bluuebunny/crossref_metadata_2025 huggingface dataset:
Front-to-package labels relevance for policy: the Nutri-Score as case study
Authors: Hercberg S , Julia C
Published: October 2023

Front-of-package nutrition labels provide simplified information on the nutritional composition of foods. They are considered efficient tools to help consumers make heathier food choices at the point of purchase and may thus contribute at preventing nutrition-related diseases (overweight and obesity, cardiovascular disease, cancer etc.). The Nutri-score is a summary graded front-of-pack label developed in France in 2014. Using a nutrient profiling system, it classifies products in five categories from A/green to E/red depending on their composition in energy, saturated fats, sugars, salt, fibers, proteins and fruit, vegetables, legumes, nuts and olive, canola and nut oils. The validation of the Nutri-Score investigated both the validation of the nutrient profiling system underlying it and its graphical format, comparing its performance to several other schemes currently in use in the world. Overall, the Nutri-Score is aligned with dietary guidelines, and the average nutrient profile of the foods consumed at the dietary level appeared to reflect the nutritional quality of the diet. At the diet level, the nutrient profile of the foods consumed has been found to be associated with higher risks of cancer, cardio-vascular diseases, weight gain or metabolic syndrome in multiple cohort studies. Finally, compared to other schemes the Nutri-Score was found to be the most effective at improving the capacity of consumers to compare products and help them make healthier food choices in purchasing situations.
Disease costs due to outdoor ambient particulate matter pollution in Germany, 2018
Authors: Plass D , Kienzler S , Tobollik M , Wintermeyer D
Published: October 2023

Introduction

In addition to the population health effects of outdoor ambient particulate matter pollution (PM2.5), estimates of the costs related to these health impacts are increasingly requested to inform policy decision-making processes. Within the UKAGEP-project the burden of disease due to PM2.5 in Germany was monetized.

Methods

First, the disease burden attributable to PM2.5 in Germany for the year 2018 was estimated using the Environmental Burden of Disease approach. To estimate the monetary impact of PM2.5, two approaches were followed. We applied the Value of Statistical Life (VSL) approach, using a monetary value of about 6.3 (2.4-7.2) million € attached to each death case. Further, we used the Value Of a statistical Life Year (VOLY) approach, attaching a monetary value of 58,623 (36.646-146.582) € to the loss of a life year. Statistical uncertainties in both the disease burden results and the VSL and VOLY values were considered, presenting a lower and upper estimate of the overall disease costs.

Results

In 2018, the overall burden of disease attributable to PM2.5 was 209,702 (194,265-391,112) Disability-Adjusted Life Years. Using the VOLY-approach, this corresponds to disease costs of about 17 (7-57) billion €. In contrast, when using the VSL-approach, the estimated 15,652 (10,390-21,466) deaths attributable to PM2.5 in this year result in disease costs of about 98 (25-124) billion €.

Conclusions

In comparison with other cost assessments, connecting EBD estimates with the VSL- and VOLY-approach allows to include indirect and intangible costs and not to simply focus on the disease treatment costs. The VSL-approach leads to remarkably higher costs because it does not take into account the age at the time of death and thus attaches the same monetary value to each death case. We recommend to use the VOLY-approach because it considers the remaining life expectancy.

Key messages

• Air pollution causes considerable disease costs in Germany.

• We recommend to use the VOLY-approach because it considers the remaining life expectancy.
Evaluation of antibiotic resistance in bacterial strains isolated from sewage of slaughterhouses
Authors: Laganà P , Gioffrè M E , Facciolà A , Coniglio M A
Published: October 2023

Background

The frequent and incorrect use of antibiotics in animal husbandry has led to the spread of antimicrobial resistance. The issue should be addressed in a One Health vision, since human and animal health, as well as the environment are interconnected. Wastewater from slaughterhouses can be contaminated with multidrug-resistant bacteria, representing a possible cross-contamination route. This study evaluated the presence of antibiotic-resistant bacteria in wastewater from slaughterhouses to highlight their role in the spread of antibiotic resistance.

Methods

In total, 18 out 35 slaughterhouses in Sicily (Italy) were considered. For each wastewater system the samples were collected before any treatment, and cultured within 24 h of sampling. The isolates were identified by API20NE, API20E profiles (bioMerieux, France). Using the Kirby Bauer test, the isolated strains were classified as resistant (R), intermediately resistant (I), or sensitive (S) to the tested antibiotics.

Results

Proteus mirabilis (85.7%) and Peudomonas aeruginosa (27.3%) were the most frequently isolated microorganisms, followed by Enterobacter cloacae, Aeromonas hydrophila, and Citrobacter freundii. The most resistant strains belonged to Enterobacter spp., which showed the highest resistance rate for macrolides, penicillins and cephalosporins. Aeromonas spp. was resistant to carbapenems while E. coli showed the highest resistance to colistine. Finally, Citrobacter spp. was completely resistant to macrolides, rifampicin, and tetracycline.

