such indicators predict patient outcomes. We assessed whether
process indicators of diabetes care are associated with
intermediate patient outcomes.
Methods
Data were collected from the GIANTT (Groningen Initiative to
Analyse Type 2 diabetes Treatment) database which contains
longitudinal data of 11247 patients from electronic medical
records of 108 Dutch general practitioners. Process indicators
measuring in 2007: (i) frequency of cardiovascular risk factor
testing, and (ii) intensification of treatment in case of elevated
risk factor levels, were linked to changes in these intermediate
analytical accounting system of Virgen de las Nieves University

Hospital. Effectiveness was measured in functional terms
(clinical) and self-perceived quality of life (SF-12 survey)
during the first six postoperative weeks.
After six postoperative weeks, in comparison with the
conventional technique, a pattern in improvements for MIS
was observed for length of hospital stay (hospitalization time
was 4.97 days shorter); for operative time (an average of
83.3 min for MIS patients and 97.8 min for the control group);
and for average length of skin incision (9.83 cm for the MIS
group and 16.2 cm for the control group). The total cost of
THA with MIS was lower (E4519.19) than the cost of
traditional hip replacement (6 722.46 E). Incremental effectiveness value in terms of quality of life was 0.11 points in the
SF-12 survey for MIS. The cost-effectiveness analysis reveals a
strong dominance of MIS versus traditional THA, with lower
costs and better outcomes.
The study showed that the minimally invasive technique
reduces inpatient resource utilization and improves selfperceived quality of life of patients compared with the
traditional approach. The more beneficial incremental effectiveness ratio of MIS versus traditional THA supports the
recommendation for expanded use of minimally invasive
surgery.
191
192
patient outcomes [HbA1c, systolic blood pressure (SBP), lowdensity lipoprotein (LDL)-cholesterol] in cohort study in the
period 200608 using multivariate regression analysis.
Results
Receiving annual tests for HbA1c, SBP, or LDL-cholesterol was
not associated with improved risk factor levels (P < 0.05).
Receiving two or more tests was significantly associated with a
worse LDL-cholesterol and HbA1c, also after adjusting for
various demographic and clinical factors. Start or intensification of treatment in patients not achieving strict or acceptable
target levels at baseline (HbA1c >7 or 8.5%, SBP 140 or
160 mm Hg, LDL-cholesterol >2.5 or 3.5 mmol/l) showed
significant associations with improvements in all intermediate
outcomes.
Conclusion
Process of care measures focusing on the number of tests
performed were not predictive of better intermediate outcomes. It seems that frequency of testing is a marker of more
serious disease. Process measures focusing on the start or
intensification of medication in uncontrolled patients showed
a clear link to better outcomes, and appear to be valuable
quality measures for diabetes care.
Vincent Busch
V Busch*, H van Stel, AJP Schrijvers
UMC Utrecht Division Julius Centre, Utrecht, The Netherlands
*Contact details: v.busch@umcutrecht.nl
Background
A recent development in The Netherlands is the integrated
child health care centre. These centres aim at offering easy
access for parents and adolescents to comprehensive preventive
health care. We studied cooperation between professionals in
the so-called Parent and Child centres (PCCs) in Amsterdam.
Methods
Qualitative analysis with Nvivo of structured interviews in a
sample of 79 health care professionals involved with PCCs
(general practitioners, physiotherapists, dieticians, paediatricians, nurses) in the region of Amsterdam and a group of 11
experts in preventive child health care.
Results
The concept of PCCs and the added value for both easy access
for parents and cooperation between professionals is supported by both professionals and experts. Experts stated that
care and cooperation should be organized around the child.
Currently, not all involved health care disciplines are fully
participating in multidisciplinary cooperation, partly caused
by space and finance constraints. Inter-professional communication, education and cooperation are still in the development phase. Debate centreed on coordination of care, the role
of the general practitioner and the age range (whether to
include children >12 years). Doubts were expressed whether
existing professional competences were sufficient for optimal
functioning in this new professional setting.
Conclusions
Although PCCs improved both access and cooperation, there
is still potential for further improvement of accessibility and
quality of preventive child health care. Lack of team cohesion,
work protocols and equal participation and -input among the
involved professionals currently still inhibits the PCC structure
to prosper towards its full potential. Therefore, further
research is needed to discover a best practices approach to
form a multidisciplinary PCC team.
Doctors information needs for referral decisions
Peter Hermeling
P Hermeling*, W de Cruppe, M Geraedts
University Witten/Herdecke gGmbH, Institute for Health Systems Research,
Witten, Germany
*Contact details: peter.hermeling@uni-wh.de
Necessity of reform in Bulgarian pharmaceutical

reimbursement systemprognostic results
Toni Vekov
T Vekov*, R Koleva-Kolarova, N Veleva
Department of Medical Ethics, Healthcare Management and Information
Technologies, Faculty of Public Health, University of Medicine, Pleven,
Bulgaria
*Contact details: rossica_koleva@yahoo.com
Issue/problem
During the past 10 years of Bulgarian health-care reform an
issue of constant discussions is the uncontrolled growth of
public expenditures on reimbursing pharmaceuticals from the
compulsory health insurance. The current reimbursement
system is based on a positive list and a fixed price per
pharmaceutical product.
The aim of this study is to perform a comparative analysis of
the expenditures for treating cardiovascular disease of 830
patients, voluntary insured in private health insurance funds,
and those of patients with identical diagnoses, compulsory
insured in the National Health Insurance Fund.
Results
The results from the analysis show that the average cost in
therapeutic reimbursement is 45.07% lower (33.85 BGN) than
the average cost in pharmaceutical reimbursement (61.63
BGN) for the treatment of identical diagnoses. Out-of-pocket
co-payments by the insured population also decrease in
therapeutic reimbursementfrom 46.56 to 5.23 BGN.
Disadvantage of the current reimbursement system is the
tendency to consume the total amount of the monthly limit
for a diagnosis irrespective of individuals diagnostic and
treatment needs. The increase of public expenditures on
pharmaceuticals could be contained through adequate balancing of the monthly reimbursement limits in different
diagnoses.
Cooperation between professionals in integrated

child health-care centres
Background
Since 2004 all hospitals in Germany have to publish quality
reports. These reports aim to inform ambulatory care
physicians about potential hospitals to refer their patients.
Our study intends to analyse doctors use of these reports for
their referral decisions and to explore the type of quality
information medical professionals need to support referral
decisions.
Methods
Structured computer-assisted telephone interviews of a
representative sample of 300 ambulatory care physicians
(general practitioners, internal specialists, surgeons, orthopaedic surgeons and gynaecologists). Doctors rated their information preferences on a literature analysis-based set of 83 quality
criteria assigned to seven categories.
Results
By April 2010, two-thirds of the interviews were conducted.
About 38% of the physicians were aware of the quality reports.
Over all 16% actually made use of specific direct or indirect
report contents during consultations. Doctors rated the
following criteria highly relevant (Top 5): (i) patients are
treated with respect; (ii) when communicating with the
attending physician, he is aware of the patients anamnesis
and procedure; (iii) the doctors own experience with the
hospital; (iv) prompt note in case of an important incident and
(v) the focus of competence within the different departments
of a hospital.
Conclusions
Referrals are mainly driven by physicians experiences and
factors that describe the physicianhospital interaction.
However, we found evidence that many information details
of the mandatory quality reports are of interest to physicians
but they are not aware of their source or do not trust the selfreported information. Increasing the rare use of hospital
reports for referral decisions will largely depend on raising
their credibility among physicians.
Lessons
The therapeutic reimbursement mechanism has several
advantages: the decrease of pharmaceuticals prices decreases
out-of-pocket spending of patients, not the public expenditures, as it is the current case in pharmaceutical reimbursement, based on the lowest price from referential lists of eight
European countries. Therapeutic reimbursement achieves
greater social impact. The pharmaceutical expenditures are
easily predicted as they are determined by the number of
patients and their diagnoses. The mechanism of controlling
pharmaceutical prescription and reimbursement is much
simplified and with low administrative costs. However, the
necessity for an adequate pharmaceutical reimbursement
policy requires the development of a programme for costeffective prescription and usage of drugs.
Leading causes of hospitalization in Serbiachanges
over time
Milena Vasic
Background
Patients are admitted to the hospital for a variety of reasons
(scheduled tests, procedures, surgery; emergency medical
treatment, administration of medication, or to stabilize or
monitor an existing condition).
Methods
The aim of this article is to define and analize the leading
causes of hospitalization in Serbian public hospitals, and their
changes durring the 8-year period (from 2000 to 2007). Data
on hospital morbidity were obtained from the Individual
Hospitals Reports collected by the Institute of Public Health of
Serbia. The diagnoses were coded using the International
Classification of Diseases-10th Revision (ICD-10).
Results
Over the studied period, there was a continuous increase of
hospitalizations for circulatory diseases and malignant tumors.
By single diagnosis tightness in the chest, i.e. angina pectoris,
was the most common cause of hospitalization (ICD-10: I20),
followed by cerebral infarctioncerebral tissue necrosis (ICD10: I63) and essential hypertension (ICD-10: I10). The most
common reason for hospitalization among men was inguinal
hernia (ICD-10: K40) with the rate ranging from 3.3 per 1000
in 2000 to 4.1 in 2004 and 2005. The second most common
reason for hospitalization of men was tightness in the chest
(ICD-10: I20) followed by chronic obstructive pulmonary
diseases (ICD-10: J44), malignant tumors of the bronchi and
lungs (ICD-10: C34) and cerebral infarctioncerebral necrosis
(ICD-10: I63). In women, spontaneous childbirth (ICD-10:
O80) was continuously the most common cause of hospitalization. Excluding hospitalization for spontaneous childbirth,
malignant breast cancer (ICD-10: C50) is the most common
cause of hospitalization in 2007. A reason for concern is the
fact that the hospitalization rate of breast cancer has increased
from 1.2 per 1000 populations in 2000 to 3.0 per 1000 in 2007.
Conclusions
The leading causes of hospitalization in Serbia over the studied
period were circulatory diseases and malignant tumors with
rising trend of hospitalizations, with some gender-related
specificities. The large proportion of hospitalizations can be
prevented, which indicates the need to strengthen preventive
and promotional activities, especially in primary health care.
Assessment of correlation between organizational
management of females cancer screening
programmes and performances in the period 200507
Fabrizio Bert
F Bert1*, A Colombo1, A Federici2, S Schioppa3, R Siliquini4
School of Public Health, Department of Public Health, University of Torino,
Torino, Italy
Health Minister, Italy Government, Rome, Italy

University of Chieti, Chieti, Italy
Chair of Department of Public Health, University of Torino, Torino, Italy
*Contact details: fabrizio.bert@unito.it
3
4
Issue/Problem
EU guidelines indicate as standard for adherence to mammography screening programmes 70% of women (5069 years),
and 85% for PAP test every 3 years (2564 years). In Italy the
screening programmes started in 1998 but, due to Regional
autonomy, many organizational differences are evident. In
2007 about one-third of the target population did not benefit
from the PAP test and one-fifth from mammography. Some
studies assess screening programme results, but not clarifying
the relationship between organizational management and
programme effectiveness.
The aim of the study is to evaluate the association between the
organizational/logistic/functional variables and levels of
screening perfomance. We selected from international literature 12 indicators of process and performance and analysed it
in the light of Italian Regional data.
Results
In Italy the extension of the theoretical and actual screening
mammography are respectively 81.4 and 62.3%. Women
compliance to mammography was 64.44%, while for cervical
cancer screening was 39.19%. Extension and adherence to
screening do not appear to be statistically influenced by Local
or Regional management, but some differences can be
highlighted and discussed about the differences between
organized screening and free and not actively proposed tests.
Lessons
High performance of screening tests seem to be related to a
Local Authority active proposal and organized setting even if,
in some populations, where the medium social level and the
awareness of screening efficacy is very high, individual
responsibility can taken in account. Secular trends of screenings performance in different Regions will be discussed in the
light of social and organizational variables in order to propose
a European framework.
Pharmacoeconomic indicators of cardiovascular drug
utilization in the Republic of Croatia and City of
Zagreb in 2008
Danijela Stimac
D Stimac1*, I Stambuk2
1
Department of Public Health, Zagreb Institute of Public Health/University of
Zagreb, School of Medicine, Zagreb, Croatia
2
Jadran Galen Laboratory, Zagreb, Croatia
*Contact details: danijela.stimac@stampar.hr
Background
In comparison with original drugs, generic drugs have the
same efficacy but considerably lower price and should
therefore be preferred to original drugs on prescribing. The
aim of the present study was to assess outpatient utilization
and rationality of cardiovascular drug prescribing in the City
of Zagreb and Republic of Croatia based on the generic to
original drug prescribing ratio.
Methods
Data on the financial indicators and number of cardiovascular
drug packages issued in 2008 were obtained from the Croatian
Institute of Health Insurance. These data were used to calculate
the number of defined daily doses (DDD) and number of
DDD per 1000 inhabitants per day (DDD/1000 per day). The
index of generic/original drug utilization was determined for
Zagreb and Croatia as a measure for assessment of prescribing
rationality; the significance of difference was determined by
2-test.
Results
The rate of prescribing original cardiovascular drugs was
significantly higher in Zagreb as compared with Croatia as a
whole. The index of prescribing generic versus original drugs
was 1.20 (249/208 DDD/1000 per day) in Zagreb and 1.65
M Vasic*, V Korac, M Krstic, V Horozovic

Institute of Public Health of Serbia
*Contact details: milena_vasic@batut.org.rs
193
194
(249/151 DDD/1000 per day) in Croatia. Difference in the

utilization of generic drugs between Zagreb and Croatia as
determined by 2-test (the level of statistical significance was
set at P < 0.05) was statistically significant (P = 0.021). The
highest differences were recorded in the most widely
prescribed drug groups, i.e. ACE inhibitors with the generic/
original drug index of 1.38 in Zagreb and 2.02 in Croatia; and
hypolipemics with the generic/original drug index of 0.96 in
Zagreb and 1.34 in Croatia. According to financial indicators,
the generic/original drug index was 1.44 in Croatia and only
0.96 in Zagreb.
Conclusions
Significantly greater influence of pharmaceutical industry
marketing in Zagreb entailed the significantly higher rate of
original drug prescribing, which is associated with considerably greater drug expenses. Measures to stimulate prescribing
generic drugs should be launched at the national level.
Prevention of passive smoking among vulnerable
groups: an intervention study in Ankara
Ozge Karadag
Issue/Problem
Tobacco is the single most preventable cause of death in the
world. In Turkey, 31.3% of adults smoke. According to the
anti-tobacco law (2008), smoking ban has been widened to
cover all public places. However, indoor passive smoking
continues to be an important public health problem in private
living areas. This intervention at the primary health care
(PCH) level aimed to sensitize and train active and passive
adult smokers to reduce indoor passive smoking in private
living areas.
Methods
The intervention consisted of in-service trainings to PCH
workers, who in turn, conducted individual 15 min. training
sessions for both active and passive smokers attending any of
the four selected PHC centres in Ankara during MayJune
2009. Pre-post intervention surveys with the participants as
well as structured interviews with the PHC workers were
conducted for monitoring and evaluation. The aim was to
assess if short individual trainings in PHC settings would be
effective to reduce passive smoking in private living areas and
if the behavioural change would be maintained over time. SPSS
15.0 software (Chi-square, t-test, ANOVA) and content
analysis were used for quantitative and qualitative data
analysis, respectively.
Results
In total, 1800 people -living in a house with indoor smokingreceived individual trainings and informational materials on
effects of passive smoking and smoking cessation centres in
four PHC centres. Of the 1338 participants surveyed before the
intervention, 58.0% were current smokers. Of the 311
participants surveyed 3 months after the intervention by
random sampling, 88.9% stated that theyve warned the
smoker/s at home not to smoke indoors. Of the current
smokers, 41.0% have started to smoke outdoor, 23.0% have
reduced the number of cigarettes smoked per day and 6.0%
have quitted.
Lessons
Results of the intervention indicate that apart from strong
anti-tobacco regulations in public places, educational interventions are also needed to protect vulnerable groups such as
children, pregnant women and elderly from passive exposure
in private living areas. Short individual trainings in PHC
settings are a cost-effective way to reduce passive smoking and
recommended for other countries with high smoking
prevalence.
Nadia Veleva
NV Veleva*, MD Draganova
Department of Medical Ethics, Health Care Management and Information
Technologies, Faculty of Public health, Medical University, Pleven, Bulgaria
*Contact details: veleva_nadia@yahoo.com
Background
The five-step nursing processassessment, diagnosis, planning, implementation and evaluation is essential for the
delivery of quality nursing care. Nursing process is widely
spread in the European nursing practice but in Bulgaria is still
not applied. The accession of our country to the EU and the
subsequent need for unification of both legislation and practice
would lead to inevitable introduction of nursing process in
Bulgaria. This study explores the views of Bulgarian nurses
about the opportunities for clinical application of nursing
process and its effect on the health-care quality.
Methods
Anonymous self-administered questionnaires were distributed
to 544 nurses during 200809. The study group included 334
practicing nurses from four University Hospitals in Pleven,
Sofia, Varna and Stara Zagora, 32 trainers from four nursing
schools in the same places, and 178 past year students.
Results
Most of the participants (79%) express their unquestionable
interest in nursing process and consciousness of the necessity
of its implementation in clinical practice. Only 37% of the
respondents consider that nowadays in Bulgaria there are
realistic possibilities for clinical application of the nursing
process. Most of the participants (64%) do not perceive
nursing process as a tool for improvement of nursing care
quality but see it as control and assessment instrument. No
significant differences were found between the answers of
respondents from different hospitals. There is significant
difference between the views of practicing nurses/teachers
who are pessimists and students who show more positive
attitude.
Conclusions
The results of this study confirm that at the moment there are
no possibilities for clinical application of professional methods
and tools for quality nursing care in Bulgaria. This study
proves that the most important factor for the implementation
of nursing process is the acquiring of profound knowledge and
understanding of the process.
Client-initiated HIV testing and counselling in

Portugal during the first semester of 2008
Joana Soares Ferreira
J Soares Ferreira*
Institute of Public Health, University of Porto, Porto, Portugal
*Contact details: joanasoaresferreira@gmail.com
HIV epidemic is a major public health priority. Client-initiated

HIV testing and counselling (CITC) is the process by which an
individual actively seeks HIV testing and counselling. CITC
centres have an essential part in hampering the epidemic. The
aim of this study was to see whether the quality of care
provided at these centres was satisfactory.
Data were obtained through an anonymous telephone survey
made to each centre and a questionnaire to be filled in by each
manager.
There were 17 centres functioning in all but two Districts.
There were six Districts where centres were closed both at
lunchtime and after 6 pm. Three centres had only one
professional working there. In five centres planning of
professionals substitutions during absences covered every
function of every professional. In 13 centres every professional
had been formally trained to perform rapid tests. There were
four centres where results were read after the reading endpoint
stability. Of 11 469 tests performed 1.27% were reactive and
0.96% were confirmed as HIV infection. Not every client was
O Karadag1*, N Bilir1, N Yardim2, F Aygul2, E Cayir1, G Sarioglu2

1
Hacettepe University Faculty of Medicine, Department of Public Health,
Ankara, Turkey
2
Ministry of Health, General Directorate of Primary Health Care, Ankara,
Turkey
*Contact details: okaradag@hacettepe.edu.tr
Quality of nursing care and nursing process (Bulgaria,

200809)
given the result hence not every reactive test was subject to
confirmation. 31.56% were not followed by counselling and no
referral was made to 20.55% of clients with an HIV diagnosis.
In 10 centres minors had to ask another person to consent the
test or previously agree that a positive result would be told to a
relative.
Higher figures of reactive tests and diagnosis were expected as
these centres are outreach services and Portugal has a
concentrated epidemic. Especial attention should be devoted
to overcome the barriers that someone with risk behaviour
wanting to known his HIV status in such a centre might come
across that were revealed so that early detection of infection
can be a reality.
An interpretive approach to formation of family
physician and rural insurance in Iran
Amirhossein Takian
Background
Accumulating the evidence generated over decades, the World
Health Report 2008 recommended the expansion of primary
health care (PHC) to achieve better population health, higher
equity and lower costs. Over the last two decades, the Iranian
model of PHC has resulted in population health indices that
match the best in the region. Despite the extensive PHC
networks in rural areas, the health-care system observed
expansion of private out-patient care and hospital-based
services. This model has shown itself to be inadequate to
meet the evolving health needs of the population and
increasingly difficult to afford. In response, a Family
Medicine (FM) programme has been implemented since
August 2005, funded through Behbar, a model of social
insurance.
Aim
Identification of facilitators of and barriers to implementation
of FM in Iran.
Methods
Data was collected between November 2006 and May 2007
through semi-structured interviews at national (19 interviews),
provincial (nine) and local (43) levels, plus a purposive
document analysis. The framework approach was used for
analysing interviews. Document analysis followed a narrative
contextual framework. We interpreted data using an interpretive framework consisting of multiple streams and network
theories.
Results
The introduction of Behbar provided FM advocates with the
opportunity to place FM on the policy agenda. They skillfully
coupled the two policies and defined FM as the only solution
to fulfill Behbar. However, the manner in which policy was
formed was the main obstacle to desired FM implementation.
Conclusions
The interpretive framework links the concept of outreaching
the poor and enhancing equity to rationing health services at a
particularly opportune moment in Iran. However, using
windows of opportunity for implementing a major policy
change, if it results in sacrifices in planning and preparedness,
may harm the policy and the future success in achieving its
objectives.
Patient-centredness and e-health in Italian research
hospitals: preliminary results of a web-based survey
Emma De Feo
E De Feo*, AG de Belvis, F Pelone, S Lupidi, S Bucci, G Ricciardi
Institute of Hygiene, Universita` Cattolica del Sacro Cuore, Rome, Italy
*Contact details: emmadefeo@yahoo.it
Background
Citizens involvement in their health care (HC) is broadly
recognized as a tool for a patient-centred approach in health
service (HS) delivery. Given the growing recognition of
patient-centredness as a HC quality indicator and its limited
implementation in practice, our study evaluated how the
Italian Research Hospitals (IRCCSs) address the dimension of
access to HS to promote a patient-centred care. The potential
benefits from e-health Technology (ehT) were also considered.
Methods
To address patient-centredness, seven specific indicators
adapted from Euro Health Consumer Index were evaluated
from 63 IRCCS: on-line (i) booking of HC services (lab tests or
specialist visit) or (ii) access to medical records, (iii)
centralized booking or (iv) Public Relations Office (URP),
(v) Register of legit doctors, (vi) Pain management hospital
committee, (vii) Map and transportation information.
Location of IRCCs and ownership (private versus public).
Results
Of included IRCCSs, 35 are private while 60% (N = 37) are
placed in the North. A significant difference appeared in
ownership by geographical area with 70.3% of northern
IRCCSs being private respect to 34.6% of Centre-South (P
= 0.009). Of note, 93.7% of IRCCSs has an URP while only one
has actually implemented the patient on-line access to medical
records. No significant differences emerged for selected
indicators by ownership. HS on-line booking is currently
offered by 51.4% of northern IRCCSs compared with 27% of
Centre-South (P = 0.05).
Conclusions
According to our results, most of IRCCSs are located in the
North because of a regional decentralized HC System.
Although the majority of IRCCSs have successfully implemented the presence of URP and Pain management protocol, ehT
seems limited to the North, thus highlighting regional
differences in patient-centredeness strategies. A coordinated
effort should be made both at hospital and policy-makers
levels to ensure a widespread implementation of patientcentred care in Italy.
A new method to assess clinical governance in
primary care. An experience in northern Italy
Maria Lucia Specchia
ML Specchia1*, AG de Belvis1, S Capizzi1, M Marino1, L Romaniello1,
P Nardella1, P Gall`1, A Biasco1, G Quaranta1, L Valerio1, S Donno1,
M Gianino2, R Siliquini2, G Viberti3, O Bertetto3, N Ibba4, A Campana4,
W Ricciardi1
1
Institute of Hygiene, Catholic University of the Sacred Heart, Rome, Italy
2
Public Health and Microbiology Department, University of Turin, Turin, Italy
3
Piedmont Region Health Services Research Agency, ARESS, Turin, Italy
4
CRS Consulting, Rome, Italy
*Contact details: marialucia.specchia@rm.unicatt.it
Background
Despite primary-care organizations should be accountable for
giving management and government assurances about the
goodness of care provided to patients and health care
professionals, systems of Clinical Governance (CG) application
are still scarce at European level.
Objective
The purpose of this project is the implementation of
DISTRICARE (District-Care), an evidence-based CG Scorecard in Primary Care (CGSPC), developed in Italy in 2009.
Methods
The project implementation was carried out between
September and December 2009 in Cuneo Local Health Trust
(LHT) consisting of six Districts (300 000 inhabitants).
DISTRICARE is based on:
1. audits built on a structured and systematic approach,
supported by a weighted questionnaire;
2. data analysis;
3. improvement operational plan.
The questionnaire, consisting of 478 items, is divided into 24
analysis areas (six CG roots and 24 CG branches, according to
A Rashidian1*, M Kabir2
1
Department ofHealth Policy and Management, School of Public Health /
Knowledge Utilization Research centre, Tehran University of Medical
Sciences, Tehran-Iran
2
Centre for PHC Expansion and Health Promotion, Deputy of Health,
Ministry of Health & Medical Education, Tehran-Iran
*Contact details: amirhossein.takian@pharmacy.ac.uk
195
196
Developing the criteria for defining underserved

areas of obstetric care in Korea
Baeg-Ju Na
JH Hwang1*, NG Lim1, YH Choi1, JY Lee1, MS Lee1, JY Hong1,
SY Hwang2, JS Han2, HG Kim2, KB Song2, YR Son3, YJ Song3
1
Department of Public Health, Konyang Graduate School of Public Health
and Welfare, Daejeon, Korea
2
GIS united, Seoul, Korea
3
Department of Public Health, Ministry of Health and Welfare, Korea
*Contact details: skqw@konyang.ac.kr
Accessibility to obstetric care among rural areas has been

worsening despite the Korean governments willingness to
support underserved areas. However, local obstetricians in
rural areas are concerned that if the government constructs
new health-care facilities for delivery in their regions, then
their income will decrease. This study was performed to
develop the criteria for defining underserved areas of obstetric
care in Korea.
The consensus method was used to develop the criteria. The
panel consisted of 12 members (four government representatives, two professors of health policy and management and six
representatives of Korean Society of Obstetrics and
Gynecology, KSOG). The panel calculated the total number
of deliveries and the delivery proportion within and outside of
the community for 245 administrative districts from 2001 to
2008 using Korea National Health Insurance Corporation data.
In addition, the driving time and driving distance to a healthcare facility for delivery were estimated using Arc GIS 9.3. The
results of these calculations were used to support the panels
decision of which criteria to include in defining underserved
areas.
The criteria developed by the panel are as follows: (i) out of
district delivery rate is 30% or more, (ii) >30% of the surface
area of a district requires a drive time of over one hour to a
health-care facility that delivers at least 50 infants every year.

Also, the panel recommended that the underserved areas be
reclassified by population size and density.
The Korean government and KSOG accepted the criteria and
recommendations. New health-care facilities for delivery will
be constructed, and pregnant women will receive additional
financial supports. Lastly, because the developed criteria were
based on evidence and geographic information system, the
conflict between government and obstetricians was resolved. In
the future, geographic information systems will be useful to
define other medically underserved areas.
National waiting list
Danijela Stimac
D Stimac1*, D Jurkovic2, D Milinovic2
1
Department of Public Health Zagreb Institute of Public
Health,Zagreb,Croatia
2
Ministry of Health and Social Welfeare Republic of Croati, Zagreb,Croatia
Issue/problem
Too long and non-transparent waiting lists are one of the
major problems in the overall health-care structure. They are
responsible for the perception of health-care corruption and
generally do not respond to the true health-care needs.
Ministry of Health and Social Welfare of the Republic of
Croatia has launched establishment of the National Waiting
List (NWL) as a central database of all requests at Croatian
hospitals, covering all medical procedures for all patients. The
NWL is being updated on a daily basis, while reliability of data
entered in the NWL is monitored by the respective code
warranting payment by the national insurance company
exclusively for the services updated in the NWL.
Simultaneously patients were referred from hospitals with
long waiting lists to hospitals where the respective procedure
could be performed earlier. Hospitals were stimulated to
introduce shift work and to reduce their waiting lists. On NWL
survey, patients with multiple appointments were identified,
called to present for the procedure at one of the institutions,
and then removed from the NWL.
Results
Survey of all waiting lists at the national level, patient referral
to hospitals without waiting lists, removal of patients with
multiple appointments for the same procedure, stimulation of
shift work to improve resource utilization and service
restructuring resulted in waiting list reduction by 3050% in
1 year. Greatest reductions were recorded in waiting lists for
orthopedic procedures. A total of 3645 patients were referred
from one to another medical institution.
Lessons
Establishing of NWL as a central and transparent database
resulted in considerable waiting list reduction. However,
additional waiting list reductions will require full health-care
system computerization, e-appointments by healthcare professionals, patient request reduction based on distinct professional guidelines for hospital appointments, and managing the
highest possible proportion of patients at primary healthcare
level.
Health systems and policies

Decentralized public health expenditure and health
outcomes effect on infant mortality rate in Colombia
municipalities
Victoria Eugena Soto Rojas
VE Soto Rojas*, V Lorant
Institute For Health and Society, Universite Catholique de Louvain
*Contact details: victoriae.soto@gmail.com
Background and Aim

According to public Economics the theoretical effect of
decentralization on the provision of public goods is mixed
due to the fact that local governments have better local
information, but central government is more efficient in the
production of public good. There is a paucity of research
analysing the influence of fiscal decentralization on public
Chambers, 2000), including continuity and integration of care

among professionals. Each area is investigated by a pool of
evidence-based questions and closed answers. The software
application allows to collect data, calculate scores and develop
benchmarks between Districts.
Results
A total of 22 interviews (11 board level and 11 other
professionals interviews) were realized. CG prerequisites and
areas were analysed; CG maturity level within each District was
established, by assigning global and partial scores, referred to
the whole LHT and each single District, CG prerequisite and
dimension, respectively.
Intra- and inter-Districts comparisons were performed. An
operational plan was elaborated in partnership with the LHT
board, supplying 17 actions in order to undertake improvement policies.
The main observed effect of DISTRICARE implementation was
to trigger improvement interventions.
Conclusions
DISTRICARE may represent a helpful toolalso applicable
in other EU countriesin order to trigger changes and
pursue quality and excellence in primary care. This is of
outstanding interest as CG has been poorly applied in primary
care settings, yet.
Health System Reforms in the Republic of Macedonia

19912010: where do we go from here?
Dance Gudeva Nikovska
V Lazarevik1*, D Gudeva-Nikovska2, B Kasapinov2
1
Institute of Social Medicine, Faculty of Medicine, Skopje, Republic of
Macedonia
2
Department of Social Medicine, Faculty of Medicine, Skopje, Republic of
Macedonia
*Contact details: dgnikovska@gmail.com
The principal objective was to evaluate the health system (HS)

reforms in Republic of Macedonia (RM) since the independence of the country in 1991 to present days.
We conducted desk research of available scientific literature on
HS reforms, review of legislation and documents available at
the Ministry of Health and Health Insurance Fund (HIF).
Official data on demographic/health status indicators were
collected from the Institute of Public Health (IPH), State
Statistical Office, doubled checked with international data sets.
In addition, we conducted interviews with number of
stakeholders working in the health care system to assess their
perceptions on the impact of the HS reforms.
RM has inherited from former Yugoslavia HS with widespread
and easily accessible health infrastructure, big hospitals,
regional network of IPH responsible for preventive activities
and social ownership of facilities. Since 1991 independence, HS
was reestablished to protect and promote values of solidarity,
equity and participation. Three phases of HS reforms have
been identified: post-socialistic, pro-market and manifesto
driven. Over the years, lack of finances has increased out of
pocket expenditure for health, and evolved as deterioration of
public hospital physical infrastructure and reduced quality of
health services in public facilities. In parallel, liberalized health
care market regulation led towards trend in commercialization
of health care services and investment in new for-profit
hospital services. Long transition and ineffective reforms in the
public health sector forced huge number of health personnel to
move to the private sector.
Despite numerous reforms, political promises and actions, HS
reforms in RM are not continuous, but are rather fragmented
and overall does not represent a success story. The key
problems are poor efficiency and quality of the services

provided in the public facilities, distortion of the social health
insurance system and politicization of HS reforms. This article
argues that in order to protect the system, public health
facilities should be more autonomous and independent from
politics. To maintain the values of solidarity and equity, HS
financing should be converted from existing social contribution-based, towards HS financed by general taxes.
US health reform legislation: Policy implications for
public health
Dennis Lenaway
D Lenaway*
US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
*Contact details: drl7@cdc.gov
On 21March 2010, the US Congress passed historic health

reform legislation, entitled the Patient Protection and
Affordable Care Act. This presentation will detail the aspects
of the Act related to public health and wellness and provide
up-to-date policy implications, decisions on allocation of
resources, and expectations for the future. This landmark
legislation provides significant opportunities for public health,
including the creation of a mandatory Prevention and Public
Health Fund appropriating $15B (US) for the 10-year period
201019. Annual funding amounts are not attributable to
specific programmes; instead, money can be spent on any
prevention, wellness, and public health activities authorized
in the Public Health Services Act. The final policy decisions
will likely result in a small amount of money being spread
across a wide variety of programmes. The Act also establishes a
National Prevention, Health Promotion, and Public Health
Council made up of Cabinet-level and other federal officials.
The Councils responsibility will be to directly advise the US
federal government on priorities in prevention and wellness as
well as produce a National Prevention and Health Promotion
Strategy identifying key priorities for intervention and
research. Currently, US federal government agencies are
drafting competing initiatives to address new and novel
aspects of prevention and wellness, or are addressing the
many new prevention programmes outlined in the Act. The US
centres for Disease Control and Prevention is providing
leadership and support for several important prevention and
wellness initiatives to be consider for funding by the Act,
including but not limited to expanding epidemiology and
laboratory capacity, investments in core public health infrastructure, and strengthening efforts to rebuild workforce
capacity and competency. The policy implications resulting
from health reform legislation are significant in that they will
drive the focus and direction of US prevention, wellness and
public health efforts into the next decade.
Explaining the impact on health of primary care
reform in Cordoba, Argentina 200106
Ana Clara Zoni
AC Zoni1*, A Rico2
1
Preventive Medicine and Quality Management. Gregorio Maranon
Hospital, Madrid, Spain
2
Health National School, Health Economics Department, Madrid, Spain
*Contact details: anazoni@hotmail.com
Background
The case study is examining a primary care reform (PROAPS)
in Cordoba, Argentina. It was designed and implemented from
2001 to 2006 by the Regional Minister of Health. The PROAPS
was designed as an alternative solution to the crisis of
sustainability and inequity of the health system in Argentina.
The reform highlights elements that are among the leading
international policies against social inequalities, with emphasis
on health promotion strategies, empowerment and community participation. The aim of this study is to describe and to
evaluate the impact of the PROAPS and to explore its causal
factors.
health outcomes. In Colombia, the financing of health services

has been totally decentralized since 1990. However, such
decentralization has been unequal depending on local institutional capacity for management and planning health plans. As
a result, the expected effect of fiscal decentralization on public
health outcomes is unclear. The aim of this study is to asses the
effect of fiscal decentralization of health resources on infant
mortality rate in Colombia.
Methods
Infant mortality rate among 863 municipalities over a 10-year
period (19982007) were related to decentralized public health
expenditure, by using a fixed-effect regression model. The
effect of fiscal decentralization is measured by the share of
health expenditure allocated by the central government to the
local municipality and by the share of the resources collected at
the local level by the municipalities. We compare the effect
according to the degree municipalities were independent from
central government.
Results
Fiscal decentralization decrease infant mortality rate. The
influence of the municipalitys own health resources on infant
mortality rate was lower than the effect of the resources that
lead from the central government. The effect was slightly
higher among municipalities being totally independent in the
management of their own health resources.
Conclusions
This study suggests that fiscal decentralization can improve
public health outcome. However, such effect depends on local
institutional capacity to improve efficiency in the management
of local health resources and achieve greater effect on public
health outcome.
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198
Noricum: a strategic role play teaching health-care

system conflicts
Florian Buchner
F Buchner*, U Frick
Health care management, Carinthia Unversity of Applied Sciences,
Feldkirchen, Austria
*Contact details: f.buchner@fh-kaernten.at
Background
Modern health-care systems attract continuous conflicts of
interests between numerous stakeholders. Rules and regulations of financing and resource allocation exert powerful
incentives on the actors behaviours and impact on access to
care and economic efficiency of service provision.
Objective
A scenario of a fictitious state (Noricum) was developed to
help students of health-care management to better understand
interests and strategies of actors in the health-care system from
their concrete experiences within this simulated process of
negotiations and legislation in Noricum.
Methods
The course is separated in three phases:
During the first conceptual phase students get a description of
the political, economical and medical situation in Noricum
after a revolutionary overthrow: A new system of financing and
organizing health-care delivery has to be established. Small
students groups take the roles of central stakeholders. Each
group confidentially formulates explicit goals and implementation strategies. Groups get feedback on their concepts. (6
weeks)
The second phase is the phase of governmental legislative
initiatives, negotiations and contracting between the stakeholders. Students must not step out of their roles and may use
only two communication channels: face-to-face negotiations
during limited time slots and e-mail. One group of students
acts as observers and documents all interactions and results.
Teachers may intervene only indirectly, e.g. by issuing press
reports. (6 weeks)
The third phase is organized as a plenary workshop starting
with observers reports on the process and results reached.
Teachers present their assessment of the health-care system

