Population health and status of epidemiology in Western European, Balkan and Baltic countries.

International Journal of Epidemiology, 2015, 300–323 doi: 10.1093/ije/dyu256 Original article

Global Status of Epidemiology

Population health and status of epidemiology in Western European, Balkan and Baltic countries Adele Seniori Costantini,1* Federica Gallo,2 Frank Pega,3,4,5 Rodolfo Saracci,6 Piret Veerus7 and Robert West8 Cancer Prevention and Research Institute (ISPO), Florence, Italy, 2Centre for Cancer Epidemiology and Prevention, AOU City of Health and Science, Turin, Italy, 3Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme and 4Health Inequalities Research Programme, University of Otago, Wellington, New Zealand, 5Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, USA, 6Institute of Clinical Physiology (IFC), National Research Council, Pisa, Italy, 7National Institute for Health Development, Tallinn, Estonia and 8Wales Heart Research Institute, Cardiff University, Cardiff, UK

Downloaded from http://ije.oxfordjournals.org/ at New York University on May 9, 2015

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*Corresponding author. Cancer Prevention and Research Institute (ISPO), via Cosimo il Vecchio n. 2, 50139 Florence, Italy. E-mail: [email protected] Accepted 1 December 2014

Abstract Background: This article is part of a series commissioned by the International Epidemiological Association, aimed at describing population health and epidemiological resources in the six World Health Organization (WHO) regions. It covers 32 of the 53 WHO European countries, namely the Western European countries, the Balkan countries and the Baltic countries. Methods: The burdens of mortality and morbidity and the patterns of risk factors and inequalities have been reviewed in order to identify health priorities and challenges. Literature and internet searches were conducted to stock-take epidemiological teaching, research activities, funding and scientific productivity. Findings: These countries have among the highest life expectancies worldwide. However, within- and between-country inequalities persist, which are largely due to inequalities in distribution of main health determinants. There is a long tradition of epidemiological research and teaching in most countries, in particular in the Western European countries. Cross-national networks and collaborations are increasing through the support of the European Union which fosters procedures to standardize educational systems across Europe and provides funding for epidemiological research through framework programmes. The number of Medline-indexed epidemiological research publications per year led by Western European countries has been increasing. The countries accounts for nearly a third of the global epidemiological publication. Conclusions: Although population health has improved considerably overall, persistent withinand between-country inequalities continue to challenge national and European health institutions. More research, policy and action on the social determinants of health are required in the region.

C The Author 2015; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association V

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Epidemiological training, research and workforce in the Baltic and Balkan countries should be strengthened. European epidemiologists can play pivotal roles and must influence legislation concerning production and access to high-quality data. Key words: Epidemiology, health status, risk factors, teaching and research, health inequalities, Europe

Key Messages • The WHO European region is one of the wealthiest in the world. Even though total population health has improved

considerably in many countries of the region over the past decades, persistent inequalities between and within countries represent a challenge for governments, health institutions and health professionals. • Strengthening prevention programmes that effectively reach low-educated groups and guaranteeing equitable access

to good-quality health care are needed. relevant training in epidemiology is offered in most of countries of the region.

Introduction This article, commissioned by the International Epidemiological Association (IEA), is part of a series of eight papers on population health and the status of epidemiology in the six World Health Organization (WHO) regions. The WHO European region includes 53 countries on the European and Asian continents [http://who.int/ about/regions/en]. This paper describes population health and stock-takes the status of epidemiology in 32 countries belonging to Northern, Western and Southern Europe according to the United Nations (UN) geographical classification,1 herein called the ‘UN32 countries’. A previous paper has considered the other 21 countries in Eastern Europe, Western Asia and South-Central Asia.2 Culturally, economically and politically, Europe is not a homogeneous region. To better describe patterns of mortality and morbidity we have not adhered strictly to the UN geographical classification but have considered the following three country groupings: (i) 18 ‘Western European countries’ which have been linked by economic and cultural roots since ancient times and have developed economic and political bonds during the second half of the 20th century, i.e. Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, The Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingdom [UK]; (ii) the seven Balkan countries, i.e. Albania, Bosnia Herzegovina, Croatia, The Former Yugoslav Republic of Macedonia (TFYR Macedonia), Montenegro, Serbia and Slovenia; and (iii) the three Baltic countries, i.e. Estonia, Latvia and Lithuania. Data are provided for Malta.

Some information about Andorra, Monaco and S. Marino, countries with fewer than 100 000 residents, is available at [www.euro.who.int/hfadb/]. A partnership, the European Union (EU), was founded in 1957.3 By the early 1990s, all Western European countries (except Iceland, Norway and Switzerland) had become members. More recently Croatia, Estonia, Latvia, Lithuania, Malta and Slovenia have joined. In 2013, the World Bank classified these and the 18 Western European countries as ‘high-income’. Albania, Bosnia Herzegovina, TFYR Macedonia, Montenegro and Serbia are ‘upper-middle-income’.4 The main data sources contributing to this report are as follows: ‘Health for All’ and ‘European Health for All Mortality’ databases provided online by the WHO Regional Office for Europe; WHO World Health Statistics; EUROSTAT statistics; EU Commission (EC) and WHO reports concerning the burden of disease, main risk factors and inequalities; the ‘EUCAN’ database; and the ‘EUCORDIS’ database. Medline-indexed academic journal articles and websites of epidemiological and public health associations, universities and health institutions were accessed to describe epidemiological activity.

Demographic Outlines The population of the European region has increased over time, reaching nearly 900 million inhabitants in 2010.5 The population of the European region is ageing. By 2010, about 15% of the European population was aged 65 years and over, and this group is projected to represent more


• There is long-standing tradition in epidemiology. Nowadays, important research in epidemiology is undertaken and

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Figure 1. Life expectancy at birth in (a) Western, (b) Balkan and (c) Baltic countries, 1970–2010. Source of data: World Health Organization. European Health for All Database (HFA-DB)5.

than 25% by 2050.6 Ageing occurred earlier than elsewhere in the Scandinavian countries where the percentage of the population aged 65 years and over peaked around the end of the 1980s. As of now, the countries with the oldest populations are Germany, Italy, Greece and Portugal, with people aged 65 years and over representing 20.6%, 20.2%, 19.1% and 18.4% of the population, respectively.5 Both declining birth rates and increasing life expectancy drive this trend. Birth rates declined

substantially after 1970, but have remained relatively stable over the past 20 years. Life expectancy of European citizens has increased over time, reaching an average of 72.9 years for men and 80.1 for women. From 1980 to 2010, life expectancy has steadily increased in the Western European and Balkan countries but decreased in the Baltic countries in the early 1990s (Figure 1). In 2010, the highest life expectancies were observed in Switzerland (82.8 years), Italy (82.5) and Spain (82.3), and the lowest for Latvia


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Figure 1. Continued.

Figure 2. Life expectancy at birth in N32 countries (data not available for Monaco), men and women, last year available (2006–10). Source of data: World Health Organization. European Health for All Database (HFA-DB)5.