Conclusions

High resistance levels were detected for some antibiotics widely used in human medicine such as macrolides, penicillins, and cephalosporins. Resistance to carbapenems and colistine, which are now considered key drugs in human medicine for the treatment of severe multidrug-resistant infections, was also reported. Thus, continuous monitoring on the correct use of antibiotics in animal husbandry is necessary.

Key messages

• Wastewater from slaughterhouses may be a vehicle of antibiotic-resistant bacteria.

• The One Health approach should be used for the management of health security, food safety and antimicrobial resistance.
Polygenic Risk Scores for cancer mortality prediction
Authors: Sciurti A , De Blasiis M R , Bolli A , Busby G
Published: October 2023

Background

Polygenic risk scores (PRSs) have shown great accuracy in predicting cancer risk. In screening-based cancer prevention, it is important to be able to predict lethal cancer risk and PRSs have the potential to improve such prediction. This preliminary analysis, conducted on the UK BioBank, investigates the ability of 5 cancer PRSs to predict cancer incidence and mortality.

Methods

Five cohorts were derived from the UK BioBank for 5 common types of cancer (breast, colorectal, lung, pancreas and prostate). PRSs for cancer were constructed for each participant. The PRS hazard ratio per standard deviation (HR×SD) for cancer incidence and mortality was estimated using two proportional hazards Cox regression models for each type of cancer controlling for genotyping array, the first ten principal components of ancestry, family history, sex (where applicable), and age at enrolment.

Results

In the breast cancer cohort, PRS showed a HR×SD of 1.74 (95%CI:1.70-1.78) for cancer incidence and 1.66 (95%CI:1.52-1.81) for cancer mortality. In the prostate cancer cohort the PRS had a HRxSD of 1.78 (95%CI:1.74-1.81) for incidence and 1.73 (95%CI:1.61-1.86) for mortality. Similar results were found in the colorectal cancer cohort with a 1.27 (95%CI:1.24-1.31) PRS HR×SD for incidence and 1.30 (95%CI:1.24-1.37) for mortality, as well as in the pancreas cancer cohort with a 1.44 (95%CI:1.38-1.51) PRS HR×SD for incidence and 1.48 (95%CI:1.40-1.57) for mortality. In the lung cancer cohort a marginal PRS HR×SD was found for incidence and for mortality [1.07 (95%CI:1.04-1.10) and 1.07 (95%CI:1.03-1.12), respectively].

Conclusions

These results suggest that, for most types of cancer, PRSs can predict cancer mortality, as well as incidence, indicating their potential use as a tool to identify people at risk of lethal disease.

Key messages

• These results may contribute to outline clinical utility of PRSs in cancer prevention.

• PRSs may be a useful addition to screening-based cancer prevention, in order to prioritise patients at risk of lethal cancer.
A pandemic's impact on Mental Health
Authors: Grabenhofer-Eggerth A , Sagerschnig S , Gruber B
Published: October 2023

Background

A small topic-specific foresight exercise that shows how monitoring the current and country-specific state of people's mental health has been done in Austria. Since the consequences of the Covid-19 pandemic cannot be precisely quantified with just one or two indicators, a different approach is needed.

Methods

A comprehensive overview of different mental health indicators is a good approach to identify general trends in the psychosocial health of the population. In the absence of survey data, it was decided to focus on available routine data. A specific country context can be understood through comparisons between countries, as was done in use case D of the PHIRI project.

Results

Even though the pandemic (or other crises) affected practically everyone's life, some population groups are showing significant psychological suffering, e.g., young people (especially girls and young women), people with pre-existing mental health conditions, and elderly.

Conclusions

Hence, interventions need to be taken at various levels of a society-wide approach. This means that despite specialized psychosocial support, interventions on “lower levels” dealing with matters of social security, community support etc. are necessary. The Austrian example was used to describe insights to future developments that are applicable to the impact of the COVID-19 pandemic to mental health of the population in several European countries.
Implementation of precision medicine in (routine) cancer care in Belgium in a fair and equitable way
Authors: Schmitt T , Delnord M , Cauët E , Van Valckenborgh E , Van Den Bulcke M
Published: October 2023

Background

Personalized medicine has been found to be highly promising in the prevention or early detection of cancers. Despite the advantages, the scope and potential of personalized health care are under-appreciated and underrealized in health systems. Taking into account the advantages that personalized medicine can bring to cancer prevention and treatment, and acknowledging at the same time the trends happening outside of the field of oncology, Sciensano Cancer Centre conducted research on the use of personalized medicine in the Belgian healthcare system.

Methods

By applying foresight methodology, we first conducted desk research and sent a survey to experts; this was then followed by two stakeholder meetings where we discussed the importance and uncertainties of the factors that have an influence on the implementation of precision medicine in (routine) cancer care in Belgium in a fair and equitable way and developed future scenarios accordingly.

Results

The main influential factors are concerned with economic issues, such as the allocated budget in the healthcare system. Similarly, technological factors around precision medicine should not be neglected: especially issues concerning digitalization will be decisive to determine the future of precision medicine in Belgium.