and evaluate negotiation strategies and behavioural aspects of
the role play. (1 day workshop)
Conclusions
The teaching concept works. Students display a high
intellectual and emotional engagement. They develop astonishingly innovative concepts and find a sustainable balance of
powers, pointing at a good understanding of the complex
interdependencies. Nevertheless, solutions may not cover all
aspects of a health-care system.
The association between managers support and a
policy regarding sickness certification on one side and
physicians sickness certification practice on the other
Christina Lindholm
C Lindholm1*, B Arrelov2, G Nilsson3, T Ljungquist4, K Alexanderson4
1
Division of Insurance Medicine, Department of Clinical Neuroscience,
2
Stockholm County Council, Stockholm, Sweden
3
Department of Neurobiology, Care Sciences and Society, Karolinska
Institutet, Huddinge, Sweden
4
*Contact details: christina.lindholm@ki.se
Background
The importance of support, guidelines and policy in the
sickness certification task has been emphasized in the last
years. The sickness certification process is complex and
collaboration around the patient is in many cases necessary.
The aim was to examine if policy or support from the nearest
manager have an impact on collaboration in the sickness
absence process.
Methods
Data from a questionnaire study of all physicians living and
working in Sweden (n = 36 898) in 2008; response rate 61%.
Included in this study; physicians aged <65 years who had
sickness certification consultations (n = 14 210). Physicians
with support from the nearest manager and/or working in a
clinic with a joint policy regarding sickness certification were
compared with physicians without this, regarding collaboration with colleagues and external actors around patients sick
leave.
Results
Thirty-four percent worked in a clinic with a fairly or wellestablished sickness certification policy. Among those, 35%
had support from their nearest manager in sick-leave cases
compared with 15% among those without policy. Physicians
with policy participated in external meetings about sick-listed
patients more often, 10% compared with 4% did this at least
weekly. They also collaborated with colleagues and other
professionals in the health care to a greater extent. 5% of
physicians who experienced support to a great or fairly extent
had every week time scheduled for guidance, feedback, and
reflection compared with 1% among those without support, 32
and 11% respectively every month. Physicians with support
also found that collaboration with colleagues and other
professionals had developed their competence in sickness
certification tasks compared with physicians without support
from manager.
Conclusions
The results indicate a positive association of a joint policy and
of support from manager on collaboration around sick-listed
patients and on competence development regarding the
sickness certification task.
Assessment of smoke-free policy and practice in
health-care institutions in Serbia
Srmena Krstev
S Krstev*, S Simic, J Marinkovic, A Jovicevic, Lj Markovic-Denic,
A Kotevic
Public Health Association of Serbia, Belgrade, Serbia
*Contact details: srmena@sbb.rs
Methods
To evaluate PROAPS impact on infant mortality rate (IMR) a
model was designed combining qualitative and quantitative
evidence. The model includes the identification of economic,
political and social determinants, the political decision-making
with its principal stakeholders, and the degree implementation
of the interventions designed.
Information was collected from a questionnaire designed using
parameters of Health Policy Monitor. Secondary data source
was the National Institute of Statistics.
Results
The IMR analysis before and after PROAPS implementation
showed a change in slope statistically significant, which
descends more quick since 2001. This result suggests that the
PROAPS may have had a significant positive impact on health.
Nevertheless its implementation faced a major political
opposition. In 2006 PROAPS was restructured. No one went
about consolidating the Primary Care strategy, neither to
negotiate with the opposition to achieve a long-term
continuity.
Conclusions
Evidence suggests that the policies implemented were an
important programmatic success but these policies require
long-term continuity. Despite the excellent design, all the
stakeholders should have been involved from the beginning,
and policy makers should to negotiate with them throughout
the process. The study of the political style of the regional
government and the central government role, as well as the
health system decentralization process in Argentina, is very
important for future research, in order to understand the
causes of political failure.
Decision making process in vaccine policy: developing

country setting
Zakhro Djabbarova
ZD Zakhro Djabbarova1*, Barry N Pakes2
1
Monitoring and Evaluation Department, Institute of Health and Medical
Statistics, Tashkent, Uzbekistan
2
Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
*Contact details: zakhro.djabbarova@mail.huji.ac.il
Background
The relatively high burden of Vaccine Preventable Diseases
(VPDs) in developing countries can potentially be mitigated by
the introduction of newer vaccines into National
Immunization Programmes. Decision-making regarding priority setting and implementation requires both high quality data
and a systematic approach. The purpose of this exercise was to
assess a rational priority setting model which can be used as a
decision making tool to select the most appropriate vaccines
for introduction in limited funding.
Methods
A decision making framework was developed by incorporating
several health-related, economic and political factors into one
scoring system. Ranking variables included disease characteristics, local disease burden, cost-effectiveness and vaccine
efficacy, local and international knowledge/ attitude/behaviour
studies and PEARL (Propriety, Economics, Acceptability,
Resources, Legality) analysis. The scheme was demonstrated
using the case example of Uzbekistan under assumptions of its
unique health care delivery system and stable collaboration
with funding agencies such GAVI Alliance and UNICEF. The
seven candidate vaccines recommended by WHO, CDC and
UNICEF were considered.
Results
According to the model, the MMR (MeaslesMumpsRubella)
as combined vaccine had the highest score and was used as the
reference point. Rotavirus cost-effectiveness local studies
pushed that vaccine to second, while donor support and

pricing policy caused meningococcal vaccine to be ranked
third. Haemophilus influenza type B and the Pneumococcal
vaccines received intermediate and inactivated polio vaccine
(IPV) the lowest.
Conclusions
In spite of limitations this priority setting framework provides
the basis for the gradual vaccine introduction into National
Immunization Programme.
Health system responsiveness in Serbia (Domain
Dignity)
Sanja Matovic Miljanovic
S Matovic Miljanovic1*, V Bjegovic2
1
Euro Health Group, Denmark/Serbia
2
Social Medicine Institute, Faculty of Medicine, University of Belgrade,
Serbia
*Contact details: smatovic@ehg.dk
Background
Dignity is one of seven domains summarizing health system
responsiveness. Domain dignity is in this context related to
receiving health care in caring environment, without discrimination and with respect.
Methods
Health system responsiveness study in Serbia was accomplished as a cross sectional study according to WHO method.
The key informants, as well as the population (selected
households) were interviewed. The health system, in relation
to patient dignity, was reviewed through questions related to
the opinion of the interviewees on how often the patients are
treated with respect; how well are human rights of patients
with communicable diseases protected in the health system; to
which extent are patients encouraged to speak about their
problems, ask questions about their diseases, treatment and
care; and how well are patients privacy during treatment and
examination respected.
Results
The majority of key informants (73%) are of the opinion that
patients are treated with respect regularly or always, while 27%
think that patients are treated with respect only sometimes.
About 56.8% of key information providers are of opinion that
patients are only sometimes encouraged to speak freely of their
concerns and to ask questions regarding illness, treatment and
care, while 4.1% think that patients are never encouraged to
speak freely or ask questions. Approximately two-thirds of key
informants stated that the wishes of the patients for privacy,
during the treatment and examination, are mainly respected.
On the other side, personal experience of the patients show
that the highest number of them was treated with dignity when
visiting health care institutions during the last year (83.1%),
and that their privacy was respected during treatment and care
(88.1%). Interviewees with lower education are more prone to
assess that they were treated with dignity.
Conclusions
Improving the respect to the persons in Serbia is demanding
regarding the attitude of health care professionals towards the
health care system users, while at the same time only minor
investments are needed. Training of PHC personnel to better
respond to population expectations regarding the basic rights
of the individual to the dignified treatment is needed.
Local government smoke-free policy in Poland after
introducing Antitobacco Act in 1995
Lukasz Balwicki
L Balwicki1*, M Balwicka-Szczyrba2
Department of Public Health and Social Medicine, Medical University of
Gdansk, Poland
2
Department of Civil Law, University of Gdansk, Poland
*Contact details: balwicki@gumed.edu.pl
1
Issue
Poland since many years has one of the biggest prevalence of
smoking people in Europe as well as damages caused by
Background
The existing Serbian Law on Smoking Ban Indoors is outdated
and will be soon replaced by the new Law on Protection from
Second-Hand Smoke that will totally ban smoking in healthcare institutions (HCI) without exceptions. Having in mind
high prevalence of smoking in employees of HCI (39.9% total,
38.5% men and 40.0% women), we wanted to assess the
current policy and practice related to tobacco control and
propose the best ways to comply with the new Law.
Methods
Research was carried out in 2009 in all HCI in Serbia. A
questionnaire specifically developed for this study was sent to
all 399 HCI. Responses were received from 363 (91.0%)
directors or other responsible persons.
Results
In spite of high awareness of existing Law (99.7%), total
smoking ban has been introduced in 28.1% institutions. In
HCI with partial ban, smoking is permitted in common
premises, corridors, designated rooms and entrances (96.1,
97.6, 99.7 and 94.5%, respectively). In more than two-third of
all institutions (71.6%) various topics related to tobacco
control are discussed at scientific meetings. However, only
14.9% have smoking cessation service, and 29.7% sent one or
more employees to the smoking cessation trainings. As the
main obstacles employee resistance (68.2%) and no mechanism for penalties (46.3%) are indicated. Surprisingly, to better
implement smoking ban more education on health hazards
related to tobacco (13.8%) is suggested, as well as stricter
control of law implementation (11.8%).
Conclusions
A booklet presenting results of the survey, data on tobacco use
and various aspects of tobacco control has been published and
distributed to all HCI. Education on smoking cessation for
HCI teams has been intensified and the existing Guidelines for
smoking cessation counselling will be revised. There is a plan to
establish a tobacco control coalition of health care institutions.
199
200
How current tobacco control measures benefit

tobacco industry?
Daniil Gonschikov
KD Danishevskiy, KM Eroshina, DA Gonschikov*
Open Health Institute, Moscow, Moscow Medical Sechenov Academy
*Contact details: dago@list.ru
Legislations in most countries outlaw sales of poisons and of

highly addictive products, which are usually labeled as
narcotics. WHO Framework Convention as well as some
national laws state in legal terms that (i) tobacco harms health
and (ii) causes addiction. There is a legislative clash between
sales of addictive poisons and basic laws, e.g. laws on consumer
rights. Under Russian Constitution, Framework law on health
protection, Law on consumer rights protection and Criminal
code sales of tobacco are illegal and criminally prosecuted.
Most tobacco control laws benefit tobacco industry over a
longer term, even if they reduce tobacco sales by several
percent, as they re-legalize the production, sales and marketing
of tobacco, although within boundaries. Excise taxation puts
government in a position of a financially dependant industries
stakeholder. The only way to redress this vicious circle is to
recognize that tobacco production and sales are illegal, to
introduce temporary moratorium on the complete ban of
sales, within several years shift tobacco products to the
controlled market, where both providers and consumers are
strictly licensed and completely remove tobacco from the
market within several decades.
Caregiver perceptions about preparation and storage
of reconstituted powdered milk formula: implications
for microbiological safety and education
Elizabeth Redmond
EC Redmond*, CJ Griffith
Food Research and Consultancy Unit, University of Wales Institute Cardiff,
Western Avenue, Cardiff, UK
*Contact details: eredmond@uwic.ac.uk
Methods used to prepare and store reconstituted powdered

milk formula have important microbiological implications for
safety and public health. Recommended procedures in the
home and health-care settings may be achieved by parents and
caregivers being equipped with adequate/correct knowledge,
positive attitudes and motivation to implement desired

behaviours that can minimise microbial risks. This study
aims to understand parent and caregiver beliefs, attitudes,
practices and information provision relating to infant feeding
with powdered milk formula.
Sixteen focus groups were conducted in seven locations
across the UK and included homogenous groups of
parents, day-nursery-nurses, hospital-nurses and health-visitors. Respondents were recruited according to employment
responsibilities, frequency of formula preparation and demographics. Each group discussion followed a structured guide
and included evaluation of educational materials.
The majority of respondents were unaware of specific
microbiological risks associated with formula and considered
current practices to be safe. Some parents reported storage of
reconstituted formula at ambient temperature when away
from the home; others reported to take water and powder
separately and reconstitute immediately before use. Common
sources of formula information for parents included family,
friends, midwives and health-visitors. A frequent barrier for
obtaining information from professional sources was an
attitude being dead against formula. Hospital nurses, midwives and health-visitors reported having limited information
to distribute regarding formula feeding and cited lack of time
and conformity to the WHO Baby Friendly Initiative as
reasons for not providing formula-based advice or bottle
demonstrations. Further discrepancies between caregiver
groups will be discussed, particularly regarding information
provision.
Information sources for parents and health-care professionals
are lacking and messages are perceived to be inconsistent and
reportedly cause confusion at a parent and professional level.
Findings from this study will help to inform the development
of informed, targeted information sources that address
microbial risks of preparation and storage of powdered
formula milk and improve public health.
The Evaluations of the primary health-care

institutions personnel about the application of
performance-based supplementary payment system
Kiymet Fettah
K Fettah*, S Sahin
Hacettepe University, Department of Health Care Administration, Ankara,
Turkey
*Contact details: kiymetfettah@hotmail.com
The objective of this study is to evaluate the impact of the

performance-based supplementary payment system (PBSPS)
on health-care provision by opinions of the health personnel
working in local health centres. The research was carried out at
16 health centres selected among 104 health centres in Ankara.
A two-stage process including qualitative and quantitative
research methods was followed. In qualitative research, indepth interviews were made with head doctors (n = 16) and
nurses (n = 16) of health centres. In this stage, 18 positive and
22 negative opinions about PBSPS as well as 22 recommendations related to solution of its problems. In quantitative
research, the questionnaire based on findings of qualitative
research, was applied to all physicians and auxiliary health
personnel in 16 health centres. According to research findings,
the most prominent positive statements are; It provides
economic benefit,It increases the efficiency by means of
providing service for more patient in less time, It reduces the
sick leaves and permissions, negative statements are; It causes
to remove the improvement of the salaries out of the agenda,
The major difference between supplementary payment of
physicians and auxiliary health staff is lowered enthusiasm of
the auxiliary health staff, The workload of the staff is
increased suggestion statements are; The differencess of the
infrastructure between the local health centres should be
removed, Improvement of the salaries should be done instead
of supplementary payment and Automatization system
secondhand smoke. Antitobacco Act from the year 1995

introduced in Poland smoke-free places: workplaces, hospitals,
schools. It was one of the first comprehensive antitobacco acts
in Europe at that time. Regulators knew that list of places was
insufficient to protect people from environmental tobacco
smoke but there was no political agreement to do more. As a
compromise, the innovative Act set the authorization for local
self-governments to expand the list of places where smoking is
banned.
Results
After 15 years from introducing the Act we evaluated the
concrete results of this regulations. In Polish Law Regulations
Database we found that only 47 urban out of all 897 local
urban and rural communes in Poland included smoke-free
policy into account. Most of them (41/47) expanded smoking
bans on public transport (bus, tram) stops, 25 on children
playgrounds, three on city markets, three on sport venues,
three on border crossing points, two on cemeteries, three on
city parks, two on beaches, one on theatre venue, one on
stairways in multi apartment buildings.
Lessons
Local self-governments had not used the possibility to
complement national smoke-free policy. It can be explained
by lack of interest of local politicians in the field, lack of central
government incentives or implementation tools. Weakness of
local NGOs and public health leaders can also be pointed out.
As a consequence upcoming in 2010 national antitobacco
regulation will solve the issue and cover with smoking bans
public places that local self-governments did not manage to do.
should be installed for monitoring the unnecessary service

usage. In order to obtain additional income, revolving fund
supplementary payment is improved working motivation
statement has a significant difference in total working period
and The major difference between supplementary payment of
physicians and auxiliary health staff is lowered enthusiasm of
the auxiliary health staff statement has a significant difference
in gender and occupation. The results of the study displays that
precautions should be taken to prevent unnecessary services in
order to increase the effectiveness of performance payment
system, and not only quantity indicators but also quality
indicators related to the performance of services provided
should be developed
Priority setting in health care: Dutch lessons for the
European neighbours
Timo Clemens
Background
Priority setting has been regarded as an option to improve
quality and efficiency of health care in Europe triggered by the
intensified problems in health system organization.
Discussions have started in European societies with a different
degree of strength. In some European countrieslike in
Germany or in many of the new Member States and accession
countriesthe debates are still at an early stage. Therefore, a
reconstruction of the Dutch debate on priority setting can help
to elucidate hindering and facilitating factors of priority setting
in other European countries.
Methods
This case study was based on a qualitative design for analysing
the various perspectives inherent to the priority setting debate.
A literature search of international and national databases and
of websites of relevant Dutch institutions was combined with
semi-structured expert interviews. Interviewees had different
backgrounds including juridical, ethical, political or economic
perspectives to match the multidisciplinary of the topic.
Results
The Dutch discussion on priority setting has started comparatively early in connection with advice of the Dutch commission
Choices in Health Care. However, problems occurred when
the established criteria were tried to translate into praxis. Until
now a coherent framework for priority setting is still missing.
Nevertheless, the illumination of the topic from different
angles beyond the health system perspective has been helpful to
identify relevant stimuli and barriers to the debate.
Conclusions
Dutch lessons learned are valuable to priority setting debates
in other European countries. Furthermore, insights and
experiences transcend borders to give input into arising
questions and will ultimately support the goal of ensuring a
sustainable health care organization throughout Europe.
Stakeholders opinions on the alcohol policy
measures in Slovenia
Sandra Rados Krnel
S Rados Krnel1,2*, T Kamin1,2
Research Department, National Institute of Public Health, Ljubljana,
Slovenia
2
Faculty of Social Sciences, University of Ljubljana, Ljubljana, Slovenia
*Contact details: sandra.rados@ivz-rs.si
1
In the process of designing and implementing the alcohol

policy (AP) rather different stakeholders with the opposing
interests are anticipated: one group wants to decrease and the
other to increase the consumption of alcohol. The aim of our
research was to study opinions on the policy impact and
importance in reducing the harm done by the alcohol among
different stakeholders in AP in Slovenia. Through their

opinions stakeholders express their perspective on the subject,
causes of a problem, evidence and solutions and thus
consequently articulate their interests.
A national questionnaire survey was completed by alcohol
policy stakeholders that were divided into four main groups:
governmental organizations (GOs), public health organizations (PHOs), non-governmental organizations (NGOs) and
alcohol and related industry (AI). The questionnaire comprised of 25 items across nine alcohol policy domains. The
percentage of overall response was 54.1%. The received data
were analysed with SPSS and the differences in the opinions on
particular alcohol measures between groups were measured
using ANOVA and t-test.
Three main factors were revealed by factor analysis: education,
regulation and pricing. All stakeholders gave most emphasis in
terms of impact and importance to the measures related to the
education, communication, training and public awareness.
GOs, NGOs and PHOs score the perception of the likely
impact of the regulatory AP measures and the importance of
imposition of regulatory measures on reducing the harm done
by alcohol significantly higher than the AI. The AI perceive the
impact and importance of pricing measures for reducing harm
done by alcohol significantly lower than the group of other
stakeholders.
In comparison to the similar research on European level we
have as well found that different interests in relation to
particular AP measures guide different stakeholders but there
are also some differences as a consequence of national and
regional particularities. Despite the fact, that stakeholders
share different opinions and interests, we have identified many
common grounds on which different stakeholders could start
cooperating to avoid impasses and prepare better and more
effective AP measures for alcohol harm prevention in Slovenia.
Public health and ethical issues: a science fiction

perspective
Grazia Orizio
G Orizio*, U Gelatti
Department of Experimental and Applied Medicine, Section of Hygiene,
Epidemiology and Public Health, University of Brescia, Brescia, Italy
*Contact details: gorizio@med.unibs.it
Issue/Problem
The field of public health, with its commitment to make policy
decisions affecting environmental and health care issues for the
population at large, cannot avoid tackling ethical dilemmas.
Even though it may seem that science fiction and public health
do not have much in common, the works of science fiction
have been a surprisingly imaginative arena for speculation
about ethical issues concerning human welfare and the social
changes brought about due to technological advances.
By reviewing several works of science fiction, the following
presentation seeks to examine several ethical issues related to
public health that have been in some ways anticipated by this
genre of literature.
Science fiction has at times motivated deep reflection about the
role of technology in society and often presents the potential
consequences in spectacular and frightening ways. Often
examined are the controversies that have arisen between
scientific research and its possible adverse social effects. A
recurrent theme has been to explore the effects of biomedical
advances and their implications in terms of eugenics and
genetic engineering. Another theme in the literature has been
the blurring border between human and non-human, including stories about mutants and life forms that are a mix of
human, mechanical and electric systems often referred to as
cyborgs. Years before the concept of nanotechnology existed,
science fiction had already dreamt of a future where anything
could be transmuted in anything, raising questions about
T Clemens1*, P Schroeder-Baeck1, T Meyer2, H Brand1, H Raspe2

Department of International Health, Maastricht University, Maastricht, The
Netherlands
2
Department of Social Medicine, University Lubeck, Lubeck, Germany
*Contact details: timo.clemens@inthealth.unimaas.nl
201
202
individual and cultural identity, justice and values. There has

also been much written about the relationship between doctor
and patient and the risks of pursuing medical advance for its
own sake, rather than for the benefit of the patient.
Lessons
In discussing about the complex relationship between
technology, medicine and societal well being, science fiction
raises questions that can be useful to public health as well, in
order to rediscover its role in a world rapidly changing, and to
tickle ethical dilemmas that are inseparable from the process of
decision making within health policy.
Conclusions
The study recommends improving supervision, developing
quality control systems, increasing resources in TB control and
further developing protocols, procedures and regulations.
Apart from improvement in health care system, participants
recommended awareness campaigns as part of TB control to
change the negative attitudes and stigma among the general
public.
Integrating health impact assessment in everyday

governance practice in Hungary
Agnes Molnar
Improving TB control system in Armenia

Varduhi Petrosyan
V Petrosyan*, R Grigoryan, N Truzyan, H Martirosyan, B Crape
Center for Health Services Research and Development, American University
of Armenia, Yerevan, Armenia
*Contact details: vpetrosi@aua.am
Health impact assessment (HIA), Health impact assessment

(HIA), a powerful tool of healthy public policy making allows
the formative evaluation of potential health consequences of
planned measures. In Hungary the integration of HIA into
governance practice is a current challenge. The financialeconomic crisis and budgetary restrictions do not favour the
consideration of healthy policy options. However, adoptable
international approaches and new directions of global health
promotion activity give a broader framework of thinking.
Our policy analysis investigates the development of HIA as a
political issue and its present policy context in Hungary. Policy
alternatives of HIA implementation were assessed by SWOT
analysis and weighted by outcome with a view to lessons learnt
from international experience.
The rigidity of the Hungarian public administration system,
the lack of intersectoral mechanisms and human-centred
processes decrease the chance of applying HIA in the policy
making process. Nevertheless, the country has a unique
opportunity opened by the EU Structural Funds to make
health promotion an integral part to the policy development
agenda. According to the recent results of parliamentary
elections we can expect new techniques of government for
tackling horizontal type public policy issues. Establishment of
an independent expert panel responsible for the screening
of national legislative proposals and the accreditation of
external HIA working groups seem to be an optimal model
of HIA implementation. The appropriate professional collaboration, capacity and baseline support from policy side
appear to be available, but the framework of implementation
faces challenges policy analysis provides a useful method to
solve.
In the current situation of emergency health policy making,
HIA offers a relatively inexpensive tool with a real chance
to articulate the importance of health as a basic value
in governance. Our case study highlights the feasibility of
incorporating HIA into the policy making process in Hungary,
offering lessons for middle-income countries, as well.
Infectious diseases
Tetanus immune status and tetanus-prone wounds
management - prospective study in a french
emergency departement
Maurice Tanguy
M Tanguy1*, V Delmas1, J Choukroun2, Y Lannehoa2, S Fanello1
1
Departement universitaire de sante publique, CHU Angers, Angers, France;
2
Service daccueil des urgences, CH Le Mans, Le Mans, France;
*Contact details: mtanguy@gmail.com
Tetanus is a severe acute toxi-infection, potentially fatal,

caused by a neurotoxin produced by Clostridium tetani; it can
be prevented by vaccination.
Objective
To assess the tetanus vaccination status and define its main
causative factors; to compare the patients self-declared
vaccination status with his actual immunization cover.
Methods
Prospective study assessing the tetanus immunization status
based on reliable evidence (injection certificates or point-ofcare quick serodiagnostic test) and its determinants among
patients consulting for wound care at the Emergency
Department of a non university Hospital.
Background
Armenia is facing a reemerging threat from tuberculosis (TB).
Armenia is ranked 10th highest for TB incidence rate among
the 53 WHO European Region countries. The rates of new
drug resistant strains of TB have grown. This study provides an
assessment of stakeholders capacities in different TB control
activities and an evaluation of potential capacities for support
and cooperation with the Ministry of Health.
Methods
Semi-structured in-depth interviews and focus group discussions were used for data collection. Participants were experts,
administrators, providers of primary and specialized care,
patients.
Results
Study participants provided a number of strengths: establishment of the National TB programme (NTP) provided a
national infrastructure for TB control. The decentralization
process brings services closer to where patients live. Free TB
services and TB medication are provided to the entire
population. Successful collaborations in TB control have
been seen in the penitentiary system and DOTS+ pilot sites.
Some of the leading challenges identified included lack of
definition of roles and responsibilities in TB control in the
civilian sector and problems in recruiting and retaining
qualified professionals in TB control in both penitentiary
and civilian sectors due to lower compensation and fewer
benefits. Participants also indicated lack of modern standards
for infection control, inadequate physical infrastructure and
substandard equipment and supplies.
Participants widely indicated that there was a lack of capacity
to conduct rigorous DOTS in the civilian sector and to expand
DOTS+ to both civilian and penitentiary sectors.
One of the important findings was stigma and fear of TB that
exist among general population and health care workers. This
stigma contributes to late utilization of TB services, negative
social consequences and spread of disease.
MD Molnar*, P Makara, R Adany

Department of Preventive Medicine, Faculty of Public Health, University of
Debrecen, Debrecen, Hungary
*Contact details: magnes@dote.hu
Results
1120 patients were included. 50% declared they had their
boosters in time, 31% did not know their vaccination status,
and 16% had some kind of vaccination certificate. As for actual
coverage, it appeared that only 61% were immunized and 8.1%
not immunized against tetanus, but for 30.5% it was
unspecified (no document, no test). The coverage decreased
significantly with age. It was better for men.
Conclusion
According to current data, our findings confirm that only 61%
of the population is immunized against tetanus, with a lack of
coverage in particular for women and elderly. Therefore we
have to change our practices to increase immunization
coverage and reduce the use of specific human immunoglobulins for tetanus prophylaxis.
A study of clients knowledge, attitude and practice
about influenza A h1n1 vaccine, Jordan 2009
Ghazi Sharkas
Background
Influenza A H1N1 infection was first identified by CDC in the
United States in the 15th of April 2009. A specific vaccine to
the virus was manufactured in October 2009. In Jordan, the
first PCR confirmed case was in June 15th and the total
number of cases until the time of this study reached to 3049
with 14 deaths. Jordan received the first quantity of the vaccine
by early November 2009. The vaccine was distributed to the
different health-care centres for free. This study aims to
evaluate clients knowledge, attitude and practice towards
influenza A H1N1 disease and vaccine.
Methods
A cross sectional study was conducted from 20th December
2009 to 3rd January 2010. Amman, Irbid and Karak cities were
selected to represent the central, north and south region. A
total of 10 comprehensive health-care centres were randomly
selected to be included in the study. A questionnaire was
designed; FETP residents were trained to interview clients. The
target groups were all clients aged 18 years and older attending
the selected health-care centres during the study period.
Sample size was 889.
Results
All study population has heard about influenza A H1N1.
60.4% of them described the disease as severe. The most
commonly reported symptom was fever (85.9%) and the least
commonly reported symptom was dyspnoea (9.4%). 94.3%
reported correctly the mode of transmission. 92.6% reported
that influenza A H1N1 was a fatal disease. Two-thirds reported
that specific treatment was available for the disease and 79.4%
reported that the vaccine was available in Jordan. Only 0.8% (7
persons) of the study population were vaccinated at the time of
this study. 28.3% were ready to take the vaccine, 70.8% were
afraid but 37.8% reported that they advice others to take the
vaccine. Vaccine complications were the major causes of
concern in 30.7% of reporters. The main source of information
was TV (54.1%). Misinformation and rumours accounted for
21.4% of respondents information.
Conclusion
Jordanian clients had good knowledge about Influenza A H1N1
disease and vaccine. The extremely low vaccination coverage
and hesitancy to take the vaccine required ongoing educational
campaigns, and correction of clients vaccine misconceptions.
Eight years of hepatitis B vaccination among high-risk
groups
Marlies van Dam
M Van Dam, IMS Ouwerkerk, A Timen
Preparedness and response unit, National Institute of Public Health and the
Environment, Bilthoven, The Netherlands
*Contact details: marlies.van.dam@rivm.nl
In November 2002 The Netherlands started a hepatitis B

vaccination programme targeted at behavioural high-risk
groups. Being a low-endemic country, The Netherlands does
not have a universal hepatitis B vaccination policy. The
programme offers free vaccination to men having sex with men
(MSM), commercial sex workers (CSW) and drug users
(DUs). Vaccination takes place at the local public health
service and at STI (Sexual Transmitted Infections) clinics and
is offered free of charge according to the 6-month schedule.
Participants are tested serologically for markers of previous or
current hepatitis B infection prior to receiving their first
vaccination. Unique in this vaccination programme is the
tailored approach in different regions of the country to reach
the target groups in their own meeting places. For example,
vaccination not only takes place at the public health service,
but is also provided in drug consumption rooms, prisons,
prostitution clubs, saunas and at gay parties.
Now, 8 years later, more than a 100 000 participants in the
programme have been vaccinated.
Among drug users (who are known in addiction care centres),
more than 90% was reached by the vaccination programme
and 45% of the DUs are fully vaccinated. Nearly 60% of the
CSW are reached by the programme and 24% of the women
received all three vaccinations. Among MSM, 55% is fully
vaccinated and 66% of the total MSM population is reached by
the program. Over the last few years, the number of CSW and
DUs receiving their first vaccination is declining, which might
be due to saturation.
After combining the data from the vaccination programme
database with epidemiological data from the nationwide
database for notifiable diseases, we can conclude that
vaccination of a significant portion of the target risk
groups contributes to a decline in acute hepatitis B infections
in The Netherlands, especially among men who have sex with
men.
Assessment of hepatitis A surveillance compared with
seroprevalence survey, Jordan (200408)
Ghazi Sharkas
G Sharkas1*, A Belbeisi2, S Elsheikh3, I Iblan1, M Assada1,
R Haddadeen1
1
Jordan field epidemiology training programme (JFETP)
2
Consultant of Jordan minister of health
3
Head of emerging and reemerging diseases Jordan ministry of health
(JMOH),
*Contact details: ghazisharkas@yahoo.com
Background
Hepatitis A virus causes acute infectious self-limiting liver
disease. It is a notifiable disease primarily transmitted via the
faecal oral route and associated with poor hygiene and
sanitation. The incidence is high in developing countries and
the illness is usually contracted in early childhood. Severity
tends to increase with age. This study aimed to asses hepatitis
A surveillance, and to discuss whether hepatitis A vaccination
is recommended in the Expanded programme of
Immunization (EPI).
Methods
A descriptive epidemiological study utilized surveillance data
of hepatitis A reported to the communicable diseases
directorate from 2004 to 2008. Results were compared with
the seroprevalence survey of hepatitis A that was done in 2008
and was not published yet.
Results
The average reporting rate of hepatitis A from 2004 to 2008
was 6.9 per 100 000 populations. About 56% were males. The
disease was rarely reported below 1 year of age (0.7%) and
most commonly reported by 59 years (41.3%). Seasonality
with increased reporting in autumn was noticed. The north
region recorded the highest reporting rate from 2004 to 2008
(average 10.4 per 100 000).
G Sharkas1*, S Abdalla2, B Abdalla1, I Iblan1, K Rawashdeh1,

M Assada1, N Qasim1, N Abdelaziz1, R Haddadin1
1
Jordan Field Epidemiology Training Programme (JFETP), Amman, Jordan
2
Head of Surveillance Jordan Ministry of Health (JMOH), Amman, Jordan
*Contact details: ghazisharkas@yahoo.com
203
204
In the community-based seroprevalence survey, the overall

seroprevalence was 25/100 000. Both genders were equally
affected. Seroprevalence increased from 21.9% below 1 year of
age to 95.6% in the age of 20 years. There were different
seroprevalences by regions . The central region recorded the
highest 26 per 100 000.
Conclusions
The majority of Jordanian adults had hepatitis A infection.
Seroprevalence was almost four times higher than the
reporting rate emphasized that 80% of infections were
subclinical. This study results are available to health decision
makers to assist in the introduction of hepatitis A vaccine in
the EPI.
Potential years of life lost due to human
immunodeficiency virus (HIV) infection in Latvia from
1991 to 2008
Anda Karnite
Background
HIV-related mortality rates in Latvia are increasing year by
year. Almost all people living with HIV/AIDS (PLH) who have
died are <65 years. Thus its important to estimate Potential
years of life lost (PYLL) and related factors which could help
clinicians in communication with patients about their life
expectancies after diagnosis and to policy makers to estimate
the costs of the infection.
Methods
Data from the National Registry of HIV/AIDS cases was used
for the time period from 1991 (when the first HIV-related
death in Latvia was registered) till 2008. Thus data on 427
death cases were analysed. PYLL were calculated as the sum of
years that PLH have lost because of premature death (<65
years). Mean PYLL between different groups was calculated
and compared using Students t-test, ANOVA as well as a
linear regression model was constructed.
Results
Mean PYLL in PHL was 29.8. There was no statistically
significant difference between gender groups. The indicator
was significantly higher in persons getting HIV from injecting
drug use comparing to other modes of transmission
(P = 0.005). Mean PYLL was higher for those living in Riga
(the capital city of Latvia) comparing to PLH living outside
Riga (P = 0.06) although this difference isnt statistically
significant. Mean PYLL was lower for PLH diagnosed in the
Highly Active Antiretroviral Therapy (HAART) era comparing
to those identified before it (P = 0.69), this difference is not
statistically significant. Older age at time of diagnosis was
found to be linked to lower PYLL (P < 0.001). In the
multivariate analysis higher PYLL indicator was found to be
significantly linked to injecting drug use and to younger age at
the time of diagnosis.
Conclusions
In Latvia factors significantly linked to the higher mean PYLL
were injecting drug use and younger age at the time of
diagnosis.
Regional surveillance of Methicillin-resistant
Staphylococcus aureus and benchmarking
Annette Jurke
AH Jurke1*, R Kock2,3, I Daniels-Haardt1, AW Friedrich3
North Rhine-Westphalian Institute of Health and Work, Munster, Germany
2
Institute of Medical Microbiology, University Hospital Munster, Germany
3
Institute of Hygiene, University Hospital Munster, Germany
*Contact details: annette.jurke@liga.nrw.de
Hepatitis E virus infection in human and pigs in

Sardinia, Italy, (200608)
Laura Andrissi
L Andrissi1*, G Masia1, G Orru`2, M Liciardi3, A Meloni1, RC Coppola1
Department of Public Health, University of Cagliari, Italy
2
Istituto Zooprofilattico Sperimentale (I.Z.S.) of Sardinia
3
Veterinary Service ASL N8-Cagliari, Italy
*Contact details: lauraandrissi@tiscali.it
1
Background
Hepatitis E virus (HEV) is responsible for a faecal-oral
transmitted acute hepatitis. The highest rates of infection
usually occur in regions with low standards of hygiene, but
sporadic cases of hepatitis E have also been reported in
industrialized countries, including Italy. Serological surveys
suggest the diffusion of strains of hepatitis E of low
pathogenicity. This disease is considered an emergent zoonosis;
could it be treated as a professional disease?
Methods
In 2008, 532 subjects (402 blood donors and 130 workers at
zoonotic risk) were enrolled. Anti-HEV antibodies were
determined (enzyme linked immunosorbent assay) and the
HEV-RNA was extracted and tested by RT-Nested-PCR, then
95 bile samples were collected from randomly selected pigs and
the RNA was extracted as above.
Results
The overall prevalence of anti-HEV antibodies was 4.3% (5.0%
blood donors, 2.3% workers at zoonotic risk). The search for
HEV-RNA in the subjects positive for antibodies, gave negative
results.
A Karnite1*, G Brigis1, J Skrule2, A Lazdina3, I Upmace3

