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WORLD HOSPITAL DIRECTORY
Health Care Management Medical European Journal of Public Health - current issue
<span class="paragraphSection">The global public health community is facing a new era of uncertainty. As the USA embarks on another political shift, the risks to global health initiatives, scientific collaboration, and evidence-based policymaking are mounting. The lessons of the past teach us that public health can be an easy target in times of political upheaval, particularly when misinformation and disinformation infiltrate public discourse. As Professor Martin McKee from EUPHA warns, “disinformation is the new normal with far-reaching implications for society, including population health.” The scientific community must be proactive, not reactive, in confronting these challenges. Our tools—science, advocacy, and capacity building—are necessary but insufficient. Public health must also embrace innovation across multiple domains while remaining connected to our core principles of equity and sustainability.</span>
<span class="paragraphSection">In their Viewpoint article, Kevin Shield and Saverio Stranges [<a href="#ckae194-B1" class="reflinks">1</a>] discuss official recommendations regarding alcohol consumption. Their view is that these go too far when they advocate for universal total alcohol abstinence. This seems reasonable but the question is where such advice is given. Their example is the Nordic Nutrition Recommendations 2023, published by the Nordic Council of Ministers [<a href="#ckae194-B2" class="reflinks">2</a>]. These recommendations certainly are quite restrictive, but they do not advocate for total abstinence. What they do say is the following: “Based on the overall evidence, it is recommended to avoid alcohol intake. If alcohol is consumed, the intake should be very low.” This message is consistent with recent epidemiological research, where no safe limits for drinking are found. While the jury is still out regarding possible positive effects from very low consumption on cardiovascular disease, these effects are outweighed by the negative effects on other diseases and trauma. For certain vulnerable groups, the recommendation is more categorical: “For children, adolescents and pregnant women abstinence from alcohol is recommended.” There appear to be no official guidelines that recommend universal abstention. </span>
<span class="paragraphSection">Guidance on alcohol and health varies substantially depending on the government or organization issuing the recommendations [<a href="#ckae192-B1" class="reflinks">1</a>]. The Nordic Nutrition Recommendations 2023, and the governments of Latvia and Lithuania advise that everyone should avoid alcohol consumption [<a href="#ckae192-B1" class="reflinks">1</a>]. This raises two questions: How do organizations arrive at the conclusion that no one should consume alcohol? And, is it in public health’s best interest to recommend total abstinence?</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The NEED (Needs Examination, Evaluation, and Dissemination) assessment framework was designed to identify and measure unmet health-related needs of patients and society across various health conditions, aiding the development of needs-driven healthcare policy and innovation. The framework consists of 25 needs criteria and 46 associated indicators that assess whether these needs are met or not. This study aims to validate the framework at the European Union (EU) level using a modified Delphi approach. We selected national and European institutes for the Delphi process based on their roles in public health, health technology assessment (HTA), medicine authorization, pricing and reimbursement (P&R), and patient advocacy. Using a modified Delphi approach, experts provided feedback on the framework’s structure (dimensions and domains), health-related needs criteria, and indicators. Two Delphi rounds were conducted via online questionnaires. A panel of 26 experts participated in both rounds of the study. The majority of the participants reported expertise in HTA (50%) and P&R (15%), followed by patient advocacy (15%) and public health (8%). Seventeen EU Member States were represented, with a higher representation of experts from Belgium (12%) and Germany (12%). The NEED framework based on expert consensus consists of 4 dimensions, 3 domains, 24 criteria, and 43 indicators. The modified Delphi technique proved effective for validating the NEED framework at the EU level. This marks a critical first step toward consensus on defining and identifying unmet health-related needs, paving the way for a more needs-driven healthcare policy and innovation landscape.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The aim of this study was to estimate the series of tobacco smoking prevalence year-by-year in Spain, by sex and age group, for the period 1991–2020. Based on smoking prevalence obtained from national surveys and smoking-related auxiliary information from public statistics, we fitted a multinomial logistic mixed model with random area and time effects. Joinpoint regression was used to identify changes in the prevalence series across the period. To analyse the precision of the model-based estimates, we calculated the coefficients of variation. Between 1991 and 2020, the prevalence of smoking in Spain decreased in both sexes. In the 15–24 age group, the prevalence of smokers showed no differences by sex until 2007, after which prevalence in men exceeded that of women. However, in women aged 55 and over prevalence of smoking has been rising since 1991. After applying the model, the precision of smoking prevalence estimates improved. The reconstruction of a detailed series of tobacco smoking prevalence provides insight into the evolution of the tobacco epidemic in Spain. A detailed analysis by sex and age shows different trends in the prevalence of smoking among women that should be considered when control measures are formulated.