(73.7) and Lithuania (73.6). Women experience higher life expectancy in all countries (Figure 2). According to the EC, during 2011 approximately 3 million and 2 million individuals (52% men) migrated, respectively, to and from one of the EU countries.7 The greatest numbers of immigrants settled in the UK, Spain, Italy and Germany. Emigrants outnumbered immigrants in Ireland, Greece, Spain and in the Baltic countries.7 In the Baltic and Balkan countries, the strong negative migration rate together with a reduced birth rate have resulted in decreased population counts and population aging.7–8

Mortality and Morbidity In Europe, over the past three decades, mortality has decreased in all countries, for all age groups, in both sexes, for most causes of death. Mortality is very low during childhood and young adulthood. Infant mortality in Europe has decreased by 55% over the past 30 years.5–6 In Western European countries rates have converged, ranging between 2.3 deaths per 1000 births in Finland and 4.3 in the UK in 2010. In the Baltic countries, the rates rose from 1985, peaked in 1995 and subsequently dropped to between 3.3 in Estonia and 5.7 in Latvia. In the Balkan countries, the rates

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Figure 3. Infant mortality in (a) Western, (b) Balkan and (c) Baltic countries, 1985–2010. Source of data: World Health Organization. European Health for All Database (HFA-DB)5.


Figure 4. Causes of death in the UN32 countries, 1999 and 2009 (Andorra, Monaco and S. Marino excluded). Source of data: World Health Organization, European Health for All Mortality Database (HFA-MDB)9.

and then fell. Greece, Portugal and Spain showed the lowest mortality in the early 1970s, whereas Finland, Switzerland and Sweden showed the greatest falls and the lowest rates towards 2010 (Figure 6). In recent years, the age-standardized mortality rates for MN surpassed CVD mortality in men in France, Italy, Spain, Portugal and The Netherlands5. In Baltic countries, rates peaked in the 1990s and then fell.5 In 2010, the highest all-cancer mortalities were reported for Croatia, Serbia, Latvia and Slovenia. The most common cancer deaths were those arising from the lung, colorectum, female breast, and stomach.5,11 However, in Western European and Baltic countries the most frequent cancers in 2012 were those arising from the large bowel, lung, female breast and also the prostate for which the increasing incidence has been correlated to increasing early diagnosis using the prostatespecific antigen (PSA) test.12. For breast and large bowel cancers, an improved survival, seen especially in Western European countries, has led to reduced mortality in spite of increasing incidence.13–14. Figure 7 shows breast cancer incidence and mortality rates for the year 2012.


range between 2.5 in Slovenia and 7.6 in TFYR Macedonia (Figure 3). In 2010, over 70% of mortality occurred among people aged 65 years and over.6 The age-standardized allcause mortality rate (all ages, both genders) was 800 deaths per 100 000 of population—a 25% reduction over 30 years.5 Rates ranged from 464 deaths per 100 000 of population (Switzerland) to 591 (Portugal) in Western European countries, from 600 to 948 in the Balkan countries and from 800 to 951 in the Baltic countries. Premature mortality differed markedly; the 0–64 age-standardized rates ranged from 138 (Sweden) to 189 (Portugal) in Western European countries, from 199 (Slovenia) to 313 (Serbia) in Balkan countries and from 314 (Estonia) to 415 (Lithuania) in Baltic countries. Death rates were higher for men than for women; the rate ratios for all ages ranged from 1.4 in Greece to 2.2 in Lithuania, and for the 0–64 year age group from 1.6 in Switzerland to 3.1 in Lithuania. Among adults, cardiovascular diseases (CVD) and malignant neoplasms (MN) are the main causes of death in terms of both rates and absolute numbers.9 Figure 4 shows the contribution of different causes of death in the UN32 countries. Time trends show considerable reductions in CVD mortality in Western European countries—approximately 30% over the past 30 years. In the Baltic countries, CVD mortality increased from late 1980s to mid 1990s (especially in the under-65s) and subsequently reduced. In the Balkan countries, there is evidence of a declining trend in Slovenia and, more recently, in Serbia and Croatia (Figure 5). Mortality from ischaemic heart disease (IHD), the most common CVD, demonstrated a similar pattern, with France, Spain and Greece exhibiting the lowest rates in the 1970s and France, Spain and The Netherlands showing the lowest rates in 2010. Mortality from stroke also declined in Western European countries, with Portugal showing the most dramatic decline but still remaining the country with the highest rate besides Greece. TFYR Macedonia, Latvia, Lithuania and Serbia exhibited the highest rates among the UN32 countries.5 Type 2 diabetes has increased in European adults. Mortality rates do not account for the whole mortality by diabetes, further (indirect) mortality resulting from death due to complications, in particular CVD. Data from available national registers indicate that the prevalence of diabetes varies substantially across the European countries, with the highest being reported for Portugal (9.4%) and the lowest, at less than 1%, for Albania, Greece and Iceland.5 Recent estimates indicate an overall prevalence of 8.5% in 2010 in the 47 European member states of the International Diabetes Federation Europe region.10 Mortality rates from MN in Western European countries rose between the 1970s and the early to mid 1990s

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Figure 5. Mortality from cardiovascular diseases in (a) Western, (b) Balkan and (c) Baltic countries, 1970–2010. Source of data: World Health Organization. European Health for All Database (HFA-DB)5.


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Figure 6. Mortality from malignant neoplasms in (a) Western, (b) Balkan and (c) Baltic countries, 1970–2010. Source of data: World Health Organization. European Health for All Database (HFA-DB)5.

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Mortality from mental and neurological diseases has increased.5 A recent study has estimated that 38% of the EU population (plus Switzerland, Norway and Iceland) suffered from mental disorders in 2011.15 External causes represent the leading cause of death in people aged 15–44 years.5 Rates declined over the past 20 years, in particular for motor vehicle accidents and suicides, the two most significant causes of death in this group. In 2010, Greece, Croatia, Latvia and Lithuania exhibited the highest rates of motor vehicle accidents; Malta, The Netherlands, Sweden and Switzerland had the lowest rates.5 Suicides were highest in Latvia, Lithuania and Finland and lowest in Spain, Italy and Greece.5 Mortality from communicable diseases decreased in Europe during the 1970s and 1980s but increased moderately subsequently. This increase may be attributed to septicaemia among older people and to increasing antimicrobial resistance.6 Concern currently focuses particularly on tuberculosis and HIV/AIDS. Mortality and incidence rates for tuberculosis have declined generally but remain high in Bosnia Herzegovina, Latvia and Lithuania. HIV infection rates slightly increased until the beginning of

the 2000s in Western European countries; afterwards they remained relatively stable. Exceptions were Switzerland and Portugal where rates—the highest in 1990s—have dropped since 1990 and 2000, respectively. In the Balkan countries, HIV infection slightly increased. In the Baltic countries rates peaked at the beginning of the 2000s, in particular in Estonia and Latvia where the highest rates in the UN32 countries were seen at the beginning of the 2010s.5 HIV infection is concentrated in populations at higher risk for unprotected sex and drug injecting, the latter transmission mode being highest in the Baltic countries.16 Mortality data do not account for the global disease burden.17 In 2004, among the UN32 countries the lowest disability-adjusted life-years (DALYs) per 100 population—a measure combining the years of life lost due to premature mortality and years lived in states of disability—were estimated for Iceland (9.8), Switzerland (10.8) and Malta (11.1), and the highest for Estonia (18.9), Latvia (19.6) and Lithuania (18.4) see [http://www.int/healthinfo/globan_bur den_disease/estimates_country/en/]. Most DALYs have been ascribed to CVD, MN and neuropsychiatric disorders, but also to injuries in the Baltic countries.6,18


Figure 7. Incidence and mortality rates of breast cancer in women in (a) Western, (b) Balkan and (c) Baltic countries, 2012. Source of data: International Agency for Research on Cancer-World Health Organization. EUCAN Database11.