1
Department of Public Health and Epidemiology, Riga Stradins University,
Riga, Latvia
2
Unit of Public Health Data Analysis, Centre of Health Economics, Riga,
Latvia
3
AIDS Programme Coordination Unit, Infectology Centre of Latvia, Riga,
Latvia
*Contact details: anda.karnite@rsu.lv
Background
MRSA is a major cause of health-care-associated infections
(HCAI). Since MRSA can be disseminated between hospitals
serving one regional patient catchment area, successful
prevention and control of MRSA-HCAI requires concerted
efforts. Therefore, regional benchmarking of hospital MRSA
surveillance data might open up opportunities to reduce
infection rates.
Methods
A total of 38 hospitals covering 10 851 patient beds and
comprising 308 000 admissions in 2009 in the Munsterland
have established a network for combating MRSA infections. In
2007 they have agreed upon a synchronized strategy for
screening of risk patients at admission and are reporting
MRSA data. Since 2007 the following indicators were assessed:
rate of nasal swabs per 100 patients admitted, MRSA incidence,
nosocomial MRSA incidence density, nosocomial MRSA-cases
per 1000 MRSA days and the number of MRSA blood cultures.
Results
In average, the rate of screening cultures per 100 patients in 33
hospitals was 30.5% in 2009 [Q(25) = 12.2%, median 25.4%,
Q(75) = 39.2%]. There was a significant (P < 0.05) increase of
this rate from 2007 to 2009. The MRSA incidence in 2009 was
in average 1.51 MRSA cases per 100 admissions[Q(25) = 0.85,
Median = 1.25, Q(75) = 1.60], which also increased significantly (P < 0.05) since 2007. The mean nosocomial MRSA
incidence density in 2009 was 0.16 nosocomial MRSA-cases
per 1,000 patient days [Q(25) = 0,04, Median = 0.13,
Q(75) = 0.24] and decreased from 2007 to 2009. In 2009,
there were an average of 7.6 nosocomial MRSA-cases per 1000
MRSA-days [Q(25) = 3.4, Median = 5.9, Q(75) = 11.7] with a
decrease compared with 2007.
Conclusion
Successful adherence to the synchronized regional screening
strategy was measurable by continued increased performance
of screening in hospitals. The enhanced screening of risk
patients resulted in a considerably better detection of MRSA
carriers at admission, which accompanied by adequate hygiene
measures resulted in decreasing nosocomial transmissions. All
surveillance data is given as feedback to the regional hospitals
and health authorities. This should improve prevention and
control of MRSA HCAI in the long run.
HEV genome was detected in 6 of the 95 swine bile samples

tested. Sequences were clustered within the genotype 3 and are
edited on GenBank under accession number: from FJ850960 to
FJ850962 and from FJ883000 to FJ883002.
Conclusions
The overall prevalence of anti-HEV shows that the virus
circulates without giving origin to cases of acute hepatitis. The
low prevalence value found in workers at zoonotic risk does
not apparently support the hypothesis of professional risk. In
this study, HEV-RNA was isolated from pigs in Sardinia for
the first time confirming the role of swine as HEV reservoir
and the possibility of virus transmission to humans.
Pseudomonas Aeruginosa resistance to third and
fourth generation Cephalosporins: the results of an
environmental investigation in a Teaching Hospital in
Rome
Stefania Bruno
S Bruno*, S Carovillano, G Quaranta, F Dalla Torre, C Turnaturi,
MG Ficarra, P Laurenti, G Ricciardi
Institute of Hygiene, Catholic University, Rome- Italy
*Contact details: bruno_stefania@rm.unicatt.it
Evaluation of prevention of professional acquired

blood borne infections in hospitals in three European
countries
Predrag uric
P --Duric*, K Polanska2, L Maruskova3, V Turkulov1
Center for Education, Tolerance, and Multiculturalism, Novi Sad, Serbia

Trnava University, Faculty of Health Care and Social Work, Trnava, Slovakia
*Contact details: duricp@gmail.com
2
3
Background
Exposure to blood-borne pathogens poses a serious risk to
health-care workers (HCW). Human immunodeficiency virus,
hepatitis B and C viruses are most commonly involved in
occupational transmission. This article presents preliminary
results from project Evaluation of prevention of professional
acquired blood borne infections in Central European hospitals
funded by the Fogarty International Center at the National
Institutes of Health with the aim of evaluate HCWs awareness
of danger of blood borne infections (BBI) and attitudes
towards prevention of exposure in Serbia, Poland and
Slovakia.
Methods
The study was conducted among 100 HCW (50 physicians, 50
nurses) of hospitals in each of three countries in January till
April 2010. Data was collected through anonymous questionnaire focused on knowledge about prevention and control
of BBI, attitudes and behaviours of HCW. Preliminary results
from Serbia and Slovakia are available at the time this abstract
is written.
Results
More than half of HCW in Serbia were vaccinated against
hepatitis B with three doses of vaccination compared with 83%
of HCW in Slovakia. Level of knowledge of HCWs about
general prevention for BBI (methods of prevention, ways of
exposure, activities in case of needle stick injury) in Serbia and
Slovakia was relatively high. More than 80% of HCW take
measures to prevent infection transmission during work with
every patient and those mostly differ by knowledge about HIV,
HBsAG or anti-HCV status of the patient. Approximately
three quarters of HCW are always wearing protecting gloves
during interventions with possible contact with patients fluids
and 90% are always changing it after every contact with
patient. Masks and protective glasses are wearing less often.
Almost every HCW in Slovakia and four from five HCW in
Serbia put medical dangerous waste always in impenetrable
containers.
Conclusions
Preliminary results demonstrate relatively high level of knowledge of HCW about prevention of BBI in Serbia and Slovakia
and also differences in attitudes and behaviours of HCW
according to prevention.
Use of primary care electronic networks to assess the

incidence of genital chlamydia in general practice
Anita Suijkerbuijk
AWM Suijkerbuijk1*, IVF van den Broek1, HJ Brouwer2,
AM Vanrolleghem3, JHK Joosten4, RA Verheij5, MAB van der Sande1,6,
MEE Kretzschmar1,6
1
Centre for Infectious Disease Control, RIVM, Bilthoven, The Netherlands
2
Department of General Practice, Academic Medical centre-University of
3
Department of Medical Informatics, Erasmus University Medical Centre,
Rotterdam, The Netherlands
4
Academic General Practice Network VUmc, Free University Medical Centre,
5
NIVEL, Netherlands Institute for Health Services Research, Utrecht, The
Netherlands
6
Julius Centre for Health Sciences and Primary Care, University Medical
Centre Utrecht, Utrecht, The Netherlands
*Contact details: anita.suijkerbuijk@rivm.nl
Background
Chlamydia is the most common curable sexually transmitted
infection in The Netherlands; it can cause serious problems in
women including cervicitis and upper genital tract infections.
In The Netherlands, most chlamydia diagnoses are made by
general practitioners (GPs). Reports on the incidence of
chlamydia rates in primary care are limited. Furthermore,
there is a need for baseline data from primary care to enable
future evaluation of the population impact of a large
Issue
In 2008 the European Antimicrobial Resistance Surveillance
System Report highlighted the geographical gradient for
Pseudomonas aeruginosa antibiotic resistance to Ceftazidime,
showing <5% resistance in the northwest (Iceland, Lithuania,
Denmark, The Netherlands, Norway, Sweden) and >25%
resistance towards the southeast (Czech Republic, Greece and
Italy).
Moreover in 2008 Martinez JL stressed the need to focus on the
role of environment because part of antibiotic-resistance
depends on water environments where bacteria mix and
exchange genes.
In order to assess the resistance proportions to Ceftazidime
and Cefepime of Pseudomonas aeruginosa strains isolated
from potential water sources in generic and high-risk wards of
a Teaching Hospital in Rome, a cross-sectional study was
carried on. Municipal water, dyalisate, fluid for the bronchoscopes disinfection effectiveness assay, double osmosis treated
water samples were routinely collected from September 2004
to October 2009. Pseudomonas aeruginosa was identified by
routine test (growth characteristics and biochemical fermentation); the antimicrobial susceptibility was tested automatically
with ATB PSE 5 strips (BioMerieux).
The chi-squared test (2) was performed in order to evaluate
the association between Pseudomonas aeruginosa isolates and
the antibiotic resistance; the statistical significance was set at
P < 0.05.
Results
Out of 1752 samples, 32 Pseudomonas aeruginosa strains were
isolated, representing 31.4% of all NFGN bacteria: 40.6%
(n = 13) of all Pseudomonas aeruginosa were Ceftazidime
resistant (2 = 5.62, P = 0.01) and 31.3% (n = 10) were
Cefepime resistant (2 = 0.54, P = 0.45) and 31.3% (n = 10,
the same Cefepime-resistant strains) showed resistance to both
Cephalosporins (2 = 4.9, P = 0.026).
Lessons
Even if our data refers to environmental strains, an important
warning rises up from the resistance proportions both to
Ceftazidime and thirdfourth Cephalosporins together: available antibiotics, above all last generations, require judicious
and prudent use, following and integrating evidence-based
data in the clinical practice.
205
206
Frequency of preventable communicable diseases

among roma population in comparison with majority
in Bardejov region in 19972006
Kvetoslava Rimarova
K Rimarova1*, M Feckova2, A Kecerova3, J Kostovcikova4
1
Institute of Public Health, Faculty of Medicine, Pavol Jozef Safarik
University, Kosice, Slovakia
2
Regional Public Health Authority, Bardejov, Slovakia
*Contact details: kvetoslava.rimarova@upjs.sk
Background
The main aim of the study was to find out and compare the
frequency of communicable diseases among Roma population
in comparison with majority population in Bardejov district in
the period of 19972006.
Methods
Data about proportion of Roma population and majority
population demography in Bardejov district were obtained
from regional municipality statistics and from Statistical Office
of Slovak Republic. Data about frequency of diseases were
obtained through an information system database EPIS from
Regional Public Health Authority Bardejov. Reporting of
infectious disease is mandatory through EPIS and it is duty of
local general practitioner (GP) and paediatricians (any primary
health care staff). Statistical analysis was performed in Excel
program, the significance was tested by Chi-square test.
Results
Average annual salmonella morbidity of majority population
was 1.8 times higher than among Roma inhabitants
(P < 0.001). Salmonella morbidity has globally declining
trend and balancing of morbidity was noticed in observed
population in district in recent years.
Average annual morbidity of dysentery diseases in Roma
population was 13.2 times higher than in majority population
(P < 0.001). In Roma population more frequent (54.31%) was
aetiological agent Shigella flexneri, while in majority population in 31.79%. Shigella sonnei occurred as aetiological agent
in Roma population in 45.69% and in majority population in
78.21%. Since 1998 dysentery disease morbidity has been
showing declining trend.
In Bardejov district from 1997 till 2006 were observed two
cycles of outbreaks of viral hepatitis type A, the both of them of
epidemic origin and both occurred in Roma settlements.
Average annual morbidity in Roma population was 27.8 times

higher than in majority.
Conclusions
Results confirmed differences in incidence of selected communicable diseases among Roma population and majority.
These findings refer to the persisting problems, which have
negative influence on health and quality of life of Roma
inhabitants, particularly children. This article is supported by
grants EU Public Health MEHO, VEGA 1/0451/09, VEGA
1/0359/10 and /KEGA 260-002UPJS-4/2010.
Results of the second generation surveillance survey
conducted among IDUs in Russia
Ksenia Eroshina
KM Eroshina1*, KD Danishevskiy1, SL Plavinskiy2
Open Health Institute, Moscow, Russia
2
St. Petersburg Medical Academy for Postgraduate Studies, Russia
*Contact details: keroshina@ohi.ru
Background
HIV epidemic in Russia is still in its concentrated stage in most
regions. The total number of HIV cases is over 520 000 with
most cases among injecting drug users (IDUs). Still harm
reduction (HR) approach has no Government support.
Currently HR programmes are implemented as part of
international projects. Association of risky behaviours and
HIV incidence among IDUs was studied.
Methods
A second generation surveillance was conducted in two stages:
(i) February 2006; (ii) October 2008 in 10 regions of Russia
with HR programmes. Structured interviews and HIV tests
were used among a random sample of IDUs: participants and
non-participants of HR programmes. HIV incidence rate was
estimated by requesting information about previous test and
retesting those previously negative IDUs.
Results
In 2006, 2771 IDUs and in 2008, 2731 IDUs participated. The
prevalence rate of risky behaviours was significantly different
between participants and non-participants of HR programmes.
Syringe sharing during last month was reported by 22% of HR
participants versus 15% of non-participants, during last
injection 8% versus 4% and condom use during last
intercourse 71% versus 64% accordingly (P < 0.001).
HIV average incidence was 52 per 1000 per year [95%
confidence interval (CI) = 3.97.5%] and did not change
among IDUs HR non-participants in 200608. Among HR
programmes users average incidence level was 29 per 1000 per
year (95% CI = 1.94.4%), falling from 3.5% in 2006 to 2.5%
in 2008. Risk ratio of HR clients versus non-clients for HIV
was 0.56 (95% CI = 0.310.97).
Conclusions
The results indicate significant difference in risky behaviours
prevalence and HIV incidence between IDUs participants and
non-participants of HR programmes. There is urgent need to
support such programmes. HIV prevention for most vulnerable populations should be included into Russian public health
strategy.
Setting indicators for assessing the HIV/AIDS 201013
Action Plan in Catalonia, Spain
Sandra Pequeno
S Pequeno1, C Medina1*, R Mansilla2, R Tresserras1, A Gimenez2
Planification and Evaluation Directorate, Ministry of Health. Catalonia,
Spain
2
AIDS Programme. Ministry of Health. Catalonia, Spain
*Contact details: camedina@catsalut.cat
1
Background
At the beginning of 2010 the HIV/AIDS Intersectoral
Commission of Catalonia approved the HIV/AIDS Action
Plan 201013. It aims the implementation of measures to
population-based screening. In this study we assessed chlamydia incidences in primary care, using electronic record systems
of four GP networks.
Methods
Two regional and two national networks were included. In the
electronic records, we identified chlamydia diagnoses by ICPC
codes (International Classification of Primary Care), laboratory results in free text and the use of antibiotics. We
calculated chlamydia incidences per gender, age group and
degree of urbanization.
Results
A large variability was observed in the way chlamydia episodes
were coded. The overall incidences in the networks ranged
from 103.2 per 100 000 to 590.2 per 100 000. Chlamydia
incidences were highest in younger age groups (up to 30 years
old), were two fold higher in women than in men and
increased with degree of urbanization.
Conclusions
We observed similar patterns in chlamydia incidence in four
different GP networks. Registries, originally intended for
individual patient care in general practice; can be a valuable
source of information for monitoring chlamydia incidence in
primary care. This information is essential for a full assessment
of the impact of population-based chlamydia screening
programmes. More efforts should be undertaken to standardize registration rules and the application of ICPC codes in GP
networks.
High prevalence of HBV and HCV among injecting

and non injecting drug users in Italy
Vincenza Regine
L Camoni1*, V Regine1, MC Salfa1, M Raimondo1, AHL Bruning2,
G Nicoletti3, P Canuzzi3, N Magliocchetti3, G Rezza1, G Suligoi1, the
Sert Study Group
1
Reparto di Epidemiologia, Dipartimento di Malattie Infettive, Istituto
Superiore di Sanita`, Roma, Italy
2
Academic Medical centre, University of Amsterdam, Amsterdam, The
Netherlands
3
Ministero del Lavoro, della Salute e delle Politiche Sociali, Roma, Italy
*Contact details: laura.camoni@iss.it
Background
Our objective was to estimate the prevalence of HBV and HCV
infections among injecting and non-injecting drug users
treated within public drug-treatment centres in Italy to
determine the correlates of infection.
Methods
The study, performed in 2005 and 2007, was cross-sectional.
Socio-demographic and behavioural data were collected. The
prevalence rates were based on serological tests performed in
2005 and 2007. A multivariate analysis of correlates was
performed.
Results
In the sample of 2582 drug users, the prevalence of HBV was
79.4% among injecting drug users and 39.4% among noninjectors and HCV was 89.3% among injecting drug users and
33.5% among non-injectors. Old age, low level of education
and intravenous drug use, not having a job, a longer history of
injecting drug use and being HIV-positive were significantly
correlated with hepatitis B for injecting drug users, as well as
attending at a drug centres in central or southern Italy, not
having a job and a longer history of drug use for non-injectors.
Hepatitis C were significantly correlated with old age, not
having a job, a longer history of injecting drug use and being
HIV-positive for injecting drug users and with an early age at
first sexual intercourse and with a longer history of drug use

for non-injectors.
Conclusions
The results indicate that these infections continue to circulate
among drug users, highlighting the need for monitoring of this
group in Italy.
Vaccination against the 2009 pandemic influenza A
(H1N1) among health-care workers in the major
teaching hospital of Sicily (Italy)
Alberto Firenze
A Firenze*, E Amodio, A Anastasi, M Morici, L Marsala,
MV Torregrossa, N Romano
Department for Sciences of Health Promotion G. DAlessandro, University
of Palermo, Palermo, Italy
*Contact details: albertofirenze@unipa.it
Background
Flu vaccination of health-care workers (HCWs) is worldwide
considered one important evidence-based public health
measure in order to prevent the disease and to avoid the
transmission of influenza.
The willingness for having vaccine uptake among Italian
HCWs was reported to be low and fear of side effects was cited
as the main reason for uncompliance. The aim of this study
was to investigate factors involved in vaccination acceptance
among HCWs and adverse reactions rates associated with
pandemic influenza vaccination.
Methods
Observational study conducted in the major teaching hospital
of Sicily from October 2009 to February 2010 on 2347 HCWs.
Socio-demographic and occupational data of all HCWs were
obtained from administrative hospital personnel records
whereas information on life-style habits, chronic diseases,
signs and symptoms after vaccination and occurrence of ILI in
vaccinated HCWs were collected by questionnaires at the end
of February 2010.
Results
A total of 419 (17.9%) out of 2347 HCWs were vaccinated
against pandemic influenza. Significantly higher coverage rates
were associated with older age, male sex, profession, job status,
working place and vaccination against seasonal influenza in
200809. Overall, 311 (74.2%) of the 419 questionnaires
distributed to vaccinated HCWs returned after a 3 months
observation period. One hundred and fifty-six workers
(50.2%) experienced at least one local or systemic adverse
reaction (43.4% local reactions and 19.6% systemic reactions).
The most frequent side effect of vaccination was pain at the
injection site (43.1%). 12 (3.8%) out of 311 HCWs stated
experienced ILI during the observation period.
Conclusions
The acceptance of the pandemic vaccine among HCWs remain
far from that recommended by WHO although flu vaccination
is an effective and safe preventive procedure. Monitoring
compliance with vaccination allows detecting HCW groups
with lower coverage helping health-care managers to plan
tailored vaccination campaigns.
Infectious diseases and testing behaviour in patients
getting substitution treatment in Germany
Tanja Wormann
T Wormann1*, HJ Jahn1, L Prufer-Kramer2, A Kramer1
1
Department of Public Health Medicine, School of Public Health, University
of Bielefeld
2
Travel Clinic, Bielefeld, Germany
*Contact details: tanja.woermann@uni-bielefeld.de
Background
In Germany, around 72 000 injecting drug users (IDU) are
receiving opioid agonist maintenance or substitution treatment (ST). ST is considered to be an effective method for
prevent the spread of infection and improve the quality of life

of infected people. It was created in the framework of the HIV/
AIDS Multisectoral Spanish Plan which was set following a
Spanish Parliament mandate.
Objective
To draw up indicators for the evaluation of the HIV/AIDS
Action Plan 201013.
Methods
The main criteria for selecting indicators were appropriateness
and usefulness of what was going to be measured. Validity,
reliability, specificity, sensitivity, measurability and availability
of data were other criteria. Calculation methods were
established and indicators were classified according to intervention areas.
Results
The Action Plan has 14 action lines, 61 projects and 164
activities related to epidemiology, prevention, clinical care,
social rehabilitation, community interventions, research,
international cooperation, communication strategies and
training. 243 Indicators related to structure, process and
outcomes according to the subjects of the activities were
defined. Eight key indicators for global assessment were
defined related to: epidemiological surveillance (two), infection prevention (one), diagnosis delay (one), improvement in
medical care (one), treatment compliance (one) and disease
prevention policies (one).
Lessons
Some activities of the Action Plan had to be reformulated upon
agreement with the interdisciplinary authors Plan due to a
lack of clarity. At the time of the developed and evaluation
schedule of the Plan, a systematic review of all targets can be
useful to define a proper indicator. Predefinated indicators will
allow not only evaluation but also monitoring the implementation of the plan.
207
208
Introduction of seven-valent Pneumococcal conjugate

vaccine and its impact on measlesmumpsrubella
immunization among infants in Italy
Laura Camilloni
L Camilloni1*, P Pezzotti1, P Giorgi Rossi1, R Baldi2, C Marinacci3,
P Borgia1, G Guasticchi1
1
Agency for Public Health, Rome, Italy
2
Baldi R: Prevention Department, ASL5 Spezzino, La Spezia, Italy
3
Marinacci C: Department of Epidemiology, ASL TO3, Turin, Italy
*Contact details: camilloni@asplazio.it
Background
The seven-valent Pneumococcal conjugate vaccine (PCV7)
immunization implies the addiction of three more injections
to a child. There is concern about potential delays in other
vaccinations. We evaluated whether the PCV7 introduction
(free since 2003) affected immunization coverage against
measlesmumpsrubella (MMR), and if geographical and
socio-cultural factors were associated with it.
Methods
Retrospective study of the vaccination registry of La Spezia
county (around 1000 newborns per year), north-western Italy.
The percentage of children vaccinated for PCV7, MMR and
age-appropriate MMR (AA-MMR) was calculated. Logistic
regression model was performed to evaluate factors associated
to MMR and AA-MMR vaccination; the number of days
without immunization by 16 months were evaluated using a
negative binomial regression. Models were stratified by period
of PCV7 introduction (I semester of 2003) and following
period (II semester of 200305).
Results
PCV7 was administered to 10.8% of children born in I/2003,
78.6% of those born in II/2003 and 93% of those born in 2005.
MMR and AA-MMR vaccination slightly declined in the

period 200305 (93.6 and 54.9% in I/2003; 90.5 and 46.4% in
2005).
PCV7 was the most important independent determinant for
MMR vaccination. For children born between II/200305,
factors significantly associated were PCV7 [odds ratio
(OR) = 10.85, 95% confidence interval (CI) 7.9314.84],
gender (females: OR = 1.42 95% CI: 1.061.91) and having a
mother >34 years (OR = 0.63 95% CI: 0.420.94).
Factors negatively associated with AA-MMR vaccination were
a non-coastal area residence (OR = 0.64 95% CI: 0.50-0.82),
having a mother with parity >0 (OR = 0.56, 95% CI: 0.470.67)
and a mothers high educational level (graduate: OR = 0.74,
95% CI: 0.590.92).
Finally factors associated with the number of days without
MMR vaccination were PCV7 (IRR = 0.06 95% CI: 0.040.11),
parity (parity > 0: IRR = 1.93, 95% CI: 1.451.56) and having a
housewife mother (IRR = 0.63 95% CI: 0.470.85).
Conclusions
The PCV7 introduction determined a slightly reduction
of MMR vaccination. Unlike the initial concern, PCV7
vaccinated children had higher coverage and less delay with
respect to their planned calendar. Geographical and sociocultural factors were associated with missed/delayed
vaccinations.
Reconsidering the choice of polio vaccine in polio

endemic countries for achieving global polio
eradication
Aikant Bhatti
A Bhatti*, TH Tulchinsky
Braun School of Public Health, Hebrew University of Jerusalem, Jerusalem,
Israel
*Contact details: aikant.bhatti@mail.huji.ac.il
Issue/problem
The global initiative to eradicate the disease has been
successful in reducing the number of polio cases by 99%. At
the present crucial end stage of polio eradication, the wild
virus continues to circulate in Afghanistan, India, Nigeria and
Pakistan. The studies in developing countries have demonstrated that even after more than three doses of oral polio
vaccine (OPV), not all the children who receive the oral polio
vaccine seroconvert. It is essential for the policy makers to
reconsider the choice of vaccine for achieving global polio
eradication.
Abstract description of the problem
The studies conducted among the children residing in
developing countries have shown that the immune response
induced by multiple doses of OPV is variable and the
immunity declines over time. Prolonged use of OPV is
associated with the risk of Vaccine Associated Paralytic
Poliomyelitis (VAPP) and Circulating Vaccine Derived Polio
Virus (cVDPV). The present article reviews the experiences
with use of sequential Inactivated Polio Vaccine (IPV) and
OPV in polio endemic regions. The peer reviewed journal
articles were searched via Pub Med and EMBASE electronic
data base system.
The IPV has been used successfully in combination with OPV
in Israel, Gaza, West Bank and Denmark for eradicating polio
and maintaining the polio free status for many years. Studies
conducted in developing countries have demonstrated that
OPV/IPV sequential schedule produces superior humoral and
intestinal immune response as compared with the OPV only
and IPV only schedule.
Lessons
From the country specific experiences and scientific evidence
available, in the current situation it will be advantageous to
incorporate IPV in campaign mode along with OPV. The
combined OPV and IPV schedule will fill the immunity gap
rapidly and reduce the risk of cVDPV and VAPP.
reducing illicit drug use and prevents new HIV-, HBV- and
HCV-infections in ST clients. Studies showed that the
prevalence of these infections in ST clients seems to be
higher than in the general population and in non-substituted
IDUs, due to long history of drug use and an easier access to
ST. ST seems to be a suitable measure to reach IDUs and to
provide health care for infected clients. Aim of this study was
to investigate the health care of ST clients regarding
prevalence, screening and treatment of infectious diseases,
particularly HIV in Germany.
Methods
From all over Germany, ST clients were surveyed by using a
standardized questionnaire.
Results
Data from 1186 ST-clients of 40 different treating institutions
were obtained. The majority were males (69.1%), unmarried
(59%), heterosexual (87.7%), born in Germany (83.5%) and
without a migration background (72.8%). The mean age was
37 years. About 12.7% of the clients had no school-leaving
certificate and around half of the clients had no professional
degree. About two-third of them receive benefit payment. The
majority of ST-clients received ST for an unlimited period
(84.9%), on average the clients received ST since 4.5 years,
most of them methadone (45.7%) or levomethadone (30.7%).
Most of the clients were tested for HBV, HCV and HIV at least
once in their lives. At the beginning of ST 81.5% of the clients
were tested for HCV, 71% for HIV and 70.4% for HBV,
respectively. Altogether, 48.7% stated to be chronically infected
with HCV, 9.1% with HBV and 4.7% were HIV-positive. Of
the 56 HIV-positive ST-clients 24 (42.9%) received an
antiretroviral treatment.
Conclusions
There is potential to improve the screening practice for
infectious diseases, especially for HIV, during ST. According
to the current guidelines for ST all clients should be
screened for drug-associated infections at the beginning of
ST to enable adequate medical care and, if clients are tested
positive for any of these infections, to prevent further
transmission.
209
Lifestyle
Benefices and risks linked to high consumption of
natural mineral waters
Marie-Pierre Sauvant-Rochat
MP Sauvant-Rochat*, C Savanovitch
University of Auvergne, Faculty of Pharmacy, Laboratory of Public Health
and Environment, Auvergne, France
*Contact details: M-Pierre.Sauvant@u-clermont1.fr
Maintenance of weight loss after lifestyle

interventions for overweight and obesity, a
systematic review
Jeroen Barte
JCM Barte1*, NCW ter Bogt2, RP Bogers1, PJ Teixeira3, B Blissmer4,
TA Mori5, WJE Bemelmans1
1
Centre for Prevention and Health Services Research, National Institute for
Public Health and the Environment, Bilthoven, The Netherlands
2
University Medical Centre Groningen, Groningen, The Netherlands
3
Department of Exercise and Health, Technical University of Lisbon, Lisbon,
Portugal
4
Department of Physical Education and Exercise Science, University of
Rhode Island, Kingston, USA
5
School of Medicine and Pharmacology, Royal Perth Hospital Unit,
University of Western Australia, Perth, Australia
*Contact details: jeroen.barte@rivm.nl
Background
Lifestyle interventions can reduce body weight, but weight
regain is common and may particularly occur with higher
initial weight loss. If so, one may argue whether the 10%
weight loss in clinical guidelines is preferable above a lower
weight loss. This systematic review explores the relation
between weight loss during an intervention and weight
maintenance after 1 year of unsupervised follow-up.
Methods
Twenty-two lifestyle interventions (during at least one month
and at least 1 year of unsupervised follow-up) in healthy
Trends in the health behaviours of Korean adults:

Korea national health and nutrition examination
survey (KNHANES), 19982008
Sunhye Choi
S Choi*, J Lee, S Kim, H An, Y Cho, K Oh, Y Kim
Division of Chronic Disease Surveillance, Korea Centers for Disease Control
and Prevention, Seoul, Korea
*Contact details: myth215@hanmail.net
Background
This study was conducted to analyse the trends in health
behaviours of adults in Korea.
Methods
The Korea National Health and Nutrition Examination
Survey(KNHANES), a nationwide survey, has been conducted
to assess the health and nutritional status of Korean
population since 1998 and continued with follow-ups in
2001, 2005, 2007 and 2008. A total of about 8000 subjects aged
>19 years from 200 households were included. We analysed
the trends in health-related behaviours, such as smoking,
drinking and physical activity, were measured by self-reported
data from the KNHANES in 1998 to 2008.
Results
Current cigarette smoking prevalence for men has been
decreasing from 66.3% in 1998 to 47.7% in 2008; however
that rate for women has maintained 67% for the past
decade. The rate of adults exposed to secondhand smoke was
also in the decline from 52.6% in 2005 to 43.1% in 2008.
While Monthly alcohol drinking rate was 60%, has not
been changed for the past decade, high-risk alcohol drinking
rate tended to increase from 14.9% in 2005 to 19.7%
in 2008. Moderate physical activity rate was 1317% in
200508, but walking rate was decreased by 28.7% from
75.6% in 2001 to 46.9% in 2008. Current cigarette smoking
rate was higher in younger adults and low-income population and monthly alcohol drinking rate was also higher in
younger population. However, there was no significant
difference in physical activity rate according to age and
income level.
Background
In France, through the National Health and Nutrition Plan
(PNNS), the concept of References Daily Intake (RDI) began
to be taken into account by consumers. The intake of mineral
elements (Ca, Mg, Na, K, HCO3, SO42, Cl, F) from food is
highlighted, but the amount provided by natural mineral water
is often under-estimated. Although they are beneficial for
human health, they may also have adverse effects beyond a
certain dose and in case of some health-disorders. For example,
sodium can increase cardiovascular diseases and sulphates have
a laxative effect, especially when combined with magnesium.
Methods
This study, based on the analysis of 64 labels of bottled water
sold in France, quantified the amounts of minerals (Ca, Mg,
Na, K, HCO3, SO42, Cl, F) brought by water. For the
calculation, the volumes recommended by the World Health
Organization are considered (i.e. 2 l/day for adult, 1 l/day for
child and 0.75 l/day for infant). The risk of excessive intake is
assessed.
Results
For the 22 still waters, the total mineralization ranked from 19
to 2580 mg l1. For child and infant, the RDI of Ca, Mg, Na and
SO42 may be frequently exceeded (respectively, with 23, 23, 5
and 32% of studied waters). For the sparkling waters, the total
mineralization ranked from 130 to 4774 mg l1. For adult, the
RDI of Mg, Na, Cl and SO42 may be also exceeded (i.e. 2, 64,
27 and 17% of the studied waters).
Conclusions
To date, the concept of nutritional education is crucial. The
mineralized bottled water should not be consumed permanently and their consumption must be adapted it to the health
status. This message is not sufficiently disseminated. If PNNS
advises unlimited water consumption, it is necessary to clarify
that this recommendation does not concern all waters.
overweight Caucasians were selected and the mean percentages

of weight loss and weight loss maintenance after 1 year of
unsupervised follow-up were calculated in a standardized way.
In addition, within four intervention groups (n>80) percentage maintenance was calculated stratified by initial weight loss
(05%, 510%, >10%).
Results
In total, this review included 999 participants with a mean
baseline weight of 95 kg. Mean weight loss during the
intervention was 9.5% and the mean percentage of maintenance after 1 year unsupervised follow-up was 54%. Weight
loss during the intervention was not significantly associated
with the percentage maintenance (r = 0.26; P = 0.13). The
percentage maintenance differed not significantly between
interventions with a weight loss of 510 versus >10%. As a
result, net weight loss after follow-up was higher for persons
with an initial weight loss of >10% (i.e. 7.0%) compared with
those who initially lost 510% of their weight (3.7%, P < 0.01).
The analyses within the four interventions confirmed these
findings.
Conclusions
The percentage of weight loss that is maintained 1 year after
an intervention does not clearly depend on initial weight
loss. However, a greater weight loss during an intervention
leads to a greater net weight loss after 1 year of unsupervised
follow-up. From this perspective, 10% or more weight loss
can indeed be encouraged and favoured above lower weight
losses.
210
Conclusions
The results demonstrate that current cigarette smoking rate of
Korean men was decreased for the past decade continuously,
nevertheless still higher. High-risk alcohol drinking and
walking rate tended to be worsening, especially for younger
and low-income population.
Reasons for continuation and cessation of smoking
among pregnant women in Northwest Russia
Olga Kharkova
OA Kharkova1, AG Soloviev2, AM Grjibovski1,3,4*
1
Arkhangelsk, Russia
2
Northern State Medical University, Arkhangelsk, Russia
3
4
Surveys of public attitudes towards smoking and

tobacco control policy in Russia: round two.
What had changed between November 2007
and May 2009
Kirill Danishevskiy
KD Danishevskiy*, M McKee, A Gilmore, K Eroshina
Open Health Institute, Moscow, London School of Hygiene and Tropical
Medicine, London, UK
*Contact details: kkirrill@mail.ru
Background
Since the political transition in 1991, Russia has been targeted
intensively by the transnational tobacco industry. The smoking
prevalence increased significantly unparalleled by government
National data collection activities on nutrition and

physical activityaspects of comparability
Grit Neumann
W Kirch*
Research Association Public Health Saxony and Saxony Anhalt, Technische
Universitat Dresden, Faculty of Medicine, Dresden, Germany
*Contact details: grit.neumann@tu-dresden.de
Background
Despite numerous initiatives to reverse the growing prevalence
of lifestyle-related disease, overweight and obesity are still on
the increase in the European population. Nutrition and
physical activity play a crucial role in combating chronic
diseases. In order to provide for suitable, evidence-based
measures at European level, the comparability of national
health data is essential. Beside the establishment of common
European indicators on nutrition and physical activity, data
collection intervals and the application of standardized data
collection methods are key factors to achieve data comparability. Against this background the following research
questions have been addressed:
Are data on nutrition and physical activity available in the
EU member states, EEA and candidate countries?
What data collection methods have been applied?
What target groups have been focused?
At what intervals have data on nutrition and physical
activity been collected at national level?
Methods
Data on available national health data on nutrition and
physical activity in the EU Member States, EEA and candidate
countries were collected and analysed. Data from national and
European activities between 1990 and 2006 were considered.
Results
The majority of the countries investigated hold available data
for the indicators on nutrition and/ or physical activity.
National health reporting activities differ, however, to a large
extent as regards applied methods of data collection, focused
target groups and data collection intervals. Whereas a multitude of data collection instruments was used to assess
nutritional behaviour at population level, fewer standardized
instruments were applied for physical activity. Towards the
end of the study period shorter data collection intervals can be
reported for both health determinants.
Conclusion
National data on nutrition and physical activity are heterogeneous. There is thus a strong need for further
Background
Female smoking during pregnancy is alarmingly on the rise in
Russia. Our aim was to study reasons for smoking continuation and cessation among pregnant women in Northwest
Russia.
Methods
Altogether, 323 pregnant women registered at prenatal care
centres in Arkhangelsk comprised the sample. Of them 71
(22.0%) smoked both before and during pregnancy. All
smokers filled in a questionnaire and were interviewed.
Quantitative data were analysed using chi-squared test.
Qualitative data were analysed by Burnards content analysis.
Results
The main reason for smoking continuation during pregnancy
was psychological dependency. Altogether, 22.2, 52.8 and
20.0% of women had respectively high, medium and low level
of this dependency. Only 17.9% of smokers tried to quit
during pregnancy, but failed. The main reported reasons for
failure to quit were stressful situations at work or at home
(57.0%), physical dependency (29.0%) and non-supportive
social environment (14.0%). The women emphasized that
most of their friends or partner smoked, so it was impossible
to quit in such environments. One reported: I smoke because
my partner smokes too and he always invites me for a
cigarette. Recognition of harm from smoking was associated
with both thoughts of quitting (P = 0.015) and readiness to
quit (P = 0.047). If pregnant women felt negative effect from
smoking for their health, they had a strong desire to quit
(68.8%).
Conclusions
Almost every fourth pregnant woman in Arkhangelsk smoked.
The most frequently reported reason for smoking continuation
during pregnancy was psychological dependency. The influence of both social and psychological factors was often
mentioned. Recognition of harm from smoking was reflected
as the main reason to quit. Urgent public health measures
including information campaigns are needed to reverse the
increasing trend of smoking among pregnant women in
Russia. Experience from previous campaigns will be discussed.
effort to control tobacco. In 2008 supported by non-governmental organization campaign Russia accessed to FCTC, but
the laws passing since favor tobacco industry. This article looks
at dynamics of smoking rates, knowledge and attitudes of
Russian people to smoking and tobacco control.
Methods
A representative sample of the Russian population (1600
respondents) was interviewed face-to-face in November 2007
and in May 2009.
Results
The smoking rates in males slightly fell. There is a significant
increase in the proportion of new quitters, with over 4 million
people ceasing smoking during 18 months of the study. There
is slight increase in awareness about tobacco consequences,
diseases caused by smoking, as well as increase in negative
attitudes to tobacco industry. There is public support for
moderate greater taxation of tobacco products and banning of
demonstration of smoking on TV, but there is no increase in
awareness about pack warnings and public places smoking
policies.
Conclusions
The majority of the Russian population would support
strengthening of tobacco control policies but there is still a
need for effective public education campaigns.
standardization efforts to increase comparability at

European level. The establishment of European Indicators
on nutrition/physical activity and further development
standardized data collection instruments are crucial in this
connection.
Childhood and current circumstances as predictors
of leisure-time physical inacitivy in early adulthood
Laura Kestila
L Kestila1*, R Sippola1, T Makinen1, K Borodulin1, O Rahkonen3,
A Kunst4, R Prattala1
1
National Institute for Health and Welfare (THL), Finland
2
University of Amsterdam, The Netherlands
3
Hjelt Institute, University of Helsinki, Finland
4
Amsterdam medical centre, Amsterdam, The Netherlands
*Contact details: laura.kestila@thl.fi
Potential public health gains in Europe: Applying

