Alcohol drinking patterns encompass various dimensions of consumption. However, most studies have focused narrowly on the quantity of alcohol consumed. This study aimed to identify alcohol-drinking patterns in middle-aged population using alcohol-related variables and to examine their relationship with coronary heart disease (CHD), stroke, and all-cause-mortality risk. The present population-based study included adults from the Danish Health Examination Survey (DANHES) cohort who were ≥40 years old and free of CHD and stroke at baseline (n = 46 141). Latent Class Analysis (LCA) was used to identify distinct subpopulations based on six alcohol-related variables (amount, frequency, binge episodes, type, within meals, at home and alone). Cox proportional hazard models were used to estimate hazard ratios (95% confidence interval) between drinking patterns and CHD, stroke, and all-cause mortality during a median follow-up of 11.8 years. Four classes of drinking patterns were identified in both sexes (labeled as "low drinkers," "low-to-moderate drinkers," "moderate-regular drinkers," and "frequent-heavy drinkers"). The more frequent drinking pattern was a median of 3 (2-5) drinks per week. Frequent heavy drinking was associated with a higher risk of stroke. Individuals in the low-to-moderate male drinking class and the moderate-regular female drinking class not under heart medication had a lower risk of all-cause mortality than low-level drinkers. Four distinct drinking patterns were identified. Among individuals 40 years and older, frequent-heavy drinking was associated with a higher risk of stroke, while low-to-moderate regular drinking might be associated with a lower all-cause mortality risk compared to low drinkers.
High emotional demands at work are associated with risk of poor health; however, it is debated whether the association is causal. To further elucidate the relation between emotional demands and health, we examined if changes in emotional demands were associated with subsequent risk of long-term sickness absence (LTSA) in the Danish workforce. We measured emotional demands in nationwide surveys from 2012 to 2018 among 14 602 workers, aged 18-64. We calculated changes in emotional demands from t0 to t1 (2 years apart) and followed the participants 2 years after t1 in a nationwide register of LTSA (sickness absence >30 days). Using Cox regression, we estimated hazard ratios (HRs) of LTSA among participants with changes in emotional demands, compared to participants without changes. Estimates were adjusted for sex, age, education, job group, depressive symptoms, and self-rated health. Increases in emotional demands were associated with an increased risk of LTSA, whereas decreases were associated with a reduced risk of LTSA. In the fully adjusted model, we observed the highest risk of LTSA among participants who changed from medium to high emotional demands (HR = 1.45, 95% CI: 1.16-1.82), compared to those retaining medium emotional demands. We observed the lowest risk of LTSA among participants who changed from high to low emotional demands (HR = 0.61, 95% CI: 0.40-0.92) compared to those retaining high emotional demands. Changes in emotional demands at work may affect the risk of LTSA. Workplace interventions should be developed and evaluated.
Assessing the health of urban populations and its determinants is crucial to ensure sustainable urban living. Burden of disease studies and health impact assessments are often used and city-level baseline mortality rates are a key parameter. However, studies tend to use unrepresentative estimates, with regional or national estimates typically applied at city-level, particularly for large-scale studies. We developed a standardized method for age- and sex-specific mortality rate estimation for 825 European cities, using open-source data. To fill for missing data, linear mixed-effects models with natural cubic splines modelled mortality and population data for 2011-19, based on city-specific trends. By generating a publicly available dataset of city-level mortality rates, and a replicable approach for other years, we sought to overcome many of the existing shortcomings in baseline mortality estimates. The highest age-standardized natural-cause mortality rates in 2018 were observed in cities in Hungary, Poland, Croatia, and Czech Republic while the lowest rates were in cities in Spain, France, and Italy. Variation between city-level and national rates was observed, with a median relative deviation of ∼16%. Our method addresses many of the common data quality and harmonization challenges associated with city-level mortality rate estimation. Advancement of effective policies and interventions necessitates robust baseline health data across cities, with good temporal coverage. To achieve this, requires strengthened efforts to improve data accuracy and consistency from regional sources to ensure accurate city-level representation. We fully documented the process and provide the code and data to be used in other studies.