Health Behaviours

Europe was the first region to develop a wide action plan to address the harmful use of alcohol.33 In the EU, alcohol policies have been guided by an EU strategy to support Member States in reducing alcohol-related harm.34 Several actions have been adopted in the countries covered by this review.35 Dietary habits can influence health. Disparities in dietary habits, and specifically in fruit and vegetables consumption, have been described across Europe.36 In Western European countries, the highest average amount of fruit and vegetables available per person-year were observed for Greece (although declining in the mid 2000s), Italy, Luxemburg, Spain and Portugal. In Finland, Iceland, Ireland, Denmark, Norway and Sweden, as well as in the Baltic and Balkan countries, fruit and vegetable availability has increased over the past 20 years.5 The average number of calories available per person has increased slightly since the 70s in Western European and in Baltic countries; a steady increase has been seen over the past two decades in the Balkan countries.5 A rise of calorific intake has led to an increased prevalence of overweight and obesity (Table 1). The estimated proportion of DALYs attributable to overweight and obesity is about 8% in the European region.25 Inter-country inequalities in smoking, alcohol and eating habits have been evidenced to underlie temporal trends and differences between countries in mortality and morbidity. The North–South gradient of IHD mortality has suggested a protective effect of the so-called Mediterranean diet. The WHO Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) project and the ‘Seven Countries’ study have evidenced that the observed declining CVD mortality is associated with declines in smoking, heavy alcohol drinking and unhealthy diets.37–38 Recent studies have confirmed the protective effect of healthy eating on CVD39 Differences in lung and stomach cancer incidence have been attributed to inequalities in dietary behaviours.40–43 Physical activity influences health. The percentage of insufficiently active people varies between countries22 and is generally higher among women (Table 1). The levels of physical activity among children and adolescents vary by country but they are generally higher among boys than girls.23

Environment Air quality is the main environmental determinant of human health in the region. Burning of petroleum fuels in transportation is the main source of air pollution in towns, airports and sea ports.44 The EU has implemented several legislative measures to improve air quality and has developed a number of Environment Action Programmes (EAPs) [http://ec.europa.


Tobacco smoking, heavy alcohol drinking, unhealthy diet and physical inactivity, both directly and through intermediate factors—such as raised blood pressure, overweight and obesity and high glucose and cholesterol levels—are the main determinants of health in the European region.19–20 With few exceptions, tobacco smoking has steadily decreased in European populations over the past 30 years.5,21 The decline was particularly steep in The Netherlands and Sweden, where the prevalence of smoking dropped from 43.0% to 20.9% and from 32.4% to 13.6%, respectively, between 1980 and 2010. Smoking declined steadily among men in all countries, whereas among females it declined only more recently and increased in some countries. However, it remained more common among men than among women except in Sweden (Table 1). Smoking prevalence in adolescents tends to be higher among girls than boys in the Western European and Balkan countries, whereas in the Baltic countries this pattern is reversed.22–23 In Europe as a whole the proportion of deaths attributable to smoking, based on mortality in 2004, was estimated be equal to 16% in both genders24 and the tobacco smoking-attributable proportion of total DALYs to be approximately 12%.25 Among men, smoking-attributable deaths are notably declining in those countries where smoking reduction started earlier, as in Finland (38% in 1970 to 15% in 2009 in men aged 35–69 years) and the UK (47% in 1970 to 22% in 2009). In contrast, the proportion among women aged 35–69 years in the Western European countries has not yet decreased and exceeds the male smokingattributable proportions in Denmark and Sweden.21,26 All EU Member States ratified the Framework Convention on Tobacco Control (FCTC), the first treaty negotiated under the auspices of the WHO,27 and almost all of these have implemented or are currently implementing comprehensive smoking bans in workplaces, indoor public places and public transport.28 Alcohol consumption has decreased in most Western European countries over the past two decades, but has increased in the Baltic countries.5 Consumption and patterns of drinking vary across Europe. In the Mediterranean region, alcohol (generally wine) is consumed daily, usually with meals. In other countries such as Germany, Austria and Belgium, beer is the beverage of choice, and there is some irregular heavy drinking in countries of Northern Europe, the British Isles and the Baltic countries.29–30 The estimated alcohol-attributable proportion of all deaths is approximately 7% Europe-wide,24 being greatest in Estonia, Latvia and Lithuania.30–32 The estimated proportion of total DALYs due to alcohol is 11% (15.2% in men, and 3.9% in women).25

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Table 1. Main risk factors Prevalence of obese adults aged 20 years and over, 2008

Country

19.2 21.2 17.1 21.0 16.8 23.1 18.8 23.4 25.7 19.3 24.5 16.1 21.6 20.4 24.9 18.2 18.3 24.4 21.7 22.7 22.8 22.8 25.5 28.1 21.6 20.2 21.5 23.9 26.1

Women 17.1 16.9 15.4 18.6 14.6 19.2 16.1 20.3 23.3 14.9 22.2 16.1 17.9 22.3 23.0 15.0 11.6 25.2 20.5 25.3 19.4 20.7 20.3 25.9 18.9 17.6 21.8 24.7 26.8

Prevalence of smokers aged 15 years and over Last year available (2006/2010) Men

33.3 16.7 30.0 36.4 22.2 25.0 ... 66.7 36.4 11.1 37.5 33.3 66.7 15.4 23.1 22.2 ... 9.5 ... ... ... ... ... ... ... ... ... ... ...

