European Regions Research Articles

TB Care in Ukraine: Understanding Access Barriers at the Primary Healthcare Level

Abstract Background In the WHO European Region, Ukraine is a high-priority country for TB control, being one of nine globally with high rates of multidrug-resistant TB. The WHO emphasizes patient-centered TB care, prioritizing patients as key figures in the care continuum. Thus, our aim was to explore barriers impacting the accessibility of TB services for patients at the primary healthcare level (PHC) in Ukraine. Methods During December 2022-June 2023, a qualitative study was conducted across eight PHC facilities in the Kyiv, Odesa, Mykolayiv, and Volyn regions. The study comprised: 4 focus groups involving 27 family doctors, 16 in-depth interviews with managers and health authorities from regional and national levels, as well as 25 interviews with TB patients. All data was transcribed, manually coded and deductively analyzed. Results All participants highlighted the benefits for patients of providing TB care continuum at the PHC level, yet the program lacks clear requirements for training of family doctors and nurses. Overall family doctors perceived positively various TB training they received; but despite this, they expressed doubts and reported a lack of practical skills, affecting the quality of care provided. Patients highlighted several barriers in interacting with healthcare providers, including stigma and cases of dismissive behavior of healthcare workers, communication challenges, and breaches of patientś data confidentiality. Patients also mentioned self-stigma, and perceptions of family doctors as poorly trained in TB. Still, patients who received healthcare services from the same family doctor “during long time” positively described their experience with TB services too. Conclusions Establishing robust patient-provider interaction at the PHC level can help overcome persistent barriers to TB care continuum in Ukraine. To achieve this, a comprehensive TB training program tailored for PHC family doctors and nurses should be developed and implemented. Key messages • Expanding TB healthcare services to primary healthcare levels in Ukraine can be beneficial for patients. Training primary healthcare staff can enhance TB care quality. • Establishing robust patient-provider interaction at the PHC level can help overcome persistent barriers to TB care continuum in Ukraine.

Training and capacity building on the effects of climate change on health: a need to up-scaling

Abstract The need to develop training on the effects of climate change on health is obvious, as the awareness on this topic is growing but the knowledge is not enough disseminated. ASPHER has taken several initiatives to address this subject. Among them, three activities deserve to be highlighted: in cooperation with the GCCHE, we have set up an intensive online course with a great success (nearly 1.000 participants in each of the 10 sessions). With the same partner we have conducted a survey in all SPHs members of our network, to be able to map training activities in the European Region and follow their development. We also work with the European Observatory on climate change and health to reinforce capacity building at European level. But this is not enough and we have to go faster and further in several directions: - by linking more closely multidisciplinary research and training, as knowledge is evolving quickly; - by developing specific training for all public health trainees. This is why we need to incorporate this topic in public health core curriculum; - by having some modules tailored to different publics: public health professionals, health professionals, but also local, national and European decision-makers and stakeholders. To conduct these activities, we have to reinforce our different partnerships and create a powerful alliance at the European level.

Processing of Larvae of Alphitobius diaperinus and Tenebrio molitor in Cooked Sausages: Effects on Physicochemical, Microbiological, and Sensory Parameters