The objectives were to explore the prospective associations between job stressors and incident lipid-lowering medications in a nationally representative sample of the working population. The data of the periodic national French ESPS survey of 2010, 2012, and 2014 linked to the national health insurance database, were used. The study sample included 8231 workers, without lipid-lowering medications within the 6 months preceding survey wave. Quantitative demands, low freedom at work, job insecurity, and tension with the public predicted incident lipid-lowering medications over a 2-year follow-up. Further investigation of lipid-related pathways linking job stressors to cardiovascular diseases is needed.
Medico-legal autopsy case files contain prevention-relevant information on causes and circumstances of death but remain underused for surveillance because key detail is recorded as narrative text and terminology varies across jurisdictions. We evaluated whether the 11th Revision of the International Classification of Diseases can generate structured, surveillance-ready outputs from these records, while signalling where coding cannot preserve medico-legal meaning. In this retrospective study at the Institute of Forensic and Traffic Medicine, Heidelberg University Hospital, Germany, we screened consecutive medico-legal autopsy case files from 1 January 2022 to 31 December 2024 and analysed all eligible reports. We generated three output layers: causes of death, injury phenotypes, and external-cause dimensions for non-natural deaths. An expert-validated quality-flag framework identified representational limitations affecting surveillance interpretation. Of 935 screened files, 921 were analysed. Overall, 196 of 921 autopsies (21.3%) had one or more quality flags. Flags affected 119 of 921 cases (12.9%) in cause-of-death coding, 60 of 921 (6.5%) in injury phenotyping, and 35 of 423 non-natural deaths (8.3%) in external-cause dimensions. Flags were most prevalent among suicides (23 of 58, 39.7%); injury-related flags were most frequent in neck injuries (32 of 137, 23.4%). Among non-natural deaths, place and mechanism were codable in over 92% of cases. The 11th Revision of the International Classification of Diseases can support structured cause-of-death, injury, and external-cause outputs from medico-legal autopsy records for public health surveillance. However, routine use requires explicit signalling of residual uncertainty and classification limitations to preserve interpretability.
Türkiye's foundational health-professions law (1928) concentrates clinical authority in licensed physicians. A 2014 regulation moved traditional and complementary medicine (T&CM) from prosecutable practice into lawful, certified-physician-only provision, centralizing supply. Demand-reported by 14.7%-60.5% of patients nationally-has outgrown this framework. Physicians hold exclusive T&CM authority yet face structural disincentives to exercise it: the public performance-payment system values a 30-minute T&CM session the same as a 2-minute prescription renewal. Unmet demand migrated to unlicensed providers. Interviews with 58 T&CM service providers across Türkiye's seven regions, completed just before these reforms, documented provider-reported harms in unlicensed provision, including scarring from improper cupping, reuse of unsterile instruments (including using a leech across multiple clients), and deaths caused by thermal sulphur gas, as well as a reactive, complaint-driven inspection system. In response, the Ministry issued three sequential regulations: licensed Health Professional Service Units (March 2025), licensed medicinal herbal teas restricted to pharmacies (2 July 2026), and licensed Wellness Centres encompassing T&CM as explicitly non-curative services (4 July 2026). All share one logic: new licensed, traceable channels for contested activity rather than tightening enforcement or deregulating. Early signals include active licensing uptake among allied health professionals; the wellness framework is only weeks old; this article is an early policy analysis, not an impact evaluation. The case offers a transferable instrument for health systems facing tension between physician-centred scope-of-practice law and rising demand at the margins of clinical practice, while suggesting that legal permission without financing reform may leave the underlying supply gap intact.