DYANMO-HIA (a standard tool for Health Impact
Assessment)
Stefan Lhachimi
SK Lhachimi1,2*, WJ Nusselder1, H Boshuizen2, JP Mackenbach1
1
Erasmus MC, Rotterdam, The Netherlands
2
RIVM Bilthovnen, The Netherlands
*Contact details: s.lhachimi@erasmusmc.nl
Background
Evaluation and quantification of the impact of policy
proposals on population healthusually, but not necessarily
done within a health impact assessment frameworkis
increasingly common practice. So far, no generic quantification tool suited to daily, applied work exists. The DYNAMOHIA project funded by the EU and undertaken by a European
research consortium fills this gap by providing a freely
available tool. To encourage wide use by practitioners and
policy makers the presentation will show how expectations on
risk factor changethrough associated diseasesare translated into changes in population health over time.
Methods and application

The presentation will show potential users an application of
the tool: quantifying the space for potential health gains and
losses for policies that influence life-style-related risk factors in
a number of EU countries. For 11 EU countries, the
development of future population health is being quantified
for three different scenarios: (i) keeping the existing risk factor
prevalence constant, imposing the risk factor prevalence of the
country with (ii) the healthiest, and (iii) the least healthy risk
factor prevalence. The results will be presented separately for
three different life-style-related risk factors (BMI, alcohol and
smoking) quantifying the resulting effects on the prevalence of
several diseases (stroke, diabetes, CVD and selected cancers)
and on summary measures of population health.
Lessons and conclusions
The application will show which of the three life-style-related
riskfactors in each country are the most salient for health gains
and losses and how the risk factors affect population health via
the included diseases. Furthermore, the audience will be able to
decide whether the tool will be useful in their daily work by
having a general idea what kind of policy-questions
DYNAMO-HIA is able to answer, what input is needed, and
how the model output can be used within a policy context.
Weight status and physical activity in a Romanian
rural population
Monica Laura Cara
I Prejbeanu1, C Rada2, Fl Badulescu1, M Dragomir1, M Cara3*
1
University of Medicine and Pharmacy of Craiova
2
3
Public Health specialist, Romania
*Contact details: daimoniquelle@yahoo.com
Background
Dolj County lies in the SouthSouth-Western Romania, being
the seventh in size of the 41 counties in the country. Its
population, of about 700 000 inhabitants, lives half in urban
and half in rural areas. Within the framework of a research
financially supported by CNCSIS UEFISCSU, project PN II
IDEI cod 72/2008, we have been studying some aspects of the
health status of the rural population of the county; this
population, often living in extremely precarious social, cultural
and economic conditions, is too frequently forgotten by the
researchers teams.
Methods
We applied a questionnaire with 119 items on 600 people
living in villages, men and women, aged 1875 years, with
different instruction levels. This analysis refers to the items
regarding their weight status (measurement and self-evaluation) and physical activity (in this environment, consisting in
farming and breeding).
Results
According to the body mass index (BMI), about half of the
subjects are normal weight, 4.3% are underweight and the
other are overweight (30.9%) or obese (15.1%). There are
significant differences according to gender (P = 0.004, women
reaching more frequently the extreme weights) and age
(P < 0.001, 57.7% of the normal weight subjects are under
the age of 35 years, 66.6% of the obese are over the age of 50).
About 32% of the group correctly estimates their ideal weight
according to their height. The self-evaluation of the weight
status significantly varies (P < 0.001) with the real weight: only
53.8% of the underweight subjects consider they are underweight, while 83.3% of the obese ones evaluate themselves as
obese. People in our group rarely measure their weight
whatever the gender, but depending on the age (P < 0.001): the
younger the more frequently. Most of them declare themselves
physically active, whatever the gender.
Conclusions
Lack of general and medical education in rural areas is not a
new problem, but it has been consistently neglected. This is
why, after evaluating the proposed aspects of the health status
Background
The life-course approach emphasises the contribution of
circumstances in childhood and youth to adult health and
health-behaviour. There is still a lot to know of the social,
health-related and economic predictors of later physical
activity.
Aims
The aims of the study were a) to examine how various
childhood living conditions and adversities predict leisuretime physical inactivity in early adulthood and b) to find out
whether these associations are mediated through the respondents education.
Data
The data derived from the Health 2000 Survey represent the
Finnish young adults aged 1829 in 2000. The analyses were
carried out on 68% (n = 1282) of the sample (N = 1894). The
cross-sectional data based on interviews and questionnaires
include retrospective information on childhood circumstances.
The outcome measure was leisure-time physical inactivity. We
used logistic regression analysis as the main statistical tool.
Results
Low parental education predicted physical inactivity in young
adults, and this effect was only partly mediated by the
respondents own educational level. In women, also longterm financial problems, parental unemployment and having
been bulllied at school predicted physical inactivity; rather
independently of the respondents own educational level. In
addition; there were educational differences in physical
inactivity; those from the lowest educational categories being
the most inactive in leisure-time.
Conclusions
Improving the living conditions of families with children is a
necessary basis to prevent the unfortunate trajectories leading
to physically inactive life-style.
211
212
of the rural population of the county, the next step of our

research will be the development of educational programmes
for health in these communities.
Eating habits, drinking, physical activity, smoking and

usage of illegal narcotics in Estonia: gender
differences
Taie Kaasik
T Kaasik1*, K Toompere2, A Metspalu1
Estonian Genome Center, University of Tartu
2
Department of Public Health, University of Tartu
*Contact details: taie@ut.ee
Care for patients with an increased risk for

cardiovascular diseases
Carla van Boheemen
C van Boheemen*, K van Geffen, D Philbert, M Bos, I van Dis,
A Strijbis, M Bouvy, L van Dijk
NIVEL, University Utrecht, University Utrecht, Netherlands Heart Foundation,
The Netherlands
*Contact details: c.vanboheemen@nivel.nl
Background
In 2009, a national standard of care for vascular risk
management (VRM) was developed. This standard, which
was sent to all general practitioners (GPs), contains requirements for optimal care. One requirement is the formulation of
a written individual-care plan which contains an extended
description of the patients cardiovascular risk factors and a
plan to reduce the risk. The aim of our study is to describe to
Temporal reliability of the Spanish version the IPEN

(International Physical Activity and the Environment
Network) in Pamplona (Spain)
Francisco Guillen Grima
F Guillen-Grima1,2*, R Orzanco-Garralda1, I Aguinaga-Ontoso1,
A Brugos-Larumbe1, JM Nunez-Cordoba2, E Aguinaga-Ontoso3
1
Department of Health Sciences, Public University of Navarra, Pamplona
2
Department of Preventive Medicine and Public Health, University of
Navarra Clinic, Pamplona
3
Department of Socio-sanitary Sciences, University of Murcia, Spain
*Contact details: f.guillen.grima@unavarra.es
Background
Environmental and policy interventions are the most promising strategies for improving physical activity (PA), eating, and
obesity. The evidence base on environmental and policy factors
is deficient. The IPEN study is study that it is been realized in
North America, Europe and Australia. Its main objective area
to find accurate estimates of the strength of associations
association between built environments and PA as well as
weight to give guidance about specific attributes of the built
environment most likely to be effective interventions.
Methods
The IPEN study use a combination of written questionnaire,
objective recording of physical activity using actigraph
accelerometers and GIS.
The IPEN questionnaire that measures physical activity as well
as questions about the environmental question was back
translated into Spanish. A random sample of 50 people from
the city of Pamplona (Spain) with ages between 18 a 65 years
received the questionnaire, one month later the completed
again the questionnaires. Kappa coefficients were computed
for categorical variables, while for quantitative variables
Student T for paired data was computed. All the calculations
were performed with SPSS.
Results
The median Kappa coefficient was 0.60. The lowest kappa were
those related with playing golf (0.001), perception of the
neighbourhood safety 0.285, and willing to use bicycle if is use
were safe 0.245. Those questions related with the built
environment such as distance to the bus stop or sport
installations have a higher kappa coefficient 0.792.
There were no differences in the questions related with time
per week spend during the last month in different activities
including physical activity. The only exception was time spent
speaking at the phone with a difference of 42 min per week
(P = 0.024)
Conclusion
The Spanish version of the IPEN has a good temporal
reliability and can be used to estimate physical activity as
well as the perception of the built environment.
Background
An improper diet, smoking, alcohol and illegal narcotics are
known to harm health. In general, unhealthy lifestyles are more
characteristic of men than women. There is some evidence
about unfavourable eating and drinking habits in Estonia. The
extensive health gap between Estonia and western European
countries, especially among male population is disclosed by
several studies.
Aims
To study a magnitude of the prevalence of unhealthy lifestyles
among Estonian adult population to explore whether the
health gap between the genders in Estonia, and also between
Estonia and the western European countries can be at least
partly explained by the lifestyle differences.
Methods
The data on health behaviour were gathered from the Estonian
Biobank Database. The final study population consisted of
4067 randomly selected respondents aged 18 years. The
data analysis was performed by the SAS statistical packages
(version 9.1).
Results
The prevalence of unhealthy lifestyles, especially in men was
high. The men consumed cereals, fruits and vegetables less
frequently, and the meat products, salt and alcohol more
frequently than women. Total of 82.1% of the subjects
consumed alcohol, 81% of them drank more than twice a
month. Men began drinking at a younger age in comparison
with women. The prevalence of smoking among men was
60.2% and among women 34.5%. Only 33.4% of the subjects
were engaged in recreational or professional sports twice or
more times a week. There were close positive correlations
between unhealthy lifestyles.
Conclusions
The prevalence of unhealthy lifestyles in Estonian population,
especially among men was much more pronounced than in
western European populations. This might contribute to the
poor health indices and the health gap between the genders in
Estonia, and between the populations of Estonia and the
western European countries. The results could be used by
policy-makers for the development of a responsible health
policy in Estonia.
what extent current care meets the requirement posed in the

care standard.
Methods
In total 600 (out of 1500) patients who received lipid lowering
drugs and/or antihypertensive drugs filled out a written
questionnaire in the spring of 2010. Patients were selected
from 15 pharmacies across the country.
Results
Preliminary results show that, shortly after the introduction of
the standard, only 6% of the patients had a written individual
care plan. Patients regularly receive advices from their care
givers about change of life style. Nevertheless, most patients are
not satisfied with the results, probably because they do not
receive enough support in changing their life style. The GP is
by far the health professional who offers the most care.
Conclusions
The requirements in the care standard for VRM are not yet
met in current practice; care is not yet as structured as
proposed in the standard of care. Efforts should be made to
further implement this standard. This project is funded by the
Netherlands Heart Foundation.
Individual health behaviour as a factor for the

efficacy of drug therapy: a study in BadenWurttemberg in Germany (200910)
Olga Battermann
O Battermann1*, S Sohn1, L Griffith2, F Meier3
1
Chair of Health Care Management, University Erlangen-Nuremberg,
Nuremberg, Germany
2
Awenydd Diagnostics GmbH, Cologne, Germany
3
Chair of Health Care Management, University Erlangen-Nuremberg,
Nuremberg, Germany
*Contact details: olga.sukhorada@gmx.de
Smoking or quitting, this is the question!

Georgiana Nitu
CA Zugravu1, G Nitu2*, M Tarcea3, M Parvu4, C Rada5
1
University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
2
Institute of Public Health Bucharest, Romania
3
University of Medicine, Targu Mures, Romania
4
Spiru Haret Faculty
5
Institute of Antropology F. Rainer, Bucharest, Romania
*Contact details: nitu.georgi@yahoo.com
Background
Romania is a country where great efforts are made in order to
lower the prevalence of smoking. Smoking is not allowed any
more in public buildings or in restaurants, cigarette packages
have health warnings and pictograms. Still, over a quarter of
the population >15 is smoking and special policies have to be
put in place in order to bring these figures down.
Methods
The present cross sectional study was carried out in 2009 and
had in target to find out demographical, nutritional and
psychological characteristics for the Romanian smokers and
quitters.
Results
In the sample, 25% smoke, 16.5% are ex-smokers and 58.3%
never smoked. The highest prevalence of smoking is between
35 and 54 years of age. More men than women smoke, but they
also quit more frequently. Divorced/widowed smoke more
frequently, married persons quit more often. In spite of the
continuous growth of the price of cigarettes, the prevalence of
smoking is high among people describing themselves as poor.
A high percent can also be found among rich people, which,
on the other hand, quit less frequently than other economical
groups. Smoking is statistically significant (P < 0.001) correlated with a greater body mass index (BMI), with greater BMI
fluctuations in time and higher difficulties in maintaining a
constant weight, with a lower preoccupation for a healthy diet
or a normal weight. Most of the quitters are overweight, but
not obese; are interested more than smokers in having a
normal weight and a healthy nutrition and have difficulties in
maintaining a constant weight after giving up to tobacco. The
sense of coherence score, a measure of strength of the resilience
and of the subjective state of health also varies, but is
surprisingly low for ex-smokers, where the manageability and
the meaningfulness are significantly lower than for smokers
and non-smokers
Conclusion
Quitters have a quite different profile than smokers. Close links
were found with the nutritional status, the attitude towards
nutrition and the psychological resilience. Public health
organizations can use these findings in organizing multitarget educational programmes, aiming both anti-tobacco, and
pro-healthy nutrition purposes.
Is knowledge of cardiovascular risk factors enough to

bring about health promoting behaviour in students?
Ben Jones
BP Jones*
Department of Vascular Surgery, Leeds General Infirmary, Leeds, UK
*Contact details: ugm3bj@gmail.com
Background
In the UK, coronary heart disease (CHD) has become a
ubiquitous cause of morbidity and a major contributor to
mortality. Knowledge of CHD risk factors is fundamental for
behavioural change. However despite adequate risk factor
knowledge, individuals do not necessarily implement health
promoting behaviour in their lifestyles.
Methods
This cross sectional survey consisted of a questionnaire,
distributed to 279 students over four sites of the University
of Leeds. This assessed the knowledge and lifestyles of students
using 55 close-ended multiple choice questions. The data was
quantitatively analysed using a weighted scoring system.
Univariate modelling was accomplished with unpaired t-tests.
Results
A significant difference in lifestyle score was evident between
high and low knowledge groups (P < 0.05) in the population
studied. A significant, weak positive correlation was also found
between lifestyle and knowledge scores (R = 0.13). Sciencebased students had significantly better knowledge of CHD risk
factors than arts-based students (P < 0.05), without a significant improvement in lifestyle score (P = 0.15). Females
(P < 0.01) and individuals with a family history of CHD
(P < 0.05) demonstrated significantly better lifestyles than
males and individuals without a history of CHD respectively,
without a significant improvement in knowledge.
Conclusions
This study confirms lifestyle is related to CHD risk factor
knowledge. It also indicates that various factors constrain
behaviour. Factors including perceived susceptibility, financial
concerns, university culture, family history, discrepancies in
knowledge and the risk taking nature that is prevalent in young
adults may all influence behaviour in this population. Given
that the pathogenesis of CHD begins early in life and health
behaviour patterns attained during childhood extend into
adulthood, this indicates that current trends in the healthrelated behaviour of students are an area for concern. Given
Background
Drug efficacy depends on different factors like compliance,
metabolism and health behaviour. A good compliance
preconditioned, the health behaviour is an important issue
for success, because the consumption of alcohol, coffee,
cigarettes or special nutrition like garlic or dietary supplements
have direct effects on metabolism. Furthermore, the individual
nutrition causes interactions with active ingredients and
constrains the efficacy. Therefore more detailed information
on health behaviour has to be included for an optimal drug
therapy.
Methods
The non-interventional cohort study in an outpatient setting
enrolled 152 multimorbid and multimedicated patients in
Baden-Wurttemberg and finished in Q1 2010. Data collection:
Socio-demographic data, standardized health behaviour questionnaire, diseases, medication, genetic information (CYP450)
and a daily medical diary for half a year. The diary contains the
structured notes about self-reported events and was analysed
with regression analysis. The health behaviour questionnaire
will be analysed with principal factor analysis (PFA) to identify
homogenous factors. These factors will be essential for testing
differences among two or more independent groups (diseases,
metabolism, etc).
Results
Preliminary results (152 patients) from the study have shown
significant progress for self-reported events (P < 0.05). The
patients note more events at the end of the study. Moreover
there is a significant correlation between body mass index and
self-reported events (P < 0.05). The calculated factors will be
integrated in further analysis.
Conclusions
Health behaviour and nutrition have effects on self-reported
events and presumably on the efficacy of drug therapy.
Therefore an advanced drug therapy should have included
more information and has to be adapted to the patients health
behaviour.
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the role of CHD risk factor knowledge as a prerequisite for the

intention of health promoting behaviour, the ongoing
education of such information to the public is fundamental.
However, it is equally important to address the variety of
constraints that inhibit beneficial behavioural changes.
Vital exhaustion and risk of cardiovascular diseases
among male ages 2564 years
Valeriy Gafarov
V Gafarov*, E Gromova, A Gafarova, I Gagulin
The Collaborative Laboratory of Epidemiology of Cardiovascular Diseases
Russia and The Laboratory of Psychological, Sociological Aspects of
Therapeutic Diseases of Institute of Internal Medicine the Siberian Branch of
Russian Academy of Medical Sciences, Novosibirsk, Russia
Use of food supplementsan analysis of inquiries

addressed to a drug information service
Lisa Goltz
M Kosa, L Goltz*, J Schroder, S Lochner, W Kirch
Institute of Clinical Pharmacology, Faculty of Medicine, TU Dresden,
Germany
*Contact details: lisa.goltz@mailbox.tu-dresden.de
Background
An increasing number of people in Germany ingest food
supplements in order to improve their state of health.
However, in many cases the use of food supplements can be
associated with risks in drug therapy or a delay in the
professional treatment of a disease.
Methods
The intake of food supplements of patients, who contacted
the drug information service at the Institute of Clinical
Pharmacology in Dresden, Germany from 200809, was
Association of formal education and health

behaviours in Croatian adult population
Ognjen Brborovic
O Brborovic*, G Pavlekovic
Andrija Stampar School of Public Health, Medical School, University of
Zagreb, Croatia
*Contact details: obrborov@snz.hr
Problem
Recent researches demonstrate that multiple measures of
socio-economic status are related to health, with both overlapping and separate effects. Level of education affects income
but also can affect a persons knowledge of how to promote
health (nutrition, exercises, smoking, alcohol consumption,
etc.). According National Consensus 2001, 11.9% of population has higher/high level of formal education, lower than in
EU countries. The aim of this study was to explore the
association between educational status and health habits
among Croatian adult inhabitants. Research was done on
randomly selected 8806 inhabitants in Croatian Health Survey
2003, older than 18 years. Respondents were classified into two
groups according to educational status: a group with lower
education (incomplete or complete primary and secondary
school86.4%) and a group with higher education (college or
university level13.6%). All analyses were done according to
sex of the participants.
Results
Results indicate that the prevalence of smoking in Croatian
adults is 40%, with sex differences (42.5% males:25.6%
females). However, higher education of men is significantly
associated with less smoking behaviour. Prevalence of alcohol
consumption depends on sex (23.5% males:4.3% females) and
also is associated with educational levels. Unhealthy diet is
more present in males (49.6% males:37.9 females) in contrast
with physical inactivity (26% males: 28.7% females). In
summary, higher education of men is associated with less
frequent alcohol consumption and smoking, and more
frequent physical inactivity and unhealthy diet. Higher
education of women was also associated with smoking and
alcohol consumption but less frequent unhealthy diet and
more frequent physical inactivity.
Background
We sought to examine the relationship between vital exhaustions (VE) symptoms and the risk development of arterial
hypertension (AH), myocardial infarction (MI) and stroke
among men ages 2564 years.
Methods
Within the framework of programme WHO MONICAMOPSY was examined representative sample of men 2564
years old (1994 year). Total sample was 657 persons. VE
symptoms were measured at baseline with the use of the
MONICApsychosocial Interview Vital Exhaustion scale. The
incidence of news cases of AH, MI and stroke was revealed at
10-year follow-up. Coxproportional regression model was
used for an estimation of relative risk (RR).
Results
Prevalence of VE in cohort of men with AH was 73.7% (58%
men had high level of VE and 15.7%an average level of VE);
with MI65.8% (an average level of VE44.7%; high level of
VE21.1%); with stroke58.8% (an average level of VE
41.2%; high level of VE17.6%). The relative risk of
development of AH within 5 years in group of men with
high level of VE, in comparison with group of men with low
level of VE was 3.2 times higher [95% confidence interval
(CI) = 1.0567.382; P < 0.05). Within 10 years RR of development AH has increased 1.6 times (95% CI = 1.0213.452;
P < 0.001). The relative risk of development of MI during the
first 5 years of supervision in a group with VE was 2.7 times
higher (95%CI = 1.0216.978; P < 0.05). Within 10 years, the
risk of development of MI in men with high level of VE made
2.25 times higher (95% CI = 1.0146.781; P < 0.05), by what
without it. Men with high levels VE during 5the years period
of had a higher risk of stroke compared with those with lower
levels of VE (RR = 3.2; 95% CI = 1,0469,838; P < 0.05).
Within 10 years the tendency to increase RR for development
stroke (RR = 4.7; CI = 2.879.92; P < 0.05).
Conclusions
Vital exhaustion predictor the higher risk of AH, MI and
stroke in middle-age men.
recorded in a relational database. Food supplements were

identified by ATC-Codes. In the present evaluation all
inquiries from patients taking food supplements were analysed
descriptively.
Results
In 2008/2009 4123 inquiries were answered by the drug
information service.
A total of 931 requests of patients taking a total of 1184 food
supplements were recorded. Specific food supplements as
reason for the inquiry were named in 324 (27.4%) cases.
Women took food supplements more frequently (64.8%) than
men. The intake of mineral nutrients (21.2%), vitamins and
coenzymes (21.0%) or combinations of these was regarded
most frequently. Questions occurred most often about food
supplements containing glucosamine/chondroitin (52.2%),
enzymes (52.6%) or lutein/omega-3 fatty acids (38.9%).
More than half of the patients taking glucosamine/chondroitin
named osteoarthritis as underlying disease.
Conclusions
Nearly one-quarter of the evaluated patients ingested food
supplements. The use of mineral nutrients and vitamins/
coenzymes was common, but did not lead to many questions.
Less well known ingredients like glucosamine/chondroitin or
lutein/omega-3 fatty acids were ingested less frequently but
caused more uncertainties about their risks and benefits.
Patients should be made aware, that food supplements are not
meant to treat specific symptoms, e.g. by reinforcing the
interdiction of misleading advertisement. Moreover, serious
adverse reactions or drug interactions caused by food
supplements should be reported to the authorities.
Lessons
Education affects health habits in different ways and is an
important social determinant of health. There is a need for
further research in sex differences. However, free access to and
participation in the education system is prerequisites to
achieving health benefits.
Overweight and school performance among Dutch
children in primary school: the PIAMA birth cohort
study
Jorien Veldwijk
J Veldwijk1*, MCE Fries2, A Haveman-Nies2, WJE Bemelmans1,
AH Wijga1
1
National Institute for Public Health and the Environment [RIVM], Bilthoven,
The Netherlands
2
Wageningen University, Wageningen, The Netherlands
*Contact details: jorien.veldwijk@rivm.nl
parental overweight. Similar results were found when comparing children who were overweight at both 8 and 12 years to
children who were not overweight at both these ages.
Conclusion
Results did not show an independent association between
childhood overweight and school performance. Parental
educational level almost entirely explained the initially
observed associations.
BeweegKuur (a course of exercise)
Sofie van den Hombergh
S van den Hombergh*, P Rijnbeek
NISB, Bennekom, The Netherlands
*Contact details: sofie.vandenhombergh@nisb.nl
Commissioned by the Dutch Ministry of Health, Welfare and

Sports (VWS), a lifestyle programme called BeweegKuur (a
Course of Exercise) has been developed by NISB in
cooperation with Dutch umbrella and patient organizations.
The BeweegKuur is a lifestyle intervention tailored to the
individual needs of patients either with health problems or
with a high risk of developing health problems. At present the
BeweegKuur is available for people who are overweight and
have a high risk of developing health problems such as type 2
diabetes mellitus, and for people who suffer from obesity.
The BeweegKuur starts and ends at the general practitioners
(GP) practice and focuses on three principles: improving
physical activity, changing dietary habits, and a long lasting
behavioural change. The GP practice is responsible for the
inclusion of the patient, their coaching and supervision and
their referral to paramedics (sports physician and dietician)
and/or local exercise coaches. The ultimate aim of the 12month intervention is weight loss and to ease transfer to local
exercise facilities.
The development of the BeweegKuur started in 2007 with
literature studies and expert meetings being used to develop a
prototype. Over the years the intervention was simultaneously
implemented and tested in practice, in collaboration with
professionals and possible patients. By the end of 2010, the
BeweegKuur will be available at 140 care locations (or primary
health care centres) across the whole of The Netherlands.
The BeweegKuur is made up of three different exercise and
nutrition programmes each varying in intensity. A costeffectiveness study will be undertaken on the most intensive
programme in 2010 and, based on results of a study by the
National Institute for Public Health and the Environment
(RIVM), it is expected that the BeweegKuur will be integrated
into the basic Dutch medical insurance package in 2012. The
BeweegKuur will then be implemented nationwide and
become available for everyone within the target group.
Mental health
Work and non-work-related explanations for gender
difference in the use of psychoactive drugs
Mikko Laaksonen
M Laaksonen*, O Rahkonen, E Lahelma
Department of Public Health, University of Helsinki, Helsinki, Finland
*Contact details: mikko.t.laaksonen@helsinki.fi
Background
Mental health problems are often found to be more common
among women than among men. We examined physical
working conditions, psychosocial working conditions and
family-related factors as explanations for gender differences in
the use of psychoactive medication in an ageing employee
cohort.
Methods
Data on the explanatory factors were derived from mail
surveys conducted in 200002 among municipal employees of
the City of Helsinki aged 4060 (N = 8960, response rate 67%).

These data were linked with the prescription register of the
Social Insurance Institution of Finland. Cox regression analysis
was used to calculate hazard ratios (HR) with 95% confidence
intervals (CI) for women as compared with men for the use of
all psychoactive drugs (ATC codes in classes N05 and N06,
excluding medication for dementia), antidepressants (N06A)
and sleeping pills and sedatives (N05B and N05C) among
younger (4050 years) and older (>50 years employees) during
3 subsequent years.
Results
Among younger women the risk for using psychoactive drugs
was only slightly larger than in men (HR 1.24, 95% CI 1.01
1.54). Adjusting for physical working conditions or psychosocial working conditions somewhat increased the difference.
There was no association for gender with antidepressants or
Background
Previous performed studies suggest an association between
childhood overweight and school performance, but the
evidence remains ambiguous. It is however of great importance to dispel these uncertainties since worsened school
performance in primary school may partly cause the lower
level of college acceptance, higher level of unemployment and
lower socio-economic status observed when overweight
children reach (young) adulthood. Therefore, the aim of the
current study was to assess the association between childhood
overweight and school performance using data from a
prospective cohort study.
Methods
Data of 2159 12-year-old children who participated in the
PIAMA birth cohort study were used. Two indicators of school
performance included: (i) the Cito-test score which is a
standardized achievement test that nearly all Dutch children
have to complete at the end of their primary education and (ii)
the teachers advice regarding a childs potential performance
level in secondary education. Height and body weight at the
age of 8 were measured by research assistants, and reported by
parents when the children were aged 12. Overweight was
defined using the IOTF reference values. Information on
potential confounders including parental educational level and
parental overweight were collected from yearly parentalreported questionnaires. Multivariate linear regression analyses
were performed to prospectively and cross-sectionally assess
the association between overweight and school performance.
Results
Overweight at the age of 8 and overweight at the age of 12 were
associated with lower Cito test-scores (P < 0.01) and lower
teachers school-level advices (P < 0.01). These associations
disappeared after adjustment for parental educational level and
215
216
sleeping pills among the younger. Among the older, the HR for
psychoactive drugs among women was 1.70 (95% CI 1.28
2.27), and it slightly increased after adjustment for physical
working conditions. For antidepressant use, the female excess
(HR 1.57, 95% CI 1.122.22) was slightly increased after
adjusting for physical working conditions. The higher HR for
the use of sleeping pills among women 2.28 (95% CI 1.50
3.47) was slightly increased after the adjustment for physical
working conditions and slightly attenuated by adjustment for
family-related factors.
Discussion
The female excess in the use of psychoactive drugs was larger in
the older than in the younger employees. Physical working
conditions, psychosocial working conditions and familyrelated factors in general did not explain the differences. On
the contrary, adjusting for physical working conditions rather
tended to increase the difference.
Health and wellbeing of adult Icelanders following
the loss of a loved one
Background
Previous studies on loss of a loved one have focused on the
impact of loss on specific dimensions of health among
survivors. Few studies have simultaneously addressed multiple
effects of loss. This study
examines multiple relationships between loss of a close relative
or friend and physical and mental well-being and self-assessed
health during the first year of bereavement.
Methods
The study employs a cross-sectional survey design and is based
on a national probability sample of Icelanders age 1875 years
who experienced loss (n = 711) during a twelve months period
prior to data collection. A multivariate adaptation model
guided by Roy was tested using loss variables, contextual
variables, and four adaptive modes. Independent variables
were socio-demographic variables, caring for basic needs, belief
in own ability, role functioning, and received and perceived
social support. Dependent variables were self-rated physical
and mental health, psychosomatic symptoms, anxiety and
depression.
Results
The study found significant relationships between loss of a
relative or a friend and physical and mental health and selfassessed health. Gender, age and education where the main
predictors of health and well-being following loss. The findings
showed that subjects were less likely to be anxious and more
likely to perceive poorer physical health with increased age.
Younger women and those having less education were more
likely to assess their health as poor. Controlling for other
contextual variables, loss of a friend was the only loss that
significantly predicted psychosomatic symptoms, and loss of a
child predicted self-assessed mental health.
Conclusions
The findings indicate, as predicted by Roys model, that
adaptive modes buffer the effects of other factors, indicating
the impact of multiple internal adaptive factors on health
following loss of a loved one.
How to present consumer quality index data to
mental health-care outpatients?
Danielle Meije
DMG Meije*, B Van Wijngaarden
Trimbos-Institute, Utrecht, The Netherlands
*Contact details: dmeije@trimbos.nl
The Trimbos-Institute (TI), The Netherlands institute of

mental health and addiction, has recently developed a
Mental health status among adolescents in South

Korea
Yu Na Ji
YN Ji*, Y Kim, S Jeong, CM Chun, YT Kim
Division of Chronic Disease Surveillance, Korea Center for Disease Control
and Prevention, Seoul, South Korea
*Contact details: jyn1102@korea.kr
Background
In South Korea, suicide was the second leading cause of death
among teenagers and the prevalence of having felt stress and
sad or hopeless were higher among adolescents than adults.
This study analysed mental health behaviours using data from
the Korea Youth Risk Behavior Web-based Survey (KYRBS,
2009).
Methods
The KYRBS was conducted on a nationally representative
sample of middle and high school students. A total of 75 066
students in 800 sampled schools completed the anonymous
self-administered web-based questionnaire. Data were
weighted to provide national estimates using SAS software to
account for the complex sampling design.
Results
About 43.2% [95% confidence interval (CI) = 42.643.9] of
students had felt stress, higher among female (50.0%, 95%
CI = 49.150.8) than male (37.3%, 95% CI = 36.638.0)
students, and higher among high school (46.6%) than
middle school (40.0%) students. Causes of stress were
examination results (55.3%), conflict with parents (15.7%),
and appearance (11.5%). During the 12 months before surveys,
37.5% of students had felt sad or hopeless (95% CI = 36.9
38.1), higher among female (43.5%, 95% CI = 42.844.3) than
A Jonsdottir1,2, G Kristjansdottir1,2*, R Vilhjalmsson1,2

1
Faculty of Nursing, University of Iceland, Iceland
2
Landspitali University Hospital, Reykjavik, Iceland
questionnaire to measure the experiences of outpatients

treatment in mental health care: the Consumer Quality Index
(CQ-Index). The project The use of CQ-Index data for mental
health-care patients can be seen as an implementation sequel.
A general tendency in health care policy is to view the users of
health care as consumers who search for the best fitting care on
the health-care market. This underlines one of the important
objectives of the CQ-Index data: to provide the (potential)
consumers of outpatient mental health care facilities with
experience-based information about the quality of available
services and providers. Consumers can use this information to
judge and compare mental health care providers and to make a
choose between them. In this context the TI executes a project
to explore the information needs of outpatients. The research
questions are:
What information (generated with the CQ-Index) do
outpatients wish to be shown?
How and where do they want this information to be shown?
On what scale do they prefer the information to be
presented: individual health-care provider, ward-, location
- or institute level?
To answer these questions the TI organized two concept
mapping meetings with outpatients and interviewed employees
of eight consumer run information and support centres. The
next step, based on the resultants of the meetings, is to develop
several draft computer-screens for the consumer website
kiesBeter.nl. These draft screens will differ in appearance:
tables, graphs and stars. The screens will be shown to 50 mental
health-care users (preferably outpatients) and to the aforementioned employees. They will be consulted about the
usability and clarity of the different screens. An advice, based
on the results of the consultation, will be presented to the
developers of kiesBeter.nl. Some preliminary results are:
outpatients appreciate data generated with the CQ-Index
but also express information needs for which data are
currently unavailable; outpatients prefer the CQ-Index
data to be presented on the individual health-care provider
level. Definite results of the project will be available this
summer.
male (32.1%, 95% CI = 31.432.8) students, and higher among

high school (40.6%) than middle school (34.5%) students.
19.1% of students had seriously considered attempting suicide
(95% CI = 18.619.6), and 4.6% had attempted suicide (95%
CI = 4.44.8).
Conclusions
In South Korea, the prevalence of having felt stress and sad or
hopeless increased as they get older, mainly because of studyrelated problems among adolescents. Accordingly, schoolbased mental health promotion programmes and community
mental health centre need to improve mental health for
adolescents.
Survival of psychiatric inpatients with substance use
disorder in the total population of Iceland for the
past 25 years
Steinn Steingrimsson
Background
Substance use disorder (SUD) is common among psychiatric
inpatients with increased mortality and morbidity. SUD is
often a co-occurring diagnosis with other mental disorders.
The aim of this study was to compare the survival of
psychiatric inpatients with and without a SUD diagnosis.
Methods
This is a total population study of all psychiatric inpatients
(18 years) in Iceland during the period 19832007. Survival
of patients diagnosed with SUD and patients not diagnosed
with SUD at first contact was compared, stratified by sex.
Analysis was performed using a Cox proportional hazards
regression model adjusted for age and calendar year at entry.
Further analysis was made for SUD inpatients with cooccurring mental disorders compared with SUD inpatients
without co-occurring mental disorders.
Results
During the study period 14 025 patients (follow-up = 156 123
person-years) were admitted. In men with SUD the survival
was not significantly different from men with schizophrenia
[hazards ratio (HR) = 1.02, P > 0.05]; however, men with
mood disorders (HR = 0.86, P < 0.05) and other disorders
(HR = 0.79, P < 0.05) had significantly better survival. In
women a SUD-diagnosis was associated with worse survival
compared with schizophrenia (HR = 0.75, P < 0.05), mood
disorders (HR = 0.60, P < 0.05) and other disorders (HR = 0.66,
P < 0.05). A co-occurring mental disorder with a SUDdiagnosis statistically increased mortality among men
(HR = 1.23 P < 0.05) but not among women (HR = 1.11,
P > 0.05).
Conclusions
SUD is a more life-threatening diagnosis than mood disorders
and other mental disorders. A diagnosis of schizophrenia has
comparable survival in men but better survival than SUD in
women. Co-morbitidy increased mortality in men with SUD
diagnosis but not in women.
Psychiatric advance directives: a stakeholders analysis
Vincent Lorant
V Lorant*, P Nicaise, C Geerts, V Dubois
Institute for Health & Society UCLouvain, Belgium
*Contact details: vincent.lorant@uclouvain.be
Background
Psychiatric Advance Directives (PADs) are documents allowing patients to notify their preferences of treatment and to
identify a surrogate decision-maker, in case of future relapses.
This intervention has been recently successfully to reduce
compulsory psychiatric commitment of patient with severe
and chronic illness. However, PAD remains a controversial
intervention and the take up rate remains very low. It also

unclear whether mental health care providers and patients do
share similar perspective on the PAD.
Aim
We undertook a stakeholders survey to analyse what PAD
alternatives were more likely to be implemented and to what
extent mental health care providers and patients were
supporting the same PAD alternatives.
Methods
In Belgium, one-hundred twenty stakeholders were selected
among mental health care providers, patients, patients
organization and policymakers. They were interviewed faceto-face using the multi-criteria analysis approach. Each
interviewee was asked to score and rank 19 different
alternatives of PAD. Each PAD alternative was scored on
four criteria: patient autonomy, provider-patient concordance,
mental care continuity, and feasibility. The different PAD
alternatives were defined according to the literature and were
classified in four stages: designing the document, filling the
document, accessing the document in case of crisis and
applying the PAD.
Results
Preliminary results indicate that different stakeholder groups
display different criteria of evaluation and were not supporting
of same alternatives. Although the PAD intervention has been
mainly designed as a document mentioning key information,
other stages should be considered as well.
Conclusion
Our study shows that the PAD is difficult to implement
because it should be considered as complex intervention
with several stages needing specific attention and because
different stakeholders groups have different preferences at each
stage.
Mental disorders in the general practitioners activity

in Polish health care systemMariusz Geremek
J Kobza*, M Geremek
Public Health Department, Silesian Medical University, Katowice, Poland
*Contact details: koga1@poczta.onet.pl
Background
Mental disorders are more and more common to all European
countries. The number of people suffering from mental
disorders has increased significantly during last decades.
Social isolation and exclusion, low quality of life characterize
patients with mental disorders. This status cause both; social
and economic costs. Modern primary care being for patients
the first level of contact with health care system should
consist mechanisms of diagnosing the most popular mental
disorders.
Methods
The aim of the study was to examine the organizational,
financial and health promotion aspects of the Primary Care
Sector in Poland. The author questionnaire survey with 49
questions concerned also mental health topic. The research of
602 General Practitioners units (selected by stratified sampling) was conducted by The Pentor Research International in
whole regions of Poland.
Results
Only 24% of the surveyed general practitioners give the mental
health consultations. Among this group of doctors mental
health consultations constitute 10% of all their procedures.
There is a big diversity of GPs mental health activity in rural
and municipal areas. The percentage of specialist refers
concerning mental disorders was on low level.
Conclusions
The mental health topic is still unevaluated part of primary
care activity in Poland. The constant increase of specialist
procedures consumption concerning mental disorders, shows,
that there is strong need of improving the general practitioners
activity in this area.
S Steingrimsson1*, T Aspelund2, S Sigfusson3, A Magnusson1

