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EUROPEAN JOURNAL OF Volume 28 Supplement 4

SUPPLEMENT 11TH EUROPEAN PUBLIC HEALTH CONFERENCE Winds of change: towards new ways of improving public health in Europe Ljubljana, Slovenia 28 November –1 December 2018 ABSTRACT SUPPLEMENT Guest editors: Ivan Erzen,Tit Albreht and Dineke Zeegers Paget

CONTENTS 1. Introduction 2. Plenary Sessions 3. Parallel Programme 4. Poster Walks 5. Poster Displays

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PUBLIC HEALTH

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European Journal of Public Health, Vol. 28, Supplement 4, 2018

1. INTRODUCTION Workshops Oral presentations (8-minute presentation) Pitch presentations (5-minute presentation) Moderated poster walks (3-minute presentation) Poster displays (throughout the programme)

average score of 4.570 or higher were accepted average score of 5.000 or higher were accepted average score of 4.500 or higher were accepted average score of 4.200 or higher were accepted average score of 3.500 or higher were accepted

Following these decisions, abstracts were grouped in sessions, sessions in tracks and tracks were linked to the contents of the plenary programme. The programme for Ljubljana 2018 is organised in 16 thematic tracks, that mix workshops, oral and pitch sessions. The 16 thematic tracks are: A. Winds of change and innovation B. European and global health issues C. E-Health technology, communication / Elderly health D. Health promotion, lifestyles and behaviour E. Environment and health / Obesity and nutrition F. Health systems and health care G. Health services research H. Health workforce / Health at work I. Infectious diseases, vaccination / Global health K. Chronic diseases L. Migrant, LGBT and minority health M. Mental health N. Maternal, child and adolescent health

International Scientific Committee, scoring for Ljubljana 2018 – – – – – – – – – – – – – – – – – – – – – – – – – – –

Prof Ro´za A´dańy, Hungary Dr Charles Agyemang, Netherlands Prof Tit Albreht, Slovenia (chair) Prof Kristina Alexanderson, Sweden Prof Arja Aro, Denmark Dr Marleen Bekker, Netherlands Prof Johan Bilsen, Belgium Dr Christopher Birt, United Kingdom Prof Stefania Boccia, Italy Dr Henrik Bøggild, Denmark Mr Yann Bourgueil, France Dr Richard Bra¨nstro¨m, Sweden Prof Silvio Brusaferro, Italy Prof Ute Bu¨ltmann, Netherlands Dr Genc Burazeri, Albania Dr Andrea Buron Pust, Spain Ms Tatjana Buzeti, Slovenia Dr John M Cachia, Malta Prof Nesrin Cilingiroglu, Turkey Dr Thomas Classen, Germany Mr Gary Clough, United Kingdom Dr Judith de Jong, Netherlands Dr Chiara de Waure, Italy Mrs Annabel Desgre´s du Louˆ, France Prof Thomas Dorner, Austria Mr Gilles Dussault, Portugal Dr Ivan Erzen, Slovenia

– – – – – – – – – – – – – – – – – – – – – – – – – – –

Prof Carlo Favaretti, Italy Dr Silvia Florescu, Romania Prof Anders Foldspang, Denmark Mr Marthein Gaasbeek Janzen, Netherlands Prof Maria Ganczak, Poland Dr Olivier Grimaud, France Prof Peter Groenewegen, Netherlands Dr Giuseppe Grosso, Italy Dr Gunnel Hensing, Sweden Dr Marija Jakubauskiene, Lithuania Ms Danielle Jansen, Netherlands Prof Marija Jevtic, Serbia Prof Ramune Kalediene, Lithuania Prof Irena Klavs, Slovenia Prof Ilona Koupil, Sweden Dr Ellen Kuhlmann, Germany Prof Giuseppe La Torre, Italy Dr Tek-Ang Lim, France Prof Jutta Lindert, Germany Dr Anne Lounamaa, Finland Dr Els Maeckelberghe, Netherlands Julian Mamo, Malta Dr Odile Mekel, Germany Prof Anjum Memon, United Kingdom Mrs Monika Mensing, Germany Dr Enni Mertanen, Finland Dr Gabriele Messina, Italy

– – – – – – – – – – – – – – – – – – – – – – – – – – –

Dr Daniele Mipatrini, Italy Dr Iveta Nagyova, Slovakia Prof Anna Odone, Italy Dr Elena Petelos, Greece Dr Brigitte Piso, Austria Klaus D. Pluemer, Germany Mr Mircha Poldrugovac, Slovenia Prof Ileana Prejbeanu, Romania Prof Ossi Rahkonen, Finland Dr Natalie Rangelov, Switzerland Dr Sofia Ribeiro, Portugal Ms Nicole Rosenko¨tter, Germany Dr Maria Rosvall, Sweden Prof Luı´s Saboga-Nunes, Portugal Prof Anna Sarkadi, Sweden Dr Peter Schro¨der-Ba¨ck, Netherlands Dr Diana Sonntag, Germany Prof Danijela Stimac, Croatia Dr Christiane Stock, Denmark Mrs Pernille Tanggaard, Denmark Dr Aura Timen, Netherlands Dr Peter Van Den Hazel, Netherlands Prof Arnoud Verhoeff, Netherlands Dr Arpana Verma, United Kingdom Prof Paolo Villari, Italy Mrs Anne Vuillemin, France Mr Denis Zmirou, France


We are delighted to introduce this abstract supplement to the European Journal of Public Health which contains the abstracts of papers presented at the 11th European Public Health (EPH) Conference, held 28 November – 1 December 2018 in Ljubljana, Slovenia. This supplement includes abstracts for the main part of the conference, including presentations (plenary sessions, oral presentations, workshops, pitch presentations, moderated poster walks and poster displays). For Ljubljana 2018, we received 1,473 abstracts of which a record number of 107 workshop abstracts. Abstracts were received from 69 countries. All abstracts were scored by the members of the International Scientific Committee (ISC) of the EPH Conference. The ISC of the Ljubljana 2018 conference consisted of 81 experts from 25 countries and was chaired by Prof Tit Albreht. We are extremely grateful to all ISC members for the hard work this involved. The members of the ISC scoring in 2018 are listed below. On average, each abstract was scored by 4.5 reviewers, each workshop by 6.9. The average score of the abstracts was 4.25 (last year 4.31). The highest score was 6.400, the lowest 1.500. The average score of workshops was 4.945 (last year 4.691). The highest score was 6.429, the lowest 2.143. The highest scoring abstracts are accepted for the EPH Conference. The rejection rate for the abstracts was 15.67% and for workshops, the rejection rate was 20.58%. The EPH Conference Executive Board met on 18 June 2017 to decide on cut-off points for workshops, oral presentations, pitch presentations and poster presentations, resulting in an excellent selection of workshops and presentations, as showcased in this abstract supplement.