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Evidence on when socioeconomic inequalities in conventional cardiometabolic risk factors emerge and how these change over time is sparse but important in identifying pathways to socioeconomic inequalities in cardiovascular disease (CVD). We examine socioeconomic inequalities in cardiometabolic risk factors trajectories across childhood and adolescence. Data were from the Avon Longitudinal Study of Parents and Children (ALSPAC), born in 1991/1992. Socioeconomic position (SEP) was measured using maternal education from questionnaires at 32-weeks’ gestation. Cardiometabolic risk factors measured from birth/mid-childhood to 18 years (y) included fat and lean mass (9–18 y), systolic and diastolic blood pressure (SBP, DBP), pulse rate and glucose (7–18 y), high-density lipoprotein cholesterol (HDL-c), non-HDL-c and triglycerides (birth–18y). Associations were examined using linear spline multilevel models. Among 6517–8952 participants with 11 948–42 607 repeated measures, socioeconomic inequalities in fat mass were evident at age 9 y and persisted throughout adolescence. By 18 y, fat mass was 12.32% [95% confidence interval (CI): 6.96, 17.68] lower among females and 7.94% (95% CI: 1.91, 13.97) lower among males with the highest SEP compared to the lowest. Socioeconomic inequalities in SBP and DBP were evident at 7 y, narrowed in early adolescence and re-emerged between 16 and 18 y, particularly among females. Socioeconomic inequalities in lipids emerged, among females only, between birth and 9 y in non-HDL-c, 7 and 18 y in HDL-c, and 9 and 18 y in triglycerides while inequalities in glucose emerged among males only between 15 and 18 y. Prevention targeting the early life course may be beneficial for reducing socioeconomic inequalities in CVD especially among females who have greater inequalities in cardiometabolic risk factors than males at the end of adolescence.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>In Germany, routine screenings are used to monitor the health and development of children and adolescents, enabling timely discovery and treatment of health issues. One such screening, called J1, is recommended for adolescents aged 12–14 years, but participation is only 43%. In the state of Bavaria, a lack of awareness is the main reason cited for not attending. ‘Your Ticket to J1’ was an invitation system implemented across the state to inform adolescents about the screening. Our study investigated whether this intervention increased J1 participation and if its effects varied by family socioeconomic position (SEP). We used pseudonymized data from a large statutory health insurer from 2016 to 2018 and containing 267 650 observations. To investigate the effect of the intervention, we employed a difference-in-differences analysis at the individual level. Assuming parallel trends at the state level, we compared J1 participation rates between Bavaria and other German states before and after the intervention. We additionally stratified analyses by SEP. The intervention led to an increase in J1 participation by about 1%. In the stratified regressions, the effect size was larger for children from families with a lower SEP. J1 participation increased by about 4% among adolescents whose primary insured parent had the lowest occupational status. A state-wide invitation system had a small but statistically significant positive impact on J1 participation and might reduce socioeconomic inequities in healthcare utilization. Informing adolescents about J1 appears to increase participation, particularly among those from families with a lower SEP.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>This study investigated the extent to which ethnic inequalities in severe COVID-19 (i.e. hospitalization or deaths) are mediated through occupational risk differences. We used a population-based cohort study linking the 2011 Scottish Census to health records. We included all individuals aged 30–64 years and living in Scotland on 1 March 2020. The study period was from 1 March 2020 to 17 April 2022. Self-reported ethnicity was taken from the Census. We derived occupational risk of SARS-COV-2 infection using the 3-digit Standard Occupational Classification (SOC2010). We estimated hazard ratios (HRs) of total effects and controlled direct effects of ethnicity on severe COVID-19 mediated by occupational risk using marginal structural Cox models and subsequent proportional change. For aggregated ethnic groups, Non-White groups experienced a higher risk of severe COVID-19 (HR 1.6; 95% CI 1.4–1.8) compared to White group (all White ethnic groups) which increased to (1.7; 1.4–2.1) after accounting for occupational risk, representing a 6.0% change. For disaggregated ethnic groups, risks for South Asian (2.0; 1.8–2.3), African, Caribbean, or Black (1.3; 0.9–1.7) and Other ethnic groups (1.1; 0.9–1.3) were higher compared to White Scottish. After accounting for occupational risk, estimated risk of severe COVID-19 remained elevated for South Asian (1.8; 1.2–2.3), African Caribbean or Black (1.4; 0.8–2.1) and Other ethnic group (1.7; 1.1–2.3) representing a reduction of 11.8% and increases of 16.4% and 59.0%, respectively. Our findings suggest that ethnic inequalities in severe COVID-19 were impacted by differences in occupational risk.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The European Commission Initiative on Breast Cancer recommends pre-scheduled appointments to enhance attendance in population-based mammography screening programmes (PMSP). Pre-scheduled appointments often lead to no-shows, resulting in inefficient use of time and staff in screening units. Requiring women to confirm their appointments can reduce no-shows but might negatively impact attendance. We conducted a non-interventional study to assess the impact of requiring confirmation on attendance rates. The study involved 291 127 women aged 50–69 invited to PMSP between 1 June 2022 and 31 May 2023. Propensity scores were used to match women who were required to confirm their pre-scheduled appointments (exposure) 1:1 with those who were not required to confirm (comparator). This was done separately in four strata based on screening history: first-time invitees, regular attendees, irregular attendees, and non-attendees. Logistic regression with generalized estimating equations was used to analyse the effect of the exposure on attendance within 60 days, separately for each stratum. If first-time invitees were obliged to confirm their pre-scheduled appointment, their attendance was 19% lower [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76–0.86]. The impact on regular attendees (OR 0.95, 95% CI 0.92–0.99), irregular attendees (OR 0.94, 95% CI 0.89–0.99), and non-attendees (OR 0.96, 95% CI 0.90–1.01) was minimal or non-significant. Requiring confirmation poses a barrier for first-time invitees but has little effect on those with previous screening history. Limiting confirmation requirements to women with prior invitations could optimize resource use in screening units without a notable decrease in attendance rates.