Conclusions

With the increasing prevalence and incidence of cancer in Belgium, several factors should be considered to implement precision medicine for cancer prevention and treatment in a fair and equitable way. Strategic foresight on precision medicine can support decision-makers in these tasks and help them develop future-oriented policies.
Socioeconomic inequalities in health-related functioning among people with Type 2 Diabetes
Authors: Meisters R , Albers J , Sezer B , de Galan B E , Eussen SJPM , Stehouwer CDA , Schram M T , van Greevenbroek MMJ , Koster A , Bosma H
Published: October 2023

Background

Type 2 Diabetes mellitus (T2DM) is a common chronic disease which disproportionally affects disadvantaged groups. People with a low socioeconomic position (SEP) have increased risk of T2DM and people with a low SEP and T2DM have higher HbA1c levels and a higher risk to develop T2DM complications compared to their high SEP counterparts. The aim of this study is to analyze longitudinal socioeconomic differences in health-related functioning in people living with T2DM.

Methods

Cross-sectional and longitudinal data from 2,004 participants of The Maastricht Study with T2DM were used. SEP was determined by baseline measures of education, occupation and income. Health-related functioning (physical, mental and social) was measured with the SF-36 and the Impact on Participation and Autonomy survey (scores 0-100). Associations of SEP and health-related functioning were studied over a 10-year period (baseline 2010-2018) using linear mixed methods adjusting for demographics, disease characteristics and lifestyle factors.

Results

Low SEP participants had significantly worse health-related functioning compared to those with a high SEP. For example, participants with low income had lower scores for physical (-4.00[CI 2.62;-5.38]), mental (-2.81[-1.52;-4.10]) and social functioning (-9.10[-6.35;-11.85]) compared to high-income participants. In addition, participants with a low education significantly declined more in mental (interaction estimate time -0.21[-0.05;-0.37]) and social functioning (-0.39[-0.02;-0.76]) compared to participants with high education.

Conclusions

In individuals with T2DM, socioeconomic health differences are apparent in health-related functioning. Moreover, differences in mental and social functioning widened even more between different levels of education. Beyond disease characteristics and lifestyle, more attention is needed for socioeconomic differences in health-related functioning for people living with T2DM, both in research and practice.

Key messages

• Among people with T2DM, those with a lower SEP have worse health-related function then individuals with a higher SEP, even with similar demographics, disease characteristics and lifestyle patterns.

• Additionally, people with T2DM and low education decline more over time in mental and social functioning than people with T2DM and high education.
Impact of implementation of a smoking prevention intervention on vocational students’ smoking status
Authors: Jensen M , Fredenslund Krølner R , Thygesen L C , Andersen S
Published: October 2023

Introduction

Smoking prevalence is high in vocational education across Europe. School-based programs to reduce smoking among older adolescents and young adults are sparse. School tobacco policies are often used though the evidence for their effectiveness is inconclusive. The implementation process of far-reaching smoking prevention initiatives such as tobacco policies can be challenging due to, e.g., nicotine dependency and attitudes towards smoking. We investigated the association between implementation of a smoking prevention intervention and students’ smoking status.

Methods

The “Focus” intervention combined a comprehensive school tobacco policy with educational activities and access to smoking cessation support. It was tested in a cluster-randomized controlled trial in 14 Danish vocational schools. Based on a conceptual model, we calculated an individual level implementation score for all students in the intervention arm, including schools’ delivery (principal and teacher surveys) and students’ receipt (student surveys) of the intervention components at 4-5 month-follow-up. We compared odds for smoking daily or weekly (regular smoking) for students with low, medium, and high implementation with students in control schools using multilevel logistic regression models (N = 1112).

Results

Students with high implementation had significantly lower odds for smoking compared to the control group (OR: 0.37, 95% CI: 0.18-0.78) whereas students with medium (OR: 1.72, 95% CI: 0.95-3.12) and low (OR: 1.26, 95% CI: 0.68-2.34) implementation had higher odds, although insignificant.

Conclusions

High implementation of the “Focus” intervention was associated with less smoking. Tendencies in the opposite direction for lower implementation may indicate a complex, non-linear relationship between implementation level and smoking behavior. This suggests that careful implementation efforts are needed to reduce smoking in older adolescent and young adult school settings.

Key messages

• Our study suggests that efforts to support implementation of smoking prevention interventions are needed to reduce smoking in vocational education and similar settings.

• To capture the complexity of the implementation process, we use an individual level measure of implementation based on a conceptual model and multiple data sources.
Exploring the Challenges in Delivering Sexual and Reproductive Healthcare in Iran
Authors: Azarmi D , Omar M , Sundar Budhathoki S
Published: October 2023

Background

Sexual and reproductive healthcare (SRH) is key to achieving sustainable development goal (SDG) 5 but remains a challenge for women in Iran. In 2012 the government discontinued funding for the Family Planning Programme which provided free contraception and recently mass civil unrest has swept country wide. Healthcare workers (HCWs) are legally inhibited with the care they can provide, with the population resorting to unsafe practices. This study aims to explore the challenges in accessing SRH services, provide insight into the barriers HCWs face, and guide policy recommendations to improve the delivery of SRH.