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Impact assessment / Health literacy Public health monitoring, reporting and screening Social security, work and health

interesting, and even more so the actual presentations, which promise to be of high quality yet again. Looking forward to seeing you in Ljubljana,

The moderated poster walks have their own sessions. And the poster displays are on display throughout the conference. As always, we greatly enjoyed reading the submissions, and learned much from them. We hope that you will find this volume equally

Dr Ivan Erzen, Chair of the 2018 European Public Health Conference Prof Tit Albreht, Chair of the International Scientific Committee Dr Dineke Zeegers Paget, Director of the EPH Conference Office


Disclaimer This supplement includes the abstracts as submitted and corrected by the authors. All abstracts have been reviewed by the International Scientific Committee. EUPHA is not responsible for any errors.

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11th European Public Health Conference: Plenary Sessions

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2. PLENARY SESSIONS PLENARY 1 should define responses to the digital world of today and tomorrow. Objectives of the plenary session

Organised by: EuroHealthNet Moderator: Mojca Gabrijelcic, NIJZ Slovenia and vice-president EuroHealthNet

To raise awareness of the positive and negative impacts of digital technologies on children and young peoples’ health and well-being, across the social gradient. To discuss with policy makers and experts possible ways forward and to gather input from panelists on the role of public health, health promotion and research

Digital technologies have profoundly changed childhood and adolescence (http://www.thelancet.com/pdfs/journals/lanchi/ PIIS2352-4642(18)30002-6.pdf). Children and youth born since 1995 have grown up with internet, as an ever present feature in their lives. Online access for many children is becoming more personal, more private and less supervised. Digital media and new technologies are changing children and youths’ lives and providing them with many new opportunities, but they can also pose challenges to their health and well-being. Internet serves as a basis for digital media and new technologies to offer remarkable opportunities to engage and empower young people to drive change, and most children who are online view it as a positive experience. Digital technologies can also bring opportunities for learning, education, and employment. In terms of health, e-mental health, for example, is a potential tool for prevention of mental health problems and for mental health promotion of children and adolescents. It can provide an anonymous, easily accessible forum for those hard to engage and it creates a platform for a forum of experiences and for prompt online intervention. But there is also concern about the dangers of excessive on screen immersion. Time spent behind screens is contributing to more sedentary lifestyles and to growing levels of overweight and obesity. There are concerns about cyberbullying, child abuse, anxiety, gaming, and gambling. In addition, it is more difficult to put in place protections to keep youth from purchasing harmful products in the on-line world than in the real world. Internet is also becoming increasingly commercialized, since the majority of digital media rely on business models centered on advertising. And online presence exposes children and youth to digital marketing. Current knowledge and public health approaches are not adequately developed to address the challenges, benefits and impacts of digital technology on children and young people’s health. There is an absence of effective guidance and regulations of digital media in many countries. New ways of improving public health in Europe

Structure of the session Welcome message and briefing (2 min) Short key notes, panelists and young people’s reflections Interaction with the audience with the online mentimeter (www.mentimeter.com) and live voting (tbd) Key notes Youth exposure to digital marketing and media (15 minutes) Jeff Chester, Executive Director at the Center for Digital Democracy, Washington, USA Life in ‘likes’ - on the social media experience of children aged 8–12 years (10 minutes) Anne Longfield, Children’s Commissioner for England, United Kingdom (TBC) Digital marketing, lifestyle determinants and health- alcohol, tobacco, nutrition, physical activity, gaming, gambling (10 minutes) Dr Joaõ Breda, WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office), Moscow, Russian Federation Panelists Improving mental health and wellbeing of young people by making better use of the internet, social media and mobile technologies (5 min) Jan Peloza, No Excuse, Slovenia Legal right to protect children from all kinds of marketing (5 min)Prof. Amandine Garde, Liverpool Law School, University of Liverpool, United Kingdom

PLENARY 2 Sustainable Development Goals - how can we address them through public health action? Organised by: WHO Regional Office for Europe Moderator: Anna Cichowska Myrup, Programme Manager Public Health Services, WHO Regional Office for Europe

The Roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy for health and well-being sets out five interdependent strategic directions: 1. Governance: advancing governance and leadership for health and well-being; 2. Equity and social justice: leaving no one behind; 3. Partnerships for health: preventing disease and addressing health determinants by promoting multi- and intersectoral policies throughout the life-course; 4. Local action: establishing healthy places, settings and resilient communities; and

5. Universal Health Coverage: strengthening health systems for universal health coverage. This session takes place in the year 2030 and looks back at what has happened since 2018 to implement the SDGs successfully (using the 5 strategic directions as a framework). What were the key decisions that were taken by policy-makers and which partnerships made it happen? What ways of working did we adopt and how did we manage the necessary changes? Three professionals (representing an international health organization, a city council and a research institute) reflect on the year 2018 and how their work, in partnership with other sectors, has shaped the future we are now in. The session will start with a welcome and framing by a moderator. Then presentations will follow: brief introduction to the European SDGs implementation roadmap, and three stories reflecting the actions in the year 2018 that shaped our future. A reflection from the key note listener is also planned.


The realities of a digital world, what it means for young people’s health

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Speakers: Bettina Menne, Coordinator Sustainable Development and Health, WHO Regional Office for Europe Charlotte Marchandise, Elected member of the City Council of Rennes, France

Nancy Fullman, Scientific Advisor at the Institute for Health Metrics and Evaluation (IHME), Seattle, USA Hans Kluge, Director Health Systems and Public Health, WHO Regional Office for Europe

PLENARY 3 Public health resources - core capacities to address the threat of communicable diseases

Robust public health capacities and capabilities are essential elements in prevention and control of communicable diseases. The European Centre for Disease Prevention and Control (ECDC) assists the EU Member States to ‘have sufficient numbers of trained specialists [. . .], and to have a capability to define health measures to control disease outbreaks’. ECDC also supports the implementation of Decision No. 1082/2013/ EU, by providing technical advice and expert guidance aiming at strengthening public health emergency preparedness (PHEP) across the EU. The logic model for PHEP makes a distinction between capacities and capabilities. Capacities represent the resources – infrastructure, policies and procedures, knowledgeable and trained personnel – that a public health system has to draw upon. Capacities necessarily reflect variations in Member States’ government and private-sector organisations. Capabilities, on the other hand, describe what Member States are expected to achieve during an emergency, and can be described in a consistent way for all countries. Capacities and capabilities are both important for an effective emergency response; however, depending on the context, different kinds of capacities may be needed to achieve the required capabilities. (See http://bit.ly/2MIbCIu) In the period 2014 – 2017, ECDC conducted a number of case studies to review public health preparedness in EU/EEA countries. Cases studies were built using a health threat (e.g. MERS-CoV, polio, Ebola and tick borne diseases) that could

How to ensure the development of competent and effective public health workforce able to address the issues related to emergency preparedness and response in times of new and evolving paradigms?

PLENARY 4 Public’s awareness of public health challenges: how to get our public health messages heard? Organised by: European Commission and EUPHA Chairs: Isabel de la Mata, DG Sante, European Commission and Natasha Azzopardi Muscat, EUPHA

In a time of internet-research and twitter-truths, it becomes more and more important for the whole public health community to learn how to engage the public to support, participate in and make healthy choices. How can we raise the public’s awareness on public health challenges? How do we increase the impact of the messages we want to convey? How can and should we communicate so we have a larger impact of what we are trying to convey? It is important that scientists – in this case public health scientists – learn how to communicate and work with politicians, journalists and citizens to get the right message across. In this plenary session, we are looking at this from different angles. After an introduction to health communication and persuasion, a panel consisting of two scientists, a journalist and a policy-translator will provide insight on how they have implemented ideas to raise the impact of public health messages and what they needed to implement these ideas. The two chairs of the session will then summarize the lessons learned in this session.