1
Psychiatric department, Landspitali University Hospital, Reykjavik,
2
Faculty of Science, University of Iceland, Reykjavik,
3
Division of Psychiatry, Akureyri Hospital, Akureyri, Iceland
*Contact details: steinnstein@gmail.com
217
218
Perceived social support is more important in

reducing depression in older PD patients than in
younger ones
Radka Sufliarska
R Sufliarska1,2,3*, M Krokavcova1,2,4, I Nagyova2,3, J Rosenberger2,5,
Z Gdovinova1, JW Groothoff6, JP van Dijk2,6
1
Department of Neurology, Faculty of Medicine, PJ Safarik University,
Kosice, Slovak Republic
2
Republic
3Institute of Public Health, Department of Social Medicine, Faculty of
Medicine, PJ Safarik University, Slovak Republic
4
First Department of Psychiatry, Faculty of Medicine, PJ Safarik University,
Kosice, Slovak Republic
5
Slovak Republic
6
*Contact details: radka.sufliarska@upjs.sk
Associations between general self efficacy, barriers

to care and self reported mental illnessa
population-based study
Lena Andersson
L Andersson1,2*, C Staland-Nyman1, G Hensing1, G Krantz1
1
The Sahlgrenska Academy at University of Gothenburg, Department of
Public Health and Community Medicine, Social Medicine, Sweden
2
Nordic School of Public Health, Gothenburg, Sweden
*Contact details: Lena.Andersson@socmed.gu.se
Background
Mental illness is an increasing health problem globally.
However, many individuals do not seek health care although
evidence-based care is available. Research has shown that self
efficacy is associated with various health outcomes and it is
of importance to investigate if it also is associated mental
illness. Early detection promotes recovery and decreases
suicide risk.
Utilization and quality of prescribing antidepressants

in Croatia, 200408
Danijela Stimac
D Stimac*
Department of Public Health, Zagreb Institute of Public Health, Zagreb,
Croatia/Univerity of Zagreb, School of Medicine, Zagreb, Croatia
Background
The purpose was to investigate the outpatient utilization of
antidepressants in Croatia, during the 200408 period using
the ATC/DDDs methodology and to investigate the relationship between the utilization of particular drug groups and the
number of suicides.
Methods
Data on outpatient drug utilization were obtained from
Croatian Institute of Health Insurance to calculate the
number of DDD, and DDD per 1000 inhabitants per day
(DDD/TID). Drug Utilization 90% (DU90%) method was
used on the drug prescribing quality assessment. Data on
suicides were collected from the suicide database kept at
Croatian Institute of Public Health.
Results
Total utilization of antidepressants (group N06A), was
between 13.6 DDDs/TID and 22.4 DDDs/TID in Croatia
during the 200408 period. Selective serotonin reuptake
inhibitors (N06AB) (from 11.5 DDDs/TID in 2004 to 17.8
DDDs/TID in 2008) accounted for 80% of drugs used for the
treatment of depression during the 200408 period. A
markedly increasing utilization, more then three times was
recorded for other antidepressants (N06AX). Utilization of
Non-selective monoamine reuptake inhibitors (N06AA)
decreased from 3.7 DDDs/TID to 1.8 DDDs/TID.
Comparison of DU90% segment between 2004 and 2008
revealed maprotiline and amitriptyline to be absent, whereas
citalipram, escitalopram and mirtazapine were added in 2008.
In observed time, utilization of sertraline increase 82%, and
utilization of maprotiline and amitryptiline decrease 68%.
During the period of observation, total rate of suicides in
Croatia decreased by 22%.
Background
Depression and anxiety in Parkinsons disease (PD) are underrecognized co-morbiditieswith a major impact on patients
quality of life-affecting up to 45% of patients. The aim of this
study was to explore how different levels of perceived social
support are associated with anxiety and depression in PD
patients stratified by age after controlling for gender,
education, disease duration and disease severity.
Methods
The sample consisted of 190 patients (50.5% female; mean age
68 9 years; mean disease duration 7 6 years). Patients
completed questionnaires focusing on socio-demographic and
clinical data. Disease severity was measured with the Unified
Parkinson Disease Rating Scale (UPDRS), social support with
the Perceived Social Support Scale (PSSS) and anxiety and
depression with the Hospital Anxiety and Depression Scale
(HADS). Data were analysed using multiple linear regression.
Results
Demographic variables (gender, education), disease duration
and disease severity explained 13% of the total variance of
anxiety in younger PD patients (<65 years), but perceived
social support did not contribute to the explanation of anxiety.
On the other hand, the above-mentioned model explained 7%
of the total variance of depression in this age group. In the
group of older PD patients (65 years), the total explained
variance of anxiety after entering the demographic variables,
disease duration, disease severity and perceived social support
was only 6%, whereas the total explained variance of
depression was 20% ( = 0.46, P < 0.001).
Conclusions
PD patients experience the positive influence of perceived
social support differently according to age. In the younger age
group, disease severity plays the primary role regarding
anxiety, while in the older age group social support is
significantly and inversely associated with depression. Social
support from friends may play a protective role in the
development of depression in older PD patients.
Aim
The aim of this study is to investigate whether low levels of self
efficacy is associated with a higher degree of mental illness and
whether level of self-efficacy influence health seeking
behaviour.
Methods
This cross-sectional study is based on data from the Health
Assets study, from 2008 in West Sweden. The study population
is a randomly selected population sample of 4027 individuals,
aged 1865 years. Data collection was done by a postal
questionnaire and the response rate was 50.4%. Bi- and
multivariate analyses were employed to investigate associations
and results were stratified on sex, age, civil status, education
and social support.
Results
A total number of 1361 (36%) out of 3811 individuals
answered Yes on the question Have you ever felt so mentally
ill that you had (felt a need) to seek care. 33% of the women
answering yes were found in the lowest quartile of the general
self efficacy scale, 20% in the highest quartile. Corresponding
figures for men were 30% and 23% respectively. The most
common reason stated for not seeking health care was a belief
that the mental illness would disappear by itself. Others
reasons mentioned were beliefs that health care would not
help, not knowing were to go or feelings of shame for suffering
from mental illness.
Conclusions
Mental illness is a serious health problem and access to
care needs to be improved. Health promotion should
also include individual traits/characteristics such as self
efficacy.
Conclusions
The outpatient utilization of antidepressant increase during
the 200408 period. The utilization pattern was improved
during observed period, showing a decrease in the number of
suicides in Croatia.
Association of obesity and health behaviour with
physician-diagnosed depressionresults of a
nationwide population-based study in Germany
Markus Busch
M Busch*, C Scheidt-Nave, U Hapke, K Gerdes, H Holling,
GBM Mensink
Department of Epidemiology and Health Reporting, Robert Koch Institute,
Berlin, Germany
*Contact details: buschm@rki.de
Alzheimers disease and dementia: prevalence and

access to the health and social care in Slovak Republic
in years 200208
Lenka Maruskova
L Maruskova*, Z Cernuskova, M Kvakova, Z Klochanova, A Brazinova
Trnava University, Faculty of Health Care and Social Work, Department of
Public Health, Trnava, Slovakia
*Contact details: maruskova@gmail.com
Background
World population is aging. Older population suffers from
dementia and its most commonAlzheimers disease (AD)
and the number of patients will grow continuously due to the
correlation with age. Dementia seriously burdens every society
as it leaves victims in need of care. This article presents analysis
of epidemiological situation, health and social care network for

dementias and AD patients in the Slovak Republic. This work
was funded by the National Institute of Health, Fogarty
International Centre.
Methods
Quantitative methods for assessment of prevalence of AD and
incidence of dementia, existing structure of health and social
care services for patients and access to above-mentioned
services were used. Data was obtained from National Health
Information Center, Statistical Office of the Slovak Republic
and regional statistics. Frequencies of treatment for dementias
(ICD-10 group F00F03) and Alzheimers disease (G30) in
200208 where considered.
Results
The population aged >65 years tripled since 1948 in Slovakia.
Total number of patients diagnosed with dementia for the first
time in their life increased from 3044 in 2002 to 4979 in 2008
and incidence was highest in region of the capital Bratislava.
The ratio of patients diagnosed with dementia for the first time
in their life to psychiatrists reduced significantly in 200208
(from 14.75 to 7.38 patients to one psychiatrist). There were
also regions with an opposite tendency. Total number of
patients treated in neurologist outpatient offices with
Alzheimers disease increased in the period with the highest
prevalence in Bratislava region. Men were less affected than
women. The ratio of patients to a neurologist increased from
6.89 in 2002 to 8.47 patients in 2008 in average for the whole
country. There are 188 facilities with 11 400 beds in total that
provide mostly social care for the patients with dementia and
AD. Data on health and social services vary in regions.
Conclusions
Prevalence of all dementias and AD in particular in Slovakia is
on the rise and seems to be an increasing epidemic threatening
public health. Even though the number of specialists who
diagnose and treat the diseases is rising as well, we conclude
the network of health and social care services is inadequate.
Dementiaepidemiological situation and accessibility
of health and social care services in four European
countries in 2008
Zuzana Cernuskova
Z Cernikova1*, L Maruskova1, S Popova2, A Coman3, M Matlova4,
A Brazinova1
1
Trnava University, Faculty of Health Care and Social Work, Trnava, Slovakia
2
Medical University of Varna, Faculty of Public Health, Varna, Bulgaria
3
Babes Bolyai University, Center for Health Policy and Public Health, Cluj
Napoca, Romania
4
Czech Alzheimer Society, Prague, Czech republic
*Contact details: cernuskova@gmail.com
Background
Dementia is a brain disorder that seriously affects persons
ability to carry out daily activities. With aging of population
number of people suffering with dementia increases and causes
a challenge for health and social care services. This article
presents preliminary results of project funded by the
National Institute of Health, Fogarty International Centre.
Epidemiological situation, access to health and social care
services in four European countriesBulgaria, Czech
Republic, Romania and Slovakiawere compared.
Methods
Morbidity of dementia in 2008 was estimated from EuroCoDe
working group data and population data obtained from
national statistics. Accessibility of health and social care
services was evaluated by numbers of physicians in charge of
dementia diagnostics and treatment (neurologists, psychiatrists) and number of social care services available for these
patients. Data for 2008 was obtained from national centres for
health information, regional statistics or other information
sources.
Results
The highest adjusted morbidity of dementia for the year
2008 was found in Bulgaria1259/100 000, followed by
Czech Republic (1181/100 000), Romania (1048/100 000) and
Background
Depression and obesity are widespread health problems that
both have major public health implications. The evidence for
an association between obesity and depression and the role of
health behavioural aspects in this relationship is inconclusive.
The aim of this study was to examine the association of obesity
and health-related lifestyle with prevalence of physiciandiagnosed depression in the general population in Germany.
Methods
In the German Health Update (GEDA) 2009, cross-sectional
health data of a nationally representative sample of 21 262
German residents aged 18 years were collected by computerassisted telephone interviews. We analysed the prevalence of
physician-diagnosed depression within the last 12 months and
its association with obesity (body mass index 30 kg m2) and
five lifestyle aspects (sport, daily physical activity, fruit and
vegetable consumption, smoking status, alcohol drinking) in
logistic regression analyses, adjusted for socio-demographic
and psychosocial factors as well as somatic co-morbidities.
Results
The prevalence of physician-diagnosed depression was 6.3%
(women 8.0%, men 4.5%). Among women 15.7% were obese
and among men 16.3%. Participants with diagnosed depression were older and more often females, obese, physically
inactive and smokers but consumed less alcohol than other
participants. In the multiple logistic regression model, obesity
[odds ratio (OR) 1.33, 95% confidence interval (CI) 1.15
1.54], current smoking [OR 1.28 (95% CI 1.131.46)] and low
sport activity were associated with a higher prevalence of
depression. Daily physical activity and fruit and vegetable
consumption showed no association with depression in the
multiple model.
Conclusions
Obesity, depression and health behavioural aspects were closely
associated in this cross-sectional study. These findings
emphasize the necessity to consider somatic and psychological
health problems alike in affected people. The promotion of
protective behaviour should be integrated in public health
interventions targeted at prevention of depression. The
causality of the observed associations should be examined in
prospective cohort studies.
219
220
Slovakia (942/100 000). The worst situation in access of

dementia patients (DP) to neurologists was in Romania (265
DP per one neurologist). Situation in other countries was quite
similarCzech Republic (87), Bulgaria (95) and Slovakia (96).
There are also differences in ratio of patients to psychiatrists
between countries, where in Romania the ratio is 200 DP per
one psychiatrist, in Bulgaria195 and in Slovakia97. The
best situation was found out in Czech Republic with the ratio
of 86 DP per one psychiatrist. Social care services are the least
available in Bulgaria where the ratio is 1709 DP per one facility.
In Czech Republic is ratio of 738 and we found the best
situation in Slovakia (271 DP).
Conclusions
Between the studied countries many differences were found as
a consequence of different health and social care systems. This
analysis allows for improvements with international examples
serving as best practice models. Dementia is an increasing
epidemic problem, threatening public health systems all over
the world and existing networks seem not prepared for it.
any anxiety, SUD, SoP, under 30% for panic disorder, MDE,
bipolar and dysthymia, 20% for any mood disorders.
Recent cohorts are associated with shorter delays and a
higher overall probability of initial TC. From 176 cases
with 12-Mo disorders, did not make treatment 63.6%
from severe, over 80% from moderate/mild categories of
severity.
Only one fifth of severe cases are seen by GM provider or by
MH specialist.
Of 12-mo cases, 24% received some treatment, 11.5% from
any MH specialist, 9% from psychiatrist, 4% from other MH
specialist and 13.5% from GM provider.
Conclusions
It is of public health importance to describe the services use
patterns, to capture the not help seeking behaviors and the
predictors of TC, to increase the service use focusing on
disorder awareness, treatment need perception, and access to
care so to alleviate the burdens and hazards from untreated
mental disorders.
The critical aspects of the lifetime and 12 months

service use of mental disorders in Romania
Martin Dlouhy
S Florescu*, M Galaon, GD Popovici, IL Gheorghe, M Ciutan,

C Vladescu
National School of Public Health, Management and Continuous Education,
Bucharest, Romania
*Contact details: florescu.silvia@gmail.com
Background
In the last decade despite the important progress of mental
disorders diagnostic and evidence-based psychotherapies, still
are unmet treatment needs.
Methods
From face to face household interviews conducted from 2005
2007, using Composite International Diagnostic Interview
(2357 respondents) were assessed lifetime (LT), 12 month (12mo) services use in the areas of mental health (MH), general
medical (GM) and complementary and alternative medicine.
By survival analysis and cumulative probability curves were
estimated the proportion of cases eventually making treatment
contact (TC), the median delay. The socio-demographic
predictors for LT, 12-mo treatment, the number of visits and
proportion of patients who received minimally adequate
treatment were also assessed.
Results
The percent of TC in the year of onset was: less than 3% for
any substance use disorders (SUD 82 cases), any anxiety
disorders (174 cases), and 10% for any mood disorders (120
cases).
The median duration of delay was 1 year for some anxiety
disorders, dysthymia, bipolar disorder, 35 years for adult
separation anxiety, alcohol abuse with dependence (AAD), 13
15 years for major depressive episode (MDE), alcohol abuse
(AA), 2132 years for social phobia (SoP), specific phobia
(SP).
The percent of those never making TC was over 90% for
generalized anxiety disorders, posttraumatic stress disorder,
around 7080% for AAD, agoraphobia, AA, SP, over 50% for
M Dlouhy*
Faculty of Statistics and Informatics, University of Economics in Prague,
Prague, Czech Republic
*Contact details: dlouhy@vse.cz
Background
Mental health services form an important component of the
national health system. However, we miss both routine
statistical information and research studies related to mental
health care. The objective of this study is to modify the existing
health accounting framework and apply such framework to
description and analysis of financial flows within a national
mental health system.
Methods
OECD, Eurostat and WHO have been engaged in several
projects aimed at the further development of health accounts
methodology. The methodology of the System of Health
Accounts has become widely accepted and is used in a growing
number of countries as the standard accounting framework.
Health expenditures are classified by the 3D methodology of
health accounts that is extended by other dimensions for the
purpose of the study.
Results
The framework of multi-dimensional mental health accounts is
introduced and, as an example, applied to mental health
expenditure in the Czech Republic.
Conclusions
Having information about the structure of financial flows in
mental health system is a necessary condition for right resource
allocation decisions. The application of the standardized
accounting framework can substantially improve the quality
of international comparisons. The mental health accounts can
serve as a useful tool for strategic allocation decisions. Such
information will be very useful for the countries that plan reallocation of resources directed from institutional to community-based care.
Mental health and social inequalities

Social inequality of indigenous children in the NT
Australia prompts innovative oral health policy &
practice
Julie Hornibrook
J Hornibrook*
Department Health & Families, Northern Territory, Darwin, Northern
Territory, Australia
*Contact details: julient3d@gmail.com
Issue
Social determinants affect health of Indigenous children in
remote communities in the Northern Territory (NT) Australia,
who have a lower life expectancy than mainstream Australians
and poorer oral health than their urban counterparts. In 2007 a
major policy initiative, the Australian Government
Intervention (AGI) resulted in Child Health Checks (CHCs)
of remote Indigenous children. Results found that 43% of
Silvia Florescu
Mental health in the system of health accounts
Non-national patients with sexually transmitted

infections in Italy, 19912007
Andrea Bruning
AHL Bruning1*, MC Salfa2*, V Regine2, L Camoni2, M Raimondo2,
M Giuliani2, B Suligoi2, the Italian STI Surveillance Working Group3
1
Academic Medical centre, University of Amsterdam, Amsterdam, The
Netherlands
2
Centro Operativo AIDS, Istituto Superiore di Sanita`, Rome, Italy
3
Angelini G (Bari), Aste N (Cagliari), Cusini M (Milano), DAntuono A
(Bologna), Del Monte S (Torino), Di Carlo A (Roma), Graifemberghi S
(Brescia), Latino MA (Torino), Moise G (Gorizia), Priano L (Genova), Urbani F
(Trento), Zuccati G (Firenze)
*Contact details: andreabruning@hotmail.com; mariacristina.salfa@iss.it
Background
In Italy, in 2007, non-nationals with a legal permit accounted
for 4.1% of the total population.
During the last decade, the number of non-nationals has
increased and their socio-demographic characteristics have
changed. Given that Sexually Transmitted Infections (STIs) are
considered a relevant health problem among non-nationals, we
assessed socio-demographic, behavioural and clinical characteristics of non-nationals with STIs, in Italy.
Methods
Data were obtained from Italys Sentinel STI Surveillance
System (19912007), which collects information on diagnoses
provided by 12 specialized STI public clinics located in major
cities. Non-nationals were defined as people who were born
outside of Italy and had a legal permit.
Results
From 1991 to 2007, 50 896 STI cases were reported; 9695
(20.9%) were diagnosed among non-nationals, most of them
from Europe (44.8%) and Africa (33.1%). More than half
of the non-nationals were males. The highest proportion of
non-nationals was observed in the group aged 1425 years
(29.6%).
The proportion of non-nationals among all STI patients
increased from 14.4% in 1991 to 27.5% in 2007 among males,
and from 6.3% in 1991 to 44.4% in 2007 among females.
The most frequent diagnoses among non-national males were:
genital warts (26.9%), non-specific urethritis (19.6%), and
gonoccocal urethritis (16.7%); and among females: nonspecific

cervicitis (34.7%), genital warts (16.9%) and chlamydial
cervicitis (9.9%).
Among the 7943 (81.9%) non-nationals who underwent HIV
testing, the overall HIV prevalence was 3.3%. HIV prevalence
was high among males (4.1%), men having sex with men
(MSM) (20.5%), and among individuals with a previous STI
diagnosis (6.4%). HIV prevalence was highest in 1991 (6.3%)
and remained stable around 3% in the last 7 years.
Conclusions
These results stress the importance of developing prevention
campaigns targeted at reducing the spread of STIs and HIV
among non-nationals at high risk of infection (e.g. males,
young persons and MSM).
Socio-economic transition and inequalities in
mortality from diseases of the digestive system:
Lithuanian experience
Ramune Kalediene
R Kalediene*, S Kaseliene
Department of Health Management, Kaunas University of Medicine,
Kaunas, Lithuania
*Contact details: ramunekalediene@gmail.com
Continuance and rise of inequalities in health is one of the

major challenges in Lithuania. However, inequalities research
is mainly concentrated at several major causes of death, while
diseases of the digestive tract are not well analysed in terms of
inequalities.
Aims
To evaluate inequalities in mortality from diseases of digestive
system in Lithuania by the level of education and marital
status during the period socio-economic transition for
planning and implementing strategies to achieve better
equity in health.
Methods
Analysis was based on routine mortality from diseases of the
digestive system statistics and census data for 1989 and 2001
for the Lithuanian population >30 years. The Relative Index of
Inequality and the Slope Index of Inequality were calculated.
Results
Lithuanian population with primary and lower education level,
and unmarried had higher mortality rates due to all diseases of
the digestive system, including liver cirrhosis and gastric,
duodenal and peptic ulcers than married and those with
university education. In 200002, as compared with 198890,
inequalities in mortality from all diseases of the digestive
system and liver cirrhosis increased due to growing mortality
in primary and lower educational groups and unmarried, and
due to decreasing mortality in higher education group and
married. Inequalities in mortality from all diseases of the
digestive system, liver cirrhosis and gastric, duodenal and
peptic ulcers in men of different marital status were higher
than those in women.
Conclusions
The study highlighted the relevance of inequalities in
population mortality from diseases of the digestive system in
Lithuania. In planning prevention and control measures of
diseases of the digestive system, special attention should be
given to inhabitants at highest risk for these diseases, i.e.
unmarried and those with the lowest education level.
Accidents and injuries and health care use among
Roma and non-Roma adolescents in Slovakia
Peter Kolarcik
P Kolarcik1,2*, A Madarasova Geckova1,2, SA Reijneveld3, JP van Dijk1,3
1
Kosice Institute for Society and Health, P.J. Safarik University, Kosice,
Slovakia
2
Department of Health Psychology, Public Health Institute, Medical Faculty,
P.J. Safarik University, Kosice, Slovakia
3
Indigenous children in remote NT have dental caries and new

funding was announced for a programme initiative to increase
remote outreach services.
The problem
A workforce model was trialled recruiting teams for 3-week
outreach contracts to remote communities. This accelerated
recruitmentcreating intensive work environments, pressure
on orientation, staff support, accommodation, roster planning
and project team support. In addition an innovative model of
dental treatment under general anaesthetic (GA) was trialled as
a one week intensive in four different hospitals, treating 40
children per week, brought in by chartered light aircraft from
remote communities.
Results
In 18 months more than 45 dental teams and 250 oral health
professionals have provided outreach and more than 5000
occasions of service achieved. The surgery intensives have been
run in four remote hospitals with more than 400 children
receiving dental treatment under GA. Recruitment has been
increased through innovative workforce models, attracted
support by urban specialist teams, increased access to services
and promoted oral health prevention.
Lessons
The policy of the AGI formed an emergency response in a
unique political context but experience has application for
remote and Indigenous communities in other countries. It has
been a catalyst to influence workforce, treatment models and
workplace culture. Through policy changes, high expectations
and new resources mind sets have changed to realise it is
possible to generate new interest and capabilities for remote
oral health services for children who are the most disadvantaged in Australia.
221
222
*Contact details: peter.kolarcik@upjs.sk
Access to primary health care among Burmese

migrants in London: a cross-sectional descriptive
study
Nyein Chan Aung
NC Aung1*, B Rechel2, P Odermatt1
Epidemiology & Public Health Department, Swiss Tropical and Public
Health Institute, Basel, Switzerland
2
European Observatory on Health Systems and Policies, London School of
Hygiene & Tropical Medicine, London, UK
*Contact details: nyein.chan.aung.dr@gmail.com
Background
An estimated 10 000 Burmese migrants are currently living in
London, but no studies have so far been conducted on their
access to health services. Furthermore, most studies on
migrants in the UK have been conducted at the point of
service provision, carrying the risk of selection bias. This study
explored access to and utilization of General Practice (GP)
services by Burmese migrants residing in London.
Methods
A quantitative survey using self-administered questionnaires
was complemented by qualitative in-depth interviews for
developing the questionnaire and triangulating the findings of
the survey. Overall, 137 questionnaires were received (57%
response rate) and 11 in-depth interviews conducted. The
main outcome variables included GP registration, GP
consultations, barriers towards GP registration and consultations, and knowledge on entitlements to health care.
Quantitative data were analysed using descriptive statistics,
association tests, and a multivariate analysis using logistic
regression. The qualitative information was analysed using
content analysis.
Results
The respondents were young and of equal gender (51.5%
female), well educated, with a fair level of knowledge on health
services in the UK. Although the GP registration rate was
relatively high (80%, 109 out of 136), GP service utilization
during the last episode of illness, at 56.8% (54 out of 95), was
low. The statistical analysis showed that being 35 years, lack
of prior overseas experience, having an unstable immigration
status, having a shorter duration of stay, and resorting to selfmedication were the main barriers hindering access to primary
health care. Many of these findings were corroborated by the
in-depth interviews.
Conclusions
Our study found that having formal access to primary health
care was not sufficient to ensure health care utilization. Some
have faced difficulties in registering with GP practices and
many of those who have registered prefer to forego GP services
in favour of self-medication, partly due to long waiting times
and language barriers. To ensure that migrants enjoy the health
services they need and to which they are entitled, more
proactive steps are required, including those that make health
services culturally responsive.
Health care seeking among male undocumented
migrants in The Netherlands
Tina Dorn
T Dorn1*, M Ceelen1, C Das2
Department of Epidemiology, Documentation and Health Promotion,
Public Health Service, Amsterdam, The Netherlands
2
Department of Forensic Medicine, Public Health Service, Amsterdam, The
Netherlands
*Contact details: tdorn@ggd.amsterdam.nl
Background
As in many European countries, access to care is decreased for
undocumented migrants in The Netherlands due to legislation.
Studies on the health of undocumented migrants in Europe are
scarce and focus on care-seeking migrants. Not much is known
on those who do not seek care.
Methods
This cross-sectional study includes both respondents who did
and did not seek care, namely undocumented migrants who
have been incarcerated in a detention centre while awaiting
expulsion to their country of origin. Data were collected
through structured interviews and reviews of medical records.
Results
Among the 224 male migrants who arrived at the detention
centre between May and July 2008, 173 persons were
interviewed. A total of 122 respondents met inclusion criteria.
About 46%of respondents reported to have sought medical
help during their stay in The Netherlands (n = 57). Care was
sought most frequently for injuries and dental problems.
About 25% of the care seekers reported to have been denied
care by a health care provider. Asian migrants were
significantly less likely to seek care when compared with
other ethnic groups, independent from age, chronic health
problems and length of stay in The Netherlands.
Conclusions
Given the low rate of health care utilization in this study,
speculation that undocumented migrants place a disproportionate burden on services is unjustified. There is a need to
better understand the reasons for the denial of care to
undocumented patients, as well as the barriers to health care
as perceived by undocumented migrants.
Hygienic and sanitary housing conditions of Roma
population in the territory of Novi Sad
Marija Jevtic
MR Jevtic1*, MB Popovic2, SN Ukropina1, SV Bijelovic1, RS Velicki1
Institute of Public Health of Vojvodina, Novi Sad, Serbia
2
University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia
*Contact details: marijamd@eunet.rs
1
Background
Roma were found to have worse health comparing to nonRoma but data about health care use and medical attended
injuries are very scarce. Data about Roma adolescents fully
lacks. The aim of this study was to compare the occurrence of
medical attended injuries and health care use among Roma
adolescents living in Roma settlements with adolescents from
the majority population and to assess the influence of socioeconomic status on this association.
Methods
In a cross-sectional study among Roma (N = 330; mean
age = 14.5; interview) and non-Roma adolescents (N = 722;
mean age = 14.9; questionnaire) we obtained data on medical
attended injuries (three items) and health care use (two items)
during the previous 12 months. The effect of Roma ethnicity
was assessed using multivariable logistic regression, adjusted
for gender, parental education attainment and social
desirability.
Results
In the area of medical attended injuries Roma differed
significantly only in the case of serious cuts from non-Roma
[odds ratio (OR) = 2.71, 95% confidence interval (CI) = 1.70
4.34, P < 0.001]. There was no significant ethnicity effect on
serious burns and fractures. Regarding health care use Roma
adolescents significantly more frequently visited a physician
because of serious illness and were hospitalized significantly
more frequently (gender adjusted ORs 3.09, 95% CI = 2.33
4.11, P < 0.001 and 1.55, 95% CI = 1.052.28, P < 0.05). The
ethnicity effect could be partially explained by parental
education attainment in aforementioned outcomes. Social
desirability had an impact only on the ethnicity effect in
visiting a physician.
Conclusions
Roma adolescents reported higher rates of serious cut injuries
and of health care use than non-Roma adolescents, but there
were no differences in serious burns and fractures. The effect of
ethnicity was to a certain degree mediated by parental
education attainment. Higher health care use among Roma
is consistent with previous research findings.
Welfare state regimes and health inequalities:

including the evidence of East Asian welfare states
Ying-Chih Chuang
Y Chuang1*, MW Flahive2, T Yang1
1
School of Public Health, Taipei Medical University, Taipei.
2
Department of Counselling Psychology, Chinese Culture University, Taipei,
Taiwan.
*Contact details: yingchih@tmu.edu.tw
Background
Welfare state regimes have been shown to be associated with
indicators of population health, such as mortality, morbidity,
and life expectancy. However, prior studies have focused
exclusively on welfare states of Europe, North America, and
Australasia. This study aims to provide empirical evidence of
the relationship between welfare state regimes and population
health by adding East Asian welfare states (e.g. Hong Kong,
Japan, Korea, Singapore and Taiwan) into the analysis.
Methods
Data were from the Organization of Economic Co-operation
and Development (OECD) health data, World Development
Indicators (WDI), and Asian Development Banks (ADB) key
indicators from 1980 to 2006. Outcome variables were infant
mortality rates and life expectancy. Thirty welfare states were
categorized into six different types of welfare state regimes
based on an expansion of Ferreras typology: Scandinavian,
Anglo-Saxon, Bismarckian, Southern, Eastern European, and
East Asian. Mixed Models were applied to analyse the data sets
with repeated measurements. Control variables are GDP and
period effects (i.e. decades).
Results
Our results showed distinct levels of population health in
different welfare state regimes. Through the 27 years analysed,
Scandinavian countries exhibited significantly lower infant

mortality than Anglo-Saxon, Bismarckian, Southern, and
Eastern European, after controlling GDP and period effects.
Regarding life expectancy, Scandinavian countries had significantly higher life expectancy than Eastern European. The
results showed that East Asian welfare states did not have
worse population health status than other welfare states.
Conclusions
There is a need to incorporate the East Asian welfare states
into the analysis of welfare state regimes and population
health. Future research should analyse the mechanism of
process by which economic, societal, and welfare characteristics influence population health in each welfare state
regime.
Poverty and health in Europe: a multilevel analysis
Timo-Kolja Pfoertner
T-K Pfoertner*
SOCLIFE Training Research Group, University of Cologne, Cologne,
Germany
*Contact details: pfoertner@wiso.uni-koeln.de
Background
A wide range of international studies could evidence a
significant association between poverty and ill health within
Europe, with a strong inter-country variation in the extent of
poverty-related health burdens. Why the relationship between
poverty and health differs within Europe is still unexplored. In
that context, David Coburn (2000) and John Lynch (2000)
offer a comprehensive concept that combines and implements
both the poverty-health association and their structural
determinants in their encompassing political context. The
purpose of current analysis is to analyse the poverty-health
relation across European countries and to define its macrospecific determinants. I tested how economic, social and
structural features, such as income inequality, social trust and
participation, and the accessibility to health care system as well
the degree of preventive measures against health inequalities
were related to the poverty health association.
Methods
The study is based on data from the European Union Statistics
on Income and Living Conditions (EU-SILC) conducted in
2006 and employs binary logistic multilevel analysis across 26
countries and 343 001 individuals.
Results
I present three main findings: (i) income poverty (<50% of
country specific income average) as well as other individual
characteristics such as age, sex, education and occupation are
significantly associated to subjective health, (ii) the association
between poverty and health differs significantly across Europe,
(iii) the results indicate that the poverty-health relation is
significantly stronger the higher the income inequality (Ginicoefficient) and the lower the voluntary participation and the
preventive measures against health inequalities (indicated by
preventive measures against tobacco and alcohol consumption) within a country.
Conclusions
Within Europe the association between poverty and health
differs significantly and is explained by economic, social and
structural factors.
Contextual socio-economic factors are associated
with differences in dietary intake and weight status,
independently of individual socio-economic factors
Ulla Toft
U Toft*, A Helms, C Glumer
Research Centre for Prevention and Health, Glostrup University Hospital,
Glostrup, Denmark
*Contact details: ulto@glo.regionh.dk
Background
Dietary intake and weight status have repeatedly been shown
to be associated with individual socio-economic status (SES),
Background
Investigation of sanitary-hygienic conditions of housing and
drinking water safety in four suburban Roma settlements in
Novi Sad has been realized through the Decade of Roma
Inclusion 2005-2015 project of the Ministry of Health of the
Republic of Serbia.
Methods
Housing conditions of 362 households were determined by
self-assessment, through a questionnaire containing 48 questions evaluating location, environmental conditions, construction, water supply, waste disposal and general sociodemographic characteristics. This study examined drinking
water quality in Roma settlements in accordance with the state
regulations.
Results
The results of housing conditions indicate that half of all the
homes have non-paved road access (49.4%), while 19.4% of
homes have paved road access. The average surface of a home
is 47.1/m2, the average number of household members is six.
Every fourth household that has over ten members has a total
surface area less then 40m2. 7.1% of homes are one-room.
72.2% of homes and 51.2% of roofs are built of solid materials.
Only 13.8% of homes have a solid floor with floor covering.
Almost all households (97.4%) are connected to citys water
supply system, however only 56.5% of households have direct
access to it. 57.3% of households have no built-in bathroom,
while 83.6% of households use outside toilets. Drinking water
quality control shows that the water in all four settlements is
microbiologically and physico-chemically proper. About
79.0% of all the homes are not connected to the sewerage,
while 62.6% do not empty the existing septic tanks. About
53.4% of households depot solid waste to local waste fields or
burn it locally.
Conclusions
Integration of suburban Roma settlements in the central-city
water supply system significantly reduced the risk of waterborne diseases. However, other sanitary conditions of housing
are still unsatisfactory, particularly in relation to urban
population of Novi Sad.
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224
Socio-economic inequalities in overweight and

obesity among adults in Turkey: a regional evaluation
Isil Ergin
I Ergin1*, H Hassoy1, A Kunst2
Ege University School of Medicine, Department of Public Health, Izmir,
Turkey
2
Academic Medical Centre (AMC), University of Amsterdam, Department of
Public Health, Amsterdam, The Netherlands
*Contact details: isil.ergin@ege.edu.tr
Background
The pattern in socio-economic inequalities in obesity and
overweight has not been evaluated for Turkey. This study aims
to determine educational and income inequalities for obesity/
overweight in Turkey within a regional perspective.
Methods
World Health Survey 2002 Turkey data was used. Among the
respondents 20 years old, 3790 women and 4057 men had
data for self-reported height and weight. Respondents were
classified according to years of education and a household
income score derived from permanent income indicators.
Logistic regression analysis was applied to assess the pattern and
magnitude of inequalities. Analyses were stratified by region.
Results
Age-adjusted obesity prevalence is 16.95% for women and
10.84% for men. Overweight prevalence is 31.40% and
35.28%, respectively. For men, high educated and high
income groups were at most risk for overweight. However,
obesity in men was most common for middle income and low
educated groups. For women, overweight and obesity were
most common among middle income and low educated
groups. The size of the inequalities showed regional variations.
The direction of some relations changed for the East.
Conclusions
For men, the pattern in overweight is representative of low
socio-economic development with predominance in high
educated and high income groups, while inequalities in obesity
signal the onset of the shift towards low socio-economic

groups. For women, this transition to inverse gradients is more
advanced. The size of the inequalities in Turkey is at an
intermediate level within the spectrum of European countries.
Some inverse findings from the East, confirms the low socioeconomic development at this part of the country.
Differentiation in terms of access to and quality of
health programmes in the Pomeranian Region,
Poland: a local government survey of the regions 2.2
million population
Agnieszka Wojtecka
A Wojtecka1*, P Popowski2, M Brzezinski3
1
Gdansk, Poland
2
Gdansk, Poland
3
Polish Society for Health Programs, Gdansk, Poland
*Contact details: agnieszka.wojtecka@gmail.com
Issue
For many years, problems related to health promotion and
early prevention has been the focus of attention for international organizations operating in the health sector, such as
WHO, OECD and the EU. In their opinion, these are the two
major fields of activity required to provide a robust and
effective health system. The survey carried out in the
Pomeranian Region provided the basis for an assessment of
programmes implemented in individual districts. The data
analysed referred to health programmes covering a population
of 2.2 million inhabitants of the region. The survey was based
on the results of a full questionnaire study including all twenty
districts of Pomerania Region. The data was collected referring
to 290 programmes implemented by the local governments in
2008. An analysis was made of the financial and qualitative
data.
Results
The survey has shown that there are significant disparities in
terms of district inhabitants inclusion in health programmes.
In 3 out of 20 districts, the local government failed to
implement any programmes aimed at the local community. A
large share of measures were short-term activities16.5% of
the activities took between one to 6 months. The average cost
of one programme was 10 000 Euro. However, most of the
programmes were low-cost activities68% of them were
completed at a cost below the average value, and the cost of as
many as 25% of the programmes was less than 1250 Euro. The
measures were predominantly focused on increasing physical
activity among the inhabitants and on improving the efficiency
of early diagnostics and treatment of cervical and breast cancer.
Lessons
There seems to be little likelihood of particularly low-cost
health programmes aimed at local populaces of a few dozen
thousand people being effective. The suggested solution might
be reducing the number of programmes and allocating more
funds towards a single programme properly designed on the
basis of Health Technology Assessment. The short-term nature
of the activities renders them insufficient, especially when it
comes to health promotion, to trigger and consolidate healthy
behaviour patterns. It is necessary, therefore, that long-term
health programmes should be considered as priorities by the
local communities.
Childhood socio-economic position and adult health
behaviours: a study of 31 182 men and women in the
Stockholm Public Health Survey
Daniel Falkstedt
D Falkstedt1*, K Engstrom1, P Fredlund1, J Hallqvist2,3,
T Hemmingsson1
1
Department of Public Health Sciences, Karolinska Institutet, Stockholm,
Sweden
2
Department of Public Health and Caring Sciences, Uppsala University,
Uppsala, Sweden
however the influence of the contextual socio-economic factors

are still not well established.
The aim of this study was to examine if there is an association
between dietary habits and residence municipality and if a
possible difference between municipalities can be explained by
differences in individual socio-economic status.
Methods
The study population comprises all adults living in the Capital
Region (1.3 million). Information on demography and SES
was derived from the Danish national registries whereas dietary
intake and weight status was based on data from questionnaire
from a random sample of 69 800 people. Response rate was
52.3%.
The Capital region consisted of 38 municipalities that were
categorized into four social classes according to the distribution of income, educational level and employment status
(contextual SES). Multilevel, linear regression analyses were
carried out in two steps: first the association between
contextual SES and dietary habits/weight status of the residents
were examined, adjusted for age and sex. In the next model
further adjustment for individual SES (education, occupation,
income) were made.
Results
The intake of fish, fruit and vegetables was significantly higher
in the two upper contextual SES groups compared with the
lowest social groups. Mean body mass index (BMI) was
significantly increasing with decreasing contextual SES. The
significant effect of contextual SES on the intake of vegetables
and fish and for BMI was maintained after adjustment for
individual SES whereas the association between contextual SES
and fruit intake became borderline significant (p = 0.067).
Conclusions
Lower contextual socio-economic status is significantly associated with lower intake of vegetables and fish and higher BMI,
independently of individual socio-economic factors.