27.3 24.0 20.0 23.2 32.4 26.4 38.0 14.5 28.0 29.6 27.0 23.1 19.0 30.8 31.2 12.5 22.0 21.0 60.0a 17.6 33.8b 36.7 30.7 22.4 40.0c 36.8 47.4 34.2 25.6

Adult smoking rate of change (1995–99) - 2006/2010 (men þ women)

Women 19.4 18.0 20.0 15.7 26.0 17.6 26.1 14.1 26.0 17.1 20.0 18.8 19.0 11.8 21.3 14.7 17.0 20.0 18.0a 11.3 21.7b 29.0 22.6 15.5 32.0c 18.7 20.7 14.4 15.8

Prevalence of insufficiently active adults, aged 15 years and older, 2008 Men

22.0 25.4 39.1 19.4 8.2 40.0 16.2 45.9 13.6 7.4 23.3 40.4 42.1 15.6 20.4 33.9 41.4 26.0 9.0 ... 16.1 ... ... 26.6 ... 11.8 12.3 1.2 9.0

30 40 35 41 28 28 17 ... 48 50 50 21 43 48 47 44 ... 58 ... 30 26 ... 63 27 ... 16 28 20 71

Women 39 45 35 35 37 29 15 ... 59 60 46 15 45 54 53 44 ... 69 ... 37 21 ... 73 34 ... 19 36 25 73

Sources of data: (i) Obesity 2008: World Health Organization, Global Health Observatory (GHO), Data Repository,22 Obesity rate of change 2000–09: Health at a Glance. 2011 OECD Indicators. released on November 2011 (http://www.oecd.org/health/healthataglance); (ii) Smoking 2006/2010: WHO HFA DB,5 Smoking 1995–99 average value: Nichols M, Townsend N, Scarborough P, et al. (eds). European Cardiovascular Disease Statistics 2012, European Heart Network, European Society of Cardiology (http://www.escardio.org/about/documents/eu-cardiovascular-disease-statistics-2012.pdf); (iii) Physical activity as prevalence of insufficiently active adults (% of defined population attaining less than 5 times 30 mins of moderate activity per week or less than 3 times 20 min of vigorous activity per week or equivalent). 2008: World Health Organization. Global Health Observatory (GHO). Data Repository.22 a Data 2000. b Data 2003. c Data 1999.

eu/environment/newprg/]. The European Environmental Agency, established in 1990 [www.eea.europa.eu/], collects data from 38 European countries, allowing monitoring of pollutants across the region. The levels of sulphur dioxide, carbon monoxide and benzene have substantially reduced over the past 20 years, whereas nitrogen oxides (NOx), particulate matter (PM), and ozone (O3) still remain at high levels. The EU limit and target values for PM10 and PM2.5 were widely exceeded over the period

2001–10 except in Denmark, Finland, Ireland and Luxembourg.45 The EU target value for O3 was not attained in most countries, in particular Italy, Greece and Slovenia. It has been estimated that in the period 2008–10, 18–21% of the EU urban population was exposed to concentrations of PM10 in excess of the EU reference value. The proportion of the urban population exposed to PM10 levels exceeding the stricter WHO Air Quality Guidelines (AQG) limit was approximately 81%.45 Many studies


Austria Belgium Denmark Finland France Germany Greece Iceland Ireland Italy Luxembourg Netherlands Norway Portugal Spain Sweden Switzerland United Kingdom Albania Bosnia and Erzegovina Croatia Montenegro Serbia Slovenia TFYR Macedonia Estonia Latvia Lituania Malta

Men

Adult obesity rate of change 2000–2009 (men þ women)


Work Work is an important determinant of health; it influences exposure to a range of hazards, but also provides income and determines social position in society. The current increasing unemployment poses a serious concern in many countries in the region (Figure 8). The European Framework Directive on Safety and Health at Work [https://osha.europa.eu/it/legislation/directives/the-osh-framework-directive/1] represented a milestone in improving occupational safety across EU Member States. However, flaws in the Directive’s application hinder the achievement of its potential [osha.europa.eu/en/le gislation/directives/the-osh-framework-directive/the-osh-fram ework-directive-introduction]. The European Agency for Safety and Health at Work sets European occupational health standards, together with the WHO Headquarters in Geneva [https://osha.europa.eu/]. Unhealthy working conditions are estimated to contribute to at least 1.6% of the total burden of disease in the European region [http://www.euro.who.int/ en/health-topics/environment-and-health/occupational-health/ data-and-statistics].

Social Determinants and Health Inequalities The cultural, environmental, social and economic diversity within and between European countries, together with the high-quality data available on both individual-level socioeconomic status (SES) (e.g. education, employment, income and occupation) and structural factors (e.g. welfare regimens, public policies and political factors) have made

Europe fertile ground for studying social determinants of health (SDH) and health inequalities.54–55 The European region, one of the wealthiest in the world, has undergone substantial socioeconomic development over the second half of the 20th century. This economic growth has been linked to the observed decline in mortality, especially in Western European countries.56 In 2010, per capita annual gross domestic product (GDP) in the European region was just under US$23,000, but with large betweencountry variation.5 An association between national income and life expectancy has been reported.55 Figure 9 shows life expectancy by GDP. Incomes have grown faster for high-income groups than for low-income groups.57 According to Eurostat, in 2011 in the EU 17% the population lived in or at risk of poverty (meaning that their disposable income was less than 60% of the national median income) with more than 20% in Spain, Greece, Croatia and Lithuania7. Moreover, child poverty has increased recently in many countries, including some high-income countries.58 Health services expenditure differs across countries. Most Western European countries have invested by building a welfare state modelled on those developed by the Scandinavian countries and the UK over the second half of the past century. Total health expenditures, as a percentage of GDP, have risen over the past decades, reaching a country average of 8.5% in 2010. Richer countries allocate higher percentages, ranging from 11.7% in France compared with 6.0% in Albania.5 Government expenditure as a percentage of total health expenditures is generally high, exceeding 80% in Denmark, Iceland, Luxembourg, Norway, Sweden and the UK, but are lower than 20% in the Baltic and Balkan countries (Figure 10). Out-of-pocket (OOP) payments (additional costs paid directly by the patients) represent an important financing mechanism in the latter countries. Association between social welfare spending and life expectancy has been reported.59 The English Black Report in 1980 (http://www.sochealth.co.uk/resources/public-health-and-wellbeing/poverty-and-inequality/the-black-report-1980/) marked an important step in drawing attention to health inequalities. This report demonstrated that, although health had improved overall since the introduction of the welfare state, it had not benefited all citizens equally. Numerous epidemiological studies have since shown that European men and women with lower education, occupational status or income carry greater disease burden (including from earlier in life) and die earlier from chronic diseases as well as from infectious diseases and intentional and non-intentional injuries.60–65 National census-linked mortality and cross-sectional studies have shown that mortality rate ratios between lower and higher SES groups range from below 2 in Sweden, Norway, Denmark, Belgium, Italy,


involving European populations have demonstrated shortand long-term adverse health effects of exposure to PM, NOx and O3.46–50 In the WHO’s Review of Evidence on Health Aspects of Air Pollution (REVIHAAP) and Health Risks of Air Pollution in Europe (HRAPIE) projects, the group of experts who reviewed the scientific evidence for the adverse effects on health of air pollution concluded that the effects in some cases occur at air pollution concentrations lower than the WHO AQG limits.49–50 Recently the International Agency for Research on Cancer (IARC) has classified air pollution and PM as carcinogenic agents to humans with robust evidence [http://www.iarc.fr/en/publications/books/sp161/index.php], thus posing further arguments for the improvement of air quality in Europe. Recent climate change represents another important environmental stressor.51–52 Europe’s average temperature is projected to continue to increase throughout the 21st century, especially in winter over North-Eastern Europe and in summer over Southern Europe.53

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Figure 9. Life expectancy by per capita (GDP) (in US$), 2010. Source of data: World Health Organization. European Health for All Database (HFA-DB)5.