Methods

A mixed methods approach was conducted for this study: a scoping review was performed using Arksey and O'Malley's framework, and qualitative semi-structured interviews were conducted in English and Farsi remotely with HCWs who have practised in Iran in the last 10 years. An inductive and deductive approach was used to guide thematic analysis.

Results

37 studies exploring barriers of accessing SRH in Iran were identified. Six qualitative semi-structured interviews were conducted. Main emerging themes included 1) Lack of education in SRH leading to knowledge gaps, 2) “Fear and shame” culture created by sociocultural taboos, resulting in unsafe abortions, 3) Gender inequality with increasing violence during civil unrest and 4) Inadequate investment in public health, with financial burden on patients.

Discussion

The basic SRH needs of women in Iran are not being met with a concerning regression in women's rights over the last decade. Socio-political factors underpin a lack of education, inadequate public health and gender inequality. Policy recommendations include ratification of women's rights to health protected by legislation, commitment to investment into preventative services for SRH and formal education. Empowerment of women and commitment to building a strong public health system will greatly facilitate the attainment of SDG 5.

Key messages

• SRH barriers are inadequate legalisation, poor education and lack of universal health coverage. This results in harmful practices, like unsafe abortions, and over-reliance on costly private health.

• To sustainably fulfil the SRH needs there must be a realisation of women's rights, restoration of state-funded reproductive health programmes and implementation of formal SRH education.
On the problem of communication in a diverse society
Authors: Kumar B , Bhopal R S
Published: October 2023

At present, beyond occasional guidelines for international meetings such as those of the GSMERH (Global Society for Migration Ethnicity Race & Health) and debates between academics, there is very little international debate about the issue of terminology and diversity. This may stem from the apparent hegemony of English and a lack of capacity to debate terms across or between languages. In general, there is a tendency to shy away from discussing how language can be discriminatory, distressing or damaging. There is more commonly, at least in political life, a discussion about “woke” or “politically correct” language, as if this represented an unacceptable brake on the use of terms that the proponents of such arguments would espouse. Alternatively, it is argued that these are the “scientific or appropriate technical terms” as if there were no room for debate or development in the use of language. And yet lists or directories such as the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the United States MESH terms are recognised as essential tools in communication between professionals. And the Disability movements have certainly been active in arguing for non-stigmatising use of terms such as “blind” and “deaf”, “handicapped”, and the like, while there is a lively debate around the labelling and categorisation of gender, sexual orientation, race and ethnicity. These, however, have barely touched the consciousness, we argue, of the health scientific community and public health. This workshop with Bernadette Kumar, Norwegian Institute of Public Health, Mark Johnson, De Montfort University Leicester and Raj Bhopal, University of Edinburgh seeks to raise the level of debate and start the process of movement towards a more informed and useful conversation that will facilitate and improve communication and respect between the “describers” and the “described”, as well as in scientific usage.
Sugar content of soft drinks, breakfast cereals, and yogurt: Results from the German product monitoring in the European context
Authors: Wolff D , Dittmann A , Gréa C , Roser S , Storcksdieck genannt Bonsmann S
Published: October 2023

Introduction

The German food reformulation initiative is guided by an annual monitoring of selected groups of packaged food. One selection criterion is a high contribution to sugar intake, as is the case for soft drinks, breakfast cereals, and yogurt. For these groups, the respective industry associations have self-committed to reduce sugar content by 15-20 % by 2025, largely focusing on products targeted at children (PTAC).

Methods

Labelled sugar content of soft drinks, breakfast cereals, and yogurt on the German market was assessed at group and subgroup level in 2016/2018, 2019, and 2022. Data were presented as mean, median, quartiles, and range. PTAC were analysed in separate subgroups. Welch's ANOVA with post-hoc test was used to examine significant changes over time. The results were compared to those of other European countries.

Results

In 2022, the monitoring included 2.579 soft drinks, 1.499 breakfast cereals, and 975 yogurts, with the share of PTAC ranging from 15 % in breakfast cereals to 5 % in soft drinks and yogurt. For soft drinks overall, median sugar content was 6.5 g/100 ml. At subgroup level, soft drinks showed significant sugar reductions as well as increases. For breakfast cereals, median sugar content was 15.1 g/100 g, with a 20.3 % drop from baseline and the highest reduction seen in PTAC (-38.4 %). For yogurt, median sugar content was 12.1 g/100 g, with a reduction of 12.7 % for the overall group and 20.2 % for PTAC. Compared to data of Portugal, Belgium, and UK, sugar reductions were in a similar range or higher for breakfast cereals and yogurt but lower for soft drinks.