3
Centre for Health Equity Studies, Stockholm, Sweden

*Contact details: daniel.falkstedt@ki.se
Socio-economic inequalities in acute myocardial

infarction (AMI) incidence and short-term case-fatality
explain gradients in AMI mortality in Scotland
Carolyn Davies
CA Davies*, AH Leyland
MRC|CSO Social and Public Health Sciences Unit, Glasgow, UK
*Contact details: c.davies@sphsu.mrc.ac.uk
Background
Ischaemic heart disease (IHD) is the leading cause of death in
Scotland, and mortality is amongst the highest in Western
Europe. Mortality rates have been falling over recent years;
however, socio-economic inequalities still exist. We explore
how much of the socio-economic gradient in acute myocardial
infarction (AMI) mortality in Scotland can be explained by
inequalities in incidence and/or case-fatality from the disease.
Methods
We used linked hospital discharges and death records for all
Scotland (5.1 million) for those aged 45-74 years. Age
standardized mortality, incidence (first time events) and
case-fatality (proportion of incidents dieing within specified
time periods) rates were calculated for 2000-2002 and stratified
by Carstairs deciles of area deprivation (D1 = most affluent,
D10 = most deprived). The effects of the socio-economic
gradients in AMI incidence and case-fatality on inequalities
in AMI mortality were explored through sensitivity analysis.
Results
In 200002, mortality rates ranged from 220 deaths per
100 000 men in D1 to 653 in D10; corresponding figures for
women were 79 and 265. This equates to an inequality rate

ratio (RR) of 2.97 in men and 3.35 in women. Respective
RRs for incidence were 2.27 and 2.92. If all areas experienced
the low incidence rates seen in D1, AMI mortality rates in
men in D10 would fall to 287 (RR = 1.31); RR in women
would reduce to 1.20. In addition, if inequalities in immediate
case-fatality (proportion dying on day of incident event)
were eliminated RR would drop to 1.03 in men and 1.05 in
women.
Conclusions
Socio-economic inequalities in AMI mortality can largely be
explained by inequalities in incident events and partly by
socio-economic gradients in immediate case-fatality after a
first AMI. To reduce inequalities in AMI (and hence IHD)
mortality, inequalities in first time events and first time event
severity must be tackled.
Lessons learned for Sweden from the WHO

Commission on the Social Determinants of Health
Karin Melinder
K Melinder*
Swedish National Institute of Public Health, Ostersund, Sweden
*Contact details: karin.melinder@fhi.se
Issue
In 2003 the Swedish government adopted a comprehensive
national public health policy. The overarching aim was: to
create social conditions that will ensure good health, on equal
terms, for the entire population. The policy was updated in
2007 with a greater focus on individual choice and responsibility. In 2008 the WHO Commission on Social Determinants
of Health (CSDH) was launched.
The Swedish National Institute of Public Health (SNIPH) in
2009 was tasked by the Swedish Government to analyse which
lessons could be drawn, for Sweden, from the CSDH work. The
analysis was conducted in collaboration with the Swedish
National Board of Health and Welfare (SNBHW) by a large
group of civil servants. The task involved analysing how well
the current national policy corresponded to the CSDH
recommendations, and suggesting modifications for public
health policy in Sweden.
Results
Social inequality in health is growing in Sweden. The SNIPHSNBHW recommendations address the need for an intersectoral, nationally-coordinated committee to lay out the
recommendations for political actions and strategies for
implementing health in all policies. This area is less prioritized
by the current government.
Other recommendations include:
monitoring of social inequality in health
cooperation between the local, regional and national
levels
reducing social exclusion in early age
a health-promoting health and medical care sector
Lessons
Many of the recommendations lie outside the area of
responsibility for the SNIPH. In their own work mostly
directed at supporting the local and regional level, SNIPH will
use the concept of proportionate universalism, taken from
the English Marmot Review, as a tool for developing evidencebased measures to decrease inequality in health.
A health observatory in the city of Nanterre, a tool
for an efficient local health policy
Hele`ne Colombani
H Colombani*, M Michaud, D Calan, D Despinoy, D Demeaux
Town of Nanterre, France
*Contact details: helene.boespflug@free.fr
Background
Nanterre (93 000 inhabitants) near Paris concentrates many
determinants of ill health that generate inequality repartition
Background
Poor social circumstances in childhood are associated with
unhealthy behaviours in adulthood, which may or may not
be explained by continuity of poor social circumstances.
The aim of the present study was to investigate associations
between childhood socio-economic position (SEP) and healthrelated behavioural factors in adult men and women of
different ages.
Methods
The Stockholm Public Health Survey 2002 is a comprehensive
postal questionnaire on health, behaviours, and social
circumstances, and it was distributed to 50 000 randomly
selected citizens, 18-84 years of age, in Stockholm County. The
response rate was 62.5% (31 182 respondents). All participants
were asked to report the main occupation of each of their
parents as well as their own occupation. Based on this
information, SEP in childhood and achieved occupational class
position could be classified. The following information from
the questionnaire was also used: education, alcohol consumption, binge drinking, life time smoking habits, weight and
height, and leisure time physical activity. Logistic regression
was used for analyses.
Results
Among both men and women, current smoking was predicted
by lower childhood SEP, although associations appeared to
weaken with increased age. Binge drinking but not high
alcohol consumption was increased in men and women from a
lower childhood SEP, although not in younger subjects. Low
physical activity, overweight, and obesity had strong associations with lower childhood SEP in both men and women.
Educational level and occupational class in adulthood
explained associations between childhood SEP and subsequent
smoking and binge drinking, but explained less of the
associations between low childhood SEP and overweight/
obesity in adulthood.
Conclusions
A lower childhood SEP seems to be associated with increased
likeliness of having unhealthy behaviours in adulthood.
Continuity of low SEP into adulthood may explain some but
not all of the adverse behavioural factors associated with lower
childhood SEP.
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226
Socio-economic status and smoking in a

representative sample of Greek population: the
HELLAS health i study
Sotiria Schoretsaniti
S Schoretsaniti*, FT Filippidis, C Tzavara, Y Tountas
Center for Health Services Research, Department of Hygiene and
Epidemiology, Medical School, National and Kapodistrian University of
Athens, Greece
*Contact details: chsr@med.uoa.gr
Background
Today there are significant differences in the prevalence
of smoking between different socio-economic groups (WHO,
2001). Socio-economic inequalities in health behaviours have
been found in many countries (Mackenbach, 2006).
Methods
Data from a national household survey of 1005 participants
(483 men and 522 women) were analysed. Respondents were
selected by means of a three stage, proportional to size
sampling design.
Results
According to our data, 43.1% of the total sample (52.4% of
men and 34.4% of women, P < 0.001) smokes daily or
occasionally. Univariate analysis for men revealed that men
with 714 educational years were more likely to smoke
compared with those with <7 years. The odds for smoking
were lower for married and windowed men, as for those with
chronic diseases. Windowed women compared with singles,
those belonging to lower socio-economical class and those
with chronic diseases had lower odds for smoking in univariate
analysis. Greater odds were found for women with >6 years of
education. Adjusting the analysis for all variables the only
factors associated with smoking in men was chronic disease

and age. Men with chronic disease had 38% lower likelihood
for smoking. Men aged from 37 to 56 years or more than
57 years had significant lower likelihood for smoking
compared with those aged from 18 to 36 years, with odds
ratios equal to 0.56 and 0.33, respectively. A different pattern
was found in women. Women aged from 37 to 56 years
were more likely to smoke compared with those aged from 18
to 36 years (OR = 1.82, 95% CI: 1.113.0), while women
aged more than 57 years were less likely to smoke compared
with those aged from 18 to 36 years (OR = 0.38, 95% CI:
0.190.75).
Conclusions
This study confirms that socio-economic differences in
smoking are a complex phenomenon.
Educational attainment moderates the association

between national happiness and personal affect
across Europe
Ana Teixeira
A Teixera1, S Moore2*
1
School of Kinesiology and Health Studies, Queens University, Ontario,
Canada
2
Axe en sante, centre de recherche du centre hospitalier de lUniversite de
Montreal, Quebec, Canada
*Contact details: mooresp@post.queensu.ca
Background
Recent studies of social networks have shown how happiness
and depression can spread through population networks.
Criticisms of such studies have stressed the need to examine
variability in the social experience of happiness, and the link
between happiness and health. This study examines the role
that educational attainment plays in moderating the association between national happiness and personal affect across
Europe.
Methods
Using data from European countries participating in the
200203 World Health Survey, we use multilevel ordinal
regression to examine cross-national variation in affect, and
whether educational attainment moderates the association
between national happiness and affect. To measure personal
affect, respondents were asked to report on a 5-point
Likert scale how much of a problem they had with feeling
sad, low or depressed over the last 30 days. Educational
attainment was categorized into five levels. Data on national
happiness come from a separate data source, the World
Values Survey which was conducted within European
countries from 19992001. Analyses adjusted for individual
age, income and gender, and national-level income
inequality.
Results
Clustering of affect was evidenced with an intraclass correlation coefficient of 5.00% (95% CIs: 2.916.92). Compared with
those with a college degree, those with less than a high school
degree were more likely to report feeling sad, low or depressed
(OR: 1.45 95%CIs: 1.351.56). National happiness was
inversely associated with feeling sad or depressed (OR 0.99;
95% CIs: 0.980.99). Educational attainment moderated the
association between national happiness and feeling sad or
depressed such that country of residence was more strongly
associated with the affect of individuals with low educational
attainment.
Conclusion
Europeans with high educational attainment are more
likely to be happy regardless of where they live. The mental
health benefits of residing in countries with high levels
of happiness accrue primarily to those at lower educational
levels.
in health status in the region. Life expectancy for males was

4.5 years less than average in the region.
Issue
The only local implementation of health policies developed at
national level has shown its limits, not taking into account the
complexity of the field. Few gains in terms of morbidity and
mortality are obtained.
The implementation since 2004, a local observatory of Health
has provided the municipality tools necessary to develop an
integrated policy for local public health.
Description
We have integrated all the socio-sanitary data collected since
1997:
Quantitative indicators: Data from the programme of oral
dental health, WHO Mental Health Survey, Survey Epidaurus
(score Spices)
Qualitative indicators: achievement of four health diagnoses in
priority neighbourhoods of the city
Results
The analysis and integration of these data allowed the
development of a methodology to have a shared vision:
The problems are not all different from those identified at
national level (i. obesity), but here are contextualized and
integrated with local determinants.
Recognition of the priorities identified only by the citizens
(pollution-related habitat) as those identified by professionals
(prematurity)
Visualize the gap between health needs and health resources
to guide the local municipal strategy in terms of prevention
and care (dental health, mental health).
Lessons
The establishment of a monitoring local health has developed
an integrated vision avoiding the simple application turnkey
ready-made programmes. It is both a tool for analysing,
sharing, development and reproducible assessment. Health
local Policy tool it allows National policies to improve
efficiency.
227
Occupational health and safety

Sickness presence, sickness absence and health
consequences: a Swedish population-based cohort
study
Klas Gustafsson
K Gustafsson*, S Marklund
*Contact details: klas.gustafsson@ki.se
Working conditions are important for survivala

prospective study in a general Swedish population
Ingemar Andersson
HI Andersson*, G Ejlertsson
Centre of Public Health, School of Health and Society, Kristianstad
University College, Kristianstad, Sweden
*Contact details: ingemar.andersson@hkr.se
Background
Working conditions as well as lifestyle have an impact on
health and quality of life. Lifestyle factors like smoking and low
physical activity have demonstrated relationships to increased
mortality. The significance of the interaction between work
factors and lifestyle on mortality is less studied. The aim was to
analyse the importance of self reported work factors in
Return to work coordination in Germany: a

cost-benefit analysis from a companys perspective
Martin Emmert
M Emmert1*, AS Esslinger2
1
Chair of Public Health Management, Friedrich-Alexander-University
Erlangen-Nuremberg, Nuremberg, Germany
2
Chair of Strategic Management, Friedrich-Alexander-University ErlangenNuremberg, Nuremberg, Germany
*Contact details: martin.emmert@wiso.uni-erlangen.de
Background
According to the German law (Social Code 84 2 SGB IX),
employers must implement corporate reintegration management measures for employees who are unfit for work for a
period of 6 weeks or longer within the previous 52 weeks. Little
is known concerning the economic consequences from an
employers perspective. Therefore, we undertook a study,
bringing light in the shadow.
Methods
It was a three step approach: First, we undertook a literature
review and conducted qualitative expert interviews for
identifying cost and benefit criteria. Second, we assessed the
theoretically identified criteria. Third, we carried out a costbenefit analysis for a service provider company in Southern
Germany with 250 employees. A comprehensive sensitivity
analysis took place.
Results
We identified four relevant cost criteria: Costs consist of
implementation, one-time conduction, ongoing costs, and loss
of productivity. We also detected seven benefit criteria e.g.
reduced absent times, productivity gains, and fewer costs for
employee replacement. In our case, the estimated cost amount
was 38 000 E; the benefit was calculated to be 185 822 E. Thus,
the demonstrated benefit exceeded the costs quite substantially
Background
In recent years, there has been considerable expansion of
research concerning sickness presence (SP), a phenomenon
that entails people choosing to go to work despite being ill.
Data from a three-wave cohort study was used to determine
whether sickness presence (SP) and sickness absence (SA) are
specific risk factors for future health problems or reduced work
ability in the Swedish workforce, and to compare the
consequences of SP and SA. Health consequences were
measured in four different self reported dimensions: general
health, physical complaints, mental well being and work
ability.
Methods
The study population (the Swedish Working Life Cohort)
consisted of a random sample of employees aged 2550
(n = 2181) with data available for the years 2004, 2005 and
2006. Cross-tabulation with chi2 test, multiple logistic
regression analysis with 95% confidence intervals (CIs) and
estimations of explained variance were performed. The design
of the investigation allowed the use of control variables,
predictors, and outcomes at different points in time.
Results
SA and SP were both found to have negative health
consequences in the 12 month follow up period. This was
evident even after control for background factors (sex, age,
education) working conditions (socio-economic position,
work demands, control, adjustment latitude). The effects
became less pronounced but significant even after control for
previous health status, and it was particularly pronounced for
those with frequent of SP or SA. SP seemed to be a stronger
predictor of negative health outcomes (poor health, physical
complaints, low mental well being, low work ability) and
showed a higher degree of explained variance than SA. SP also
appeared to lead to SA, whereas SA did not have a significant
impact on future SP.
Conclusions
This study indicates that both SP and SA have negative health
consequences and that there may be a dose-response relationship between the degrees of SA and SP and the deleterious
effects on health. In general, the results suggest that SP had a
stronger negative impact than SA did in the present
population-based cohort study.
interaction with lifestyle as predictors of survival in a general

population
Methods
A random sample of an adult (age 2574) general population
responded (response rate 90%) to a comprehensive questionnaire on health, lifestyle, work and socio-economic factors
in 1988. Individuals having a work or having worked until
their retirement were included in the study (n = 1406).
Mortality data for this cohort between 1988 and 2002 was
obtained from the national register of causes of death. Cox
proportional regression models with hazard ratios (HR) for
mortality risk, adjusted for age, gender and education, were
used to study initially reported factors possibly influencing
survival.
Results
As expected lifestyle factors like smoking, low physical activity,
and obesity increased the mortality risk. Among work factors
monotonous (HR = 1.57) and stressful work (HR = 1.68)
showed increased mortality whereas vibrating work tasks
(HR = 0.61) and good social support (HR = 0.57) related to
increased survival. In the final regression model with lifestyle
factors and working conditions together, three significant
factors remained as predictors of survival: smoking
(HR = 1.68), social support (HR = 0.54) and stressful work
(HR = 1.61).
Conclusions
The report of stress in work situations results in a mortality
risk as high as the risk of smoking. Independent of these risks
good social support seems to improve survival. Workplace
health promotion has to include the totalitylifestyle, and
social as well as work-related factorsto be effective.
228
(147 000 E). Conducting the programme was associated with

an overall cost-saving-relationship of 1:4.8. Sensitivity analyses
demonstrated the robustness of this result.
Conclusions
This investigation contributes to further knowledge on the
cost-effectiveness of return to work coordination from
the perspective of an employer. It could be shown that the
implementation might lead to cost-savings, even in the
short term. The results should contribute to further
acceptance and implementation of the measures in daily
practice.
Smoking and disability retirementa register-based
follow-up study
Ossi Rahkonen
O Rahkonen1*, J Lahti1, M Laaksonen1, S Karvonen2, O Pietilainen1,
T Lallukka1, E Lahelma1
1
Department of Public Health, University of Helsinki, Helsinki, Finland
2
National Institute for Health and Welfare, Helsinki, Finland
*Contact details: ossi.rahkonen@helsinki.fi
Permanent disability incidence in a cohort of social

security affiliated workers, 200407
Xavier Duran Jorda`
FG Benavides1,2, X Duran1*, J Miguel Martnez1,2, P Jodar3, P Boix1,4,
M Amable1,5
1
Centro de Investigacion en Salud Laboral (CiSAL). Universitat Pompeu
Fabra
2
CIBER de Epidemiologa y Salud Publica
3
Departament de Cie`ncies Polticas i Socials. Universitat Pompeu Fabra
4
Instituto Sindical Trabajo Ambiente y Salud
5
Universidad Nacional de Lanus, Argentina
*Contact details: xavier.duran@upf.edu
Objective
To describe the incidence of permanent disability, workrelated and non work-related, by several socio-economic and
geographical variables.
Methods
The study design was a retrospective cohort of 768 454 workers
cover by the Social Security General Schedule, selected in 2004
The impact of health problems in sickness absence

might be underestimated in Sweden
Gunnel Hensing
G Hensing*, K Holmgren, L Andersson, G Krantz, E-L Petersson,
C Staland Nyman
Social Medicine, Institute of Medicine, The Sahlgrenska Academy at the
University of Gothenburg, Gothenburg, Sweden
*Contact details: gunnel.hensing@socmed.gu.se
Changes in the welfare systems including the sickness

insurance scheme are ongoing in several countries, and
better knowledge on the extent of health problems in
sickness absence seems needed. The overall aim of this cross
sectional study was to assess and compare self-rated health,
common symptoms and mental well-being in two samples of
incident sick-leave cases with the general population. The
study was performed in Sweden, 2008, and three samples of
individuals aged 1964 years were selected. The final study
populations consisted of 3310 consecutive new employer
reported sick-leave cases, 498 consecutive new self-reported
sick-leave cases and 4027 individuals from a random general
population sample. A mailed questionnaire was distributed.
Validated questions and instruments on health and demographic data was analysed in bivariate and multivariate
analyses. Poor self-rated health, high levels of symptoms and
low mental well-being was reported by a significantly higher
proportion in the two sick-leave samples compared with the
general population. In logistic regressions with the general
population as reference we adjusted for age, income,
occupational class and current sick-leave. The fully adjusted
OR for poor self-rated health, high levels of symptoms and
low mental well-being respectively were 1.54 (95% confidence intervals 1.241.91), 1.95 (1.542.48) and 1.41 (1.11
1.79) among the employer reported male sick-leave cases and
1.94 (1.342.82), 1.76 (1.142.70) and 2.11 (1.403.17)
among self reported male sick-leave cases. Corresponding
figures for women were 1.80 (1.562.08), 1.42 (1.221.66)
and 1.21 (1.031.43) and 2.10 (1.602.75), 1.97 (1.12.57)
and 1.78 (1.352.36). Differences in health problems between
the groups remained significant in the fully adjusted model.
We conclude that sick-listed individuals have a higher
burden of illness also after control for current sick leave
than the general population. Consequence analyses of more
rigorous legislation and increased demands need to take this
into account.
Background
The health consequences of smoking are well-documented but
less is known about the effect of smoking on disability
retirement. The aim of this study was to examine the impact of
smoking on subsequent disability retirement of various
diagnoses among middle-aged public sector employees.
Methods
Baseline survey was collected in 200002 among middle-aged
employees of the City of Helsinki (n = 6373, 80% women).
Data on disability retirement were obtained from the Finnish
Centre for Pensions (200008) and were linked to the
questionnaire data using unique person numbers. To examine
the independent effect of smoking age, socio-economic
position, working conditions, alcohol drinking, physical
activity and body mass index were adjusted for. Hazard
ratios (HR) and their 95% confidence intervals were calculated
using Cox regression analysis.
Results
There were 511 (7.9%) disability retirement events during the
follow-up. Baseline smoking predicted disability retirement
(HRs for current smoking among women were 1.71 [95%CI
1.382.10], among men 1.58 [1.062.36]. Risk for disability
retirement increased with number of smoked cigarettes.
Especially strong was the effect among those who smoked
more than 20 cigarettes per day, for women HR = 2.1 [1.53.0],
for men HR = 2.6 [1.74.1]. Age and gender adjusted Hazard
ratios due to mental diagnoses were 2.2 [1.43.7] and due to
musculoskeletal diagnoses 2.1 [1.33.2)]. Adjusting for confounders attenuated the effects but mainly they remained.
Conclusions
To support quitting smoking among employees may prevent
work disability retirement.
and followed up until 2007, and based in the Continuous

Working Life Survey. In this period, 7749 cases (7032; 90.7%,
non work-related) were identified. Incidence rates were
calculated dividing cases by times from each worker cover
by the social security general schedule and included in the
cohort (1 937 920 worker-years). Rate ratios (RR) and
their confidence intervals at 95% CI), crude and adjusted,
were estimated by Poisson regression models using a
robust estimation of standard errors of the parameters
models.
Results
Permanent disability incidence non work-related was 10 times
greater than work-related (36.3 versus 3.7 per 10 000 workeryears). Incidences were highest for men, and increasing with
age and lesser education level. Asturias was the region with the
highest incidence comparing with Madrid, for non workrelated (56.7 versus 23.3) as well as work-related (7.8 versus
1.9). This differentials was maintained (RR = 2,2;
CI95% = (1.9; 2.5) years RR = 3,2; CI95% = (2.1; 4.9), for
work-related and non work-related respectively), after adjusting by age, sex, educational level, company sizes and economic
activities.
Conclusions
In this first cohort study of permanent disability, we observed
great differences in incidences by demographics, social and
geographical characteristics which have to be analysed in
depth, especially those differences observed by regions.
Sickness certification norms in Norway and Poland,

a comparative study on GPs recommendation of
sick leave in respiratory tract infections
Nils Fleten
N Fleten1*, K Wennevold1, M Godycki-Cwirko2, H Melbye1,
PA Halvorsen1
1
Department of Community Medicine, University of Troms
2
Department of Family and Community Medicine, Medical University of
Lodz, Poland
*Contact details: nils.fleten@uit.no
Disability pension after coronary revascularization.

A 15-year follow-up in Sweden
Margaretha Voss
M Voss1*, M Vaez1, K Alexanderson1, T Ivert2, K Pehrsson3,
N Hammar4
1
Department of Clinical Neuroscience, Karolinska Institutet, Stockholm,
Sweden
2
Department of Thoracic Surgery, Karolinska hospital, Stockholm, Sweden
3
Department of Cardiology, Karolinska University Hospital, Stockholm,
Sweden
4
Institute of Environmental Medicine, Karolinska Institutet, Stockholm,
Sweden
*Contact details: margaretha.voss@ki.se
Background
Cardiovascular disease is a major cause of chronic illness in
Western countries as well as globally. Coronary revascularization by coronary artery bypass graft surgery (CABG) or
percutaneous coronary intervention (PCI) are common
treatments. Many patients return to work and an active life
after revascularization but the knowledge about disability
pension (DP) after CABG and PCI is limited the aim of this
article is to describe DP within 1 year following CABG or PCI
in Sweden.
Methods
Patients were recruited from The Swedish Register of Coronary
Bypass Surgery and The Swedish Coronary Angiography and
Angioplasty Registry. Information on DP the year after the
intervention was obtained from a national register including
information on all DP in Sweden: date of start and end of each

period, the extent of the DP (part/ full-time) and information
about the diagnosis for each period of DP. All patients were
followed regarding mortality by the national cause of death
register. Information about socio demographic and socio
economic variables (e.g. level of education, income, unemployment benefits, type of occupation and country of birth)
were obtained for all patients.
Results
During 19922006, 71 512 individuals 3063 years of age
underwent a first CABG (N = 27 308, 16% women) or PCI
(N = 44 204, 22% women) in Sweden. Of these 23% had DP at
the time of intervention. Within 1 year after the coronary
intervention 1502 (7%) and 1723 (5%) among CABG and PCI
patients respectively, had received DP and the majority of these
were full-time. The most common diagnoses of DP were
cardiovascular (60%), musculoskeletal (16%) and psychiatric
(7%) diseases.
Conclusions
DP, primarily due to cardiovascular disease, is common
among patients undergoing coronary revascularization by
CABG as well as PCI.
The usefulness of National guidelines for sickness

certification
Britt Arrelov
Y Skaner1, G Nilsson1, B Arrelov2*, E Minas3, C Lindholm3,
K Alexandersson3
1
Cefam, Karolinska Institute, Stockholm, Sweden
2
MMC, Karolinska Institute, Stockholm, Sweden
3
Department of insurance medicine, Karolinska institute, Stockholm,
Sweden
*Contact details: britt.arrelov@sll.se
Background
A guideline for sickness certification was introduced in Sweden
2007. These guidelines were meant to be used by both
physicians and social insurance officers (SIO). The guidelines
consist of two parts: Comprehensive principles and diagnose
specific recommendations for duration and grade of sick leave.
The aim of the study was to investigate how useful physicians
find them.
Methods
A comprehensive questionnaire about sickness certification
practice was sent to physicians in Sweden in October 2008. In
this study are 3182 physicians mainly working in PHCC, who
had consultations concerning sickness certification at least a
few times a year and who used the national guidelines at least a
few times a year included.
Results
There was no gender difference regarding the use of the
guidelines. Younger physicians and physicians with only a
medical degree and registered physicians used them more often
than older and more specialized physicians. Two-thirds of the
physicians reported that the guidelines had facilitated their
contacts with the patients, >40% their contacts with the SIO
and 30% their contacts with the health care staff and with the
patients workplace or employment office. Almost one-third
answered that the guidelines had helped them to develop their
skills and one-third valued the diagnosis-specific recommendations for sick-listing as very beneficial for the quality in that
task. Less than half considered it to be very or fairly
problematic to use the comprehensive principles or to issue
sickness certificates in accordance with the diagnosis-specific
recommendations. A large proportion of the physicians said
they would need to further develop their competence to use
the guidelines.
Conclusions
The national guidelines for sickness certification are well
received by the physicians and contribute to the sickness
certification process through better communication between
involved actors and higher competence among physicians.
Background
High rates of sickness absence in Norway have stimulated
public debate on general practitioners (GPs) sickness certification practice, and introduction of guidelines are proposed.
Short-time sickness absence certified by GPs most frequently
end on Fridays and Sundays, while self-certified sickness
absence seems to have more normal distribution.
The objective of this study was to compare GPs recommendation of sick leave in Norway and Poland in respiratory tract
infections.
Methods
In 2009, a total of 216 GPs in Poland and 171 in Norway,
were asked for their recommendations on sick leave or not,
and if yes, for how many days in four vignettes describing
patients with pneumonia, sinusitis, common cold, and
exacerbation of chronic obstructive airway disease (COPD).
Results
Although Norwegian GPs generally were more restrictive on
recommending sickness absence, a characteristic and identical
pattern of recommending sick leave for 3, 5, 7, 10, or 14 days
were observed in both countries. Recommendations of 4, 6 or
8 days duration were infrequent. If sick leave was recommended, length of 3, 5 or 7 days amounted to 63.4% in
pneumonia and 79.3% in COPD. Correspondingly recommendations of 2, 4, 6, and 8 days, amounted to 4.6 and 5.2%.
Conclusion
This study demonstrate an identical bi-national normative
pattern of issuing sickness certificates, independent of
weekdays, national legislation, and sick leave schemes.
The normative pattern may explain why extended selfcertification schemes can reduce mean length of short-time
sickness absence. Any introduction of guidelines my
influence the norms in either direction and should be
closely evaluated.
229
230
Focus group study on womens actions, emotions,

and reflections regarding work after breast cancer
surgery
Lena-Marie Petersson
M Nilsson1*, M Olsson2, A Wennman-Larsen1, L-M Petersson1,
K Alexanderson1
1
Karolinska Institutet, Department of Clinical Neuroscience, Division of
Insurance Medicine, Stockholm, Sweden
2
Karolinska Institutet, Department of Neurobiology, Care Sciences and
Society, Division of Social Work, Stockholm, Sweden
*Contact details: marie.i.nilsson@ki.se
Risk assessment of occupational accidents in

pulp-and-paper industry in Northwest Russia
Zhanna Varakina
ZhL Varakina1,2,3*, AM Vyazmin3, AL Sannikov3, AM Grjibovski1,4,5
1
Arkhangelsk, Russia
2
Department of Research Management, Northern State Medical University,
Arkhangelsk, Russia
3
Department of Public Health, Health Care and Social Work, Northern State
Medical University, Arkhangelsk, Russia
4
5
*Contact details: ravenzh@land.ru
Background
Occupational health and safety is an important public health
issue associated with the level of national economy and
reflecting social development. A recent study from Northwest
Russia showed that the incidence of fatal occupational
accidents (FOA) is higher than in neighbouring countries.
The agriculture, hunting and forestry sector has the highest
incidence of FOA warranting further research. The aim of the
study was to perform qualitative risk assessment of accidents in
pulp-and-paper industry in Northwest Russia.
The Kosova Police from 200507: sickness

absenteeism or presenteeism?
Ardita Baraku
A Baraku1*, P Verdonk2, N Boumans3
College Iliria, Institute for Scientific Research, Prishtina, Kosova
2
University of Maastricht, Faculty of Health and Life Sciences, Institute for
Public Health Genomics, Maastricht, The Netherlands
3
Maastricht University, Faculty of Health and Life Sciences, School Caphri,
Department of Social Medicine, Maastricht, The Netherlands
*Contact details: arditabaraku@yahoo.com
Background
Sickness absenteeism studies in police services, in Kosova as in
other countries, are scarce. The purpose of this study is to
explore sickness absence trends at the Kosova Police (KP) by
researching demographics (gender, age and ethnicity), work
factors (employee category, working region and hierarchical
level) and medical profile of the reported sickness absence.
Methods
This study explored records of 6960 employees (79% of
employees in total) who reported sick during the time period
200507. Sickness absence percentage, frequency and duration
were used as measures of absenteeism and related to the
demographics, work factors, and medical profile.
Results
Over the years in the KP, the average sickness absence: (i)
percentage varied from 1.28% in 2005, increasing to 1.82% in
2006, declining to 1.33% in 2007; (ii) frequency has
continuously increased from 0.85 in 2005 to 1.38 in 2007,
while; (iii) duration has continuously decreased (from 5.5 days
in 2005 to 3.51 days in 2007).
Females have higher sickness absence rates than males. The
minorities, younger employees and Border police employees
utilize more short-term absences, while elder employees utilise
less frequent but longer absences. Hierarchically, lower level
employees have higher sickness absence rates than higher level
employees. Respiratory diseases, Injuries and Musculoskeletal
diseases were the most frequent reasons for sickness absence.
Conclusions
Sickness absence levels among KP are comparable to sickness
absence levels in EU countries, yet with much lower
parameters. Given the lack of health and social insurance in
Kosova, this indicates presenteeism, with various consequences, including the possible impediment of KP to maintain
Background
Breast cancer incidence as well as survival rates have increased,
but research on factors of importance for return to work
(RTW) after surgery is scarce. The aim was to explore what
actions women, who have had breast cancer surgery, have
taken regarding RTW and their reasoning and emotions
behind this.
Methods
Four focus group interviews with 23 women were conducted
28 months after breast cancer surgery. The groups were
strategically composed regarding treatment and age, to
increase homogeneity. The transcribed interviews were analysed inductively through qualitative content analysis.
Results
Three types of actions were identified: Women themselves
decided actively about sick leave or RTW and about when or to
what extent they returned to work. The decisions were based
on e.g. health, economy, a search for normality, or on
reappraisal of working. Retrospectively, most women who
continued to work during treatment were satisfied with this,
even if they initially felt forced to continue working e.g. by
economical reasons.
A second type of action was whether and how to ask for/make
use of adjusted work conditions. Reasoning behind this were
availability of a supportive environment or own wishes of
different tasks.
Thirdly, actions regarding disclosure of the diagnosis, degree of
disclosure, and to whom, was an issue. Reasons for choices
were a sense of security in colleagues knowing, or fear of
being discriminated. The women reflected about advantages/
disadvantages when the workplace is updated or about
possible ways to signal less work capacity during or after
treatment. Most women disclosed their disease at least to some
extent and were satisfied with this, while some women
were still anxious that disclosure may lessen opportunities at
work.
These results are useful in planning future interventions,
targeting RTW.
Methods
A cross-sectional study was conducted at the Arkhangelsk
pulp-and-paper mill in 2009 in a random sample of employees
from each production shop (n = 322) who answered a semistructured questionnaire on lifestyle, work experience characteristics and self-assessment of health. Occupational hazards
were analysed by criteria for quality risk assessment of
accidents at working place developed at Tampere University
of Technology (Finland, 1994). Proportions were compared by
chi-squared tests.
Results
Most of the responders were males (71.7%) with average age of
38.9 years. Altogether, 85.9% responders considered their
working place as dangerous (n = 277). Among males this
proportion was higher than among females (88.7% versus
78.6%, P = 0.02). Sixty two percent of the responders estimated
their health as good. Qualitative assessment of risk of
occupational accidents revealed substantial and intolerable
risks of accidents in 31.3 and 25.3% of responders, respectively.
Substantial risk was estimated in 32.4% of males and 28.6% of
females (P = 0.51). Corresponding proportions for intolerable
risk were 23.9% versus 28.6% (P = 0.32).
Conclusions
Our results suggest that pulp and paper industry employees in
Northwest Russia have very high risks of occupational
accidents. Urgent actions on occupational safety promotion
are required. Recommended interventions, their feasibility and
potential impact will be discussed.
safety and order. Further research at the KP and national level

would facilitate understanding in-depth factors influencing
sickness absence, with the aim to establish appropriate
legislation, policies and programmes to support employees
health/wellbeing and permit recuperation time.
Subjective health in relation to return-to-work among
people on long-term disability benefit: a 1-year
prospective cohort study in The Netherlands
Angelique de Rijk
A De Rijk1*, A Van Hal2, C Joling3, A Meershoek2, F Nijhuis1
1
Department of Social Medicine, Faculty of Health, Medicine and Life
Sciences, Maastricht University, Maastricht, The Netherlands
2
Department of Health Ethics and Society, Faculty of Health, Medicine and
Life Sciences, Maastricht University, Maastricht, The Netherlands
3
TNO Quality of Life, Hoofddorp, The Netherlands
*Contact details: angelique.derijk@socmed.unimaas.nl
Gender, work-home interference and burnout among