How to get our messages heard? - Aljosˇa Bagola, Pristop, Slovenia If the end goal of creative endeavors in art is catharsis, then the end goal of creative endeavors in communication is effectiveness. Modern technology brings new possibilities and challenges for effective communication. With social media presence in every household and, through handheld devices, practically every pocket, an effective communication can reach very far. Even though messages delivered through social media are short and may seem to require relatively little preparation, they are, in reality, derived from a script that is extensive and well thought-out. During the presentation, strategies and techniques employed in social media advertising and possible implications for public health interventions will be discussed. Panel: Carlo Signorelli, Italian Society of Hygiene, Preventive Medicine and Public Health, on the increasing threats of vaccine hesitancy in Italy Benedicte Carlsen, Department of Health Promotion and Development Faculty of Psychology at the University of Bergen, Norway Christina Berndt, Health editor, Suddeutsche Zeitung, Germany Jan Eyckmans, Head of Communication, Federal Ministry of Health, Belgium


Organised by: ASPHER, ECDC, EHMA Moderators: Katarzyna Czabanowska, ASPHER, and Karl Ekdahl, ECDC

cause infectious disease outbreak and review focused, among other elements, on interoperability of plans between sectors and cross border aspect. In response to the Ebola outbreak, the Centre also visited three Member States with the aim to review their preparedness to respond to highly contagious haemorrhagic diseases. All assessed countries demonstrated to have a cadre of highly motivated and well-performing experts, even in settings where salaries have been severely cut. With increasing urgency, developing and maintaining a welltrained and competent public health workforce, as an asset for the future of the public health, is becoming a clear priority. The trends affecting public health workforce demographics including aspects linked to recruitment, retention and ageing of the workforce - call for policy attention to ensure that this particular public health asset does not get depleted. Other trends and new paradigms in public health, like big data and molecular diagnostics, call for a new generation of public health specialists with competencies relevant to the traditional as well as new facets of communicable disease prevention and control. The aim of this one-hour session is to stir the debate around the essential public health capacities and capabilities needed to effectively address prevention and control of communicable diseases in the European context. The session will start with a keynote speaker, followed by a lively expert panel discussion reflecting different perspectives: policy, education and training, practice perspective, including an example of good practice. Key question addressed:

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11th European Public Health Conference: Parallel Programme

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3. PARALLEL PROGRAMME 1.A. Workshop: Key factors for effective school-based health promotion: lessons learned from Jerusalem communities Practical training in designing and implementation of school-based interventions.

General: Adoption of positive health behaviors is a key factor in promoting health and preventing chronic disease. Schools are an ideal setting for implementation of health promoting interventions in children and young adults, as they provide suitable access, structure, and mechanisms as well as a professional faculty trained in education. Evidence suggests that many school-based interventions (SBI) focus mainly on health education. These programs provide the students with information to improve their knowledge and occasionally life skills, factors that are necessary but, in most cases, not sufficient to impact behavior. Effective and sustainable SBIs should be designed and implemented based on school needs assessment and employ a holistic approach with objectives and activities at all socio-ecological levels: school policy, environment, classroom education, life skills and community involvement. Additional key components include intensive in-service teacher training, appropriate cultural adaptation, and integration of process and outcomes evaluation. In many communities and cultures the implementation of health promotion within the school setting is challenging. Therefore, a comprehensive approach for the implementation of HP programs should serve as the basis for such processes. Objectives: The purpose of the proposed workshop is to provide participants with a comprehensive approach, including skills and practical step for implementation of effective, sustainable SBI.Skills of the organizing center: The center has 6 years of successful experience in implementation of school-based health promotion interventions with outcomes data in varied cultures, in partnership with the Israeli Ministry of Education (MoE). The workshop chairperson has extensive school-based health promotion experience in Israel and other countries. Format of workshop: The workshop will include 5 presentations: An introduction including the rationale and main supporting factors for success of school-based interventions (as described above) with a focus on step by step process in planning and evaluating SBI; a depiction of teacher training as a key factor to the successful SBIs and three case studies presenting three diverse Israeli school communities and age groups. The three cases include a program trial of SBI in Palestinian primary school girls in East Jerusalem, a SBI with high school girls in an Ultra-orthodox Jerusalem community, and unique programs implemented in special education schools. Each presentation will describe the process of planning and implementation of a needs-based intervention including process evaluation of the factors that worked and didn’t work in that setting. A short Q &A session will follow the presentation. The workshop will also include a small group-based practical session, where participants will design a needs assessment and set needs-based intervention goals, objectives, and activities with a focus on cultural adaption. Key messages: A comprehensive approach for effective, sustainable schoolbased health promotion with 3 diverse case studies

Teacher training in health promotion as a key component to the success of school based interventions Osnat Keidar D Zwas The Linda Joy Pollin Cardiovascular Wellness Center for Women, Jerusalem, Israel Contact: [email protected]

Most teachers report lacking the knowledge and skills to deliver health promotion (HP) topics in school. HP research stresses the importance of teacher HP training (THPT) for successful HP programs. In Israel, while most teachers are not trained in HP during their graduate studies, HP is quickly becoming an integral part of the nation’s school system. To close this gap, the Israeli Ministry of Education (MoE) organizes in-service training, which teachers join on a voluntary basis. The Linda Joy Pollin Center for Women’s Cardiovascular Health integrates THPT in all of its schoolbased programs. All THPTs are in partnership with the MoE, integrating content and skills specific to the school, teachers, and students. The proposed presentation will describe the principle of THPT integration in school HP programs and showcase two THPTs in diverse school settings, highlighting evaluation methods and its impact on teachers’ HP knowledge and skills. THPTs targeted all school faculty, so that most teachers were trained at the initiation of the intervention. Training was conducted by certified teachers and included the topics of healthy nutrition and physical activity, methods for integrating these topics into the class and school system, conducting needs assessment, composing a school HP program based on findings, and program evaluation. Following the THPT in an Ultra-orthodox Jewish high school, teachers reported that the course afforded them the following healthy living-related gains: 86% gained knowledge, 88% gained motivation, and 90% gained skills. Following the THPT for the faculty of 7 primary schools in East Jerusalem, there was a net DID of 45.6% increase in the number of teachers who reported engaging in school HP in comparison to control schools. Teachers’ engagement in HP was found to be a mediator in student adoption of healthy behaviors. Conclusions: THPT is key element to the success of school HP interventions. Health promotion intervention in Palestinian primary schools: A randomized control trial Maha Nubani Huseini D Zwas The Linda Joy Pollin Cardiovascular Wellness Center for Women, Jerusalem, Israel Contact: [email protected]

Background: Most Palestinian children have poor eating behaviors (EB), lack physical activity (PA) and are significantly more overweight than their counterparts. The presentation describes the development, application, and evaluation of school-based intervention in Palestinian primary schools designed to