The importance of assessing end-of-life (EoL) care has grown due to increased life expectancy and chronic disease prevalence. Despite awareness of holistic care, cancer patients often receive aggressive treatments that may reflect disparities influenced by socioeconomic factors. This study investigates EoL care among cancer patients in Italy, focusing on the impact of socioeconomic position (SEP). A retrospective observational study was conducted using Italian health databases, focusing on cancer patients aged 35 years and older who died between 2015 and 2019 in Lazio, Italy. SEP was assessed using educational attainment and a composite deprivation indicator at the census-section level. EoL care intensity was measured using hospitalization rates, emergency department visits, medication use, and place of death. Logistic regression models [OR (95% CI)] were used to explore socioeconomic associations with care intensity. The study included 84 936 subjects, predominantly aged over 75, with lung, colorectal, and breast cancers being the most common. During the last month of life, individuals with middle to higher educational levels (upper-middle, university degrees) had increased risks of hospitalization (OR 1.06; 95% CI: 1.02-1.10; OR 1.09; 95% CI: 1.03-1.15), anti-neoplastic therapies (OR 1.29; 95% CI: 1.21-1.38; OR 1.48; 95% CI: 1.36-1.61), and in-hospital death (OR 1.08; 95% CI: 1.03-1.12; OR 1.16; 95% CI: 1.10-1.23) and lower risks of ED admissions (OR 0.91; 95% CI: 0.87-0.94; OR 0.76; 95% CI: 0.71-0.80) and opioid therapy (OR 0.90; 95% CI: 0.86-0.94; OR 0.87; 95% CI: 0.82-0.92). Similar results were observed when using the area-based SEP indicator. Socioeconomic differences influence EoL care pathways for patients with cancer in Italy. These findings suggest complex interactions between socioeconomic factors and care preferences, highlighting the need for tailored and equitable EoL care strategies.
Evidence is inconclusive on whether immigrants are at higher risk of substance use disorders compared to non-immigrants. We investigated the risk of drug and alcohol use disorder (DUD and AUD) in first- and second-generation immigrants with refugee and non-refugee backgrounds using the nationwide Swedish longitudinal healthcare and legal registers. We included 798 141 males and 756 903 females who turned 16 years of age between 2005 and 2020. DUD and AUD were identified between ages 16 and 25 years using healthcare and legal registers. Immigrants were categorized into first- and second-generation refugees and non-refugees. Cox proportional hazard models estimated DUD and AUD risk in relation to immigrant status (non-immigrants as reference), adjusting for covariates. Sensitivity analyses were conducted using healthcare register data only. DUD risks were higher among most refugee and non-refugee immigrants compared to non-immigrants, i.e. hazard ratios (HRs) ranged from HR: 1.05, 95% CI: 0.95-1.15 (first-generation female refugees) to HR: 2.63, 95% CI: 2.54-2.73 (first-generation male refugees). AUD risks among immigrants were lower or similar to non-immigrants, i.e. HRs ranged from HR: 0.55, 95% CI: 0.49-0.62 (first-generation female refugees) to HR: 1.17, 95% CI: 1.03-1.34 (first-generation male non-refugees). Sensitivity analyses restricted to healthcare registers yielded somewhat attenuated associations for DUD, particularly among first-generation male refugees. Refugee and non-refugee immigrants in Sweden were generally at elevated risk of DUD, whereas AUD risks were largely similar to or lower than that of non-immigrants. The findings were broadly robust in analyses restricted to healthcare data.
High-risk human papillomavirus (HR-HPV) screening effectively reduces cervical cancer incidence, but limited specificity leads to excessive colposcopy referrals. Extended HR-HPV genotyping improves triage by accounting for genotype-specific oncogenic risks, offering a more precise framework for patient management than traditional pooled testing. This study analysed real-world screening data from a Finnish cohort of 2368 HR-HPV-positive women (Tampere region, 2017-2019) with up to 6.5 years of follow-up. Extended genotyping was performed using the Seegene Anyplex™II HPV28 Detection assay. Genotype-specific prevalence and cumulative incidence of histology-confirmed High-grade Squamous Intraepithelial Lesions or worse (HSIL+) were assessed and stratified by reflex cytology. Among 3099 detected HR-HPV genotypes, HPV16 was most prevalent (14.3%) and carried the highest HSIL+ risk (35.7%), followed by HPV33 (24.6%) and HPV18 (20.8%). A clear risk hierarchy emerged: the lowest-risk group (HPV59/39/68/51/56/66) had an HSIL+ incidence below 4.2%. Notably, HPV16-positive women with NILM/ASC-US cytology faced a 23.9% HSIL+ risk, exceeding the 21.1% risk seen in the lowest-risk genotype group even when accompanied by LSIL+ cytology. For those with both NILM/ASC-US and the lowest-risk genotypes, HSIL+ incidence was only 3.4%. A distinct hierarchy of oncogenic risk exists within this population-based cohort. Incorporating genotype-specific data into national screening algorithms is strongly supported. This allows for immediate colposcopy for high-risk groups (e.g. HPV16 with mild cytology) while justifying extended follow-up for lower-risk types, optimizing clinical resources and reducing unnecessary procedures.