Dutch General Practitioners
Inge Houkes
H Abrahams1, P Verdonk2, I Houkes1*
1
Department of Social Medicine, Maastricht University, Maastricht,
The Netherlands
2
Institute of Public Health Genomics, Maastricht University, Maastricht,
The Netherlands
*Contact details: Inge.Houkes@socmed.unimaas.nl
Background
Compared with the general working population, burnout
levels among Dutch General Practitioners (GPs) are high.
Furthermore, the number of female GPs is increasing rapidly

across Europe. An earlier study showed that the prevalence and
onset of burnout differ between men and women, but this
study did not address gender aspects. Gender is thought to
reflect femininity and masculinity, and not merely the
biological sex differences (being male or female). This study
aims to assess the relationship between gender and burnout
among GPs, taking other burnout determinants such as workhome interference (WHI), work characteristics and coping
into account.
Methods
A cross-sectional survey was performed in a sample of 261
Dutch GPs (51% men). The questionnaire included the
Maslach Burnout Inventory, and validated scales for gender
(femininity and masculinity), WHI, coping and work characteristics. Data were analysed through multiple hierarchical
regression analyses.
Results
Male and female GPs are equally feminine, but men are more
masculine than women. Regression analyses show that a high
level of femininity is related to high levels of emotional
exhaustion (beta = 0.20**), while masculinity relates to lower
emotional exhaustion (beta = 0.19**). Sex does not add to the
explanation of burnout, but WHI, workload and passive
coping do. Work characteristics and WHI appeared to mediate
the relationship between gender and burnout.
Conclusions
Gender appears to be related to burnout, work characteristics
and WHI among GPs. Hence, there may be gender-related
differences in work quality and workplace health of GPs. In
line with EU policies aimed at reducing the gender gap at the
labour market (European Commission, 2008) and taking the
rapid femininization of the GP profession into account we
recommend more gender-sensitive public health interventions
for this professional group, such as innovative and flexible
work arrangements for balancing work and private life.
Prognostic factors for shifting between return to

work and multiple benefits during a 5-year follow-up
after occupational rehabilitation
Irene yeflaten
I yeflaten1*, L Lie2, C Ihlebk2, E Eriksen2
1
The National Centre for Occupational Rehabilitation, Rauland, Norway
2
Uni Health, Rauland, Norway
*Contact details: irene.oyeflaten@air.no
Background
Longitudinal studies are required to understand more about
the complex RTW process after rehabilitation and to explore if
there are different sick-leave patterns between different sociodemographic subgroups. The aim of this study was to examine
if duration of sick-leave before rehabilitation and sociodemographic factors as gender, age, medical diagnosis, and
occupation predict different sick-leave patterns or RTW
outcomes in a 5-year follow-up period after a 4-weeks
inpatient occupational rehabilitation program.
Methods
The sample consisted of 584 patients (66% females, mean age
44 years [SD = 9.3], long-term sick-listed; mean duration 9.3
months [SD = 3.4] for psychological (47%), musculoskeletal
(46%) and unspecific/other diagnosis (7%). Register data from
The National Insurance Administration in Norway was
analysed in an eight state-model: working, graded sick-listed,
sick-listed, medical rehabilitation, vocational rehabilitation,
part-time disability pension, time-limited disability pension
and permanent disability pension. Extended proportional
hazards regression models, were applied to analyse sociodemographic prognostic factors for shifting between any of the
eight states during the 5 years follow up.
Results
Age; relative risk (RR) = 3.30 [95% confidence interval
(CI) 2.29, 4.73], female gender; RR = 2.13 [1.09, 4.16] and
Background
Literature suggests that health becomes less of a reason for not
returning to work reduces as time goes by. Therefore and to
de-medicalize, return-to-work (RTW) interventions often not
focus on health. However, participants may perceive their illhealth being ignored. Our objective was to analyse the role of
subjective health in people on long-term disability benefit who
were offered various RTW interventions.
Methods
A 1 year prospective cohort study was performed among a
representative sample of disability benefit claimants (n = 242).
Inclusion criteria were: disability benefit for >5 years; had reassessment of work disability; offered one or more RTW
interventions. Data were collected every 3 months (T1-T5).
Variables included: gender, age, disability benefit duration,
subjective health (range 0100), psychosomatic complaints,
meetings with health care workers, admission at hospital and
type of RTW intervention (standard, irregular, combined).
Repeated measures and Cox regression analyses were applied.
Results
Subjective health slightly improved (P = 0.000) and psychosomatic complaints slightly decreased (P = 0.042) during the
study period. Every 3 months period, 67.877.3% of the
respondents consulted health care workers and 2.09.9% were
admitted at hospital. Subjective health at the start (OR 1.019,
P = 0.001), and participating in irregular interventions from T3
on (OR 0.446; P = 0.028) were significant determinants of
RTW.
Conclusions
Even though the respondents subjective health improved after
starting the RTW intervention, low subjective health reduced
the RTW chance substantially (10% lower subjective health
score equals 19% lower RTW chance). Moreover, the
respondents frequently consulted health care workers. The
experience of ill-health should thus not be ignored in RTW
interventions for people on long-term disability benefit.
Participation in the irregular RTW interventions was related
to lower RTW because these interventions may have delayed
RTW beyond the study period. Claimants revived disability
benefit for a long period seem in need of interventions that
address, in addition to other issues, health issues without
medicalization of their problems.
231
232
having an unspecific/other diagnosis; RR = 3.39 [1.70, 6.74]

gave highest risk for shifting to full-time disability pension.
Sick leave length before rehabilitation gave an increased risk
for going from sick-listed to any benefit RR = 1.05 [1.03, 1.07],
for going back to work RR = 1.02 [1.01, 1.04] and for
having new periods of sick leave RR = 1.04 [1.01, 1.07]. Bluecollar worker had the highest risk for shifting from the state
working.
Conclusions
Our findings indicate different RTW outcomes for different
socio-demographic subgroups. Rehabilitation programmes,
the work place, and the system should increase focus on
women, individuals with higher age, unspecific diagnosis and
blue-collar workers in the RTW process after long-term sick
leave.
The impact of employment advice in primary care
Fiona Ford
Background
The UK Pathways Advisory Service (PAS) provides Jobcentre
plus employment advisors in primary care to tackle worklessness and improve health. This study explores the impact of
the PAS advisor in a deprived GP practice in northern Britain
compared with evaluation of a similar project in London
which showed reduction in GP consultation and antidepressant prescribing rates, following provision of employment
advice.
Public health education and competencies

Screening for Helicobacter pylori infection in France,
who and why?
Gregoire Jeanblanc
H Pham-Orsetti, G Jeanblanc*, O Scemama, C Rumeau-Pichon,
F Meyer
Economic Evaluation and Public Health Department - French National
Authority for Health - Paris- France
*Contact details: g.jeanblanc@has-sante.fr
Problem
Helicobacter pylori (HP) infection is widespread in developed
countries (3050% of adult population). It is specifically
located in the stomach and systematically results in chronic
inflammation, which could either progress to peptic ulcer
(10%) or, rarely, through premalignant stages, to adenocarcinoma (1%). It was recognized as a carcinogenic agent for
gastric cancer (GC) by the World Health Organization. GC
incidence is low in Western and Northern Europe and
decreasing such as HP infection prevalence. European
guidelines (European Maastricht III Consensus Report,
March 2005) recommend testing asymptomatic people for
HP in restricted indications. We evaluated the public health
relevance of introducing screening for HP infection in the
general population in France. Such a screening has been
recommended in the Eastern Asia in countries with high GC
incidence.
Methods
We reviewed the screening for HP infection in French
population based on a systematic literature review and using
the French ANAES (National Agency for Accreditation
and Evaluation in Health) criteria for appraising the appropriateness, effectiveness and efficiency of a screening
programme.
Results
There is some evidence that eradicating HP is effective in
reducing in GC incidence. However, all identified studies were
performed in countries with high GC incidence. Furthermore,

no studies on the effectiveness of a HP screening programme
could be identified. Five economic evaluations of HP screening
were retrieved. These studies showed that HP screening would
be cost-effective but results were sensitive to the prevalence of
HP, the efficacy of HP eradication on GC development, and
the time horizon. The disadvantages of HP eradication,
including increased antimicrobial resistance due to widespread
use of antibiotics, treatment adverse events (which may affect
observance), the need for second line antibiotic treatment in
case of first line failure in 30% of the cases should be
considered.
Conclusions
The French National Authority for Health does not recommend a general population-based screening programme for
HP infection in prevention of gastric cancer.
Road traffic accidents: can road safety education

prevent hazardous behaviours?
Gabriele Messina
R Zampetti2, G Messina1, F Vencia1, L Genco2, L Di Bartolomeo2,
N Nante1*
1
University of Siena, Dept. of Public Health, Health Services Research
Laboratory, Italy
2
Adolescent Service, Former Local Health Authorities 1, Salerno, Italy
*Contact details: nante@unisi.it
Introduction
Road traffic accidents represent a global widespread problem
(especially among people aging 1539 years) and rank first in
terms of life expectancy years loss. Young drivers run a greater
risk reducing with each year of increasing age.
Aim
To demonstrate the effectiveness of a road safety education
programme (EP) among young people.
F Ford*
School of Public Health & Clinical Sciences, University of Central Lancashire,
Preston, UK
*Contact details: drfordetc@aol.com
Methods
Similar methodology was used to collect GP consultation data
retrospectively for the 18 months prior to referral to the PAS,
and a subsequent time of 1423 months (adjusted to 18),
including anti-depressant, analgesic and anxiolytic prescribing,
from approximately 66 consecutive PAS referrals, with background and follow up employment outcome data on a total
sample of 659.
Results
Out of the overall PAS sample, 23% returned to work, 17%
were referred to Condition Management Programme, 7% were
signposted into education and 11% for welfare/debt counselling. Men were 30% more likely and those with a job five times
more likely to go back to work. The advisor referred 54% of
those in employment to occupational health, and contacted
31% of employers.
In the practice dataset, 57% of PAS referrals were men, 77%
were South Asian, usually with either mental health problems
(48% with a predominance of men), or musculoskeletal
problems (39%). Mean GP consultation rate increased
significantly following PAS referral (6.01:8.33, P = 0.004),
while antidepressant, pain relief and anxiolytic prescribing
fell (P = 0.007). There was evidence of GPs and PAS working
together to tackle complex combinations of health and social
problems. Reasons for these findings will be explored further
in service user focus groups.
Conclusions
Provision of employment advice in primary care is associated
with significant reduction in prescribing, which may represent
demedicalization of socio-economic problems. Impact on
consultation rates was dependent on context.
Health technology assessment of the new 13-valent

pneumococcal conjugate vaccine introduction in the
Italian context
Flavia Kheiraoui
G La Torre1, C de Waure2, F Kheiraoui2*, ML Specchia2, S Capizzi2,
A Malaj2, A Zollo3, R di Virgilio3, P Refolo4, L Mantovani5, W Ricciardi2
1
Clinical Medicine and Public Health Unit, Sapienza University of Rome
2
Institute of Hygiene, Catholic University of the Sacred Heart, Rome
3
Pfizer Italia
4
Institute of Bioethics, Catholic University of the Sacred Heart, Rome
5
University of Naples Federico II
*Contact details: flavia.kheiraoui.iphu@rm.unicatt.it
Background
Nowadays different pneumococcal vaccines are available in
Italy; the introduction of the new 13-valent pneumococcal
vaccine (PCV13) will be thus challenging. The aim of the study
was to evaluate the PCV13 introduction in Italy through the
Health Technology Assessment multidisciplinary approach.
Methods
The epidemiological context was studied through literature
review and national databases consultation. PCV13 efficacy
was assessed analysing available results from clinical trials,
while a systematic review and a metanalysis of published
studies were performed to evaluate the main competitor [7valent vaccine (PCV7)] efficacy and effectiveness. A Markov
model was used to perform the cost-utility analysis from the
National Health Service perspective. Regional vaccination offer
strategies, vaccination services flaws and needs for citizens and
medical doctor empowerment were considered in the organizational analysis and ethical involvements were discussed.
Results
Invasive pneumococcal diseases (IPD) incidence rate in
Western European children under 2 years was 8.924/
100 000. In Italy IPD incidence rates, in 2008 post-vaccination
scenario, were about 5 and 2 for 100 000 respectively under 1
year and from 1 to 5 years; anyway data are not completely
reliable because of under-notification. Diseases due to
serotypes 19A and 3, covered by PCV13, are increasing.
PCV13 efficacy and safety were demonstrated similar to PCV7,
with a 35% higher estimated serotypes coverage. PCV7 efficacy
and effectiveness in preventing vaccine-serotypes IPDs were

shown >90% and >80%, respectively. PCV13 was demonstrated highly cost-effective versus no vaccination, with an
incremental cost-effectiveness ratio of about 2000 euro/QALY,
and cost-saving in comparison to PCV7. The homogenization
of regional vaccination strategies and improvements in
vaccination registries and monitoring should be anyway
promoted. From the ethical viewpoint PCV13 can be positively
judged if equal access to the vaccination will be guaranteed.
Conclusions
The HTA of PCV13 demonstrated that the new vaccine could
be value for money in Italy.
Education programme on management and ethics
of hospice care
Gena Grancharova
S Aleksandrova*, G Grancharova
Faculty of Public Health, Medical University, Pleven, Bulgaria
*Contact details: dean-ph@mu-pleven.bg
Background
With the introduction of hospices in Bulgaria in 1999 a need
for qualification in the new area appeared. At the time only the
National oncology hospital delivered courses on palliative care
for health professionals mainly clinically oriented and not
focused on management and ethics of hospice care.
The objective of the training programme is to contribute to the
development of positive attitude and to extend the students
views and knowledge about hospice care. The programme
includes 15 academic hours: 12 h lectures and 3 h visit to a
hospice. The interactive lectures offer discussions of theoretical
questions as well as cases and films.
Results
The programme was introduced in 2002 at the Faculty of
Public Health and is directed to bachelor and master degree
students in Healthcare management. Most of the students are
practicing nurses and midwives. All in all 440 students passed
through the programme till now. The programme was
accepted with great interest and approval. The annual students
assessment of the programme vary between 3.64 and 3.82 (at
the maximum score 4.00). Accordingly, students examination
achievements were very good. The examination assignment
consisted of two parts: case discussion focused on the concept
of good death and essay on the main characteristics of
hospice care.
Conclusions
The successful introduction of this education programme
among students in Healthcare management is a good basis
for further development and implementation of such programmes in other educational degrees as well as in other
relevant specialties. Appropriate education programmes for
hospices personnel can be developed in association with
clinicians.
The programme was presented at the UNESCO Regional
Meeting of Experts in Ethics Teaching in Split in 2005. The
programme was highly appreciated for its innovation and was
included in the Global Ethics Observatory database of teaching
programmes.
Results from an EU project on the teaching,
training and registration of public health physicians
specializing in environment (PHEEDUNET)
Irene Kreis
A Kreis1*, Pvd Hazel2, VSG Murray1, GS Leonardi1
CRCE, HPA, England, UK
2
University of Nijmegen, The Netherlands
*Contact details: ikreis@uow.edu.au
1
Background
EU Public Health Executive Agency Project No: 2006335
(PHEEDUNET), a European network for the training and
development of public health (environment) [PH(E)] physicians was conducted 200810.
Methods
The EP involved people aging 1316 years living in Local
Health Authorities (LHA) 1-Salerno, from 2004 to 2009. Intersectorial collaboration was obtained from LHA 1, local police,
Italian Automobile Association, charity associations and civil
defence, which organized conferences, focus groups, seminars,
practical activities in some secondary schools of LHA 1 (12
zones over 20). We compared accident incidence rates in two
periods: JuneAugust 2003 (before the beginning of EP) and
JuneAugust 2008. Descriptive analysis was carried out. Chi2
test was used to assess if EP influenced changes in road
accidents in the two periods.
Results
Road accidents occurred in 2003 and 2008 were respectively
1104 and 903. The median age was 31.9 years (SD 15.2) with
the highest occurrences between 20 and 24 years (19%),
followed by 25 and 29 years (15%). The most frequently
injured body regions were upper and lower limbs, respectively
27 and 25%, followed by the spine and back (21%) and head
region (17%). Most injuries occurred during rush hour traffic:
10.0013.00 am (24%) and 6.009.00 pm (27%). Statistical
differences in the incidence rates were highlighted comparing
the two periods (P < 0.001) but none comparing the 12 zones
which had EP versus 8 without it (P = 0.196).
Conclusions
Road safety education represents only an initial strategy to
change wrong driver behaviours, other complementary
activities play a role. Our initial findings seem not to associate
the decrease of the accidents to the EP. Our results are
consistent with other European studies in which there is
downward trend in the last 4 or 5 years.
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From knowledge translation and knowledge

brokerage towards knowledge co-creation: an
innovation systems perspective on the public health
knowledge infrastructure in The Netherlands
Lenneke Vaandrager
L Vaandrager1*, L Klerkx2, J Naaldenberg1, F van den Driessen
Mareeuw1, W de Regt3, J Zandvliet3, G Molleman4
1
Wageningen University, Health and Society, The Netherlands
2
Wageningen University, Communication and Innovation Studies, The
Netherlands
3
ZonMw, The Hague, The Netherlands
4
MAAT, Nijmegen, The Netherlands
*Contact details: lenneke.vaandrager@wur.nl
Problem
The Netherlands Organization for Health Research and
Development (ZonMw) is concerned about the fact that
science-based knowledge is not efficiently used for innovation
in public health policy and practice. Therefore a study was
carried out to explore underlying mechanisms that explain
how knowledge is exchanged (or not).
Methods
The innovation system perspective served as the theoretical
framework to study the complex process of exchange,
interaction and co-creation of knowledge, and served to
classify failures. Qualitative interviews were carried out with
stakeholders from the knowledge infrastructure in public
health. The following questions were addressed:
Who are the players, what are the different roles and how is
knowledge created and exchanged?
Which factors influence the interactions between different
stakeholders and what does this imply for knowledge
production and exchange, and consequently innovation?
Results
Underlying mechanisms which inhibit optimal learning and
innovation are:
1. Interaction failures, such as unclear role divisions and,
competition, engendering fragmentation.
2. Capacity failures among practitioners
3. Institutional failures, such as the evidence-based debate
about what good or bad knowledge is and influence of
powerful players on policy priorities, financing and
evaluation structures.
And while intermediary structures exist to translate and broker
knowledge in bilateral relationships between domains, there is
lack of a neutral systemic broker creating linkages amongst
several actor domains.
Lessons
To deal with the problem of interaction failure between
science, policy and public health practice special attention is
needed to capacity development (especially how to find and
use appropriate information), active (rather than passive)
knowledge exchange through personal contact, enabling a
process of co-creation and making implicit knowledge on
intervention implementation explicit. It requires an innovation
culture, which implies that the mindsets and incentives of
several actors should be geared towards producing socially
relevant knowledge. This innovation culture requires capacity
building (skills, time and money) as well as incentives
(funding, deliverables, rewards).
A comparative study of master of public health
students at the University of Liverpool in two
different learning environments: online and
on campus
Francine Watkins
F Watkins*, D Stanistreet, S Woolf
Division of Public Health, University of Liverpool, UK
*Contact details: fwatkins@liverpool.ac.uk
Background
Opportunities provided by new technologies and virtual
learning environments (VLE) are a key area of development
for those responsible for providing Public Health training
programmes. Adapting postgraduate public health training for
online environments is complex and there is little published
literature available which focuses on this type of development
in public health. To date the use of e-Learning in public health
training remains at an introductory stage and more reflection
is needed to understand the impact of these different methods
of delivery on student experience. The University of Liverpool
has developed a wholly online Master of Public Health (MPH)
programme based on the highly respected on campus MPH
programme and this research explores the training experiences
of students in these two distinctly different learning
environments.
Objectives
The objective of the research was to explore two different public
health learning environments and the impact of these on the
learning experience of students. A qualitative methodology was
used and data was analysed using thematic analysis, producing
a framework of ideas to inform future online learning.
Results
The motivation of students to achieve on both programmes
was outstanding. Students on the online programme did
appear less constrained due to the flexibility of online learning.
They benefited from interaction with students from around
the world; were more likely to interact using different
technologies and they understood the growing importance of
technologies in public health approaches. Students on the on
campus programme felt they benefited from face to face
interaction but were also less open to using VLE.
Conclusions
Changing student expectations and greater diversity within
public health indicate the need for those responsible for public
Objectives
We assessed registration rules to determine if specialization
in environment public health exists for physicians in the EU
and associated countries. Also, availability of relevant training
was assessed to identify what was available
Results.
For 10 countries, registration rules were identified. The
registration systems were either competency or skills-based
models. Usually the competency models emphasize integration
of skills and knowledge but are more difficult to translate to
training programmes. The skills-based models are easier to
translate to training but are less clear in their recognition of
strengths of medical professionals.
Many courses on public health were identified in many
countries and in related disciplines such as environmental
health. However, no single course caters in full for the needs of
a medical environmental public health specialist. We searched
for environmental public health, environmental epidemiology,
toxicology, risk assessment, risk communication and crisis
management as well as newly emerging issues such as climate
change and extreme events.
Our assessment shows that for those interested in
Environmental Public Health, finding the relevant courses is
complex and difficult requiring persistence and commitment.
Further, most public health degrees have little environmental
public health content, thus not generating interest or knowledge among general public health practitioners about environmental factors.
Conclusions
Specialist public health (environment) practitioners have a
place in the public health system of Europe. Therefore
environmental public health requires advocacy to general
public health practitioners in Europe. The authors consider
that initial training courses exists but are not always easily
accessible. PHEEDUNET should maintain its website of
detailed course information whilst this is a European
wide training programme for these specialists should be
established.
health training to engage with different learning environments

in line with technological advances and explore the provision
of flexible public health training.
Mapping public health capacity in the EU
Christoph Aluttis
C Aluttis1*, S Van den Broucke1, H Brand1, C Costongs2, C Chiotan2,
R Otok3, B Baer4, E Jelfs4, F Barnhoorn5, D Levin6, M McKee7, C Price8
1
Maastricht University, Maastricht, The Netherlands
2
EuroHealthNet, Brussels, Belgium
3
ASPHER, Brussels, Belgium
4
EHMA, Brussels, Belgium
5
EUPHA, Utrecht, The Netherlands
6
IUHPE, Paris, France
7
European Observatory on health Systems and Policies, Brussels, Belgium
8
European Commission, DG SANCO, Brussels, Belgium
*Contact details: C.Aluttis@gmail.com
Health strategy of the Aquitaine region and their

innovative policies
Solange Menival and Ewelina Piznal
E Piznal*, S Menival
Air Project, Conseil Regional dAquitaine, Bordeaux, France
*Contact details: ewelina.piznal@aquitaine.fr
The increase of health inequalities in European countries

indicates the needs to develop a database that will include
practices that contribute to reducing these health inequalities.
These are political issues that guarantee access to primary care
for all citizens.
The Aquitaine Region suffers from a lack of medical care which
has led to improving access to primary care and ensuring
better patient management.
Their approach is to support the operatives in maintaining
access to primary health in rural areas, in particular,
recommending that there be more Health Centres.
Prevention, promotion and education in health, and the
granting awarding of scholarships are also a part of Aquitaine
policies.
Aquitaine also led the European approach in the European
Network of Regions improving Citizens Health which resulted
in the launch of the Addressing Inequalities Intervention in

Regions Project.
This projects main objective is to identify innovative
intervention and to develop a catalogue of good practices to
reduce health inequalities in primary care settings. This
catalogue will include innovative actions, with instructions to
implement them, in the European regions taking into account
their specific and political context. This European project
represents fifteen countries and unites universities and political
institutions.
The Aquitaine Region was also driving force behind two
European Conferences: Reducing health inequalities in
Europe: a regional approach, and Health: how to reduce
the impact of the inequalities in the European regions. Issues
include socio-economical, environmental and accessing primary care. Objectives were to ensure exchanges among the
European regions about practices and actions implemented.
Developing paneuropean competency-based

professional standards and accreditation framework
for health promotion
Gerard Van der Zanden
GH Van der Zanden1*, MM Barry2, B Battel-Kirk3, R Parish4,
S Bensaude De Castro Freire5
1
Health Institute NIGZ, Woerden, The Netherlands
2
National University of Ireland, Galway, Ireland
3
BBK Consultancy, Dublin, Ireland
4
Royal Society for Public Health, London, UK
5
International Union for Health Promotion and Education, Paris, France
*Contact details: gvanderzanden@nigz.nl
Issue
This article reports on the project Developing competencies
and professional standards for health promotion capacity
building in Europe (CompHP project), which seeks to develop
consensus on core competencies, professional standards and
accreditation mechanisms for health promotion capacity
building in the European region.
Description
Funded by the Executive Agency for Health and Consumers
(EAHC) as part of the EU Health Programme, the CompHP
project (200912) takes a consensus building approach and
aims to work in collaboration with practitioners, policymakers
and education providers across Europe. The project partners
represent a wide geographic spread across EU member states
and candidate countries and therefore reflect the diversity of
health systems and levels of development of health promotion
in Europe. The project involves a detailed consultation process,
which will assist in developing competencies, standards and an
accreditation framework for health promotion, which will be
designed to be adaptable to varying contexts and needs across
the European region.
Objectives
To share information on the development and progress of the
project to date and to generate discussion with conference
participants to inform future developments. The article will
include an introduction to the project and outline its rationale,
key objectives and working methodology. Progress to date will
be reported on, including the findings of two rounds of a
Delphi survey on consensus building for developing competencies for health promotion and the results of an international
literature review on competencies. The progress on developing
professional standards, again using consensus building processes will be included as will the early stages in testing the
application of the competencies, standards and accredition
framework standards in academic and practice settings.
Special attention in the presentation will be on findings from
an international review of the literature on accredition
in health promotion, the debate on the suitability accredition for health promotion practitioners and the drivers and
barriers to implanting accreditation frameworks in this
discipline.
Background
In the past decade, the so-called Third Public Health
revolution has confronted the public health community with
important challenges due to changing goals, approaches and
actors. Addressing these challenges requires an increased
capacity of public health professionals and organizations.
The EU Health Programme commissioned this work in order
to inform actions by Member States (MS) and other
stakeholders to help strengthen public health capacities.
Methods
Based upon a comprehensive literature review, a consensusbased conceptual model of public health capacity was
developed and used as a framework for data collection on
the public health capacities of the EU MS. Data were collected
through a mixed methodology involving document analysis
and key informant interviews, validated through focus groups
and in depth case studies.
Results
A quantified assessment was obtained of key public health
capacities in the 27 EU MS in terms of six consensus-based
dimensions of capacity: knowledge development, workforce,
organizational structure, resources, partnerships and leadership and governance, along with qualitative information and
case illustrations.
Conclusions
Mapping the existing public health capacities allows identification of the main strengths and weaknesses with regard to
public health capacities in the EU MS, and provides a basis for
strategic planning and target setting to enhance the capacities
for public health in the EU; including action to be taken at EU
level.
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236
Making every contact count. Yorkshire, UK, 200910

Clare de Normanville
C De Normanville1*, K Payne2, V Ion3
1
Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield,
2
Public Health Directorate, NHS Yorkshire and The Humber, Leeds
3
True Blue Consultancy, Sutton on Trent, UK
*Contact details: c.denormanville@shu.ac.uk
Innovative LLL of general practitioners in quality

improvement supported by information technology.
Project presentation
Stogniew J. Sitko
SJ Sitko1, T Tomasik2, V Kijowska3*
1
Institute of Public Health, Jagiellonian University Medical College, Krakow,
Poland
2
Department of Family Medicine Jagiellonian University Medical College,
The College of Family Physicians in Poland, Krakow, Poland
3
Zdrowie i Zarza dzanie (Health & Management, Ltd.), Krakow, Poland
*Contact details: viola.kijowska@gmail.com
Background
General practitioners (GPs) involvement in the CVD firstline treatments, prevention and health promotion is a
problem of highest importance in European public health
(PH). First stages of the treatment of patients with chronic
diseases (especially CVD) may be improved by due to new
approach to LLL of GPs and implementing modern information technology (IT) in existing educational systems. The
presentedInGPinQI project (six Partners from five EU
countries: PL, CZ, SI, NL, DK) is focused on the quality
improvement (QI) education in: hypertension and diabetes
Health for sale: health-related advertisements on the

Italian press
Maura Bressanelli
M Bressanelli, G Orizio*, L Covolo, U Gelatti
Department of Experimental and Applied Medicine, Section of Hygiene,
Epidemiology and Public Health, University of Brescia. Brescia, Italy
*Contact details: gorizio@med.unibs.it
Background
Despite the fact that in Italy drug advertisement is strictly
restricted to over the counter (OTC) drugs, numerous ads do
have a health-related content. This should not come as a
surprise, since health care is one of the major concerns among
the public and as a consequence one of the world largest
business. Aim of the study is to assess the status of healthrelated advertisement in the Italian press.
Methods
We examined newspapers with the highest average national
circulation, adopting the following classification: newspapers
(N), free newspapers (FN), online version of newspapers
(OLN), and weekly newsmagazines (WN).
We analysed issues published in July and November 2009,
assessing the total number of ads for issue, the number of ads
present on the front page, and identifying the subject of the ad:
drugs, integrators, products, food, medical centres, wellness
centres, thermal baths, doctors, insurances, legal consultations,
other.
The following data are preliminary and refer only to the July
issues.
Results
A total of 388 issues were examined: 150 N, 54 FN, 155 ONJ
and 29 WN. We found 850 advertisements (average 2.2 ads per
issue): 50% on N (av. 2.8 /i), 6.9% on FN (1.1/ i), 1.2% on
OLN (0.6/i), 41.9% on WN (12.3/i). The subjects were
distributed as follows: food 28.1%, integrators 27.9%, products
15.2%, medical centres 9.2%, thermal baths 3.5%, drugs 3.4%,
insurances 2.2%, wellness centres 0.8%, legal consultancies
0.2%, doctors 0.1%, and other objects 9.4%.
Issue/problem
In 2007 NICE guidance on behaviour change included the
need to equip practitioners with the necessary competencies
and skills to support behaviour change. NHS Yorkshire and
The Humber Strategic Health Authority identified that to
deliver this agenda; a whole systems approach was needed that
looked at the contribution of the entire workforce rather than
specific elements. Commissioning behaviour change services is
problematic as service levels and workforce competence are
difficult to articulate. Moreover the wider public health ethos
is not fully embedded into the culture of commissioners,
resulting in a gap in understanding of workforce planning and
development that could demonstrate meaningful impact on
the public health agenda.
Sheffield Hallam University was commissioned to develop a
Prevention and Lifestyle Behaviour Change Competence
Framework. It was developed from an extensive review of
the literature and through a modified-e-delphi. The framework
is simple and flexible with four levels of practice covering 11
competences. Testing was through a case study approach.
Additionally, a scoping exercise to facilitate integration into
the social care setting has been carried out.
Effects/changes
Ten NHS Primary Care Trusts (community health care
commissioners and providers) have begun implementing the
framework. Preliminary results indicate that it is acting as a
catalyst for changing organizational development culture to
look at quality outcomes in relation to the workforce.
Commissioners and Providers are using it to understand the
basis for behaviour change and the balance of population
versus individual approaches.
Lessons
The development of such a framework requires a whole
systems collaborative approach that includes commissioners,
providers, educationalists and practitioners. This ensures it is
responsive to different audiences; is not prescriptive, and starts
from the basis of where the population/individual is.
Additionally it should add value and not detract from existing
practice or roles. Finally the framework needs to support
robust and transparent commissioning and provision of public
health services in financially challenging times
mellitustwo of the most important problems of PH in

Europe. The framework of European curriculum of QI training
programmes for GPs will be evaluated and analysis of required
competencies in the QI will be conducted. Training materials
and courses developed will be based on the data of the
identified gaps in the educational systems and required GPs
competencies relating to the vital problems in the European
communities, namely: (i) inequalities in health and social
determinants of health, (ii) growing patient expectations, (iii)
fragmentary GPs education on QI, (iv) unused expert
knowledge of GPs, etc.
Objectives
Main objective: to improve the existing training programmes
for both, GP and teachers in FM and their competencies in the
field of QI by implementing an innovative tools in existing
educational systems in Europe supported by IT. Thus, the GPs
real requirements can be reflected in every stage of planning,
execution and assessment of training programmes, and further,
the improved VET planning can be multiplied on EU level.
Results
Expected outcomes of the project are: (i) GuideBook, (ii) new
guidelines for the management of: arterial hypertension and
diabetes mellitus, (iii) innovative VET program, (iv) distancelearning module on QI, (v) Internet tool to identify individual,
QI educational needs of GPs. These, will have universal
character, adaptable to educational systems in all project
countries, and beyond.
Conclusions
Project will provide GPs with opportunities for VET advancement and enable developing of common, European frame of
reference for GPs occupational competencies. Its outcomes
will lead to broad the GPs educational offer and its quality and
attractiveness improvement.
OTC drug advertisements were found only on WN (89.6%)

and N (10.4%). These ads were related to: anti-itchy drugs
(37.9%), disinfectants (27.6%), ointments (20.7%), drugs for
stomach and bowel dysfunctions (10.3%), anti-inflammatory
drugs (3.4%).
Conclusions
Our analysis shows a high frequency of health-related
advertisements on Italian magazines and newspapers. Food
and integrators dominate the ads, while the presence of drugs
in advertising is definitely more limited. The latter is very likely
due to the legal restrictions. The considerably high frequency
of health-related ads in the Italian press suggests that among
the public and the industry the concept of health is becoming
more and more akin to the one of individual wellness.
Introducing problem-based learning into public health
master education through joint university
collaboration
William Sherlaw
The EHESP School of Public Health, France and the University

of Maastricht, has collaborated on introducing student
directed problem-based learning (PBL) into the
Europubhealth (EPH) Erasmus mundus Master course
Integration Module on global public health. This collaboration, part of a recent Erasmus Mundus Associate membership
agreement, offers EPH students a structured learning opportunity based around the PBL philosophy to develop learner
autonomy in a constructive and collaborative educational
process. This involves students setting their own learning goals;
offers scope for creative, and critical thinking; and the
application of knowledge to a public health issue . We believe
such training goals involving cross-cutting competencies will
stand future public health professionals in good stead when
they come to tackle both known and emerging public health
challenges. Maastricht university experts in partnership with
EHESP academic staff and EPH scholars, experienced lecturers
from third country universities, have designed case studies
based around the common theme of hard to reach groups.
Students from 20 countries work in small autonomous groups,
allowing them to experience the rich assets of cultural
diversity. Each group is facilitated by a scholar. Particular
emphasis has been placed on methodological and ethical
dimensions of issues undertaken and the development of
indicators for assessment of cross-cutting competencies. With
this in mind preparatory collaborative training and on site
training sessions in Rennes supervised by Maastricht
University and EHESP staff have been organized for the
scholars, for the EPH students, as well as other pedagogical
diffusion activities on the value of PBL for EHESP staff.
Integrating community health and medical education
in a new medical school
Olapeju Simoyan
O Simoyan*, J Townsend, M White
The Commonwealth Medical College, Scranton, Pennsylvania, USA
*Contact details: peju105@gmail.com
The Commonwealth Medical College (TCMC) is a new

medical school in Northeastern Pennsylvania that uses a
distributive model of education with three clinical campuses.
According to the Northeastern Pennsylvania Area Health
Education Center, the majority of counties in this region
include federally designated shortage areas for primary care,

dental care and mental health care. TCMCs strategies for
community engagement involve research activities and collaborations with community-based organizations. Medical and
graduate students work with both faculty and community
mentors to conduct research that is relevant to public health
and participate in community-service learning activities. The
regional model allows for students to work on projects that are
relevant to the regions in which their assigned campuses are
located.
In 2009, a regional health needs assessment was conducted
with 23 focus groups within TCMCs service area. Major
themes identified during the needs assessment were access to
mental and dental health care and drug and alcohol problems.
Participants expectations from the new medical school
included more physicians, a different kind of physician,
better health care in the region and connection with the
community.
In TCMCs first year, 18 institutional review board- approved
projects were conducted by medical and graduate students
under the supervision of faculty and community mentors.
Research topics included surveys of physicians regarding
autism screening practices, compliance with treatment
among HIV positive patients and smoking cessation in a
methadone clinic, amongst others. These pilot studies have
yielded baseline data on which community interventions and
curricular planning can be based.
Educational sessions that focus on interprofessional education
are also an integral part of our curriculum. A task force
consisting of members of various health professions has
been formed to plan and coordinate these activities during
which medical students interact with students from other
health professions and the importance of teamwork is
emphasized.
TCMC will continue to collaborate with community partners
as we train future physicians to make a lasting impact both in
clinical medicine and public health.
Consumer knowledgeattitude and behaviour on
the food
Osman Ceyhan
O Ceyhan1*, G Ural2
University of Erciyes Faculty of Medicine Department of Public Health
Talas, Kayseri, Turkey
2
University of Erciyes Institute of Health Sciences Talas, Kayseri, Turkey
*Contact details: oscey@erciyes.edu.tr
1
To ensure the food safety the customers should comply with

the certain rules at storing, stowing, preparing, cooking, and
serving stages beginning from the purchase of these foods. This
research has been planned and executed to detect the
knowledge-attitude and behaviours of the consumers who
live in iSTANBUL Province, Bakrkoy District on the safety of
food. The research has been made with sampling method. The
research space consists of the consumers who live in _Istanbul
province while the sample contains 300 consumers who
participated in the research study.
Research data have been collected with the face to face
interview technique using a questionnaire which consists of 4
topics and 39 questions. Data from the survey has been
analysed by the means of SPSS 15.0 software.
According to the findings obtained from the survey, 67.3% of
the consumers
who participated in the research are the women. Almost half of
the consumers (58.7) are elementary school graduates. 79.2%
of the consumers could not answer correctly the factor which is
important in purchase of tinned foods. Again, 64.6% of the
participants have falsely answered the appropriate method for
defreeze of frozen meat. 54.6% of consumers could not know
the foods in the risk group and 50.6% the diseases which may
result from not being washed of the hands after the toilet.
95.4% of the women have answered correctly whether the
nutrients which are sold outdoors are healthy or not. This
W Sherlaw1*, K Czabanowska2, G Burazeri2, H Brand2, J Pommier3,