Proteins from insect production represent an interesting (environmentally friendly) option or supplement to commercial livestock farming. At present, however, the larval stages of T. molitor (mealworm) and A. diaperinus (buffalo worm) have been authorized as food for human consumption EU-wide, as have the nymph and adult stages of Locusta (L.) migratoria (Locusta migratoria, Linnaeus, 1758) and Acheta (A.) domesticus (house cricket, Acheta domesticus, Linnaeus, 1758). However, there is the problem that insects that are recognizable as a whole tend to be avoided by consumers, especially in the European region, as they are reminiscent of living things and can cause aversion and disgust in consumers. Against this background, in the present study, five batches of two types of cooked sausages were produced: on the one hand, with turkey, and on the other hand, with pork lean meat as a base. In different formulations, 10% and 20% of the meat contents (turkey or pork) in these meat products were replaced by deep-frozen, pulverized T. molitor and A. diaperinus larvae. The effects of the addition of these insects in the products on the microbiological and physicochemical parameters of these cooked sausages, compared to a product without insect content, directly after heating, were investigated. After production, a storage trial was also carried out to determine whether possible insect ingredients could influence the growth of inoculated bacterial species (Bacillus (B.) cereus, Escherichia (E.) coli, Listeria (L.) monocytogenes, and Campylobacter (C.) jejuni) and how the addition of insect larvae affectsthe sensory and physicochemical properties during storage. The study showed that the products with insects had reduced lightness (turkey p C = 0.025), increased yellowness (pork p S = 0.0009, p C < 0.0001 and turkey p C = 0.0027) and a reduced red color (pork p S < 0.0001, p C = 0.0001) after heating when compared to the cooked sausages without insects. However, no significant differences between the various cooked sausages with or without insects in terms of cooking loss, firmness, and protein, ash, and fat or water contents were found. The microbiological tests showed, on the one hand, that the prior microbial reduction (e.g., in the form of blanching) of the insect larvae was essential in order to guarantee the flawless microbiological quality of the cooked sausages and, on the other hand, that the addition of insects to the cooked sausages did not significantly affect the growth of the inoculated bacterial species and that no sensory differences could be detected during storage. Despite the significant color effects on the product, A. diaperinus and T. molitor larvae would be suitable as protein or meat alternatives in cooked sausages, but they would have to undergo pre-treatment, primarily with regard to microbiological safety. The extent to which a complete replacement of meat is possible has to be investigated in further studies.

Reduced physical activity in youth during the COVID-19 pandemic: systematic review and meta-analysis

Abstract Background Emerging research suggests that physical activity among children and adolescents decreased during the COVID-19 pandemic. As a summarizing analysis of changes in youth’s physical activity for Europe is lacking, we performed a systematic review and meta-analysis to close this research gap. Amongst others, we examined the relevance of restriction stringency policies and potentially vulnerable groups. Methods In consideration of the PRISMA statement, we searched seven databases and included studies for children and adolescents (≤19 years) of the WHO European Region that compared physical activity during the pandemic with a pre-pandemic baseline using validated measurement instruments. We used the Oxford Stringency Index as an indicator of restriction stringency. Screening for eligibility, data extraction, assessment of the study risk of bias (using ROBINS-E instrument) and certainty grading of evidence (using the GRADE approach), were all done in duplicate. Data were pooled in random effects models (Trial registration: PROSPERO: CRD42023395871). Results Of 14,897 non-duplicate records, 26 publications (n = 15,038 pre-pandemic, n = 13,041 during pandemic) met our inclusion criteria. Comparison before vs during the COVID-19 pandemic revealed a significant reduction in total physical activity (standardized mean difference [SMD], -0.57 [95% CI, -0.95; -0.20]) and moderate-to-vigorous physical activity (SMD, -0.43 [95% CI, -0.75; -0.10]), corresponding to a decrease of 12 min/day (a 20% reduction of the WHO recommendation). Subgroup analyses suggested that children aged 8-12 were particularly affected. The analyses outline a possible association between school closures and more reductions in physical activity. Conclusions A sharp decline in all forms of physical activity was recorded among European children and adolescents during the COVID-19 pandemic, particularly in middle childhood. Policy-makers, teachers and practitioners must act to reverse this decline. Key messages • Physical activity in European children & adolescents decreased significantly during the COVID-19 pandemic. • Immediate action by policy-makers and practitioners is imperative to reverse this trend.