While Holistic Health Promotion is mandated in Hungary, little is known about its school-level implementation, especially in small schools. We analyzed national data of 2883 elementary schools, and (i) compared the implementation between small (10-99 students) and not-small schools, and (ii) conducted county-level socioeconomic comparisons within the subsample of small schools. Health promotion activities were implemented inconsistently across schools. Small schools (N = 320) reported fewer structured working groups (9.7%) and lower engagement of school health staff in program development (doctors: 3.1%, nurses: 6.9%, psychologists: 0.9%). Participation in national food schemes was markedly higher in low socioeconomic status (SES) areas than in high SES small schools (Milk Scheme: 83.5% vs. 46.5; Fruit & Vegs Scheme: 86.9% vs. 67.3%). Menu planning was aligned with the Public Catering Act in two-thirds of all schools (68.9%), which falls short of full adherence. Coverage of nutrition education was high (95.5%). Experiential learning tools like school gardens (31.7%) and educational kitchens (18.8%) were predominantly found in high SES context. After-school physical activity opportunities were significantly limited in small schools. The availability of bullying (32.2%) and digital addictions (52.2%) prevention measures was limited in low SES context. Parental health literacy programs showed moderate integration across all groups (average score: 6 out of 10). This study provides the first nationwide school-level evidence on variation in the implementation of health promotion policies. Findings highlight modest differences by size and SES, and underscore the need for targeted actions to support small and disadvantaged schools.
Mental well-being has been shown to follow a U-shaped pattern across the life course in cohorts studied to date, with psychological distress worsening as people enter their forties. The reasons for this decline remain a puzzle. This study examined the social determinants associated with this phenomenon and their relative importance as predictors of mid-life mental health. We used data from the 1970 British Cohort Study, aged 26, 34, and 42 (N = 6992, 51.5% female). Mental distress was measured with the nine-item Malaise Inventory. We contrasted a group of those whose mental health declined with those exhibiting stable mental health. Random forest (RF) and logistic regression models explored whether decline was predicted by socio-economic and family factors, physical health, and health behaviours (at ages 26, 34, or birth). Social class at birth (variable importance [VI] = 0.027) and income quintile at 34 (VI = 0.027) were the most important predictors in RF analysis. Regression confirmed that working-class background (odds ratio [OR] = 1.53 [1.27-1.85]) and being in the highest-income quintile at 34 (OR = 0.68 [0.53-0.88]) strongly predicted the mental health decline. The predicted probability of decline was two and a half times higher for those with an unfavourable, compared to a favourable, combination of social determinants (28% vs 11%). Importantly, a working-class background was not associated with mental health decline between ages 26 and 34. Early-life social class and income were among the strongest predictors of mid-life psychological distress. Decline was concentrated among those exposed to economic disadvantage, suggesting that this group should be a particular focus of mid-life mental health prevention and support.
Urban design has a direct impact on health and health inequalities. The Barcelona City Council implemented the Green Corridor project in 2022 in several streets of the Eixample district. The objective of the present study was to assess the effect of this project on the quality of public space from a health perspective approach. A quasi-experimental study was performed. The intervention group consisted of a sample of street sections of the intervened streets, and the comparison group consisted of a sample of street sections of a nearby street. The quality of public space was assessed in both groups before (2022) and after (2024) the intervention was implemented using an instrument designed ad hoc, which assessed eight different dimensions and several subdimensions. A difference-in-differences analysis was performed to compare pre-post differences between the intervention and comparison streets. In the intervention streets, significant improvements were observed in all the dimensions assessed. Greatest differences between the intervention and comparison groups were observed in the natural areas dimension (4.94 points difference), followed by the maintenance and cleanliness dimension (2.55 points), architectonic characteristics (2.28 points), safety (1.61 points), and environmental characteristics (1.00 points). Urban design transformations such as the Green Corridor project can improve living conditions in neighbourhoods by increasing urban green spaces and facilities, reducing motorized traffic, improving walkability, enhancing air and noise quality, and promoting social interaction, all of which can have a beneficial impact on residents' physical and mental health.