Conclusions

The monitoring shows significant sugar reductions for soft drinks, breakfast cereals, and yogurt. Judged against the WHO Europe nutrient profile model, however, further reduction efforts appear desirable for public health. Observed results were in a range similar to other European countries, but more harmonized monitoring methods would aid better comparability.
Building public trust and confidence in secondary use of health data in Ireland
Authors: Bedenik T , Bennett K
Published: October 2023

Background

Secondary use of health data can drive research and healthcare improvements with implications for policy and practice. However, relevant legislation, implementation of technical safeguards, and ethical data management are essential. Existing evidence suggests general public support for secondary data use, but with specific concerns about privacy, confidentiality, misuse of data and trust. The aim of this study is to explore key stakeholders’ perspectives on secondary health data use in Ireland, and mechanisms to build a culture of trust.

Methods

The study adopts a qualitative cross-sectional approach. Participants include academics and researchers, healthcare professionals, data controllers and ethics experts, industry, and patients and public, recruited through purposive sampling. Data is collected through focus groups discussions, and reflexive thematic analysis is employed.

Results

The preliminary results suggest that benefits of secondary data use include access to large datasets, streamlined research, reduced bias, and cost-effectiveness, which may lead to improved patient outcomes. Barriers include an underdeveloped national data infrastructure, difficulties with access and linkage, complex ethical regulation, and narrow predetermined indices of health. Concerns related to data sharing are context-dependent, and influenced by patients’ socio-demographic characteristics. Trust appears to be both a bottom-up and top-down process, facilitated through clear communication, organizational openness, transparency, accountability, fairness, respect, and patient and public involvement (PPI).

Conclusions

The study identifies strong support for secondary health data use among the stakeholders, notwithstanding an identified need for structural improvements, strong safeguards, education and training, and meaningful PPI. This research helps inform public health practice and policies towards building a culture of trust pertaining to secondary data use.

Key messages

• This study produces novel insights to help advance research and policy on the barriers and facilitators to building trust and confidence in the access and use of health data for secondary purposes.

• This study contributes to qualitative research methods related to eliciting people's views and perspectives in a safe, collaborative and efficient manner.
Audit&Feedback in emergency care: a pre-post intervention study in Lazio (Italy)
Authors: Agabiti N , Angelici L , Acampora A , Angioletti C , de Mattia E , Pinnarelli L , Colais P , De Belvis A G , Davoli M
Published: October 2023

Background

Within EASY-NET Italian Programme (NET-2016-02364191), we evaluated the effectiveness of a structured Audit & Feedback (A&F) intervention in improving care quality for ST Elevation Myocardial Infarction (STEMI).

Methods

A&F intervention involved sending periodic reports via e-mail to participating hospitals in Lazio Region (about 5 million inhabitans). Volume, process and outcome indicators were calculated by hospital through Health Information System, compared with regional mean and target values. Health managers and clinicians were feedback recipients. Study design: pre-post intervention with control group (web-based regional periodic publication of indicators). Proportion of STEMI treated within 90 minutes with Percutaneous Transluminal Coronary Angioplasty (PTCA) was calculated in 2021 (pre) and in 2022 (post). Patients level adjusted Difference-in-Difference model (DID, 95% CI) was applied. Stepwise procedure identified individual (e.g. age, sex, clinical conditions) and hospital (e.g. hospital type) covariates entering in the model.

Results

A total of 19 hospitals were evaluated, 8 as controls. The number of analysed STEMI was 5084 (2651 in 2022) of which 3272 (1731 in 2022) in exposed hospitals. Overall, mean age 66 years, males 74.7%. Proportion treated with PTCA within 90 minutes in 2021 was 55.1% in exposed hospitals, and 57.9% in controls; in 2022 60.0% in exposed hospitals 66.4% in controls. Adjusted percentage difference in post/pre change between exposed and non-exposed hospitals was not significant in univariate and multivariate model (-3.6%, p = 0.218 and -4.4% p = 0.126).

Conclusions

These results cannot demonstrate a difference between exposed and not exposed hospitals. Possible explanations could be the short follow-up evaluated and the influence of covid-19 pandemic. In fact, several hospitals in both exposed and control group still had entire hospital wards dedicated to covid-19 management in 2021.

Key messages

• A&F methodology designed and implemented in EASY-NET project represents a challenging instrument to promote quality of care.

• Monitoring hospital performance through periodical reporting allows continuous quality improvement.
Family caregivers’ subjective poverty: the effect of nutritional guidance on their quality of life
Authors: Savela R M , Nykänen I , Koponen S , Suominen A L , Schwab U , Välimäki T
Published: October 2023

Background

Family caregiving may increase the risk of poverty, whereas poverty increases the risk of adverse health outcomes, creating health inequalities. Although the issue is significant, family caregivers’ social determinants of health are little assessed in the previous intervention studies. Therefore, we aimed to assess the effects of individually tailored nutritional guidance on financially vulnerable family caregivers’ quality of life and nutritional status.