Organised by: The Linda Joy Pollin Cardiovascular Wellness Center for Women, Hadassah Medical Center, Jerusalem, Israel Chairpersons: Osnat Keidar, Israel, Elisheva Leiter, Israel Contact: [email protected]


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School-based Public Health Intervention in the Ultraorthodox Jewish Population Elisheva Leiter D Zwas The Linda Joy Pollin Cardiovascular Wellness Center for Women, Jerusalem, Israel Contact: [email protected]

Background: Ultra-Orthodox Jewish (UOJ) women are low SES, culturally insular minority subsect in Israel. They report engaging less in health behaviors (HB) and higher rates of diabetes and obesity. Poverty, multiparity, limited media exposure, and underrepresentation in research likely impact their health. Health promotion interventions (HPI) in this population are unknown. This presentation describes the design, process evaluation, and outcomes of school-based HPI with UOJ female high school teachers. Methods: Utilizing bottom-up approach and the socio-ecological model, the HPI targeted teachers from three girls’ high schools. Due to cultural sensitivities, the intervention targeted teachers’ personal HBs initially, followed by HP. The needs assessment informed the HPI design, including HP training, health newsletters, health promotion posters and a walking program with pedometers. All components were culturally sensitized and pre-approved by school staff. Process evaluations indicated moderate to high participation rates (45-83%). 246 teachers completed questionnaires before and 6 months post intervention, including HB, knowledge and self-efficacy.

Results: Post HPI, teachers reported increased whole grain (p 65 years seems to show that age-related recommendation prevails over pathology-related recommendation among dialysis patients. Internet appears not to contribute to increase knowledge and awareness of risks. For all these reasons, investing more in the informative campaigns for chronic patients and involving specialists in attentive recommendation during vaccination campaign, could be worthy. Key messages: Vaccination coverage in dialysis patients is not routinely monitored and is lower than recommended. Age-related recommendation prevails over pathologyrelated recommendation:it’s necessary to invest more in the informative campaigns for chronic patients.

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Is mandatory vaccination influencing maternal decision to vaccinate children in Slovenia? Mario Fafangel M Fafangel, V Ucˇakar, A Kraigher National Institute of Public Health, Ljubljana, Slovenia Contact: [email protected]

Background: High parental confidence is important to maintain vaccination coverage needed for community-level protection against vaccine preventable diseases. In Slovenia 9 childhood vaccinations are mandatory. We quantified vaccine confidence and hesitancy among mothers in Slovenia and how non-mandatory vaccinations would affect their behavior, to advise on maintaining and improving vaccination coverage. Methods: In 2016 we conducted the first nationwide cross-sectional survey among mothers of children 150 times) compared to heterosexuals. Gay men also had an elevated risk of depression, suicidality, and violent assaults compared to heterosexuals. Bisexual men had 16 times higher risk of being HIV-positive than heterosexual men. Number of psychosocial syndemic conditions was significantly associated with HIV infection among gay men (adjusted odd ratio [AOR] = 1.67; 95% confidence interval [95% CI]: 1.18, 2.36), but not among bisexual and heterosexual men (AOR = 0.51; 95% CI: 0.07, 3.59; AOR = 1.92; 95% CI: 0.96, 3.84). Among gay men, the association between co-occurring sydemic conditions and odds of HIV infection was synergistic (i.e., more than additive). Conclusions: This study confirms emerging evidence of the syndemic health threats affecting sexual minority men, finds stronger evidence for syndemics among gay compared to bisexual men, and suggests the need for HIV-prevention interventions that comprehensively address the co-occurring, and synergistically perpetuating, disparities affecting this population. Key messages: Gay men are at increased risk of both HIV and a number of other psychosocial health conditions. There is a strong need for HIV-prevention interventions that comprehensively address the co-occurring disparities affecting this population.



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3.M. Depression and suicide A history of depression and the risk of incident dementia Kaarina Korhonen K Korhonen1, T Leinonen2, L Tarkiainen1, P Martikainen1 University of Helsinki, Helsinki, Finland 2 Finnish Institute of Occupational Health, Helsinki, Finland Contact: [email protected]

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Multiplicative effect of mild depressive symptoms with diabetes on other chronic conditions Vale´ry Bocquet V Bocquet1, M Ruiz-Castell2, TT Makovski2, G Aguayo2 1 Competence Centre in Methodology and Statistics, Strassen, Luxembourg 2 Epidemiology and Public Health Research Unit, Department of Population Health, Strassen, Luxembourg Contact: [email protected]

Background: Depression and diabetes are each important public health issues. The combination of both has already been studied but their association with other chronic conditions is less investigated. The present study aims to measure the association between these two conditions to estimate other chronic diseases. Methods: In the framework of the European Health Examination Survey, a 2013-2015 cross-sectional study (n = 1508) was led from an adult random sample. During two visits, lifestyle and health data were collected. Diabetes was defined with an HbA1c6.5%, a self-reported physician diagnosis and/or use of glucose lowering medications. Depressive symptoms were defined as a score of 5 on the Patient Health Questionnaire (PHQ-9). An individual 4-item status describing the presence/ absence of depressive symptoms and/or diabetes was created. Potentially associated additional chronic disease(s) was searched from the list of 16 diagnoses, diagnosed by a medical doctor after exclusion of diabetes, depression and anxiety. The impact of the association between depressive symptoms and

The role of poor mental health in explaining postseparation excess mortality Niina Metsa¨-Simola N Metsa¨-Simola University of Helsinki, Helsinki, Finland Contact: [email protected]

Background: Separation predicts an elevated mortality risk, most pronounced in external and alcohol-related causes. This may partly result from poor mental health increasing the probability of separation, or be mediated by separation-related changes in mental health. Methods: Using register-data, we followed 213,224 Finns aged 25 to 64 and married at December 31, 1994 for psychiatric morbidity (psychotropic drug purchases / hospital admissions with psychiatric diagnosis), separation and mortality from 1995 to 2012. We modelled hazard ratios (HR) of post-separation allcause and cause-specific mortality using Cox regression, and examined the effect of adjustment for time-varying psychiatric morbidity. Results: Compared to continuously married men, among separated men the age-adjusted HR for all-cause mortality was 2.45 (95% CI 2.33-2.57). Adjustment for pre-separation psychiatric morbidity attenuated the HR to 2.35 (2.26-2.47), and further adjustment for psychiatric morbidity during the separation process to 2.12 (2.01-2.23). The corresponding HRs for women were 1.68 (1.56-1.82), 1.65(1.53-1.78) and 1.50 (1.391.62), respectively. Adjustment for post-separation psychiatric morbidity had no additional effect. Age-adjusted HRs for external and alcohol-related mortality were much larger, but the attenuating effect of psychiatric morbidity was similar as for all-cause mortality. Mortality differences due to other causes of death were less pronounced, but the attenuating effect of psychiatric morbidity was larger. All results are preliminary. Conclusions: Psychiatric morbidity attenuates 20 to 30% of post-separation excess all-cause mortality and mortality due to external and