Cancer-related mortality among People Experiencing Homelessness (PEH) is twice as high as in the housed population, with one-third of deaths in this community linked to conditions preventable through timely healthcare. The Health Navigator Model (HNM) is a person-centred approach to improve healthcare access for PEH. This study assessed the feasibility of implementing the HNM across four European countries. A non-randomised, single-arm pilot study was conducted from June 2022 to December 2023 in Austria, Spain, Greece, and the UK. Trained Health Navigators supported adult PEH-excluding those with cancer diagnoses or cognitive impairments-through tailored guidance, education, and referrals. Feasibility indicators (demographics, recruitment, retention, engagement) were collected at baseline and follow-up points. Health Navigators' experiences were explored via qualitative interviews. Out of 1981 individuals approached, 652 PEH participated. The average age was 47.4 years; 64.1% were male, 41.6% relied on state benefits and 62.4% had experienced homelessness for over a year. Nineteen Health Navigators (mean age 34.95 years) were involved. Engagement included cancer education (N = 494), health consultations (N = 286), specialist referrals (N = 212), and screening tests (N = 169). Follow-up rates were 69% at the first time point and 42.5% at the second. Low cancer awareness, prioritisation of subsistence needs over health, and system-level barriers were identified as challenges, while building trust with individuals and stakeholders emerged as facilitators. Health Navigators reported increased empathy, awareness of PEH's needs, and confidence in empowering them as key benefits of their role. Training skilled Health Navigators, building trust and fostering strong inter-organisational collaborations are key to successfully implementing the HNM among PEH.
Despite the demonstrated safety of human papillomavirus vaccines, concerns have arisen regarding potential associations of human papillomavirus vaccination on reproductive health. The objective of this registry-based study was to compare overtime association of vaccination and early pregnancy outcomes. Twenty thousand four hundred twenty-six women born in 1992-1995, who participated in a Finnish community-randomized human papillomavirus vaccination trial, and age- and community-aligned unvaccinated controls born in 1990-1991 (n = 19 473) were followed up for 11 years. Data was obtained from the nationwide Finnish Care Register for Health Care. Incidence rates of adverse early pregnancy outcomes were compared between the human papillomavirus vaccinated and unvaccinated group. The mean age at first abnormal pregnancy result was 23.5 years in the human papillomavirus vaccinated group and 22.2 years in the unvaccinated group. 1.6% of human papillomavirus vaccinated women experienced a miscarriage compared with 5.3% of unvaccinated controls (P < .0001). No miscarriages occurred in close temporal proximity to vaccination. Rates of ectopic pregnancies were low and comparable across all groups (0.6-1.0%). Among women with a history of abnormal pregnancy outcomes, 55.6% of human papillomavirus vaccinated individuals had at least one live birth, compared with 70.3% of unvaccinated women. Human papillomavirus vaccination was not associated with an increased risk of miscarriage or other adverse early pregnancy outcomes. These results provide reassurance that human papillomavirus vaccination is safe with respect to reproductive outcomes, supporting its continued use in adolescent and young adult populations.
Increasing taxation is one of the most effective tobacco control policies. However, cigarette taxes in Switzerland remain lower than in other European countries. This study analyses the arguments supporting or opposing an increased taxation that were put forward by members of the Swiss Parliament and by the Swiss Government between 2010 and 2025. Arguments in favour of higher taxes are mainly youth protection and taxation according to product risk. Arguments against higher taxes are mainly illicit and cross-border trade, followed by the negative economic impact. The Government often takes a status quo approach when responding to parliamentary requests.