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>We previously reported short-lived improvements in mental health literacy following the Every Mind Matters campaign, followed by a return to baseline levels. In this study, we aimed to examine whether either socioeconomic status or ethnicity moderated these improvements. We conducted regression analyses on a nationally representative, repeated cross-sectional dataset of nine survey waves from September 2019 to March 2022. Interaction terms (ethnicity*wave, socioeconomic status*wave) were entered into regression models to assess the moderating effect of these variables. Where significant interactions emerged, we obtained marginal estimates and plotted them for ease of interpretation. We found no evidence that improvements seen in mental health literacy following the launch of Every Mind Matters were moderated by ethnicity or socioeconomic status. Over time, there was some evidence of lower scores relating to symptoms recognition, knowledge of actions to improve mental health, and desire for social distance (stigma) among adults of lower socioeconomic status, which converged again for symptom recognition. These findings suggest that while a web resource can empower people and improve mental health literacy, in relation to ethnicity and socioeconomic status, it may be that while this can avoid a widening of inequalities it is insufficient to lead to a narrowing of them.</span>
<span class="paragraphSection">The news that the Trump administration has ordered scientists at the US Centers for Disease Control and Prevention (CDC) to withdraw or retract articles containing terms such as “gender,” “transgender,” “LGBT,” or “transsexual” is as shocking as it is dangerous. The editors of the <span style="font-style:italic;">British Medical Journal</span> (<span style="font-style:italic;">BMJ</span>) have rightly condemned this act of political interference in scientific discourse [<a href="#ckaf018-B1" class="reflinks">1</a>]. Writing on behalf of the <span style="font-style:italic;">European Journal of Public Health</span> and European Public Health Association (EUPHA), we stand alongside them in resisting these moves. Such censorship is not only an assault on scientific integrity but also a harbinger of the creeping authoritarianism that Europe has seen before, one that we must resist with all the force of history.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle"> </div>Rising public concern about comprehensive child and adolescent well-being has led to the development of school-based interventions with the potential for high-reaching and effective support. While some interventions have shown effectiveness, limited understanding exists regarding how social inequalities are considered and evidenced in such interventions. This study examines how social inequalities are considered in universal school-based interventions and their potential to affect inequalities through differential effects. A systematic review following the PRISMA protocol was conducted using the following databases: PubMed, Web of Science, CINAHL, Scopus, ProQuest and APA PsycArticles. Studies published between 2014 and 2023 were included. Screening and data extraction were conducted independently by two researchers. Of 10 028 initial articles, 44 were included in the final analysis. These studies primarily involved physical activity and mindfulness interventions in schools. Despite many studies including information regarding students’ social backgrounds, such as socioeconomic position and immigrant background, the analysis of differential intervention effects among demographic groups was limited and mostly based on sex. Most differential effect analyses showed no significant differences based on social background, and no clear differences were found based on intervention type. While some universal school-based interventions show promise in reducing social inequalities in students’ well-being, more empirical research is needed to explicitly target these questions. This review highlights the critical need for comprehensive intervention studies to consider and report relevant dimensions of social background and their interactions with intervention effects.<div class="boxTitle">Trial registration</div>PROSPERO; registration no. CRD42023423448</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Deeply concerning changes to UK health trends have been noted since the early 2010s, including a widening of mortality inequalities. Given the importance of urban areas to national health outcomes, we sought to address gaps in the evidence by examining trends in intra-city mortality inequalities across Britain, including assessing the impact of the peak COVID-19 pandemic period. Age-standardized mortality rates were calculated (for England, Scotland, and 10 major UK cities) by age (all ages, 0–64 years), sex, year (1981–2020), and country-specific and city-specific area-based quintiles of socio-economic deprivation. Trends in absolute and relative inequalities in mortality by country and city were analysed by means of the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII), respectively. Profound changes to mortality trends and inequalities were observed across both nations and all cities in the decade up to 2020, including increases in death rates among the 20% most deprived populations of almost every city. For deaths at all ages, this was particularly evident in Leeds, Liverpool, Edinburgh, Dundee, and Glasgow. For 0–64 years, Scottish cities stood out. With few exceptions, both absolute and relative inequalities increased in the same time period. COVID-19 further increased death rates and inequalities. The analyses provide a hugely concerning picture of worsening mortality and widening inequalities across England and Scotland. When viewed in the context of the evidence for the impact of UK government austerity policies on population health, they represent a wake-up call for both current and future UK governments.</span>