Methods

The data were collected between June 2019 to June 2020. Study participants (n = 113) were randomized into intervention (n = 63) and control (n = 50) groups and further divided into those experiencing subjective poverty (n = 36) or financial security (n = 77). The intervention group received individually tailored nutritional guidance. Paired samples t-test, McNemar's test, or alternatives were used to assess the intervention's effectiveness on quality of life and nutrition.

Results

The preliminary results show that family caregivers who experienced subjective poverty had a lower overall quality of life (p <.001, 95% CI -12.1, -5.3), physical health (U = 1824, p = .004), psychological health (U = 1780, p = .013), and environmental quality of life (U = 2262, p <.001) at baseline. However, after the intervention, their overall quality of life improved (p = .010, 95% CI -15.9, -2.3). Similarly, there was an improvement in their psychological health (Z= -2.0, p = .047) and environmental quality of life (Z= -2.4, p = .017). Their risk of malnutrition also slightly decreased, and daily fruit and vegetable servings increased without statistical significance.

Conclusions

Individually tailored nutritional guidance improved the quality of life of family caregivers experiencing subjective poverty. The results may guide healthcare in narrowing health inequalities.

Key messages

• Individually tailored nutritional guidance can narrow quality of life inequalities among family caregivers of different financial groups.

• Healthcare should enable nutritional guidance to family caregivers.
The role of working conditions in educational differences in ischemic heart disease mortality
Authors: Almroth M , Hemmingsson T , Falkstedt D , Thern E
Published: October 2023

Background

The educational gradient in cardiovascular mortality is well established, but still not completely understood. One important mechanism may be working conditions. This study aims to investigate the extent to which job control and heavy physical workload explain educational differences in ischemic heart disease (IHD) mortality while also accounting for risk factors established in childhood and adolescence.

Methods

This register-based cohort study is based on men who completed their mandatory conscription (age 18-20) for the Swedish military in 1969/1970. This includes 37,419 men who also had a registered occupation in 2005. IHD mortality was measured in the cause of death register. Educational differences in IHD mortality, followed between 2006 and 2019, were measured using Cox proportional hazards regression models. Models were first adjusted for socioeconomic, cognitive, health and behavioral factors measured in childhood and during conscription. Models were further adjusted for physical workload and job control in 2005 (measured during mid-50s). These occupational exposures were measured using Job Exposure Matrices (JEM). Percent attenuation in hazard ratios (HR) after adjustment were calculated using the formula ((HR crude-HR adjusted)/(HRcrude-1))*100.

Results

Crude models showed a clear educational gradient regarding IHD mortality (HR 2.67, 95% confidence interval 2.08-3.42 for the lowest educated compared to the highest educated). Adjusting for earlier risk factors resulted in a 39-50% reduction in HR estimates. Further adjusting for physical workload and job control resulted in around 75% reductions compared to the crude model.

Conclusions

Physical workload and job control explained around 25% of the increased risk of IHD mortality in those with lower education. Improvement of the physical and psychosocial work environment could lead to a reduction in IHD mortality and smaller educational differences.

Key messages

• Physical workload and job control played an important role in educational differences in IHD even when accounting for a variety of early life risk factors.

• Improving the physical and psychosocial work environment could lead to a lower incidence of IHD deaths and reduced educational inequalities.
Use of the WHO Nutrient Profile Model in Germany: feasibility and public health implications
Authors: von Philipsborn P , Holliday N , Leibinger A , Huizinga O , Klinger C , Okanmelu E , Geffert K , Rehfuess E
Published: October 2023

Background

Exposure to marketing for foods high in sugar, salt, and fat is considered a key risk factor for childhood obesity. To support efforts to limit such marketing, the World Health Organization Regional Office for Europe has developed a nutrient profile model (WHO NPM), published as second edition in March 2023. The German government plans to use this model in new food marketing legislation, but it has not yet been tested in Germany.

Methods

We applied the WHO NPM to a random sample of 660 food and beverage products across 22 product categories on the German market from Open Food Facts, a product database. We calculated the share of products permitted for marketing to children under current market conditions and for hypothetical reformulation scenarios. We assessed practical challenges in applying the WHO NPM and the effects of model adaptations.

Results

The median share of products permitted for marketing to children across the 22 categories was 20% (interquartile range (IQR) 3-59%) and increased to 38% (IQR 11-73%) with model adaptations proposed by the German government. With targeted reformulation (i.e. a 30% reduction in fat, sugar, sodium, and/or energy) the share increased substantially (defined as a relative increase by at least 50%) in several product categories (including bread, processed meat, yogurt, convenience foods, and savoury plant-based foods), but changed less in others. Practical challenges included the ascertainment of the trans-fatty acid content of products, among others.

Conclusions

The application of the WHO NPM in Germany was found to be feasible. Its use in the proposed legislation on food marketing in Germany seems likely to serve its intended public health objective of limiting marketing in a targeted manner specifically for less healthy products. It seems plausible that it may incentivise reformulation in some product categories. Practical challenges could be addressed with adaptations and procedural provisions.

Key messages

• The practical application of the WHO Europe Nutrient Profile Model 2023 edition to a random sample of food and beverage products on the German market was found to be feasible.