The process of developing a framework for code of ethics

Abstract Issue/Problem The World Health Organisation (WHO) and Association of Schools of Public Health in the European Region (ASPHER) roadmap for the professionalisation of the public health workforce has noted ethics as a pillar for professionalisation. It also highlights the need for code of ethics and professional conduct for all public health professionals and institutions. The Global Network for Academic Public Health (GNAPH), in collaboration with EUPHA, ASPHER, and the UK Faculty of Public Health has been working together for a code of ethics. Description of the problem The WHO/ASPHER group asked for a framework to be developed by the expert group as part of the rollout of the professionalisation agenda. The objective of this work was to develop a guide that is applicable to different countries within Europe to develop their own of code of ethics and conduct. A modified Delphi approach to building consensus amongst professionals in ethics included law, academia, and public health professionals. The questions sought to be answered were what and how to develop a framework and what should be included in the guide for creating a public health code of ethics. Results Throughout this method we developed five values, and twelve principles that are essential for the development of a code of ethics through a consensus building exercise. This framework was the first of its kind as part of the professionalisation agenda for different regions. There will be ongoing work piloting this framework in practice with various professional groups and institutions. Lessons Throughout this process, the need and demand across the public health community for ethical education and development of code of ethics was made evident. Collaboration between academics, ethicist, lawyers, and public health professionals and policy makers were key in developing a public health code of ethics. Identifying the challenges with monitoring and evaluating of its implementation a public health code of ethics. Key messages • Ethics, and a code of ethics are an essential component of the professionalisation agenda of the public health workforce. • There is need for continued collaboration and partnership with public health professionals and institutions in enacting its implementation and evaluation.

Physical fitness in youth: a systematic review of changes during and after the COVID-19 pandemic

Abstract Background Restrictions during the COVID-19 pandemic induced changes in the fitness behavior of children and adolescents, which may be associated with long-term public health challenges. This systematic review analyses how physical fitness has changed during the pandemic and to what extent the changes remain in the aftermath of the pandemic. Methods We conducted a systematic search in seven databases with a peer-reviewed search string for studies until Dec 2023. Our inclusion criteria encompassed studies with children and adolescents ≤19 years living in the WHO European Region and in which validated measurements were used (single measurements or test batteries). Eligibility screening, data extraction and risk of bias assessment (using ROBINS-E instrument) were all carried out independently by two reviewers. We published an a priori protocol in a peer-review journal and conducted reporting in accordance with the PRISMA 2020 statement. Trial registration: PROSPERO: CRD42023395871. Results Our search retrieved 28 studies from 15 WHO European Region countries with an age range from 5 to 19 years. Physical fitness was reported in 21 validated single measurements (e.g. 20 m shuttle run, handgrip strength, standing long jump) and 9 validated test batteries (e.g. Alpha-Fitness Battery, German Motor Test, International Physical Performance Test Profile). The preliminary analyses pointed to a sharp decline in youth physical fitness during the COVID-19 pandemic. After restrictions were eased, physical fitness improved, but remained under pre-pandemic levels, particularly in boys. Conclusions The findings indicate a potential suboptimal behavioral adaptation of children and adolescents after the COVID-19 pandemic. Medium and long-term programs to change passive behavior and improve physical fitness are urgently needed. In addition to individual prevention programs, stronger consideration should also be given to schools and sport clubs regarding activities promoting physical fitness. Key messages • Physical fitness in children and adolescents remains below pre-pandemic levels after restrictions removal. • Initiating immediate public health action to increase physical fitness is urgently needed.

Are prison settings included in national preparedness plans?

Abstract With the aim to explore the extent to which places of detention are considered in national preparedness planning in the WHO European Region, a desktop review was conducted and combined with responses to the Health in Prisons European Database (HIPED) survey from Member States referring to 2020. In both searches, the aim was to identify the existence of: 1) national pandemic preparedness plans written prior to the COVID-19 pandemic; and 2) national pandemic preparedness and response plans specific to the COVID-19 pandemic. Where prisons were included, all aspects of pandemic preparedness relating to prisons were extracted and collated as per the main domains of the WHO checklist for influenza pandemic preparedness plans. The desktop review found that 30 Member States had pandemic plans accessible online, but only seven included any mention of prisons. Responses to the HIPED survey suggested wide dissemination of a COVID-19 preparedness and/or response plan, but only six out of 36 Member States referred to prisons or the vulnerabilities of people living in places of detention. The combined findings suggest that prisons are rarely considered in national planning and that lessons from previous pandemics have not led to a change in recognizing that prisons are high-risk environments for pathogen transmission and that failing to consider them in national planning may lead to impacts that affect the wider community.