<span class="paragraphSection">WalshDavid and McCartneyGerry. Social Murder? Austerity and Life Expectancy in the UK. Bristol: Policy Press, 2025. 224 pp. ISBN 978--4473-7310-0 (ePDF) </span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>This study examines the long-term physical health impacts of pregnancy outcomes, comparing women who experienced live births to those who had pregnancy losses (miscarriages or stillbirths). While previous research has documented short-term links between pregnancy outcomes and physical health, fewer studies have explored these associations over the long term, particularly considering women’s preconception health. Data were drawn from the Understanding Society Survey [UK Household Longitudinal Study (UKHLS)] from 2009 to 2023. The sample included 2386 women who reported their first pregnancy and were observed over multiple time points, both before and after pregnancy. Physical health was assessed using the Physical Component Summary (PCS) from the 12-item Short Form Survey (SF-12) questionnaire. Linear fixed-effects models were used to analyze changes in physical health relative to pregnancy outcomes, adjusting for socioeconomic, demographic, and mental health covariates. The analysis revealed a sharp decline in physical health (PCS score) at the end of pregnancy for both groups, with a more pronounced decline among women experiencing pregnancy losses. Post-pregnancy, these women continued to report lower PCS scores compared to those with live births, particularly in the 2 years following pregnancy. The confounders did not fully explain the observed differences. Pregnancy losses are associated with a significant and lasting decline in women’s physical health, even after controlling for socio-demographic factors. Women who experience losses often report worse health than those transitioning to motherhood, with symptoms potentially including fatigue, pain, and cardiovascular diseases. These findings underscore the importance of long-term health monitoring and support for women following miscarriage or stillbirth.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The increasing prevalence of chronic conditions is a significant challenge for healthcare systems worldwide, not only from a public health perspective but also for the aggregate cost that these represent. This paper estimates the additional use of healthcare services due to chronic health conditions and their associated costs in nine European countries. We analyzed inpatient and outpatient healthcare utilization using longitudinal data (Survey of Health, Ageing and Retirement in Europe [SHARE]). We implemented a difference-in-differences approach across multiple time periods. Monetary estimates were derived using WHO-CHOICE healthcare service costs. To compare countries, we calculated the healthcare cost burden of chronic conditions as a percentage of total health expenditure. People with chronic conditions require significantly more healthcare services than those without such conditions, averaging three additional outpatient visits and one extra overnight inpatient stay annually. These patterns vary across countries. In Germany, outpatient care usage is particularly high, with an average of four additional visits, while Switzerland leads in inpatient care with two extra overnight stays. The associated costs also differ widely, influenced by variations in healthcare demand, service pricing, and the prevalence of chronic conditions in each country. Chronic conditions significantly increase healthcare utilization, and demographic trends suggest this demand will continue to grow steadily. This rising pressure poses serious challenges for healthcare systems, necessitating a shift toward more efficient service delivery models.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>There is a well-understood relationship between inequalities in income and health. We assessed how changes to income tax and social security—options recently devolved to the Scottish Government—could affect income and life expectancy inequalities. We used the microsimulation model UKMOD to estimate policies’ effects on household income distribution by socioeconomic deprivation, compared to baseline (Scottish income tax schedule for 2022/23). We then used the ‘Triple I’ (Informing Interventions to reduce health Inequalities) scenario modelling approach to estimate mortality effects for the income changes and calculated inequalities in life expectancy at birth. Scenario health impacts were determined largely by how much money they gave or took from households in the most deprived areas. Policies that increased incomes for households in deprived areas tended to reduce inequalities in life expectancy. Although we found this also applied to tax-cutting policies that increased income inequality, our estimates did not account for the public spending cuts that these costly policies would necessitate and their likely widening effect on health inequalities. Combining the best-performing (i.e. greatest positive impact) revenue-generating and revenue-spending policies we modelled—tax increases targeted at high earners and a doubling the value of social security benefits—would generate net revenue while reducing income inequality by approximately 10% and inequalities in life expectancy by 8% to 9%, but sizeable inequalities would remain. A multifaceted approach based on combinations of policies—including, but not limited to, bolder income tax measures—is required to achieve meaningful reductions in inequalities.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The aim of the present study was to describe the effect of an individual’s mental health disorder on the resources of his or her adult siblings. A subject rarely analyzed on a large scale. The French National Health Data System (SNDS) collects data on individuals, including their characteristics and the types of healthcare used. A national observational sectional case–control study included individuals covered as of 1 January 2019 and receiving yearly at least one healthcare reimbursement in 2019 including their SNDS data collected from 2013 to 2018. The main variables of interest were a Complementary Universal Health Coverage (CUHC) granted to people who had limited resources. There is also a long-term disease (LTD) status qualifying also for 100% for a specific disease and an ecological index of social deprivation of the place of residence. Conditions were also collected using a specific tool including LTD and hospital diagnosis. Analyzed siblings included 280 709 cases with at least one member suffering from a mental health disorder and 561 418 randomly selected control individuals were addressed using a multilevel model. Siblings of people with mental health problems were more likely to benefit from CUHC or to live in the most deprived area. In addition, the study also highlighted the importance of parental background, which appears to be poorer than in the control population. Social inequalities are particularly marked among the siblings of a person suffering from mental health disorder. Further studies are needed to better understand and enlarge these observational results.