Background: The contribution of depression to the risk of progressive dementia remains unclear. Apart from being a risk factor, depression may also be a prodromal symptom of dementia, and thus the possibility of reverse causation needs to be considered. To disentangle a history of depression from prodromal depressive symptoms of dementia, we measured depression over 15 years before the follow-up for dementia. Methods: We followed up a population-representative sample of Finnish men and women (n = 255 315) for incident dementia at the age of 70+ in 2000–2012 from hospital discharge and medication reimbursement registers. Depression 15–29 years before the baseline was identified from hospital discharge registers of 1970–1996. Hazard ratios were estimated using Cox regression models, adjusting for education, marital status, age, gender, calendar year and region of residence. Results: 15.7% (n = 41,744) developed dementia during the follow-up. A history of hospital-treated depression was identified in 3,431 individuals, who had a 31% higher hazard of dementia (95% CI 1.16–1.47) compared to those with no history of depression. The excess risk of dementia of the depressed was not related to education or marital status. Conclusions: The results support the hypothesis that depression is a risk factor for dementia rather than merely a prodromal symptom of dementia. Key messages: Depression may increase the risk of progressive dementia. Mental health problems in midlife may adversely affect cognitive ageing.

diabetes to estimate chronic diseases used as outcome was measured by logistic regressions. Results: In this study, 21.6% had at least mild depressive symptoms, 6.0% had diabetes, 1.7% had combined depressive symptoms and diabetes, and 58.8% had other comorbidities. There were no association between diabetes without depressive symptoms and other chronic conditions (OR = 1.95), but a significant association was observed between depressive symptoms without diabetes and other chronic conditions (OR = 2.07) and between diabetes with depressive symptoms and other chronic conditions (OR = 5.20). Conclusions: This study shows that even few depressive symptoms on individuals combined with diabetes have a significant impact on the presence of other chronic conditions. Moreover, after numerous adjustments there is still a multiplicative effect (+29%) of these two conditions on occurrence of other chronic conditions. Key messages: Even few depressive symptoms combined with diabetes have a significant impact on the presence of other chronic conditions. The odds-ratio to have other chronic conditions is much higher for individuals with diabetes and mild depressive symptoms than for individuals with only diabetes or with only mild depressive symptoms.


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alcohol-related causes, and up to 50% of excess mortality attributable to other causes of death. This attenuation is mainly due to psychiatric morbidity during the separation process. Support measures are needed for individuals going through separation to avoid psychiatric morbidity and associated deaths. Key messages: Psychiatric morbidity partly explains mortality differences between separated and continuously married men and women, mainly due to incident psychiatric morbidity during the process of separation. Support measures are needed to prevent separation leading into psychiatric morbidity and to reduce associated excess mortality.

Mukil Menon G Netuveli1, P Watts2, M Menon3, T Van Bortell1 1 Institute of Health and Human Development, UEL, London, UK 2 School of Health Sports and Biosciences, UEL, London, UK 3 East Anglia Deanery, Norwych, UK Contact: [email protected]

Backgound: Frailty and depression in older ages have a bidirectional relationship sharing symptoms and characteristics. Most of the evidence for this has come from cross sectional studies. In this paper we use birth cohort data to study the relationship between depression and frailty. Methods: Data from National Child Development Study were used. Primary outcome measure was a binary variable for frailty based on a 20-item inventory of physical health related conditions at age 50 years. Main exposure was depression (based on Malaise score >7) measured at 23, 33 and 42 years used singly as well as an accumulation score. We used multiple logistic regression models. We addressed missing data problem through Bayesian multiple imputation. Results: There were 9790 participants of which 6522 had complete information. Modelled separately, Depression at 23yr, 33yr and 42yr was significantly associated with frailty (OR 2.81, 95%CI 2.24, 3.53; OR 3.67, 95%CI 2.79, 4.82; OR 3.07, 95%CI 2.56, 3.68 respectively). With accumulation score a gradual increase in the likelihood of frailty with each unit increase (once: OR 3.12, 95%CI 2.60, 3.74; twice: OR 3.99, 95%CI 2.97, 5.37; thrice: OR 4.94, 95%CI 2.95, 8.26). Fitting separate models for men and women showed that the odds ratios for men were greater than that for women. All the covariates in the model had significant coefficients in all analyses except for father’s social class at birth. It was non-significant in all analyses with cumulative scores and in subgroup analyses in males. The analyses of imputed datasets also revealed the significant predictive power of depression in earlier life. However, the effect sizes were attenuated and in the case of accumulation score the gradient was reversed. Conclusions: Depression earlier in life predicted frailty at later ages. Public health significance of this lies in the potential to reduce physical burden of disease in old age by paying attention to mental health at younger ages.

Socio-economic inequalities in suicide across European countries: causation or confounding? Vincent Lorant V Lorant1, J Perelman2, D Kapadia3, J Mackenbach4 1 Universite´ catholique de Louvain, Bruxelles, Belgium 2 Escola Nacional de Sau´de Pu´blica, Lisbon, Portugal 3 University of Manchester, Manchester, UK 4 Erasmus MC, Rotterdam, Netherlands Contact: [email protected]

Background: A recent international comparison study showed that socioeconomic inequalities in suicide did not decrease in the last decade. Two causal mechanisms have received varying degrees of support in the literature: low socio-economic status may directly increase the risk of suicide (hereafter ‘‘causation’’) or low-socio-economic status and suicide may share confounders (hereafter, ‘‘confounding’’). This paper aims to assess whether educational inequalities in suicide (EIS) are due to causation or confounding. Methods: The DEMETRIQ study collected and harmonized registerbased data on mortality follow-up of population censuses from fifteen Northern, Southern, Western, and Eastern European populations. More than 89,554 suicides were registered among 300 million person-years. Four tests of causation vs confounding were implemented. Test 1: a decreasing (increasing) EIS over the lifecycle supports confounding (causation). Test 2: greater (lower) EIS in males than in females supports confounding (causation). Test 3: At the country-level, EIS is more related to the income inequality index or poverty (causation) or to the share of suicide among the younger age group (confounding). Test 4 uses instrumental variable approach that exploits changes in the legislation of compulsory educational age. Results: For test 1, we found that educational inequalities in suicide decreases over the lifecycle; Test 2 indicated that educational inequalities in suicide were systematic in males but not in females; Test 3: EIS were more correlated with the proportion of suicides in the younger age group (rho = 0.70) than to income inequality (rho = 0.07). Test 4 indicated that higher education was associated with higher suicide rate, not lower. Conclusions: We found stronger support for the confounding explanation. Educational inequalities in suicide should be addressed by early targeting of vulnerable groups who struggle to complete education. Key messages: Educational inequalities in suicide are more likely to be confounded by early life-cycle factors. Educational inequalities in suicide should be addressed by early targeting of vulnerable groups who struggle to complete education.

3.N. Child health Improving dental health in young children of immigrant background Heidi Lyshol H Lyshol1, U Goth2, S Djurasovic3, L Brændø3 1 Norwegian Institute of Public Health, Oslo, Norway 2 VID University, Oslo, Norway 3 Oslo Municipality, Oslo, Norway

Contact: [email protected]

Background: Inequalities in dental health persist between minority and majority populations in Scandinavian countries. Studies demonstrate that young children of immigrants generally have more caries than majority children.