A Magdelaine4
1
Department of Nursing Science EHESP School of Public Health Rennes
France
2
Department of International Health University of Maastricht The
Netherlands
3
Department of Human and Social Sciences and Health Behaviour EHESP
School of Public Health Rennes France
4
Department of Pedagogical Development and Evaluation EHESP School of
Public Health Rennes France
*Contact details: William.Sherlaw@ehesp.fr
237
238
question has been answered correctly by 87.5% of the men

(P > 0.05). 33.6% of the consumers take care of TSE assurance,
24.0% take care of expiration date, and 12.7% take care of the
trade mark of the foods before purchasing.
Aligning teaching programmes with the UK Public
Health Skills and Career Framework A validation
experience
Carmen Aceijas
C Aceijas1*, N Foster2
University of East London [UEL]
2
School of Health and Bioscience [HAB], London, UK
*Contact details: c.aceijas@uel.ac.uk
Community health course

Vesna Juresa
V Juresa*, V Musil, Z Sosic, M Majer
Department of social medicine and organization of health care, University
of Zagreb, School of medicine, Andrija Stampar School of Public Health,
Zagreb, Croatia
*Contact details: vjuresa@snz.hr
Background
Since 1952 many generations of medical students attended The
Community Health Course at University of Zagreb School of
medicine, organized by Andrija Stampar School of Public
Health. The practical part of the course is performed in rural
communities where students work under supervision of local
health professionals in out-hospital care and take parts in
activities of local county public health institute.
The legislation on health impact assessment: the

current national and regional regulatory framework
Alessandra Colombo
A Colombo*, F Bert, M Ceruti, E Lovato, R Siliquini
School of Public Health Department of Public Health University of Turin,
Dept. of Public Health University of Turin. Network Italiano HIA
*Contact details: alessandra.colombo@unito.it
Background
Amsterdam Treaty and European constitution establish that
member States must have specific legislation on HIA (Health
Impact Assessment). By now few European countries regularly
use HIA. In Italy, Regions have independent legislation in
sanitary field and health remains almost everywhere matter of
sanitary politics.
The aim is to make a correct evaluation of the Italian
legislation on HIA and EIA and also to map the ongoing
collaboration on HIA projects between Italy and other EU
countries.
Methods
We have reviewed international scientific literature on Medline
(19992009) and the official government publications, using a
standardized reading grid.
Results
The HIA and EIA procedures were introduced by EEC
Directive 85/337 and have been implemented in Italy in 1988
through two legislative decree, leaving Italian Regions to
legislate on it.
A total of 16 regions (76%) enacted law on EIA, five regions
(24%) are still pending, one region (5%) issued guidelines on
HIA. These laws has been analysed on some points
competent offices and technical organisms [66% involve
regional organism and 9.5% use ARPA (Agenzia Regionale
Protezione dell Ambiente)]active public involvement is used
only in four regions (19%). Some other points have shown
many discrepancies between regions. Up till the end of 2009
only two European Projects were characterized by coordination
activities regarding HIA (HIA-NMAC, RAPID-HIA).
Conclusions
In Italy there arent specific laws on HIA items but just on EIA,
and are heterogeneous between Regions. The European
collaboration projects are actually few. An improved central
cooperation would help Italy and other countries where HIA
isnt yet part of legislative process.
Background
The University of East London (UEL) is one of a few
Universities in the UK with undergraduate (UG) and
postgraduate (PG) teaching programmes in public health
(PH). The PH programmes are designed to meet the needs of
students from a variety of backgrounds, and at PG level draws
professionals from a range of health professions.
The programmes, particularly the PG programme, have grown
considerably over the last few years. In light of increasing
interest and the publication of UK professional competencies
in the Public Health Skills and Career Framework (PHSCF), it
was necessary to redevelop our programmes. At the end of
2009, all health programmes underwent a revalidation,
providing opportunity to align with the PHSCF.
Objectives
To demonstrate the process of aligning and redeveloping
existing BSc and MSc PH programmes with the core
competencies and skills outlined in the PHSCF. To highlight
the challenge of aligning teaching programmes with professional frameworks.
Methods
Programme Leaders and teaching staff mapped existing
modules to the framework at levels 4 and 7 (UG and PG,
respectively) and developed new modules to cover deficits. The
PG programme was also mapped with the UK Faculty of PH
curriculum. The revalidation approval process involved
internal (UEL) and external review. Students were also
consulted.
Results
The UG programme consists of 36 modules with embedded
competencies taken over 3 years and the PG is an 18-month
programme with six, 30-credit modules designed to ensure
competencies outlined in the PHSCF. Student consultations
revealed that clear definition and alignment of their programmes was reassuring. Internal and external reviewers
approved the new programmes, noting their clear focus and
vision.
Conclusions
The alignment and revalidation processes have implications for
PH graduates as well as UK education/training institutions.
There are also similar implications for European frameworks
that are currently being developed.
Objectives
The course is based on approach in medical education, that
main fields of action for physicians are human settlements, not
laboratories and consulting rooms. The students attend the
course throughout 6 days with 18 seminar hours and 30 h of
practical. They are required to describe and evaluate (using
grade from 1bad to 5excellent) activities of each course
day.
Results
Analysis of students (n = 225) course evaluation in academic
year 200708 showed that students were very satisfied with
preparatory seminar (98%), final seminar (97%), course
content (89%), organization (90%) and practical work:
community nurse service (94%), water sampling (87%),
general practice (93%), health promotion activities (93%)
and field research (98%). Satisfaction with the course was very
emotionally expressed in descriptions and essays, such as:
. . .practical with community nurse in the poorest area in the
poorest county in Croatia changed my life. In only few hours I
learned to want less and to give more. Each medical doctor
should experience it, because it is a real world.
Conclusions
The course encouraged students to comprehend the importance of communities in the health of individuals and families.
Students have opportunity to perceive community inside and
outside of health care system, and to study epidemiological
and socio-medical determinants of health, throughout activities of health and social care systems.
239
Public health epidemiology

Maternal gestational diabetes and congenital heart
defects in infants
Virginija Dulskiene
V Dulskiene*, R Kuciene, J Medzioniene
Institute of Cardiology, Kaunas University of Medicine, Kaunas, Lithuania
*Contact details: V.dulskiene@med.kmu.lt
Comparison of alcohol consumption in Estonia and

Finland in 19942006
Kersti Parna
K Parna1,2*, K Rahu2,3, S Helakorpi4, M Tekkel2,3
1
Department of Public Health, University of Tartu, Tartu, Estonia
2
Estonian Centre of Behavioural and Health Sciences, Tallinn/Tartu, Estonia
3
Institute for Health Development, Tallinn, Estonia
4
National Institute for Health and Welfare, Helsinki, Finland
*Contact details: kersti.parna@ut.ee
Background
Alcohol consumption has been regarded as an important
contributor to the high premature mortality rates. The
objective of this study was to describe and compare alcohol
consumption and its socio-demographic determinants
among adults in two neighbouring countries Estonia and
Finland.
Methods
The study was based on a 2564-year-old subsample of
nationally representative postal cross-sectional surveys conducted in Estonia (n = 10 340) and Finland (n = 19 672) during
19942006. Amount of alcohol consumed were examined. The
effect of socio-demographic factors on pure alcohol consumed
per week was calculated using linear regression.
Results
Throughout the study period, amount of alcohol consumed
per week increased for both genders in Estonia and for women
The European Health Interview and Health

Examination Surveys database is a practical tool for
comparison and development of survey methods in
Europe
Sanna Ahonen
S Ahonen1*, P Koponen1, J Maki-Opas1, J Tafforeau2, A Aromaa1
1
National Institute for Health and Welfare (THL), Helsinki, Finland
2
Scientific Institute of Public Health (IPH), Brussels, Belgium
*Contact details: sanna.ahonen@thl.fi
The European Health Interview and Health Examination

Surveys database (HIS/HES database) has been developed in
the framework of the European Health Survey System. It
contains up-to-date information on health survey methods,
questions and examination protocols. It enables researchers to
make comparisons and to follow up the development of
recommendations and new instruments. Although the first
version of the database was released in 2001, the user
satisfaction and common use purposes of the database were
not known. Therefore a survey was conducted to examine the
usage and to improve the usability of the database.
The Digium Enterprise software was used to carry out a user
survey during AprilMay 2009. An e-mail with a link to the
survey was mailed to all users who had accessed the HIS/HES
database during the past 2 years (604 persons). The survey
questionnaire comprised 15 items on the respondents background, perceived usability of the database, strengths and
weaknesses of the database and needs for improvements.
A total of 113 replies were received from 27 countries. The
database was most commonly used by researchers to identify
surveys by region or country, to search questions or
measurement methods by using a health topic and to explore
the methodology applied for specific surveys. The users found
the database comprehensive and they appreciated the fact that
it contains information on all the major population surveys in
one place. However, respondents expected better search
methods, more frequent updates and a more user-friendly
structure.
The HIS/HES database is a relevant tool for researchers
planning to develop or to evaluate national and European
population health surveys. It is also used in the process of
developing standardized instruments for new surveys. The next
version of the database will include improvements to the
structure and search functions, based on the results of the
survey.
Background
A number of previous studies have reported that maternal
pregestational and, less consistently, gestational diabetes
mellitus are associated with increased risk of birth defects.
This study examined the relationship between maternal
gestational diabetes and risk of congenital heart defects
(CHDs) in infants.
Methods
Case and control subjects were born between 1999 through
2005 and enrolled in Kaunas Birth Defects CaseControl
Study. Information was obtained through a telephone interview from parents of 187 case infants with CHDs and
randomly selected parents of 643 control infants without any
malformations. Multivariate logistic regression was used to
estimate odds ratio (OR) and 95% confidence intervals (CIs)
while controlling for potential confounders.
Results
In this study, 11.8% of the cases and 3.9% of the controls were
born to mothers with gestational diabetes. Among case infants
of diabetic mothers, 60.0% had a simple heart defects and the
most frequent diagnosis was septal heart defect. In the
univariate analysis, maternal gestational diabetes was associated with 3-fold increased risk of CHDs (OR 3.28, 95%
CI = 1.776.07) (P < 0.0001). In multivariate logistic regression
analysis, adjustment for maternal age, education, social status,
cigarette smoking during the month before pregnancy to the
end of the 1st trimester and folate intake during the 3rd
through 8th weeks of pregnancy did not change the relationship, although the OR decreased but remained statistically
significant. Our results showed that an adjusted OR for
mothers with gestational diabetes to deliver newborn with
CHDs was 2.97 (95% CI = 1.535.76) (P < 0.001).
Conclusions
Maternal gestational diabetes was significantly associated with
CHDs in infants.
in Finland, but was stable for men in Finland. In the final study
year, proportion of medium risk alcohol drinkers per week was
nearly 1.5 times higher among men in Estonia than in Finland
(16.2 and 11.6%, respectively), but about half that among
women in Estonia than in Finland (4.7 and 10.0%,
respectively). Compared with ethnic majority in Estonia,
amount of pure alcohol drunk per week was 6 g higher
among women of ethnic minority. In Finland, amount of pure
alcohol drunk per week was 31 g lower for men and 8 g lower
for women of ethnic minority. Compared with married/
cohabiting adults, greater amount of alcohol consumed per
week was more prevalent among single and divorced/separated
respondents in Finland, but only among divorced/separated
men in Estonia. Compared with higher educated adults,
amount of consumed alcohol per week was higher among men
with secondary and basic education in Estonia (18 and 26 g,
respectively), but 7 g lower among women with basic
education in Finland.
Conclusions
National alcohol policies should reflect findings of alcohol
epidemiology in order to introduce measures that will reduce
alcohol-related harm in the population effectively.
240
Close contact and social network (social support) and

risk of cardiovascular diseases
Elena Gromova
E Gromova, V Gafarov*, I Gagulin, A Gafarova
Russia
A survival analysis of newborns with congenital

anomalies in Latvia from 2000 to 2007
Irisa Zile
I Zile1,2*, A Villerusa1
1
The Public Health and Epidemiology Department of Riga Stradins
University, Riga, Latvia
2
The Centre of Health Economics, Riga, Latvia
*Contact details: irisa.zile@vec.gov.lv
Background
The infant mortality rate from congenital malformations in
2007 in Latvia was247.91 per 100 000 compared with the
European average 161.87.
Objective
To study the differences in infant survival in connection with
different factors in maternal characteristics and the characteristics of newborns.
Methods
The source of the data was the Register of Newborns. All
newborns born between 2000 and 2007 and who had been
diagnosed with congenital anomalies according to ICD-10:
Q00Q99 were analysedtotally 327 cases. The KaplanMeier
Method and Coxs regression were used.
Results
About 48.6% (159) (95% CI 43.354.0) of newborns with
congenital anomalies died in the early neonatal period, 19.9%
(65) (95% CI 15.924.5 in late neonatal, 29.7% (97) (95% CI
25.034.8) in the post-neonatal period and 1.8% (6) (95% CI
0.83.9) died later.
The underlying factors for the increased risk of

diabetes mellitus type 2 in rheumatoid arthritis
patients
Pedro Laires
P Laires1*, G Fonseca2, R Garcia3
1
Epidemiology, Faculty of Medicine, Lisbon, Portugal
2
Rheumatology, Faculty of Medicine, Lisbon, Portugal
3
Bioepi, Clinical and Translational Research Center, Lisbon, Portugal
*Contact details: laires.pedro@gmail.com
Rheumatoid Arthritis (RA), a chronic inflammatory disease,

may predispose to the development of Type 2 Diabetes
Mellitus (T2DM). We aimed to compare incidence rates of
T2DM in RA versus non-RA populations and study the
influencing factors.
The study population consisted of participants in the National
Data Bank for Rheumatic Diseases (NDB), where patients with
rheumatological disorders completed semiannual questionnaires, from 1998 through 2008. Osteoarthritis (OA) patients
were used as controls. T2DM was determined based on selfreports of disease and on the use of hypoglycemic medication.
The association between RA and T2DM was investigated using
COX logistic regressions adjusted for relevant clinical and
demographic covariates.
A total of 14 481 participants diagnosed with RA (79.5%
female; mean age 58.1 years) and 3441 participants diagnosed
with OA (84.5% female; mean age 63.6 years) were followed
during 69 943 person-years. RA subjects had lower Body Mass
Index (BMI) and less major comorbidities than controls. In
patients with RA the T2DM incidence rate was 10 per 1000
person-years, while the incidence rate for OA was 15 per 1000
person-years. Both rates are superior to most estimates
calculated among the US population. However, the covariate-adjusted risk of T2DM in patients with RA versus OA was
not significant (Hazard Ratio = 0.94; 95% CI = 0.791.12,
P = NS). Male gender, age, BMI, non-caucasian ethnicity,
major comorbidities, low education level and prednisone
intake were significantly associated with the incidence of
T2DM. Some RA drugs had a clear protective role on TDM2,
mainly methotrexate (19% risk reduction; P = 0.022) and
hydroxicloroquine (47% risk reduction; P < 0.001).
RA per se is not associated with increased risk of T2DM. Both
RA and OA are associated with known TDM2 risk factors, such
as BMI and some comorbidities, increasing the incidence rates
of TDM2. Some drugs for RA treatment have a significant
protective effect on the TDM2 risk. This knowledge may
support preventive measures in some RA patients in order to
reduce risk of T2DM onset.
Background
The aim of the study was to investigate the effect of social
support on the 10-year risk of cardiovascular diseases (CVD)
in men aged 2564.
Methods
The researchers studied a random representative sample of
male residents of a Novosibirsk district aged 2564 years
(1994). The level of social support was evaluated by BerkmanSyme method: close contact index (CCI) and social contact
index (SCI). All the cases of AH, MI, stroke which occurred in
the cohort within 10 years (19952004) were investigated. The
relative risk (RR) of CVD was evaluated using a Cox
proportional regressive model.
Results
The relative risk of development of AH, MI, stroke during the
first 5 years of supervision in a group with low and medium
CCI compared with men with high CCI was 2, 2.35 and 3.9
times higher, accordingly. Within 10 years, RR of development
of CVD with low and medium CCI compared with men with
high CCI made for MI2.6 and stroke2.5 times higher. In
subjects with low SCI compared with subjects with high or
medium SCI RR of development of AH, MI, stroke during the
first 5 years was three, two and four times higher, accordingly.
Within 10 years, RR of development of CVD with low and
medium SCI compared with men with high SCI made: for
MI2.17 and stroke3.42 times higher (P < 0.05). The
highest rate of CVD was found in men with low CCI and
SCI belonging to the groups of widowers, divorced people,
subjects with incomplete secondary or primary education, as
well as in pensioners and people with low level of social
support.
Conclusions
The results show that CVD risk in men aged 2564 years is
associated with low level of social support.
Newborns who were born to mothers who had ante-natal care,

survived for 44.1 days (95% CI 35.153.2), but newborns who
were born to mothers who did not receive ante-natal care
survived for 22.1 days (95% CI 11.2-32.9), (P < 0.01).
Complications during delivery were associated with a higher
mortality risk (non adj. HR = 1.5; 95% CI 1.21.9) and
influenced the differences of survival rates (P < 0.001).
The mortality rate of newborns from multiple deliveries
was higher than single deliveries. (non-adj. HR = 2.3; 95%
CI 1.34.0. The differences in survival rates were found within
the gestational time (P < 0.001). The survival of newborns who
had ultrasonic examination was higher (2 = 3.7, P < 0.05).
Factors, such as the birth weight, the diseases of mothers and
the lifestyle of parents had an effect on survival, but there were
not statistically valid.
Conclusions
The most important factors in the survival of newborns with
congenital malformations were ante-natal care - timely and
valuable- and skill in the assistance of delivery. More careful
ante-natal and obstetrics health care could reduce the mortality
rate of newborns with congenital anomalies in Latvia.
Gastroesophageal reflux disease in relation to sleep

problems: a population-based study
Catarina Jansson
C Jansson*
*Contact details: catarina.jansson@ki.se
Evaluation of appropriateness and determinants of

caesarean section in an Italian region from 2007 to
2008
Manuela Chiavarini
M Chiavarini1*, A Gili2, L Pieroni2, L Minelli1
Department of Medical and Surgery Specialities and Public Health,
University of Perugia, Italy
2
Department of Economics, Finance and Statistics, University of Perugia,
Italy
*Contact details: chiavarini@inwind.it
Background
The caesarean section (CS) rate continues to rise in many
countries around the world even though this increase is not
associated with improvement in maternal and perinatal
mortality or morbidity. The CS rate can be analysed by using
Robson Classification (RC), which categorizes women in 10
groups on the basis of category of pregnancy, obstetric history,
course of labour and gestational age.
Methods
To evaluate appropriateness and determinants of CS we
utilized data obtained from a population-based study using
routine maternity discharge data (CEDAP).
A logistic regression analysis was performed in order to
quantify the relationship [in terms of odds ratio(OR)]
between CS rate and specific characteristics and clinical

conditions of mother.
Results
The study included 13 901 deliveries performed in Umbria, an
Italian Region, from 2007 to 2008: 29.4% of them with a CS,
ranged from 4.4% (Group 3) to 100.0% (Group 5).
Group 2 (nulliparous, single cephalic, 37 weeks, induced or
CS before labour) gave the most contributions, with the 41.8%
of overall CS.
Analysis showed that some factors increase significantly
probability of CS:
high maternal age [99% confidence intevral (CI) = 1.83.4],
low-medium educational level (99% CI = 1.11.4), previous CS
(99% CI = 20.832.1), preterm delivery (99% CI = 1.11.8),
abnormal lie (99% CI = 40.890.8), specific pregnancy diseases
(99% CI = 1.52.5), induced labour (99% CI = 1.92.4) and
multiple pregnancy (99% CI = 6.119.4).
Conclusions
This study showed that multiple factors can affect CS rate and
that a relevant number of potentially not appropriate CS has
been performed (such as Group 2). To promote a reduction of
unnecessary CS can be planned audit activities about relationships between risk factors and CEDAP results
Cause-specific profiles of infant mortality in Italy:
an explorative analysis.
Monica Pace
F Grippo, E Grande, M Pace*
Health Service, Italian National Institute of Statistics, Rome, Italy
*Contact details: mopace@istat.it
Background
Infant mortality in Italy is among the lowest in Europe,
especially for infants aged 28 days or more. Although the trend
for this major public health indicator is decreasing, some
differences are still observed as for area of residence, citizenship and other demographic variables. These differences are
well documented for the overall mortality, but little is known
about causes of death. The objective of this study is to explore
the patterns of mortality by cause, according to some
demographic variables. In particular, the association between
underlying cause and the other conditions reported on the
death certificate is explored.
Methods
Data refers to 1928 infant (<1 year of age) death certificates
occurred in Italy in 2007. All the reported causes (3.8 causes
per certificate) have been coded according to the ICD-10 and
underlying cause has been selected. A multiple correspondence
analysis has been performed considering underlying and
associated causes of death and demographic variables such as
infant age, residence, maternal age, citizenship.
Results
Two main axes have been derived, accounting for 60% of the
total variance. The first axis is mainly associated with the age of
decedents and typical underlying causes for each age: age <28
days is associated with maternal and perinatal causes; older
ages with congenital malformations of circulatory system and
other causes not originating in the perinatal period. The
second dimension mainly opposes patterns for Italian and
non-Italian citizens with some differences by area of residence
too. The non-Italian citizenship associates with very young
maternal age, but not with specific causes of death, either
underlying or associated. Disorders related to the length of
gestation and perinatal respiratory disorders are observed to
play a role as associated causes for earlier ages.
Conclusions
The performed analysis highlighted cause-specific profiles of
infant mortality in Italy according to some demographic
variables. The study of multiple causes of death is a promising
approach for better characterization of mortality profiles from
a public health perspective.
Background
Gastroesophageal reflux disease (GERD) is a common and
increasing public health problem, affecting up to 20% of adult
populations in the Western world, generating a great amount
of suffering among patients and reducing work productivity.
Sleep problems are, like GERD, increasing health problems in
industrialized countries. It is important to clarify the
association between sleep and GERD, but only a few
population-based studies have been conducted.
Methods
A population-based, cross-sectional, case-control study based
on two large health surveys performed in the Norwegian
county Nord-Trondelag in 198486 and 199597. GERD was
assessed in the second survey, including 65 333 participants
(70% of the countys adult population). The 3153 persons
reporting severe reflux symptoms were defined as cases and the
40 210 persons without reflux symptoms were defined as
controls. Data on insomnia, sleep problems and several
potential confounders were collected in questionnaires. Odds
ratios (ORs) with 95% confidence intervals (CIs) were
estimated using unconditional logistic regression, in crude
and multivariable models.
Results
In models adjusted for age, sex, tobacco smoking, obesity and
socio-economic status, positive associations were observed
between presence of insomnia (OR 3.2, 95% CI 2.73.7),
sleeplessness (OR 3.3, 95% CI 2.93.8), problems falling asleep
(OR 3.1, 95% CI 2.53.8) and risk of GERD. These
associations were attenuated after further adjustments for
anxiety, depression, myocardial infarction, angina pectoris,
stroke and gastrointestinal symptoms, but remained statistically significant.
Conclusions
This large, population-based study indicates a link between
sleep problems and GERD that is not explained by known risk
factors for GERD such as smoking and obesity. This link may
potentially be bidirectional and the finding may contribute in
explaining the reduced work productivity associated with
GERD.
241
242
Regional differences in parity and their impact on

breast cancer incidence in Croatia
Jadranka Bozikov
T Glivetic1*, J Bozikov2
1
General Hospital Zabok, Zabok, Croatia
2
Andrija Stampar School of Public Health, School of Medicine, University of
Zagreb, Zagreb, Croatia
*Contact details: jbozikov@snz.hr
Pilot comparison of European Health Interview

Survey (EHIS) questions
Antti Tuomi-Nikula
A Tuomi-Nikula1*, P Koponen1, J Tafforeau2
1
National Institute for Health and Welfare (THL), Helsinki, Finland
2
Scientific Institute of Public Health (IPH), Brussels, Belgium
*Contact details: antti.tuomi-nikula@thl.fi
Background
This study was carried out as a part of the European Health
Surveys Information Database (EUHSID) project in order to
assess the feasibility of evaluating the comparability between
(i) the source EHIS questions and the questions used in
national surveys, and (ii) national survey results.
Methods
The source questions of the EHIS Health Status Module questions were compared with the corresponding national questions used in Belgium, Bulgaria, Cyprus and Czech Republic. A
three level classification scale was created in order to rate the
questions as totally, partially or non-comparable. Questions
and answer categories were examined separately.
In a second step summary data from the same countries were
examined, to further evaluate how the differences in questions
used might affect the comparability of the survey results.
Prevalence of symptoms of visually induced motion

sickness and visual stress during and after viewing a
3D movie
Angelo G Solimini
AG Solimini*, G La Torre, A Mannocci, D Di Thiene, A Boccia
Department of Experimental Medicine, Sapienza University of Rome, Rome,
Italy
*Contact details: angelo.solimini@uniroma1.it
Background
The increasing popularity of commercial movies showing 3D
computer generated images has raised concern about image
safety and possible adverse side effects on public health. The
aim of this article is to quantify the general prevalence of
adverse health symptoms suffered by the spectators during and
after viewing a commercial 3D movie.
Methods
We designed a self-administered questionnaire with 23 items
including socio demographic variables, current health assessment, daily use of computer or videogames and the proximity
to the screen of the sit. We enrolled 171 adults who saw a 3D
movie in a movie theatre in the past 3 months. Among the
possible visually induced symptoms we asked for the presence
of visual discomfort and fatigue, headache, dizziness, vertigo,
palpitation, nausea, vomiting at three different times (during
the movie, just after the end and 2 hours later).
Results
The Cronbach alpha was 0.43. Most of responders were <50
years of age (92.8%), 52% were females, 41.5% used
prescription glasses or lens, 37.4% used computer for more
than 8 h per day, 14% declared to suffer of recurrent headache,
3.5% of car motion sickness, 8.2% of recurrent vertigo. At least
a single visually induced symptom was reported by 59.1% of
responders (52.5% during the movie, 34% right after and
15.2% after 2 h). During the movie view, frequent symptoms
reported were visual discomfort and fatigue (32.7% of
responders) and dizziness (7.4%). After the movie visual
discomfort and fatigue (13% of responders), dizziness (8%)
and headache (8%) were reported. Presence of at least one
symptom is associated with responders suffering of recurrent
headaches (P = 0.036) and computer intensive use (P = 0.038).
Conclusions
The high prevalence of visually induced symptoms resulting
from this survey along with the increasing commercial offer of
3D movies point to a potentially increasing public health issue.
Antibiotics consumption in Zagreb in comparison
with resistance of uropathogenic strains of
Escherichia coli in pregnant and other women
Maja Maric-Bajs
M Maric-Bajs, M Leppee*, A Mlinaric-Dzepina, J Culig
Background
It is well known that multiparity together with a first full
pregnancy at younger age is protective factor for breast cancer.
Thus the fluctuations in parity among women across regions
should be reflected in increasing breast cancer incidence in the
regions with lower parity, particularly in countries in
transition having urban population in some parts and still
traditional society in others.
An ecological study design was used to explore the impact of
lower parity on breast cancer incidence across Croatian
counties.
Methods
Differences in parity based on census data were analysed and
compared with age-specific breast cancer incidence obtained
from the National Cancer Registry for a 5-year period (1997
2001) across 21 counties in Croatia. Age-specific breast cancer
incidence rates for 5-year age groups (seven groups only i.e.
4074 years) were regress to the percentage of women with one
or more, two or more and three or more live births. In
addition age-standardized parity for the fraction aged 4074
years of female population for each county was calculated and
correlated with age-standardized breast cancer incidence.
Results
Negative correlations were found between percentage of women
with two or more live births and age-specific breast cancer
incidence in 5-year period in all age groups (4074 years) and it
was statistically significant at P < 0.05 in all age groups except in
the oldest group in which a coefficient of determination (R2)
was 13.2% while in other groups it was between 20 and 28.9%.
Parity and breast cancer incidence were standardized within
each county (partial standardization to the Croatian population
aged 4074 years was applied) and statistically significant
negative correlation was found with R2 equal to 42.1%.
Conclusions
Lower parity has a significant impact on breast cancer
incidence at population level and it determines a certain
proportion of its variance, particularly in societies in transition
and thus it should be taken into account while assessing the
risk for groups or individuals and planning of intervention
programmes such as screening or health education.
Results
Of all questions, 91% were rated as totally comparable, 6%
partially comparable and 3% non-comparable. For answer
categories, the corresponding numbers were 72, 28 and 0%.
Variation between the four countries was significant.
Comparing summary data for some of the questions demonstrated that there were clear variations in the prevalence figures
of e.g. proportion of persons who assess their own health to be
good or very good. Different numbers of answer categories
only had a minor effect on these prevalence figures.
Conclusions
This comparison is a practical first step. With the procedures
developed in this examination it is easy to make even more
comparisons and ratings by different criteria.
A detailed evaluation covering all national EHIS surveys would
be feasible and illustrative. Such an extensive evaluation would
be valuable in the implementation of the ECHI shortlist
indicators to be derived from the EHIS. It could also be used in
revising the questions for the second round of the EHIS.

Department of Pharmacoepidemiology, Andrija Stampar Institute of Public
Health, Zagreb, Croatia
*Contact details: marcel.leppee@stampar.hr
HIV infection among blood donations in European

Countries in 2006
Mariangela Raimondo
M Raimondo1*, V Regine1, L Camoni1, MC Salfa1, AHL Bruning2,
B Suligoi1
1
Centro Operativo AIDS, Istituto Superiore di Sanita`, Rome, Italy
2
Academic Medical Center, University of Amsterdam, Amsterdam, The
Netherlands
*Contact details: mariangela.raimondo@iss.it
Background
Monitoring HIV prevalence in blood donations is important
to evaluate blood safety and to compare the HIV epidemic
across countries. Blood safety against the transmission of
infectious diseases is ensured by European regulations which
recommend for selection of donors through a questionnaire
pre-donation and serological screening. The objective is to
compare HIV prevalence among blood donations in the three
macro-European areas and in various Western European
countries.
Methods
Data on blood donations were provided by the European
Monitoring Centre for HIV, the National Blood Service and
Health Protection Agency and Italian Surveillance System of
transfusion transmitted infectious diseases.
Results
In 2006, the highest prevalence of HIV among blood donations
was observed in Eastern Europe (37.6 per 100 000 blood donations), followed by Central (3.8 per 100 000 blood donations)
and Western Europe (1.8 per 100 000 blood donations). Among
Western European countries, Spain, Italy, and Israel showed the
highest prevalence: 6.0, 3.8 and 2.1 per 100 000 blood
donations, respectively.
Conclusions
The data show the highest HIV prevalence among blood
donations from Eastern Europe, reflecting the high HIV
circulation already reported in this area. Among Western
European countries, Spain, Italy, and Israel show the highest
HIV prevalence among donations. The results could reflect a
low perception of the risk of transmission through sexual
contacts, or a lower efficacy of pre-donation selection.
Exposure to electromagnetic fields and non-specific
physical symptoms: a systematic review of
observational studies
Christos Baliatsas
C Baliatsas1,2*, I Van Kamp2, J Bolte2, M Schipper2, J Yzermans3,
E Lebret1,2
1
Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The
Netherlands
2
National Institute for Public Health and the EnvironmentRIVM, Bilthoven,
The Netherlands
3
Netherlands Institute for Health Services ResearchNIVEL, Utrecht, The
Netherlands
*Contact details: christos.baliatsas@rivm.nl
Background
Various physical symptoms are attributed to environmental
factors. EMF exposure is one of these but there is no
convincing evidence of a causal relationship. The current
review aims to address the strength of evidence for an
association between actual and perceived exposure to EMF
and non-specific physical symptoms. To gain more insight into
the relationship between exposure and outcome a metaanalysis was performed. The role of demographic, environmental and psychological characteristics on symptom report is
also investigated, accompanied by recommendations for future
research.
Methods
The following electronic databases were searched for the
detection of observational studies that published between
January 2000 and April 2010: Medline, Embase, SciSearch,
PsychInfo, Psyndex and Biosis. In addition, a wide range of
keywords was used, related to EMF exposure, subjective
sensitivity to EMF and physical symptoms. Under specific
inclusion criteria, 28 studies in the peer-reviewed literature
were systematically identified.
Results
There were important differences and methodological limitations among the reviewed studies in terms of symptom
assessment, exposure characterization, the investigation of
confounding factors and the use of criteria for identifying
sensitive to EMF samples. Although results suggest that
exposure to EMF is related to increased symptom report, they
should be interpreted with caution because of the forenamed
shortcomings. Psychological and social components seem to be
related to symptom report, but evidence is still restricted.
Conclusions
Improvement in exposure and outcome assessment and
comparability of the future studies in these domains, the
subdivision of EMF exposure into actual and perceived and the
investigation of the role of psychological determinants are
crucial factors in order to comprehend the mechanisms by
which EMF exposure could lead to physical symptoms.
A geographers insight into the field of cervical
cancer screening: providing geographical
informations to decision makers
Denis Leroux
D Leroux1*, L Cloutier2, AM Grenier3
University of Quebec at Trois-Rivieres, Department of Geography,
Trois-Rivieres, Canada
2
University of Quebec at Trois-Rivieres, Nursing Department, Trois-Rivieres,
Canada
1
Background
In this article is compared the resistance of uropathogenic
strains of Escherichia coli (UPEC) to antibiotics in women in
generative ages and pregnant women during two year period
(2004 and 2008) in Zagreb. Also is compared resistance and
the consumption of antibiotics.
Methods
For sensitivity testing to 16 different antibiotics, the standard
disk-diffusion method was used. Data on antibiotic utilization
were used to calculate the number of defined daily doses
(DDD) and DDD per 1000 inhabitants using Anatomical
TherapeuticChemical/DDD methodology. Data on antibiotic
consumption during pregnancy were collected using a
questionnaire from 893 women after delivery.
Results
The resistance of UPEC to antimicrobial drugs during 2004
was not different in pregnant and in non-pregnant women,
with the exception of amoxicillin and nitrofurantoin, with
statistically higher resistance in pregnant women (P < 0.01).
Four years later the statistically higher resistance to norfloxacin
was observed in non-pregnant women (P < 0.01). Comparing
the resistance in 2004 and 2008, in the both groups of women
statistically significant decrease of resistance to cefalexin and
nitrofurantoin was detected (P < 0.01). Outpatient utilization
of antimicrobial drugs in Zagreb increased significantly, from
32 to 39 DDD per 1000 inhabitants per day. The most used
antibiotic was co-amoxiclav, and his utilization increased from
9.6 to 12.2 DDD per 1000 per day. Amoxicillin and coamoxiclav were used during pregnancy by 9.6% interviewed
women.
Conclusions
The observed significant decrease of resistance to cefalexin
makes that antibiotic the drug of choice for treatment of
urinary tract infections in women in generative ages, and
together with co-amoxiclav can be administered in pregnancy.
Constant monitoring of urinary tract pathogens resistance to
antimicrobial agents ensures the effectiveness of empirical
therapy, which versatile are narrowed because of the potentially
harmful effects of antimicrobial drugs on the foetus.
243
244
3
Mauricie Health Agency, Trois-Rivieres, Canada
*Contact details: denis.leroux@uqtr.ca
Reduction of cervical cancer incidence and death in population

can clearly benefit from organized screening, focusing on a
specific population. According to Canadian statistics, the
province of Quebec has the lowest cervical screening rate in the
country. This situation can be partly attributed to the lack of
organized screening programme in the province. A pilot
project has been put forward by health authorities with the
objective of increasing women participation to PAP test and
develop recruiting strategies. A geographic health information
system was developed to assess regional screening rates and
map geographical inequalities of women participation to PAP
test. This system is also used for evaluating recruiting strategies
using a geographical approach.
Data of women participation to PAP test were extracted from
hospital databases and linked to statistics databases to produce
socio-economic profiles of the population participating to PAP
tests. Postal code was used to georeference each woman to her
living geographic area in the territory. Maps were produced to
show high and low participation rates to PAP tests, and

geostatistics were used to identify areas of significantly lower/
higher participation rates.
With this approach, populations participating in PAP tests
can be profiled, and geographic areas with low-level participation can be identified using a geographic information
system. These areas can then be the object of specific and
targeted efforts in recruiting strategies to increase
participation rate. A recruiting campaign involving publicity
in different media was tested and results evaluated. Real-time
monitoring of womens characteristics in response to
recruitment strategies can also be undertaken with such a
system.
Results of this at large recruiting campaign show that efforts
should be put to contact not-participating women individually
with letters rather than simply use recruiting publicity. This
project also underline the contribution of geographic information systems to support public health studies and help decision
makers take better decisions.

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6.

MODERATED POSTER SESSIONS: ABSTRACTS

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