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Marketing authorization holders of vaccines typically need to report brand-specific vaccine effectiveness (VE) to the regulatory authorities as part of their regulatory obligations. COVIDRIVE (now id. DRIVE) is a European public–private partnership for respiratory pathogen surveillance and studies of brand-specific VE with long-term follow-up. We report the final VE results from a two-dose primary series AZD1222 (ChAdOx1 nCoV-19) vaccine schedule in ≥18-year-old individuals not receiving boosters. Patients (<span style="font-style:italic;">N</span> = 1,333) hospitalized with severe acute respiratory infection at 14 hospitals in Austria, Belgium, Italy, and Spain were included in the test-negative case–control study in 2021–2023. Absolute VE was calculated using generalized additive model (GAM), generalized estimating equation (GEE), and spline-based area under the curve (AUC, measuring VE up to 6 months after the last dose of AZD1222). Overall VE (against coronavirus disease 2019 [COVID-19] hospitalization) of an AZD1222 primary series was estimated as 65% using GEE (95% confidence interval [CI]: 52.9–74.5), and 69% using GAM (95% CI: 50.1–80.9) over the 22-month study period (comparator group: unvaccinated patients). The AUC of the spline-based VE estimate was 74.1% (95% CI: 60.0–88.3). VE against hospitalization in study participants who received their second AZD1222 dose 2 months or less before hospitalization was 86% using GEE (95% CI: 77.8–91.4), 93% using GAM (95% CI: 67.2–98.6). During this study period, where mainly the severe acute respiratory syndrome coronavirus 2 Omicron variant was circulating, a two-dose primary series AZD1222 vaccination conferred protection against COVID-19 hospitalization up to at least 6 months after the last dose.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Stillbirth rates have stalled or increased in some European countries during the last decade. We investigate to what extent time-trends and between-country differences in stillbirth rates are explained by the changing prevalence of advanced maternal age and teenage pregnancies or multiple births. We analysed data on stillbirths and live births by maternal age and multiplicity from 2010 to 2021 in 25 European countries using Kitagawa decomposition to separate rate differences into compositional and rate components. Rates significantly decreased in six countries, but increased in two. Changes in maternal age structure reduced national stillbirth rates by a maximum of 0.04 per 1000 in the Netherlands and increased rates by up to 0.85 in Cyprus. Changes in the prevalence of multiple births decreased rates by up to 0.19 in the Netherlands and increased rates by up to 0.01 across multiple countries. Maternal age differences explained between 0.11 of the below-European average stillbirth rate in Belgium and 0.13 of the above-average rate in Ireland. Excluding Cyprus, differences in multiple births explained between 0.05 of the below-average rate in Malta and 0.03 of the above-average rate in Ireland. For most countries, the increase in advanced-age pregnancies contributed to rising stillbirth rates over time, while reductions in multiples led to decreases in rates. However, large parts of the trends remain unexplained by those factors. By 2021, neither factor explained the differences between countries, due to increased compositional uniformity and declining stillbirth risk for advanced maternal age.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>A drug consumption monitoring revealed that Montenegro is one of the major consumers of antimicrobial drugs in Europe. The aim of this study is to obtain the first data on the knowledge, attitudes, and practices of the general population in Montenegro regarding antibiotics use. This cross-sectional study was designed according to the methodology of Eurobarometer survey on antimicrobial resistance, created by the European Commission. The standardized questionnaire was conducted in Podgorica, in October–November 2022. A total of 532 participants completed the questionnaire. More than a half of responders (60.9%) have received antibiotics within the last 12 months and among them 33.4% was missing a medical prescription, nor the antibiotic was administered by a medical practitioner. The rest of the responders mostly had some antibiotics left over from a previous course (13.0%), had taken it from a pharmacy (11.4%), or elsewhere without a prescription. The most frequent reasons for antimicrobial therapy were <strong>“</strong>cold” (22.5%), “sore throat” (21.0%), “cough” (19.4%), and “COVID-19” (coronavirus disease 2019) (17.9%). Throat swab, blood test, urine test, or other test that could identify the cause of the illness preceded antimicrobial therapy in 46.3% participants. Only one-half of the participants were convinced that antibiotics are ineffective in viral infection treatment. This study is the first report on public knowledge, attitudes and practices regarding antibiotics use and resistance in Montenegro and it highlights the need for the knowledge improvement among general population, better regulations for antibiotics procurement and a campaign regarding appropriate antibiotics use among youth.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Personalized medicine (PM) has the potential to revolutionize healthcare by delivering treatments tailored to individual patients based on their unique characteristics. However, ensuring its effective implementation presents complex challenges, particularly in terms of long-term sustainability. To address these challenges, the IC2PerMed project fosters collaboration between the European Union and China. This study, building on insights from the project, aims to identify key priorities for advancing PM, focusing on Clinical Studies and Funding Systems, with special attention to optimizing resource management, distribution, and protection to support sustainable development. A two-round Delphi survey was conducted to achieve consensus on common priorities among China and Europe related to Clinical Studies and Funding Systems. Consensus was measured using the Content Validity Index, requiring an agreement level of 80% or higher for item inclusion. The survey identified 20 key priorities in PM research, split evenly between research initiatives and funding mechanisms. Notable priorities include developing technology for deep phenotyping, standardizing methodological approaches, and fostering public–private collaborations. In funding, the emphasis was placed on involving patient voices in research design and establishing synergies among funders to support larger projects. The findings underscore the importance of structured collaboration between Europe and China in advancing personalised medicine. By addressing identified priorities in research and funding, this initiative can significantly enhance the efficacy of PM, ultimately improving healthcare outcomes globally. The study sets a precedent for future international partnerships aimed at fostering innovation in health sciences.