Innovative tools from WHO Europe to protect children from digital marketing of unhealthy products

Abstract Children in the WHO European Region are extensively exposed to marketing of unhealthy products, including tobacco, alcohol, HFSS foods, and gambling, which negatively influences their dietary choices, behaviors, and perceptions of a norm, threatening their health rights. Recognizing the urgency to protect children’s developmental potential and rights, WHO has actively addressed this issue both within Europe and globally. In 2010, WHO issued recommendations for Member States on marketing foods and beverages to children. Building on these efforts, the CLICK framework for monitoring digital marketing to children was introduced in 2018. In 2023, WHO released guidelines urging countries to adopt comprehensive, mandatory policies to protect children from HFSS food marketing. Despite political commitments and policies, children and adolescents continue to be exposed to unhealthy product marketing, increasing their risk of NCDs as online activity rises. At the same time, while efforts have focused on restricting specific products, rapid changes in digital marketing strategies necessitate broader measures. Emerging trends include promoting brand loyalty among young children through brand characters and logos. Tools and support are urgently needed to monitor and implement WHO recommendations in online settings, including brand marketing. Despite WHO recommendations, few countries have implemented mandatory policies. Reliable monitoring mechanisms are essential. To address this gap, the WHO Regional Office for Europe developed the KidAd platform to monitor children’s exposure to digital advertising.

Screening for congenital Chagas disease in a non-endemic area: a cost-effectiveness analysis

Abstract Background Due to climate changes, immigration, and globalization, Chagas Disease (CD) also afflicts nations without vector transmission. In Europe, congenital CD (cCD) is a significant public health issue, perpetuating the disease: it is crucial to perform CD screening in pregnant women at risk, as the treatment of infants is effective in eradicating the infection. Only a few European regions have a definite algorithm for diagnosing cCD, but no official guidance has been published at the national or European level. To support policymakers, this study aims to outline a cost-effectiveness analysis of CD screening in non-endemic areas, such as Italy, in pregnant women born or arriving from endemic countries and in their newborns. Methods To measure the economic impact of cCD screening, a decision tree model will be used to compare the test option (screening, diagnosis, treatment, follow-up) with no test option (no screening, progression of disease). Model parameters will be taken from relevant scientific literature. The primary outcome will be the Incremental Cost-Effectiveness Ratio (ICER) between the two options. Sensitivity analyses will be conducted to determine how changes in prevalence, transmission rate, screening adherence, and treatment adherence may affect the ICER. Results We expect the ‘test’ option to be cost-effective even with significant reductions in prevalence, transmission rate, adherence to screening or treatment. Threshold levels of these variables will allow to critically extend the results to areas with reduced immigration, patchy distribution of migrants at risk, health logistical limitations, and limited access to care for immigrants. Conclusions Our findings can help policymakers implement official screening programs and diagnostic algorithms for cCD in Italy and other non-endemic countries. This contributes to SDG 3 by combating the spread and burden of neglected tropical diseases and contributing to maternal, child, and migrant health. Key messages • Screening for congenital Chagas Disease in a non-endemic area may be cost-effective and cost-saving. • Study findings could provide useful information for health policymakers to combat Chagas Disease in Europe.

The spatial dimension of ageing and growth in European regions

AbstractThis study aims to tackle the potential effects of population ageing on regional growth dynamics in the EU. We collected information at a NUTS2 level for EU countries from the years 2000 to 2020 to understand the extent to which the ageing of EU society might impact the EU convergence process. Our results emphasize that the ageing of EU society does not seem to harm the possibility of regional economic growth if we think that immigrants can fill openings in local labour markets (left by retired persons), as well as new jobs stemming from new services needed by retired persons (mostly in health and daily care). Our outcomes also stress the relevance of considering the spatial dimension of the analysis to detect the place-based dimension of this dynamic and, hence, the need for tailored policies.