Figure 8. Unemployment rate, annual average, men and women, 2012. Source of data: European Commission. Eurostat, Statistics Database.7.


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Portugal and Spain to above 3 in Estonia (and in some Eastern European countries).66 Epidemiological research demonstrates that inequalities in health are largely explained by inequalities in behaviours (e.g. smoking, alcohol drinking, physical activity and diet).67–72 For example, SES inequalities in lung cancer mortality are relatively large in The Netherlands and the UK, where the prevalence of smokers in high SES classes declined earlier, but are smaller in France, Spain, Italy and in particular in Portugal, where smoking cessation started later and where inequalities in smoking by SES are smaller.71–72 A study of 10 Western European countries estimated that smoking accounted for 50% of educational inequalities in lung cancer risk.67 People of lower SES also have less access to high-quality health care and prevention services, with implications for mortality from CVD and some cancers.73–75 Health inequalities have remained or even widened over recent decades. In many Western European countries, whereas total mortality has declined, absolute inequalities by SES have been fairly stable but relative inequalities have widened.76 Increasing unemployment, recent austerity measures and weaker social protection appear to partially explain this phenomenon.77–78 An inverse ‘U’-shaped trend in mortality occurred in the Baltic countries around the mid 1990s. Over this period, mortality rates declined only

in the high educational groups, whereas the huge increase occurred among the lower educated groups and has been ascribed to risky health behaviours associated with increased levels of poverty and marginalization.79–80

Epidemiological Research, Education, Scientific Productivity, Personnel In all countries of the region, epidemiological research is undertaken and epidemiological education is offered both by universities where research and teaching are strictly correlated and by national (governmental) health institutions.

Education Across the region universities are leaders in education in epidemiology. Examples of institutions providing considerable epidemiological education are the London School of Hygiene and Tropical Medicine, which is part of London University, and the Erasmus University in Rotterdam, as they attract students from other European and non-European countries. During the past decades the EU has fostered restructuring procedures to standardize educational systems across Europe. In 1999, the Bologna Declaration started a process to overcome the segmentation of the European higher education sector. This led to the establishment of the European Higher


Figure 10. Per capita health expenditures (in US$) by source of financing: Public, Private and ‘Out_of_pocket’ (OUP), 2010. Source of data: World Health Organization. European Health for All Database (HFA-DB)5.

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provide epidemiological postgraduate education, with eight countries (Belgium, Denmark, Germany, Italy, The Netherlands, Spain, Sweden and the UK) offering considerable curricula, i.e. at least five national universities offer educational programmes in epidemiology and public health. To these countries, France has to be added, where the Institut de Sante´ Publique, d’E´pide´miologie et de De´velopement (ISPED) actively cooperates with universities to implement teaching in epidemiology/public health nationwide. Within the Baltic and Balkan countries the offer is less extensive. Nevertheless, in the Baltic countries at least one university offers a masters course (in Lithuania two courses). The offer is similar in the Balkan countries, with the exception of Montenegro. Serbia offers epidemiological education at two universities; particular emphasis is given to public health as it is taught within medicine masters degrees and PhD courses. Advanced training for health professionals and statisticians with an interest in epidemiology is quite consistent in the Balkan, Baltic and Western European countries. Also in these activities, the EU acts as a promoter. The European Programme for Intervention Epidemiology Training (EPIET)—which is included in the Training Programmes in Epidemiology and Public Health Interventions Network (TEPHINET) and is carried out by the European Centre for Diseases Prevention and Control (ECDC) seated in Stockolm [www.ecdc.europa.eu/]— provides professional training and practical experience in intervention epidemiology, for public health professionals and medical practitioners. Also, the International Agency for Research on Cancer (IARC) [www.iarc.fr/], the WHO’s specialized cancer agency based in Lyon, France, offers training courses in cancer epidemiology. In the Baltic and Balkan countries, developments in public health education have occurred in recent years through international networks. In particular, the Open Society Institute (OSI) Network Public Health programme has developed training for public health professionals from Central and Eastern Europe and the former Soviet Union [http://health.accel-it.lt/en/about_us/]. Erasmus–Western Balkans (ERAWEB) is a joint mobility programme offered by eight Western Balkan universities and six EU universities, aimed at promoting research in medicine and health sciences and to promote students’/faculty members’ mobility [http://erasmus-westernbalkans.eu/]. The European Educational Programme in Epidemiology [www.eepe.org/] held in Florence since 1988 is the first epidemiological summer school established in the region, with a faculty drawn from globally leading institutions. Over two 2000 students have attended the programme since its inception. Today, epidemiological summer schools are held by universities and public health institutions in


Education Area (EHEA) which aims to ensure more comparable degrees and encourage student mobility and employability across European countries.81 All countries included in this paper are EHEA members and have remodelled or are currently remodelling their higher educational systems. The EU is strongly committed to standardization of education in epidemiology, as demonstrated by the establishment of programmes for the European Public Health Master [www. europubhealth.org], the EU Master of Science in Epidemiology [www.lsht.ac.uk/study/cpd/eu_mse.html] and the European Master and Doctorate of Science in Advanced Epidemiology [http://madeineur.eu]. All three programmes are (partially) supported by the EC and they represent an example of joint masters, i.e. they are offered by a consortium of universities across Europe. The Association of Schools of Public Health in the European Region (ASPHER) was founded in 1966 as part a worldwide initiative to establish Associations of Schools in every WHO region, to support public health education. During late 1980s, ASPHER laid the foundations for a European Master in Public Health. Today it aims to enhance epidemiological teaching and training of professionals in public health and it has over 100 institutional members located throughout Europe, with all countries included in this review, except Luxembourg, BosniaHerzegovina, Montenegro and Malta, having at least one [www.aspher.org/]. To define the consistency of educational courses in epidemiology, searches of universities’/professional societies’ websites were performed and an e-mail survey on teaching activities was carried out among professional societies. Education in public health was also considered because public health is probably the principal practical application of epidemiology. So not considering educational courses labelled as ‘public health’ would have led to a bias in the total educational offer. In total 118 institutions were identified that provide postgraduate education in the region (see Supplementary data 1, available at IJE online). The quality and comprehensiveness of this information may be biased by inaccurate and/or dated internet sources and relatively low survey response (50%). Master degree courses are the primary qualification for professionals and designed to cover five ‘core’ disciplines: epidemiology, biostatistics, environmental health, health policy, and social and behavioural sciences. A master degree usually takes 2 years of full-time study and requires the candidate to conduct and present in a thesis an original research project. Doctors of Philosophy (PhD) and postdoctoral programmes comprise advanced professional degrees with an average duration of 4 or 5 years, that aim to develop integrated interdisciplinary expertise and include original research cumulating in a doctoral dissertation (Table 2). All Western European countries except Luxembourg



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Table 2. Number of institutions giving post-graduate training in epidemiology and public health Countries