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Human movement behaviour typically unfolds in 24-h cycles, with children being additionally influenced by their parents. Therefore, the aim of this study was to investigate the adherence of 3–10-year-old children to the World Health Organization’s (WHO) 24-h movement behaviour guidelines in relation to the behaviours of their mothers/fathers. Data from the Czech cross-sectional FAMIly Physical Activity, Sedentary behaviour and Sleep study included 381 families (with at least one child aged 3–10 years) from urban and rural areas across all three regions of Czechia. Twenty four-hour movement behaviour (sleep, sedentary behaviour, and physical activity) was monitored using ActiGraph accelerometers placed on the non-dominant wrists of children and their parents for seven consecutive days. Children's adherence to the WHO guidelines was analysed using logistic regression analysis. 25.9% of girls and 26.7% of boys simultaneously met all three 24-h movement behaviour guidelines (sleep + sedentary + physical activity), and 44.7% of girls and 46.1% of boys met any combination of two of the three guidelines, regardless of the children’s gender, weight, or calendar age. Maternal overweight/obesity significantly (<span style="font-style:italic;">P</span> = .05) decreased the odds of children achieving at least two of the three guidelines, while parental university education and maternal adherence to at least two of the three guidelines significantly (<span style="font-style:italic;">P</span> = .05) increased the odds of children complying with these guidelines. Parents, especially mothers, play an important role in influencing their children in meeting 24-h movement behaviour guidelines and in shaping a healthy lifestyle.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Maternal mortality remains a critical global health challenge, with 95% of deaths occurring in low-income countries. While progress was made from 2000 to 2015, regions such as Ethiopia continue to experience high maternal mortality rates, impeding the achievement of the sustainable development goal to reduce maternal deaths to 70 per 100 000 live births by 2030. This study evaluated the effectiveness of a Social and Behavior Change Communication (SBCC) intervention to improve maternal health behaviors. A community-randomized trial was conducted in three districts of Jimma Zone, rural Ethiopia, involving 5057 women. Sixteen primary healthcare units were randomly assigned to either the intervention (SBCC) or control (standard care) group. Data on socio-demographics, antenatal care (ANC) visits, maternal health knowledge, attitudes, and institutional childbirth rates were collected at baseline and endline. Statistical analyses included <span style="font-style:italic;">t</span>-tests, effect sizes, and generalized estimating equations. The intervention group demonstrated significant improvements. Maternal health knowledge increased from 5.68 to 7.70 (<span style="font-style:italic;">P</span> < .001, effect size = 0.34), attitudes improved from 37.49 to 39.73 (<span style="font-style:italic;">P</span> < .001, effect size = 0.29), and ANC visits rose from 3.27 to 4.21 (<span style="font-style:italic;">P</span> < .001, effect size = 0.50). Institutional childbirth rates increased from 0.52 to 0.71 (<span style="font-style:italic;">P</span> < .001, effect size = 0.18). ANC attendance (B = 0.082, <span style="font-style:italic;">P</span> = .002) and positive attitudes (B = 0.055, <span style="font-style:italic;">P</span> < .001) were significant predictors of institutional childbirth. The SBCC intervention significantly enhanced maternal health knowledge, attitudes, ANC utilization, and institutional childbirth rates, highlighting the value of community-based strategies in improving maternal health behaviors.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The discontinuation of futile therapy is increasingly discussed in Polish clinical practice. Given the need to ensure patient well-being, it is essential to consider whether all clinical options resulting from medical progress should be used for every patient and on what grounds decisions to limit therapy should be based. The aim of our study was to determine the opinions of Polish medical doctors on this topic. We anonymously surveyed physicians across various specialties. An analysis of the collected data was carried out using descriptive and analytical methods. A total of 323 physicians participated in the study; 93% of them were aware of the problem of futile therapy in adults, with intensivists being significantly more aware (<span style="font-style:italic;">P</span> = 0.002). Additionally, 95% of respondents supported the idea of discontinuing futile therapy, and over 68% used the therapy discontinuation protocol. Among the most common reasons for undertaking futile therapy, respondents cited fear of legal liability (93.5%), as well as fear of being accused of unethical behavior (62.2%) and fear before talking to the patient/patient’s family and their reactions (57.9%). Respondents also identified factors that would facilitate making decisions about limiting futile therapy, including precise qualification criteria for limiting therapy and education in this area (95.3%), the patient’s declaration of will (87.5%), and a clear legal act (81.3%). The majority of study participants supported the idea of limiting futile therapy, and this issue is well known among Polish physicians.