Depression earlier on in life predicts frailty at 50 years

Key messages: Depression at younger ages is predictive of frailty at age 50 years. Public health interventions can be designed to reduce physical burden of disease in old age by paying attention to mental health at younger ages.



Obesity and cognition during childhood: Findings from the Millennium Cohort Study Hanna Creese H Creese, R Viner, S Hope, D Christie UCL, London, UK Contact: [email protected]

Systematic reviews have reported adverse effects of obesity on cognitive ability and educational attainment in childhood and adolescence. However, most studies are from the US, have small sample sizes and are lacking in adjustment for important factors, such as socioeconomic characteristics. Using data from the nationally-representative UK Millennium Cohort Study (MCS), we examined whether overweight or obesity and cognition were associated cross-sectionally at age 14 years, and the extent to which any association was explained by potential explanatory factors comprising of child and maternal characteristics, family type and household socioeconomic characteristics. Cognitive performance was measured by vocabulary scores, derived from a shortened version of the Applied Psychology Unit (APU) Vocabulary Test, and the Cambridge Gambling Task taken from the Cambridge Neuropsychological Test Automated Battery (CANTAB). The CGT assesses decision making and risk taking behaviour with scores for the quality of decision making, deliberation time and overall proportional bet which is measure of risk taking. Weight and height were measured objectively, and body mass index was categorised using International Obesity Task Force (IOTF) cut

points. Cross-sectional linear regression analysis showed that obesity was associated with lower word activity (b: -0.67, 95% C.I. -0.97 - -0.37) and poorer decision making scores (b: -0.03, 95% C.I. -0.05 - -0.01) at age 14. Overweight was associated with longer deliberation time (b: 112.9, 95% C.I. 29.6 – 196.2). However, after accounting for a wide range of potential confounding factors, we found no evidence for a direct relationship between overweight or obesity and cognition in adolescence. Findings highlight the importance of considering the social inequalities which are associated with both obesity and lower cognitive ability in childhood. MCS provides data for further analysis to explore pathways between obesity and cognition over time. Key messages: Findings highlight the importance of considering the social inequalities which are associated with both obesity and lower cognitive ability in childhood. Using data from the nationally-representative UK Millennium Cohort Study (MCS), we examined whether overweight or obesity and cognition were associated crosssectionally at age 14 years. Childhood maltreatments, child-to-adult BMI and cardiometabolic disease risk in mid-adulthood Leah Li L Li, SM Pinto Pereira, C Power University College London Great Ormond Street Institute of Child Health, London, UK Contact: [email protected]

Background: Childhood maltreatments (abuse/neglect) have been found to be associated with adverse late outcomes. Less is known about their associations with BMI trajectories and adult cardiometabolic disease risks. Methods: In the 1958 British birth cohort, a population sample of all born (17000) in a week, March 1958, followed to adulthood, we examined associations of different forms of maltreatments with life-course BMI trajectories and adult cardiometabolic markers. Results: Neglect (approximately 20% of participants) was associated with elevated adult (not childhood) BMI, e.g. for obesity at 45y ORadj = 1.16(95% CI:1.02-1.32). Abuse (12%) was also associated with elevated BMI in adulthood, not childhood, i.e. the abused had faster BMI gains than the non-abused, and associations were independent of adult covariates. For physical abuse (6%), ORadj for obesity increased over age, in females from a lower risk [ORadj = 0.34(0.16-0.71)] at 7y to a higher risk [ORadj = 1.67(1.25-2.24)] at 50y. For sexual abuse (1.6%), OR increased from 0.23(0.06-0.84)] at 7y to 1.34(0.86-2.10) at 50y among females. Neglect and physical abuse were associated with blood lipids and HbA1c (e.g. for physical abuse ORadj of high LDL-c was 1.25(1.00-1.56), HbA1c was raised by 2.5(0.74.3)% (males) and HDL-c was lower by 0.06(0.01-0.12)mmol/ L (females)). Associations for sexual abuse were similar to those for physical abuse but 95% CIs were wide. For psychological abuse (10%) ORadj of elevated triglycerides was 1.21(1.02-1.44) and HDL-c was lower by 0.04(0.010.07)mmol/L. Maltreatments were not associated with raised blood pressure. Conclusions: Childhood neglect was associated with increased obesity risk and poor lipid and HbA1c profile in adulthood. Physical/ sexual abuse was associated with faster child-to-adult BMI gains, higher risk of adult obesity and poorer lipid/HbA1c profiles. These distinct patterns of associations may have a long term impact on cardiometabolic outcomes. Key messages: Child maltreatment (particularly neglect and physical abuse) were associated with greater adiposity and poorer lipid/ HbA1c profiles in mid-adulthood.


An intervention was devised to decrease caries incidence at age 5 in children from immigrant-rich areas where childhood caries has been high. Methods: The intervention was carried out in 2 city wards in Oslo on children born in 2014 and conducted in three rounds at health centres in Oslo, where children attend regular health checks. Parents were educated in their mother tongue about tooth brushing, use of fluoride toothpaste and suitable drinks for children at night. Brushes and toothpaste were distributed, and brushing technique was demonstrated. Questionnaires in 11 languages were collected, including information about parents’ background and children’s dental hygiene. 333 children took part in all three project phases. Participants and non-participants were examined for caries at age 3. Results: The proportion of children whose teeth were brushed twice a day at age 3 was 94.0% among participants. Another study shows that 52% of children brush twice a day. At 15-18 months/3 years 97.6%/100% of the participants were using fluoride toothpaste. Only 91.3% of the non-participating children had started using this at age 3. 4.8% of the participants had other drinks than water at night, whereas 63% of non-participating children had other drinks at night. Local dental clinics report improvement in the 2014 cohort compared to an earlier cohort: One has had an increase from 82.6% to 90.3% of caries-free 3-year-olds, while another has had an increase from 79.4% to 91.3%. However, the full results will not be visible until 2019, when data on 5-year-olds from all Oslo’s dental clinics can be compared. Conclusions: Preliminary data show that the intervention had a strong effect on the behaviour of parents of young children and the incidence of caries. Key messages: Giving parents information about dental hygiene at regular intervals may alter their behaviour regarding tooth brushing, fluoride toothpaste use and drinks offered at night. Providing culture sensitive and adequate information about dental hygiene has a strong impact on the oral health of small children.

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Child-to-adult BMI and adult lifestyles may be key mediators for many associations.

Protection motivation factors and social norms should be incorporated in child safety promotion interventions.