Type of epidemiological training Master Philosophy Post-doctoral degrees doctorates programmes

2 3 1 1 2 4 1 2 2 7 – 4 – 1 2 4 3 5

1 – – 1 – 2 – 1 – 2 – – – – – 1 1 2

4 6 5 2 4 14 2 2 2 11 – 5 1 3 11 8 4 21

– – –

– – –

1 1 2

– – 1 – – – 2

– – – – – – –

1 1 1 1 – 1 2

1

–

1

a The Institute of Public Health (ISPED) provides epidemiological education, in collaboration with universities nationwide.

many countries (Austria, Denmark, Finland, France, Germany, Greece, Italy, Lithuania, The Netherlands, Spain, Slovenia, Sweden, Switzerland and the UK). The established academic tradition in epidemiology of Western European countries is also reflected in the number of European textbooks and reference works. Two of the world’s leading publishing companies in science and health information, Elsevier and Springer, have headquarters in The Netherlands and Germany, respectively. In 2008, Springer also acquired BioMed Central, becoming the largest open-access publisher in the world. The British Oxford and Cambridge University Presses, the world’s oldest

Research institutions and funding In all Western European countries (except Switzerland), all Baltic countries and Croatia, Slovenia and Malta, national health institutions are involved in surveillance of and research in communicable diseases. These bodies are affiliated to the European Centre for Disease Prevention and Control (ECDC), the EU agency aimed at strengthening Europe’s defences against infectious diseases [http://www. ecdc.europa.eu/en/Pages/home.aspx]. No scientific research institution for all noncommunicable diseases exists at European level (nor, in fact, worldwide). IARC is a unique institution carrying out research in the fields of cancer biology, epidemiology and prevention, and management of the IARC biobank, one of the largest biobanks in the world. The European Cancer Observatory is an EC-funded project developed at the IARC in partnership with the European Network of Cancer Registries within the Europe against Cancer: Optimisation of the Use of Registries for Scientific Excellence in research (EUROCOURSE) project. The observatory provides comprehensive information on cancer burden in Europe through three websites [www.eco.iarc.fr/ eucan/Default.aspx; www.eco.iarc.fr/eureg/Default.aspx; www.eco.iarc.fr/eurocim/Default.aspx]. High-quality population-based and disease-oriented biobanks have been established in many European countries.82 A particular, large expertise has been developed by European epidemiologists in the field of cancer screening programme monitoring and evaluation, in particular in Western European countries in most of which populationbased screening is undertaken (Supplementary data 2, available at IJE online). The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), an agency of the EU, was established in 1993 in Lisbon (Portugal) [http://www.emcdda. europa.eu/]. The Cochrane Collaboration is an international independent network, in official relationship with the WHO— and supported by national governments, international governmental and non-governmental organizations, universities, hospitals, private foundations and personal donations—which promotes systematic reviews to inform healthcare decisions. It was founded in the UK and currently includes working groups of experts from more than 120 countries. Over 5000 reviews are available online in the Cochrane Library [www.thecochranelibrary.com/].


Western European countries Austria 3 Belgium 5 Denmark 4 Finland 2 Francea 6 Germany 10 Greece 1 Iceland 2 Ireland 1 Italy 8 Luxembourg – Netherlands 5 Norway 1 Portugal 2 Spain 10 Sweden 7 Switzerland 4 United Kingdom 18 Baltic countries Estonia 1 Latvia 1 Lithuania 2 Balkan countries Albania 1 Bosnia-Herzegovina 1 Croatia 1 TFYR Macedonia 1 Montenegro – Slovenia 1 Serbia 1 Other countries Malta 1

Total number of Institutions

publishing houses, are also based in the region and have specialized sections for life sciences and for epidemiology, biometrics and biostatistics.

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policies or services and 10% specifically addressed older people. Just over a quarter of projects investigated causes of diseases, of which approximately one-third focused on genetic and environmental determinants and about 20% on gene-environment interactions. Project objectives ranged over deepening knowledge on disease aetiology, improving diagnostic tools and treatment, disseminating knowledge and covering the gap between science and its applications in prevention and clinical treatment. Over 90% of ‘epidemiological’ projects were led by a Western country. The UK coordinated approximately a quarter of projects, followed by The Netherlands, Germany, France and Italy. The UK, Germany, Italy, The Netherlands, France, Spain and Sweden were the most frequent project participants. The Baltic and Balkan countries participated in 11% and 10% of the projects, respectively. Other European countries were included in about 40% of projects and non-European countries in about 18%.

Publications We conducted a systematic search of Medline-indexed journal articles to estimate publication activity, mainly in the period 1993–2012.84 An epidemiological publication about a country/countries was defined as a Medlineindexed paper with ‘epidemiology’ appearing as a Medical Subject Heading (MeSH) or ‘epidemiol*’ appearing in the title or abstract of the publication, ‘humans’ appearing as a MeSH heading and the country/countries appearing as a MeSH heading or in the title or abstract. This definition is comparable with that used in the majority of articles in this series.2 The exact strategy is available from authors on request. Approximately one-third (32.4%) of 1993–2012 epidemiological publications about any country in the world concerned one of the UN32 countries, with the great majority (96.4%) reporting about a Western European country. Growth in epidemiological publications about Western European countries was particularly strong, moving from an average of 41 publications per year in 1950–69 to 1966 in 2000–12. A similar pattern was observed for the Baltic countries (from 1 per year in 1950–69 to 20 in 2000–12) and Balkan countries (from less than 1 to 62). The UK, Italy, France and Germany were the countries on which the largest numbers of epidemiological publications reported (Figure 11). However, the 1993–2012 country publication rate per million of population, a summary measure over many years of research activity, were highest for Iceland (793), Denmark (308) Bosnia-Herzegovina (321) and Sweden (262). An additional Medline search was conducted to determine each epidemiological publication’s country of


Out of the 16 ‘methods groups’, 8 are placed in Europe as well as 7 of the 11 ‘fields and networks’ and 37 of the 53 ‘review groups’ [http://www.cochrane.org/contact]. National statistical organizations are active in all countries and cooperate with EUROSTAT, the EU statistical office that provides demographic, economic, social and health statistics (ec.europa.eu/eurostat). Health research priorities and strategies are defined by national governments with support from international organizations, principally the WHO Regional Office for Europe that provides all 53 European countries with statistics on demography, mortality, morbidity, risk factors and health services. The EC is aimed at harmonizing the health status of citizens in member states through two structures, the Directorate for Research and Innovation and the Directorate for Health and Consumers (DG SANCO), of which the latter has national contact points in all 18 Western countries, in the Baltic countries, and in Croatia, Slovenia and Malta. The Public Health Innovation and Research in Europe (PHIRE) project has evidenced that health research strategies were present in 15 EU member states and that public health research was identified in three national strategies.83 The EU European Medical Research Council [www.esf.org/] and Science Europe [www.scienceeurope.org/] further boost biomedical research and assist between-country collaborations. Funding for biomedical and public health research is provided mainly by national governments. The EC promotes and funds research in any field of science through multi-annual programmes settled by the DirectorateGeneral for Research and Innovation [http://ec.europa.eu/ research/index.cfm]. Besides public funding, a relevant number of non-governmental organizations provide funds for biomedical and public health research. The contribution of industry is generally limited to funding clinical trials. To determine the areas covered by EU-funded epidemiological research, we have analysed the Community Research and Development Information Service (CORDIS) database provided by the EU publications office [http:// cordis.europa.eu/], which includes all research projects supported under the 5th, 6th and 7th Framework Programmes. We searched the database for ‘epidemiological’ projects defined as disease modelling, aetiological studies, clinical trials (excluding phase I), intervention trials, data mining and biobanking, epidemiological surveillance, health promotion, health policy evaluation and health service research. The exact strategy is described in Supplementary data 3 (available at IJE online). Approximately 50% of CORDIS-indexed ‘epidemiological’ projects concerned non-communicable diseases, 20% communicable diseases, 10% evaluated health