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Breast cancer screening programmes can lead to better disease outcomes, but women from deprived backgrounds are less likely to participate and more likely to present with late-stage cancer. This study aimed to explore associations between deprivation and breast cancer screening outcomes in Ireland during 2009–2018. Data on all female breast cancer cases diagnosed in Ireland during 2009–2018 were extracted from the National Cancer Registry Ireland. Associations between area-level deprivation, using the Pobal Haase-Pratschke deprivation index, and detection of breast cancer through BreastCheck, Ireland’s breast screening programme, and stage of screen-detected breast cancer were explored. Unadjusted risk ratios (RRs) and 95% confidence intervals (CIs) were calculated. Among screening eligible women in Ireland in 2009–2018, there was no difference in risk of breast cancer detection through BreastCheck across deprivation quintiles (RR for most compared to least deprived group: 1.01, 95% CI: 0.96–1.06). In women with screen-detected breast cancer, the risk of late-stage cancer detection increased with deprivation in 2009–2013 (RR for most compared to least deprived group: 1.45, 95% CI: 1.10–1.93), but no association was observed between deprivation and cancer stage in 2014–2018. Notwithstanding its limitations, including the risk of confounding by uncontrolled variables, this study suggests screening eligible women in Ireland have had similar outcomes from breast cancer screening, regardless of deprivation level, since the national roll-out of BreastCheck. Associations between deprivation and screening outcomes should continue to be monitored to ensure Ireland’s breast cancer screening programme is helping to reduce health inequities.</span>
<span class="paragraphSection">The inaugural hybrid International Symposium, jointly organized by the EUPHA Chronic Disease Section and Santé Publique France, held on 26–27 June 2024, at Santé Publique France in Paris, marked a key shift in the dialogue from managing and preventing single chronic diseases to tackling the complexities of multimorbidity in both public health and primary care settings. Experts from across Europe explored multimorbidity’s prevention, surveillance, clinical management, and policy implications. This editorial aims to provide a synthesis of the symposium’s key messages on multimorbidity definitions and their potential impact on research, surveillance, and policy.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>The Community Acute Respiratory Infection (CARI) surveillance programme, established by Public Health Scotland (PHS) in November 2021, aims to monitor respiratory infections in communities, replacing prior schemes to ensure early detection of outbreaks and inform public health interventions. Positioned as a cornerstone of PHS’s national infectious respiratory diseases plan, CARI is pivotal for safeguarding public health. This study presents key findings from the 2022/23 CARI season and evaluates the programme’s performance during this period. CARI uses a network of sentinel general practitioner (GP) practices across Scotland to monitor patients with acute respiratory infection symptoms, employing multiplex polymerase chain reaction testing for 10 common pathogens. Results are linked to enhanced surveillance data, providing insights into infection trends during the season. The evaluation comprised an online GP survey and a quantitative assessment of programme performance. In the 2022/23 season, 180 GP practices participated in CARI, testing 15,823 samples. Swab positivity peaked in December 2022, driven by a large spike in influenza A activity. The evaluation showed that CARI is highly useful, with positive feedback on simplicity, flexibility, and acceptability. Representativeness varied across health boards and age groups. Despite occasional laboratory processing delays, data quality remained good, with timely reporting and stable participation. CARI reflected patterns in infections observed in secondary care in Scotland and Europe, providing valuable insights into disease patterns and impact. It also provided timely intelligence to key decision-makers, enabling prompt public health response. Changes for the 2023/24 season aim to further optimize the programme.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Conjugal ties may contribute to a convergence of health behaviours between migrants and natives, but the association between intermarriage and health outcomes remains understudied. We investigated mortality patterns among Finnish migrants in Sweden according to the spouse’s country of birth and compared these patterns with those observed in the native populations of both Sweden and Finland. Leveraging register data from Sweden and Finland, we identified all married Finnish migrants aged 40–64 and their spouses in Sweden in 1999 and corresponding reference groups in both countries. We used a combination of direct matching and inverse probability weighting to adjust for sociodemographic differences between the groups. We followed individuals for all-cause, alcohol-related, smoking-related, and cardiovascular disease (CVD) mortality during 2000–17. Accounting for sociodemographic characteristics, Finnish migrant men married to Swedish-born as opposed to Finnish-born spouses showed lower all-cause [incidence rate ratio (IRR) 0.94, 95% confidence interval (CI) 0.90–0.98], and CVD mortality (IRR 0.88, 95% CI 0.81–0.95), levels more akin to native Swedes. Migrant women with Swedish-born spouses instead had higher smoking-related mortality (IRR 1.41, 95% CI 1.24–1.61) than those married to Finnish-born spouses, mirroring the higher smoking-related mortality of native Swedish women. Individual-level regression analysis on migrants further indicated lower alcohol-related mortality for intermarried men, adjusted for duration of marriage (IRR 0.74, 95% CI 0.56–0.98). These findings suggest that intermarriage with a native spouse can facilitate the convergence of health behaviours and behaviour-related mortality between migrants and natives.