Numerous studies have tried to understand the causes of mental health problems, mostly focusing on single exposures. These approaches often fail to capture the complex and interconnected nature of mental health problems. This study aims to investigate the associations of concurrent age-specific changes in explanatory factors, encompassing personal, health, lifestyle, and social factors and depressive symptoms in individuals aged 15 to 32 years. Individuals born in 1989 were followed from 2004 to 2021 with surveys at ages 15, 18, 21, 28, and 32. Inverse probability weights and multiple imputations with chained equations were used to account for attrition and missing data. Descriptive characteristics for each wave were estimated as well as the changes in depressive symptoms and explanatory variables between each wave. Fixed effect regression models and dominance analyses examined the contribution of change in each explanatory variable to the change in depressive symptoms between each wave. Lastly, analyses of asymmetric change were estimated to detect asymmetric associations of explanatory variables and depressive symptoms. The relative importance of the explanatory variables changed between age points. Between all age points, stress was the most dominant variable with a relative contribution above 30% between all age points, while the contribution of sense of coherence increased through the waves from 17% to 25%. Self-esteem, self-rated health, and psychosomatic symptoms had also high dominance with shifting contributions through the ages. The associations between explanatory factors and depressive symptoms are dynamic and preventive strategies should be tailored towards the different life stages.
Existing research on screen time and adolescent psychological wellbeing often overlooks how digital engagement interacts with other daily activities. Uncertainty remains about which activities are complemented or displaced by digital use, and whether specific combinations of activities are beneficial or detrimental to wellbeing. We used detailed time-use diary data from 3,288 participants in the UK Millennium Cohort Study, collected during the age-14 survey. Adolescents recorded their activities in 144 consecutive 10-min slots over a 24‑h period, selecting from 44 pre-specified activity types. Latent profile analysis was used to identify distinct time-use patterns. This approach accounts for the interdependence and trade-offs among different activities, rather than examining each of them in isolation. Associations between these profiles and later psychological wellbeing, measured using the Strengths and Difficulties Questionnaire, were examined using multinomial logistic regression. Three time-use profiles emerged: (i) 'Frequent digital users' (21.0%), with high digital engagement, especially gaming, more common among males and those from lower socioeconomic backgrounds, showing poorer psychological wellbeing; (ii) 'Physically active, moderate digital users' (59.7%), who balanced digital and non-digital activities with high physical activity, showing more favourable psychological wellbeing; and (iii) 'In-person socialisers, low digital users' (19.3%), with low digital use and high face-to-face interaction, showing intermediate level of psychological wellbeing. Findings suggest that a balanced mix of daily activities is associated with more favourable adolescent wellbeing, highlighting the importance of promoting overall activity balance rather than focusing on digital time alone.
This study aimed to assess cancer prevention literacy (CPL) levels and awareness of the European Code Against Cancer (ECAC) among the adult population in the European Union (EU), as well as identify social determinants associated with CPL. A cross-sectional study was conducted (February-March 2024) via an online survey across 23 EU-countries (n = 2312). Multivariate logistic regression models examined associations between explanatory variables (age, gender, educational level, history of cancer, region, and digital health literacy [DHL] quartiles) and knowledge outcomes (CPL, ECAC awareness, and cancer prevention specific knowledge topics). Although 81.4% of participants demonstrated sufficient CPL, 61.1% were unaware of the ECAC. Men were less likely to have sufficient CPL than women (OR = 0.66, [0.49-0.89]), and participants with an education below the university level had lower odds of CPL than those with higher education (OR = 0.50, [0.39-0.64]). DHL was the strongest predictor of CPL, with, participants in the highest DHL quartile being more than three times more likely to have sufficient CPL than those in the lowest quartile (OR = 3.11, [2.12-4.67]). Having a personal or family history of cancer also increased the odds of sufficient literacy (OR = 1.47, [1.10-1.94]). The findings reveal that while overall CPL appears sufficient, ECAC awareness remains alarmingly low. Persistent social and gender inequalities exist; lower educational level, male gender, and older age were consistently associated with lower CPL. DHL emerged as a key CPL determinant. Coordinated and targeted interventions are required to address these social inequalities and maximize the ECAC's preventive impact across Europe.