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(principal) origin. More than half (57.7%) of the total 1993–2012 epidemiological publications about Western European, Baltic and Balkan countries were principally authored by a researcher affiliated to an institution in these countries. In absolute terms, the largest number of epidemiological papers was principally authored by researchers from institutions located in the UK, followed by Italy, France and Spain (Table 3). Estonia and Croatia were the most productive among the Baltic and Balkan countries, respectively. When considering the scientific productivity of each country regardless of which country/ countries epidemiological publications reported on, it emerged that about one-third of epidemiological publications of which the principal author was affiliated to an institution in any country of the world was principally authored by a researcher affiliated to an institution in the WHO region. In particular, the UK leads publication activity, accounting for 24.3% of 59 671 epidemiological publications in the period 1993–2012, followed by France (13.4%), Italy (11.8%) and Germany (10.0%). Of all the epidemiological papers for 1993 to 2012, 63% could be classified as belonging to one of: communicable diseases; maternal, perinatal and nutritional

conditions; cancer; CVD; other non-communicable diseases; and injuries. The percentages of such publications about communicable diseases (25%), maternal, perinatal, and nutritional conditions (3%), cancer (23%), CVD (11%), other non-communicable diseases (48%), and injuries (15%) weakly corresponded with the burden of disease in the region (estimated from mortality data). Western European, Baltic and Balkan countries also publish several epidemiological journals. The Journal R 85 Citation ReportsV categorizes scientific journals according to the main subjects of published articles. We searched for scientific journals falling into categories that mainly included public health, general medicine and epidemiological research, finding that 174 (41%) of the indexed 420 journals originated in a country of the region. Out of these 174, 89 were published in the UK, 11 in France and Germany and 10 in Italy and The Netherlands.

Personnel Although formal statistics of the number of epidemiologists are not available, it is well known that epidemiological workforces vary across countries. Some Western


Figure 11. Number of publications (1970–99) and publication rate (1993–2012) of Medline-indexed epidemiological papers, by decreasing rate within different groups of countries. Publication rate is defined as the ratio of number of epidemiological papers published in 1993–2012 to population size in 2008, expressed per million of inhabitants. Population data refer to 2008, source: United Nations, Department of Economic and Social Affairs. World Population Prospectus: The 2008 Revision. New York, NY: United Nations, 2008. Data for Macedonia refer to 2010 and data for Montenegro refer to 2011, source: World Health Organization. World Health Statistics. Geneva: World Health Organization, 2012. The search was based on the word ‘epidemiol*’ appearing in the title or abstract of the paper. As this term is not always included, the number of identified papers could to be an underestimate of the total number. However, this search strategy included ‘epidemiology’ as a MeSH term, allowing all papers labelled as epidemiological by a Medline indexer, through objective inclusion/exclusion criteria, to be included in this analysis. Because this analysis does not take into account citation indices such as the journal’s impact factor or the researcher’s h-index, it is unable to differentiate high- or low-quality publications or to quantify relevance and impact of epidemiological contributions.85.

318


Table 3. Quantity of epidemiological papers concerning the country which are principally authored by a researcher affiliated with an institution in the country, 1993_2012. To determine each epidemiological publication’s country of (principal) origin, the condition that countries appeared in the search field containing the institutional affiliation of the paper’s principal author has been included Country

Number of epidemiological papers about the country

247 358 1015 808 2565 1731 570 101 284 2621 20 1269 633 258 1872 1602 452 3808 64 15 52 10 2 243 20 5 74 82 26 20807

% of epidemiological papers principally authored by a researcher affiliated with an institution in the country

58.4 48.1 51.6 60.2 61.3 58.9 46.8 74.3 39.5 43.8 61.5 55.6 75.5 59.7 55.1 50.2 66.1 45.4 63.2 38.3 41.3 21.7 44.1 45.6 15.4 1.7 62.5 64.5 7.1 48.4 64.1 45.6 45.6 57.8

European countries, including the UK, Denmark, France, Germany, Italy, The Netherlands and Spain, have the benefit of a long tradition of epidemiological activities. They have a highly qualified epidemiological workforce

Challenges and Perspectives Within the limits of this paper which generally surveys the epidemiological profile and the status of the epidemiological research in 32 countries, it emerges that differences exist among European countries in health profile as well as in knowledge of the health status of the population and in health research strategies. The WHO European policy framework ‘Health 2020’ aims at supporting actions to ‘significantly improve the health and well-being of populations, reduce health inequalities, ensure people-centred, equitable and of high quality health systems’ [http://www. euro.who.int/en/health-topics/health-policy/health-2020the-european-policy-for-health-and-wellbeing]. The overarching aims of the EU Third Health Programme for 2014–20 are aligned to promote health, prevent diseases and facilitate access to better and safer health care for EU citizens. Measuring population health and implementing cost-effective, evidence-based interventions have been emphasized as ‘core aspects’ of the health research in the EU programme ‘Horizon 2020’ [http://ec. europa.eu/programmes/horizon2020/en]. Epidemiologists, therefore, might make a substantial contribution to setting priorities and planning actions for monitoring and improving population health. Western European countries have a long-standing tradition of epidemiological research. In these countries, the dialogue with health planners begins


Western European countries Austria 514 Belgium 694 Denmark 1687 Finland 1319 France 4358 Germany 3701 Greece 767 Iceland 256 Ireland 649 Italy 4260 Luxembourg 36 Netherlands 1680 Norway 1061 Portugal 468 Spain 3726 Sweden 2422 Switzerland 996 United Kingdom 6022 Baltic countries Estonia 155 Latvia 69 Lithuania 118 Balkan countries Albania 65 Bosnia and 121 Herzegovina Croatia 389 TFYR Macedonia 31 Montenegro 70 Serbia 153 Slovenia 128 Other countries Malta 57 Total 35972