The influence of protection motivation factors and social norms on child safety

Effectiveness of the oral hygiene education for 4-6 year old children and their parents in Kaunas

Mateja Rok Simon

Iveta Kucˇinskaite_

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M Rok Simon , A Korosˇec , M Bilban 1 National Institute of Public Health, Ljubljana, Slovenia 2 Institute of Occupational Safety, Ljubljana, Slovenia Contact: [email protected]

According to scientific data 82 percent of 6 year old children in Lithuania had at least one teeth damaged by caries. Watching poor tooth brushing habits of children and a lack of knowledge among parents, Kaunas city Public Health Office decided to run a project called Smiling Children of Kaunas. The project took 9 months. The main goal of the project was to create skills of correct tooth brushing for 4-6 year old children and improve their parents’ knowledge about oral hygiene. At the end, effectiveness of the project will be evaluated. Question: What is the condition and skills of oral hygiene among 4-6 year old children in Kaunas before and after the project? Steps of the project: Guidelines including tooth brushing calendars, information about oral hygiene for parents and how education of oral hygiene should be organized at kindergartens were created. 12 thousand children in Kaunas’ kindergartens got a tooth brush every 3 months and brushed their teeth every morning after breakfast. In addition, they had interactive lessons about oral hygiene and information was given to their parents. Before the project and after 9 months, 300 children were examined by oral hygienists. Their Oral Hygiene Index (OHI) and International Caries Detection and Assessment System (ICDAS) were measured. Before the project 46 children had a score of OHI regarding ‘‘good’’ oral hygiene while the rest 254 children were evaluated as ‘‘fair’’ or ‘‘poor’’ oral hygiene. The average of OHI was 1.6 showing that overall oral hygiene of children was ‘‘fair’’. The average of ICDAS was 4, demonstrating high intensity of caries among 4-6 year old children. The second examination (after nine months) just started and will be finished in May. Collaboration and involvement of local policy makers, public health specialists, students and private business can bring relevant effect for public health in building complex education of oral hygiene for children and their parents. Key messages: Evidence based public health projects help to shape local policy and priority settings. Collaboration with local policy makers from education and health units, public health specialists, students and private business can bring relevant effect in building complex oral hygiene education.

3.O. Effectiveness of preventive health programmes How the Dutch survive screening implementations Ronald Zwartkruis R Zwartkruis1, C Mast2, H Mekenkamp3 1 NETQ Healthcare BV, Utrecht, Netherlands 2 Topicus Healthcare, Deventer, Netherlands 3 MedicalPHIT, Utrecht, Netherlands Contact: [email protected]

National screening programmes (for colorectal cancer, cervical cancer, breast cancer, etc.) are complex programmes. The breast cancer screening programme was introduced in the Netherlands in 1990. The programmes are now on a new platform: ScreenIT. Introduction of this platform comprises

implementation of a link between national data and image banks, laboratories, systems of healthcare providers, mammographs and analysis equipment. Volumes are high (more than 5,000 examinations per day for breast cancer screening) and downtime results in queues and in the worst case, appointments need to be rescheduled. This demands high efficiency and solid and seamlessly integrated systems (inter-operability and mutual communication). ScreenIT makes it possible for screening programme examinations to be performed and monitored, and facilitates scientific studies. Annually, 3.8 million clients are invited, 5.5 million examinations are performed and 3,500 lives are saved.


Background: The intention of parents to protect their child’s health depends upon motivational factors; however, the influence of these factors on ensuring child home and car safety has rarely been researched. The aim of the study was to assess the effect of factors based on Protection Motivation Theory and social norms on parental child safety behavior and to use the knowledge in future child safety promotion interventions. Methods: A cross-sectional survey was carried out in outpatient clinics for children’s healthcare across Slovenia. The sample was selected by the method of stratified area probability proportionate to outpatient clinics’ size sampling. 904 parents of 3year-old children participated in the study, response rate was 95.9 %. A self-administered questionnaire was completed by parents. Multiple logistic regression was used to assess the association between parental behavior as dependent variable, and motivational factors, social norms and other potential correlates as independent variables. Results: Parents with low perceived safety measure efficacy had higher adjusted odds for non-use of child car seat (OR 2.60; p = 0.002), medicine lockable cabinets (2.73; 0 05). Conclusions: Adolescents from higher occupational social classes systematically performed healthier behaviours over time compared to those from lower occupational social classes, whereas material inequalities in adolescent health and health behaviours remained stable or decreased. Therefore, effective interventions focusing on intangible resources are key in reducing future health inequalities. Key messages: Occupational class-based Inequalities in adolescent health increased for several health behaviours. Actions to reduce health inequalities should not only focus on a redistribution of material factors but also address intangible resources as they became important drivers of health inequalities.



conditions it occurred in. Descriptions of their formative social conditions, and references to maladaptive behaviours which led to homelessness, indicate that they believe social conditions affected their life chances: these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities. Key messages: Homelessness is more complex than the absence of accommodation. The measure to tackle homelessness should focus immediate concern of absence of accommodation and long-term determinants of homelessness. Homelessess reflects unequal society.

Dusan Petrovic D Petrovic, S Stringhini, R Heinzer, J Haba-Rubio Centre Hospitalier Universitaire Vaudois (CHUV), Universite´ de Lausanne, Lausanne, Switzerland Contact: [email protected]

Background: Obstructive sleep apnea (OSA) is a common sleep-breathing disorder which has been associated with a higher risk of cardiovascular events, metabolic disorders, and autoimmune diseases. The main risk factors for OSA include obesity, smoking, and craniofacial anatomy, however, some studies suggested that socioeconomic status (SES) plays an important role in the aetiology of OSA. Here, we investigated the associations between two indicators of SES and two measures of sleep-breathing disorder, and whether these associations were explained by body mass index (BMI). Methods: We used cross-sectional data from the Swiss CoLaus study, including a total 2160 participants. SES was measured through occupation and education. Sleep-breathing disorders were assessed using the apnea-hypopnea index (AHI: 20; 30 episodes/h), which is the number of apnea/hypopnea episodes per hour of sleep, and the oxygen desaturation index (ODI: 15; 30 episodes/h), which is the number of oxygen desaturation episodes per hour of sleep. The contribution of BMI to the socioeconomic gradient in AHI/ODI was calculated by using the counterfactual mediation method. Results: Low occupation and low education were associated with a higher risk of apnea-hypopnea episodes, and a higher risk of oxygen desaturation episodes, with stronger associations for occupation and ODI indexes (occupation–AHI30: odds ratio (OR) = 1.88, 95% confidence interval (CI)[1.07;3.31], ODI30: OR = 2.29, 95%CI[1.19;4.39]; education-AHI30: OR = 1.21, 95%CI [0.85;1.72], ODI30: OR = 1.26, 95%CI[0.83;1.91]). BMI contributed to the socioeconomic gradient in AHI/ODI indexes, with mediation estimates ranging between 43% and 78%. Conclusions: In this Swiss population-based study, we found that low SES is a risk factor for sleep-related breathing disorders and that these associations are partly explained by BMI. These findings may help implement policies for identifying high-risk profiles for OSA, and contribute to reduce later health consequences. Key messages:

Socioeconomic status is a determinant of sleep breathing disorders. The socioeconomic gradient in sleep breathing disorders is explained by BMI. Socio-economic characteristics associated with premature mortality across small-areas in Cyprus Demetris Lamnisos D Lamnisos1, N Middleton2 Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus 2 Department of Nursing, School of Health Sciences, Cyprus University of Technology, Limassol, Cyprus Contact: [email protected] 1