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Despite significant therapeutic advances, lung cancer remains the biggest killer among cancers. In France, there is no national screening program against lung cancer. Thus, in this perspective, the Foch Hospital decided to implement a pilot and clinical low-dose CT screening program to evaluate the efficiency of such screening. The purpose of this study was to describe the prevalent findings of this low-dose CT screening program. Participants were recruited in the screening program through general practitioners (GPs), pharmacists, and specialists from June 2023 to June 2024. The inclusion criteria included male or female participants aged 50 to 80 years, current smokers or former smokers who had quit less than 15 years prior, with a smoking history of over 20 pack-years. Chest CT scans were conducted at Foch Hospital using a low-dose CT protocol based on volume mode with a multi-slice scanner (≥60 slices) without contrast injection. In total, 477 participants were recruited in the CT scan screening, 235 (49%) were males with a median age of 60 years [56–67] and 35 smoke pack-years [29–44] and 242 females (51%) with a median age of 60 years [55–60] and 30 smoke pack-years [25–40]. Eight participants showed positive nodules on CT scan, as a 1.7% rate. 66.7% of diagnosed cancers were in early stages (0-I). It is feasible to implement structured lung cancer screening using low-dose CT in a real-world setting among the general population. This approach successfully identifies most early-stage cancers that could be treated curatively.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Declining response proportions in health surveys may lead to increased non-response bias. Multiple reminders are often used to increase response proportions, and, thus, we aimed to determine if the use of reminders decreased the magnitude of non-response bias among web-mode invited in the Danish National Health Survey 2023. In the Danish National Health Survey 2023, a national random sample of 23 467 individuals (aged ≥16 years) with residence in Denmark were invited by a secure electronic mail service. Invited individuals received up to five inquiries: (i) web invitation, (ii) web reminder, (iii) paper invitation including a questionnaire and a prepaid return envelope, (iv) paper reminder, and (v) paper reminder including a questionnaire and a prepaid return envelope. The cumulative response proportions after first-, second-, third-, fourth-, and fifth inquiries were 19.1%, 28.9%, 37.2%, 39.3%, and 42.0%, respectively. In general, third, fourth, and fifth mailing respondents were more often men, at younger ages, with non-Western backgrounds, and unmarried compared to first mailing respondents. Furthermore, third, fourth, and fifth mailing respondents were in general found to have less favorable health behavior than first mailing respondents, but also a lower prevalence of fair or poor self-rated health and long-standing health problems. In conlusion, reminders are an effective way to increase the response proportion. Furthermore, the use of reminders was found to decrease the magnitude of non-response bias; however, the decrease was small due to the low number of individuals responding after fourth and fifth inquiries.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>During the COVID-19 outbreak the transdisciplinary research project CAVE (Community Engagement and Vulnerability Assessment in Epidemics) investigated perceptions and practicability of public health communication among stakeholders of care and social facilities in Austria. It aimed at finding accurate definitions of vulnerability in the context of epidemics and at developing operational models for engagement of vulnerable groups in co-creating epidemic response mechanisms. Transdisciplinary methods included semi-structured interviews, focus group discussions, and desk reviews as well as spatial analysis and composite indicator-based mapping methods. Informants and participants in the community engagement phase represented clients as well as middle and lower management levels of Austrian care and social facilities for older persons and persons with cognitive impairments, persons depending on mobile healthcare services, homeless people, and socially deprived communities. A narrow definition of vulnerability as well as missing strategies for participation and community engagement limited communication with stakeholders and the implementation of protective measures. An inclusive definition of vulnerability beyond medical and physical indicators should be employed to account for social, psychological, and emotional aspects contributing to a higher risk of being affected by epidemics. The CAVE model provides a multi-level definition of vulnerability that allows for participatory engagement in co-creating adapted crisis response measures. We suggest policymakers and health authorities to consider a broader definition of vulnerability and to commit to pro-active engagement with stakeholders representing these sectors. This requires the establishment and maintenance of communication structures as well as political recognition of civic participation in the creation and implementation of epidemic response measures.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Although the Republic of Moldova had good vaccination rates, anti-vax messages have recently begun to spread, eroding the population’s confidence. Vaccination coverage against measles, mumps, and rubella at the target age of 12 months decreased from 95% in 2008 to 83% in 2021. The recent measles outbreak in Romania and three confirmed cases in Moldova, combined with the refugee crisis, have highlighted the importance of vaccination and sparked online conversations on this subject. A mixed-methods study was conducted, involving social listening activities on immunization using the <span style="font-style:italic;">Talkwalker</span> software and qualitative analysis of the identified narratives. Out of 450 identified comments, 30 were selected for further analysis. Over 5 months, a total of 865 results were obtained, with an engagement rate of 6300. The peak in results occurred between 11 and 18 December, driven by the recent measles outbreak in Romania, which saw several confirmed cases and one death, as well as the first cases of measles in Moldova after 3 years. However, no significant increase in the engagement rate was recorded. Comments on immunization tended to reflect distrust in authorities and doctors, political and ideological views, and a lack of knowledge about the risks of vaccine-preventable diseases. The analysed conversations are assessed as having a low risk of spreading, though some employ techniques to influence or manipulate behaviours. The topic of vaccination is used to promote political ideologies through messages issued by the mass media. The information vacuum must be filled with messages designed to produce attitude change regarding vaccination.</span>
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