• With targeted reformulation, the share of products permitted for marketing to children under the WHO Europe Nutrient Profile Model increases substantially.
Adherence to the Mediterranean Diet and Urinary Sodium Excretion in people at high risk of dementia
Authors: Rodrigues J , Barbosa M , Sousa D , Costa A R , Lunet N , Tedim Cruz V , Padrão P
Published: October 2023

Background

Both adequate sodium intake and adherence to the Mediterranean Diet (MedDiet) are largely described as important factors for the prevention and control of hypertension and cerebrovascular diseases. However, data regarding sodium intake in the MedDiet is scarce. This study aims to quantify the association between the MedDiet adherence and sodium excretion.

Methods

This cross-sectional analysis was carried out under the MIND-Matosinhos randomized controlled trial, a community-based program for Portuguese adults at high risk of dementia. The adherence to the MedDiet was assessed through the Portuguese version of the Mediterranean Diet Adherence Screener questionnaire, and a score ≥10 indicated a high adherence. A 24h urine collection was used to evaluate creatinine and sodium excretion. Excessive sodium excretion was defined as ≥ 2000 mg/day. Sociodemographic, lifestyle and health-related data were obtained through structured questionnaires. The association between the adherence to the MedDiet and urinary sodium excretion (recoded into two categories by the median) was quantified by calculating Odds Ratios (OR) and respective 95% Confidence Intervals (95% CI) using a binary logistic regression.

Results

A total of 126 individuals (24 to 83 years old; median age of 70.0) was included in this study (58.7% female). High adherence to the MedDiet was observed among 15.9% of the sample whereas excessive sodium excretion was reported by 84.1%. After adjusting for confounders, participants with high adherence to the MedDiet showed a higher sodium excretion (OR = 4.05; 95% CI: 1.33-12.37).

Conclusions

A high adherence to the MedDiet was associated with a higher sodium excretion. Thus, an increased adherence to this dietary pattern seems to have limited effects on the adequacy of sodium intake. This highlights the importance of public health measures to reduce sodium intake when following a MedDiet namely by improving consumer empowerment.

Key messages

• Despite the well-known protective effect of the Mediterranean Diet on hypertension and cerebrovascular diseases, the role of sodium intake within this dietary pattern is still understudied.

• The Mediterranean Diet can be an important source of hidden sodium, which enhances the need to invest in public health measures to reduce sodium intake, namely through culinary medicine education.
Monitoring drugs and prison in Europe: key issues and challenges in collecting information and evidence on drug related problems and interventions in prison
Authors: Montanari L
Published: October 2023

The EMCDDA published a methodological framework to monitor drugs and prison in Europe, with the objective to set up methods and tools for collecting and analysing harmonised data across Europe on the issue of drugs and prison. Two data collection tools are available: a “European Questionnaire on Drug use among people in Prison (EQDP)” aimed at collecting epidemiological data on drug use and drug related problems on people incarcerated during a given time period and; a “European Facility Survey Questionnaire in Prison (EFSQ-P)” aimed at collecting data on availability, coverage and provision of drug related interventions inside prison. The two monitoring tools include a short and long version and are accompanied by methodological guidelines. The toolkit should be used across countries to improve international comparisons and European harmonisation as well as to provide data to national governments or international organisations (e.g. EMCDDA, WHO, UN and others). Based on challenges identified among responding countries a check list of key issues in collecting data on drugs and health information in prison settings was drafted. This check list aims to provide a practical guide for those who want to start gathering data on drugs and health in prison; it has been drafted and agreed by a group of European experts who have implemented drugs monitoring in prison using the EMCDDA tools. The check list aims to discuss possible options and present best practices in drugs monitoring in prison in the different phases of research/data collection. The check list includes examples and recommendation on how to address the following issues: accessing prison, planning data collection, sampling procedures according to type of data to be collected, mode of administration/data gathering, data analysis and dissemination; ethical issues, involvement of people living in prison and staff in all phases of data gathering.
Cancer prevention for people experiencing homelessness: Co-designing the Health Navigator Model
Authors: Schiffler T , Gil-Salmerón A , Doñate-Martínez A , Rico Varadé M , Barrio Cortes J , Kouvari M , Karnaki P , Moudatsou M , Tabaki I , Grabovac I
Published: October 2023

Introduction

Cancer is the second leading cause of death for people experiencing homelessness (PEH) due to limited access to cancer prevention services. This study aimed to co-adapt the Health Navigator Model (HNM), integrating end-users’ and organizations’ voices in the design of a care delivery model combining Patient Navigation and Patient Empowerment - models that have been shown to benefit different health outcomes by reducing health inequalities and improving access to cancer prevention services.

Methods

Participatory qualitative research was conducted through focus groups between December 2021 and January 2022 across four European countries (Austria, Greece, Spain, and United Kingdom). Seven focus groups with an overall sample size of 56 participants were conducted, including 41 professional stakeholders and 15 PEH. Focus groups were audio-recorded, transcribed verbatim, and thematically analyzed.