Background: Geographical investigations are a core function of public health monitoring providing the foundation for resource allocation and policies for reducing health inequalities. This study investigated the patterning in all-cause premature mortality and its association with a range of socioeconomic indicators. Methods: Standardized mortality ratios of premature adult mortality (ages 15-64) were calculated across 369 communities for the period 2009-11. The social gradient in health in terms of twenty-one 2011 census indicators was estimated in Bayesian hierarchical Poisson models with spatially unstructured and structured random effects. Results: SMRs were unreliable at this level of aggregation (median population: 316, IQR: 111-1104, 13% of areas>3000). Significant differences remained in spatially smoothed maps (range: 0.79-1.25), with higher rates in remote areas. Indicators strongly associated with increased mortality were: households with no computer, not owner-occupied households, unemployment, low education, single-person households and population aged over 65, all with a statistically significant increase of 10-18% per SD increase. Negative associations were observed with population aged less than 14 (0.83, 95% CI = 0.76-0.90 per SD increase), proportion of houses constructed after 2000 (0.91, 95% CI = 0.85-0.97) and households with six and over members (0.91, 95% CI = 0.84-0.97). Observed associations did not attenuate when models adjusted for indicators of rurality. Conclusions: There appears to be an urban-rural divide in premature mortality, with remote areas at disadvantage. The set of indicators associated with mortality are indicative of economic, material, occupational, educational and/or social disadvantage. They are also typical characteristics of rural life. The impact of rurality should be further investigated, since many of these indicators may not capture the differential meaning of the underlying concepts in rural areas e.g. seasonal nature of employment. Key messages: The pattern of premature mortality reflects various aspects of social disadvantage. Different aspects of disadvantage may be relevant or carry different meaning in rural and urban areas.

3.Q. Work, health and sick leave Burnout and work ability and the role of shift work – results from the Study on Mental Health at Work Grit Mu¨ller G Mu¨ller1, U Rose2 1 Federal Institute for Occupational Safety and Health, Dortmund, Germany 2 Federal Institute for Occupational Safety and Health, Berlin, Germany Contact: [email protected]

Background: Mental health problems like burnout are important risk factors for work disability and early retirement. A limited number of studies have been investigating the association between burnout and work ability so far. The aim with this paper was to investigate the association between burnout and work ability in a representative sample of employees in Germany and


Social inequalities in sleep-related breathing disorders: evidence from the CoLaus study

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The impact of occupational health on worklife expectancy, a Danish study on the years 2012-2016 Jacob Pedersen J Pedersen National Research Centre for the Working Environment Denmark, Copenhagen, Denmark Contact: [email protected]

Background: To what degree does the occupational health of the workforce impact the labor market affiliation in terms of worklife expectancy? This question plays a central role in the Danish flexible labor market system with high labor force participation, relatively generous and accessible social benefits, and a low formal employment protection with a high turnover. Methods: A survey of 16.406 employed Danes from 2012 is merged with longitudinal register data on social benefits to gain a follow-up period of approximately five years, but no later than the official pension age of 65 years. By using a Multi-state design and modern survival analysis, we estimate the worklife expectancy and divide the results into periods of work, unemployment, and sickness absence. The analyses are done for five occupational health scales divided into good and poor health. Results: For a 40 year old woman without the possibility of voluntary early retirement, one can expect a 1.1 year decline in the total worklife expectancy due to physical strain at work. The total decline is made by 2.4 years decline in time of paid work, and with a 0.8 years increase of sickness absence and half a year increase in unemployment. Similar results are made for men and several ages. Conclusions: Results suggest a significant influence of occupational health on worklife expectancy and work disability among Danish employees. With the new methods utilizing the detailed Danish registers one has the ability to estimate work-life expectancy even for small groups, which is often the case when subgrouping levels of occupational health.

Key messages: Results suggest a significant influence of occupational health on worklife expectancy and work disability among Danish employees. Worklife expectancy is a method for communicating complex patterns of labor market affiliation. Risk of sickness absence during pregnancy due to multiple work factors Camilla Sandal Sejbaek CS Sejbaek1, J Pedersen1, H Bay1, CH Ramlau-Hansen2, V Schlu¨nssen1, JP Bonde3, P Kristensen4, KS Hougaard1 1 National Research Centre for the Working Environment, Copenhagen, Denmark 2 Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark 3 Department of Occupational and Environmental Medicine, Bispebjerg Hospital, Copenhagen, Denmark 4 Department of Occupational Medicine and Epidemiology, National Institute of Occupational Health, Oslo, Norway Contact: [email protected]

Background: In Denmark, 65% of the women working during pregnancy experienced sickness absence for >4 weeks during pregnancy in 2010. To keep women at work in this period, more knowledge about work factors associated with sickness absence is needed. We hypothesised that an increasing number of potential risk factors at work is associated with increasing absence from work during pregnancy. Methods: Women from the Danish National Birth Cohort (1996-2002) working 30 hours/week and pregnant with one child were included (N = 50,142). Information about working conditions was collected from an interview at gestational week 17 (mean). Five risk factors at work – posture, shift work, demand, control, and lifting – were assigned values of 0 or 1 and summed into one variable (0-5). Information on the women’s first sickness absence was retrieved from the Danish Register for Evaluation of Marginalization (gestational weeks 11-30, yes/no). Data was analysed by Cox regression with hazards ratios and 95% confidence intervals (95% CI) with gestational age as the underlying variable. Results: Most women experienced one (19.5%), two (34.7%) or three (25.9%) risk factors, while no (3.6%), four (12.6%) or five (3.8%) risk factors were less prevalent. A total of 24.4% of the women were absent due to sickness before gestational week 31. Preliminary results show that the hazard ratio for sickness absence increased with the number of risk factors the women were exposed to. Hazards ratios in the adjusted analysis increased from 1.3 (95% CI 1.1-1.4) for exposure to one risk factor to 3.2 (95% CI 2.8-3.8) for exposure to all five risk factors compared to no exposure to these risk factors. Conclusions: Absence from work during pregnancy was significantly associated with the number of risk factors. On the basis of our findings, we recommended job adjustments addressing risk factors at work among pregnant women. Key messages: Managers at work should be aware of the number of work factors pregnant women experience. Job adjustment addressing risk factors at work may be needed to decrease sickness absence among pregnant women. Labor market participation and accumulation of multimorbidity: A life-course approach Monica Ubalde-Lopez M Ubalde-Lopez1,2, A Calderoń-Larranãga2,3, LG Platts2, H Westerlund2, HX Wang2 1 Center for Research in Occupational Health, Universitat Pompeu Fabra, Hospital del Mar Research Institute, Barcelona, Spain 2 Stress Research Institute, Stockholm University, Stockholm, Sweden


to evaluate whether shift work increases the vulnerability to limitations in work ability due to burnout symptoms. Methods: Data was taken from the Study on Mental Health at Work, a representative study of German employees initiated by the Federal Institute for Occupational Safety and Health. Overall, 4,511 computer-assisted personal interviews were conducted in 2011/12. Work ability and burnout were assessed with the Work Ability Index (range 0-49) and the exhaustion subscale from the Oldenburg Burnout Inventory (range 1-4), respectively. Multiple linear regression models were estimated to investigate the relationship between burnout, shift work and work ability (complete information available for N = 3,403). Results: Employees with high burnout levels show reduced levels of work ability, considered as moderate. An increase in burnout levels is associated with a decrease in work ability by -5.7 (p