Number of epidemiological papers principally authored by a researcher affiliated with an institution in the country

available in academia and in their national health services and, in some countries such as Germany, Finland, Italy, Denmark, Ireland, France and Latvia, within institutes devoted to other disciplines, such as environmental protection agencies, institutes for food and nutrition and institutes for economics. In the IEA-Europe member register, albeit a very crude measure of the number of epidemiologists, Western European epidemiologists represent about 90% of the whole European memberships. In the Balkan and Baltic countries, the role of epidemiologists is not yet fully exploited. Recently, efforts to develop the workforce as well as research and education in epidemiology and public health have commenced, facilitated by a number of international projects implemented around the turn of the millennium.86 Professional associations are active in most countries (Supplementary data 4, available at IJE online). These societies play important roles in education, in knowledge-sharing and in fostering debate within the scientific community. The European Epidemiology Federation of the IEA includes 16 national societies and the European Young Epidemiologists network. It sponsors European regional conferences held by an affiliated society in its respective countries on a rotating basis [www.iea-europe. org/].


population. Intersectorial policynmaking that adopts ‘health in all policies’ and ‘health equity in all policies’ approaches is recommended.55 The health system plays a central role for improving health and health equity through addressing differences in risk factors (e.g. through smoking cessation programmes targeted at disadvantaged groups) and guaranteeing access to high-quality health care, including medical innovation for all population groups. This requires monitoring of access to services and the development of good performance indicators.55 In particular, the Baltic countries would benefit from placing a greater focus on SDH, health promotion and disease prevention, addressing people of lower SES.79 Further research is also required on factors that have not received sufficient attention in the region, such as indigeneity, ethnicity, migrant status, gender identity and sexual orientation. Recently all the European countries have committed to the principles of universal access, equity and solidarity as core values of European societies. Additional research on structural SDH such as welfare regimens, social and health investments, and individual policies is a priority. The paradox that inequalities have persisted or even widened during the expansion of the welfare states and increased during the recent global economic crisis underlines the necessity and urgency of this research domain.92–94 Improving data collection and data quality and comparability across countries is indispensable to guarantee individual and population health. A proposal for a personal data protection regulation that would permit the use of an individual’s data only with the explicit consent of that individual has passed the EU Parliament and is currently debated within the EU Council. Many epidemiological and public health associations, including the European Public health Association (EUPHA) and IEA, foresee difficulties for epidemiological and public health research arising from this proposed regulation. Limiting the use of an individual’s personal health-related data only to cases of ‘high public interest’—as stated in the regulation’s article concerning health research—would probably make large sections of epidemiological work impossible, at least in some countries. In conclusion, epidemiologists can contribute considerably to improving population health and health equity in Europe. The dialogue between epidemiologists and health planners needs to be strengthened to guarantee translation of epidemiological evidence into cost-effective policies. The importance of epidemiological research must be further explained to legislators, when rules are formulated that regulate the production, maintenance and sharing of data, in order for legislators to better understand the potential of epidemiological resources to contribute to the health of European citizens.


to produce interesting results in some fields such as communicable diseases monitoring, health promotion and cancer screening. However, the planning of teaching and training and the definition of competency frameworks for public health workforce development would require more emphasis on epidemiological skills development. The currently high level of epidemiological research activity and productivity represents a valuable and rich resource for society, which should be maintained and enhanced. In the Baltic and Balkan countries, education in the discipline is relatively less developed. Stronger teaching and training programmes and dedicated funding initiatives are needed to raise the level of epidemiological work, in particular in the field of non-communicable diseases monitoring and prevention, healthy behaviour promotion and intervention policy evaluation. An exemplary collaborative project primarily aiming at producing an overview of public health research was the 3-year Strengthening Public Health Research in Europe (SPHERE) collaboration of 16 partners. This was founded under the leadership of the UK Faculty of Public Health of the Royal College of Physicians with funding from the EU Commission’s Sixth Framework Programme, and evidenced a relative underinvestment in national structures and health research strategies in some countries, notably in the Baltic and Balkan countries [http://www.who.int/nmh/ publications/ncd_report2010/en/]. Countries need to make their research competencies and tools available through high level, international cooperation, to examine the similarities and differences in risk factor distribution and disease occurrence and evaluate the performance of the healthcare and prevention services. There is a need to link epidemiological profiles on health and health determinants with information on policies at national and European levels and to measure how much policies affect the projected trends. Encouraging results have been evidenced on the effects of tobacco control policies and alcohol and smoking restriction on peoples’ behaviours.87,88 Even though total population health has improved considerably in many countries of the region, persistent within- and between-country inequalities continue to challenge national governments and European institutions. The results of epidemiological studies suggest that inequalities in mortality most likely reflect inequalities in disease incidence and risk factors. They also suggest that policies and public health interventions can impact differently with regard to SES,75,89–91 and that reducing inequalities in health requires the implementation of health and social policies that address the SDH and effectively favour the adoption of healthy behaviours in disadvantaged groups of

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Supplementary Data Supplementary data are available at IJE online.

Funding Funding by the International Epidemiological Association is acknowledged.

Acknowledgements

Conflict of interest: None declared.

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We thank colleagues who have contributed to the survey on teaching and training: Ellen Aagaard Nøhr, University of Aarhus (Denmark); David Batty, University College London (UK); Biljana Danilovska, Center for Public Health - Skopje (TFYR Macedonia); Livia Giordano, AOU City of Health and Science, Turin, Italy; Eva Grill, University of Mu¨nchen (Germany); Andrej Gribovski, Norwegian Institute of Public Health, Oslo (Norway); Biljana Kocic, University of Nisˇ (Serbia); Alessio Petrelli, National Institute for Health, Migration and Poverty, Rome (Italy); Alberto Ruano, University of Santiago de Compostela (Spain); Laufey Tryggvado´ttir, Icelandic Cancer Registry, Reykjavı´k (Iceland); Maurice Zeegers, Maastricht University (The Netherlands). We thank for their comments and suggestions: Roberto Bertollini, WHO, Geneva (Switzerland); Francesco Forastiere, Regional Health Authority of Lazio, Roma (Italy); Livia Giordano, AOU City of Health and Science, Turin, Italy; Giuseppe Gorini, Cancer Prevention and Research Institute, Florence (Italy); Katrin Lang, University of Tartu (Estonia); Gavino Maciocco, University of Florence (Italy); Giovanna Masala, Cancer Prevention and Research Institute, Florence (Italy); Mati Rahu, National Institute for Health Development, Tallinn (Estonia); Marco Zappa, Cancer Prevention and Research Institute, Florence (Italy). We thank Nigel Barton for analysing the CORDIS database; Simona Gallo Mosala for collation of questionnaires and internet searches on teaching institutions and Lucia Castellucci for editing. We thank Cesar Victora for guidance in the preparation of the article. Contributors: A.S.C. conceived the structure of the paper and wrote the manuscript. F.P. performed the bibliometric research. F.G. performed the survey on education. A.S.C. and F.G. performed the analysis of the CORDIS database. F.G., F.P., R.S., P.V. and R.W. contributed in revising critically the manuscript and providing it with suggestions on the design and relevant contents. F.G., F.P. and R.W. contributed to revising and editing the final version. All the authors approved the version to be published.



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