Results

Analysis identified four key features of the HNM, including (1) assessment of needs and barriers to access health care (e.g., seeking solutions regarding barriers to care); (2) promoting cancer awareness and self-management (e.g., encouraging user involvement in health-related decisions); (3) facilitating access to preventive services (e.g., coordinating and supporting attendance of clinical appointments); (4) providing practical assistance (e.g., assisting with paperwork). Regarding the profile of health navigators, a health or social care professional background accompanied by active engagement with relevant/local stakeholders to improve intervention delivery is enhanced.

Conclusions

The HNM is a person-centered intervention to improve self-care and build relationships with PEH. Health Navigators should provide practical assistance, coordinate access to cancer prevention care and promote cancer awareness and self-management. The HNM is currently piloted and evaluated across four European countries as part of the Horizon 2020 CANCERLESS project (GA 965351).

Key messages

• The Health Navigator Model is a person-centered intervention responsive to the needs of people experiencing homelessness, building trusting relationships, and improving levels of self-care.

• Health Navigators should provide people experiencing homelessness with practical assistance and coordinated access to cancer prevention care while promoting cancer awareness and self-management.
The role of civil society in promoting effective policies
Authors: Berteletti F
Published: October 2023

The fifth presentation will reflects on the work by civil society in promoting more effective policies and the barriers faced from the alcohol industry in particular.
Lessons from the health system resilience testing pilot in Finland
Authors: Tynkkynen L , Karreinen S , Keskimäki I , Satokangas M , Viita-aho M
Published: October 2023

Finland is a Nordic welfare state with universal access to health care. The health system has recently undergone a major reform and health care and social and rescue services are organized by 21 well-being service counties, the city of Helsinki and Helsinki-Uusimaa Hospital district which all get funding from the state. Publicly funded health services are mainly provided by public health centers and hospitals. The resilience testing tool developed by the European Observatory on Health Systems and Policies and the OECD was piloted in Finland in the early April 2023. The participants (n = 17) represented e.g. the key ministries, the Prime Minister's Office, Ombudsman for children, well-being service counties, municipalities, and the university hospitals. The tool was piloted by using a pandemic scenario in which those most seriously affected are small children with substantially increased hospitalizations and mortality. The adults are mainly asymptomatic. At population level the spreading of the disease is rapid and overwhelms the service system in waves. The scenario was chosen because it is difficult to predict the onset and cause of the next pandemic, or its effects on the health system. The Covid-19 pandemic placed health systems around the world to a test, but it is important that preparedness to the next pandemic is not developed solely based on the experiences from Covid-19. In this presentation we describe the main lessons learned from the Finnish resilience testing pilot. These include both lessons related to the tool itself and its further development as well as lessons from the discussions based on the pandemic scenario. The discussions by the multi-stakeholder group reflected well the health system subfunctions presented in the resilience testing tool framework. However, the discussions also captured themes that are not currently visible in the framework such as ethical considerations, values, and political determinants of health system response.
Conditions for implementation of whole school health promotion in the Netherlands
Authors: Vennegoor G , Van Assema P , Molleman GRM , Van Empelen P , Dieleman J , Jansen MWJ
Published: October 2023

Background

Around 35 years ago, the Health Promoting School (HPS) framework was introduced to promote student health behaviors. It is an integrated approach, including education, school health policy, health services, and a stimulating social and physical environment. Implementation of such whole school HPS programs often remains challenging due to the dynamic school system. In order to strengthen implementation and reduce heterogeneity in effects, the present study aimed to understand what works, for which schools and under which conditions.

Methods

In 2020, 535 schools filled out the HPS Implementation Questionnaire to determine the degree of HPS implementation, showing considerable variety. Based on their implementation scores, 21 ‘lower HPS’ and 22 ‘higher HPS’ schools (16 primary; 15 secondary; 12 secondary vocational) were recruited by Public Health Services for a visit in 2022 to examine differences. Data on implementation and 35 contextual factors (related to individuals, the school organization, HPS framework, and socio-political environment) were collected by observations, a semi-structured group interview, a questionnaire, document analysis, and field notes. Data were analyzed thematically in Nvivo, and will be followed up by Qualitative Comparative Analysis in R.

Preliminary results

Most evident conditions for degree of implementation were: 1) capacity (time), 2) employee attitude (mainly at primary schools), 3) program champion (mainly at secondary schools), 4) professional implementation support, 5) turbulence (e.g. merger), and 6) management support (mainly at secondary schools). Activity budgets and social support among employees were key factors as well, but did not explain differences in implementation.

Conclusions

In order to strengthen implementation of HPS programs, more efforts are needed to: 1) intensify support for schools in terms of time and professional advice, and 2) achieve a positive school climate among employees and management.

Key messages

• Implementation of HPS programs is challenging due to the dynamic nature of schools.

• Offering support and achieving a positive school climate are crucial to strengthen HPS implementation in schools.