7.F. Scientific session: Living lab Cartesius: multidisciplinary cooperation for health monitoring of an ‘urban blue zone’

Abstract This workshop will be based on health monitoring in living lab Cartesius; a neighbourhood that is currently developed in the city of Utrecht, the Netherlands (Home - Cartesius Utrecht (cartesius-utrecht.nl). The design of this neighbourhood is inspired by the concept of the “blue zones” of Pes and Poulain, places in the world, that they argue are inhibited by the healthiest, longest-living populations because they integrate sustainability, climate adaptation and healthy living. In Cartesius citizens will for example be encouraged to move by inviting outer spaces, meet each other in the community areas and eat healthily nudged by the food options in the food court. An important element of these blue zones is the incorporation of green spaces in the neighbourhood. Examples are (community) parks/gardens, a green walking route around the neighbourhood, trees in the bike parking lots, green facades etc. The neighbourhood is designed to become a home to local species such as plants and animals as well as people. In addition, climate change adaptation is incorporated, the appartements are well insulated and contain solar panels and green and white roofs. Preventing heat stress is considered in the green design of the outdoor spaces and special drainage and water storage equipment throughout the neighbourhood. The municipality has been closely involved in this project from the start, they created the call for developers to create a healthy urban neighbourhood and after selecting the Cartesius project they have remained involved in its development. Of special interest to the municipality is community building (in new neighbourhoods) in order to strengthen social cohesion and prevent loneliness. We will conduct a research on this topic of which the results could permanently impact how new neighbourhoods in Utrecht will be approached. Designers, developers, research institutes, governments and the current inhabitants are now collectively working on a holistic monitoring programme in this neighbourhood to collect evidence for the effects of the “blue zone” interventions and design choices on behaviour, health and well-being of residents. This workshop will focus on various aspects of the Blue Zone Concept, the importance of green in urban living, the participatory role of local residents, the role of stakeholders and the relevance for local governance. First of all the participants will be informed about a unique healthy/green urban living concept based on the blue zones currently in development. The participants will get insights in the process of developing a new healthy neighbourhood where different challenges (e.g. climate adaptation, community building, healthy living environment) are experimented with stakeholders from the quadruple helix (private, government, science and societal stakeholders). Simultaneously, we want to allow room for ample time for audience interaction to share their experiences on similar multi transdisciplinary cooperations and monitoring strategies. Key messages • This session will provide room for knowledge exchange in the area of healthy urban living and transdisciplinary collaboration. • Specific focus on holistic monitoring of the effectiveness of health interventions in urban living areas and (international) policy implications. The concept of Cartesius The workshop will start with a presentation about the concept of the Cartesius neighbourhood. The incorporation of the elements of the Blue Zones will be discussed and images of both the current state of the development and artist impressions of the future finished neighbourhood will be presented. Room for (among other topics) discussion about the ‘translation’ of the blue zone concept to this urban area. This presetntation will be done by Marije Lammers (University Utrecht, postdoc and coordinator monitoring programme healthy urban living in Cartesius) Incorporating citizens in monitoring 300 appartements in Cartesius are already realized, in which +/- 600 citizens are currently living. In a time span of about 8 years the number of apartments will have increased to 3000, with about 6000 inhabitants. The current citizens are involved in designing the monitoring strategy and community building approach. In order to measure effectively whether the health interventions in Cartesius will impact the citizens’ health their involvement and cooperation is crucial. Room for (among other topics) discussion about involving citizens in monitoring and community building effectively. WHO Europe Healthy Cities This presentation will discuss how developments in the Cartesius neighbourhood are in line with WHO Europe Healthy Cities ambitions for bringing about change and achieving improved health, well-being and equitable and sustainable development in cities across the European Region and globally. Room for (among other topics) discussion about possibilities for international knowledge exchange and applications. This presentation will be by: Kira Fortune, Regional Advisor, Healthy Cities, Health Promotion and Well- being, World Health Organization

Disability-adjusted life years 19 former socialist economies in the European region, 1990-2019

Abstract Background Within the Western Balkan Strategic Partnership Project (Work Package 4: Use of Population Health Metrics for Enhanced Surveillance), we conducted a study to describe health progress in 19 former socialist economies (FSEs) in Europe from 1990 to 2019. Our metric of choice was age and sex-standardized rates per 100,000 population of total disability-adjusted life years (ASR-DALY). Methods We applied joinpoint regression with extracted ASR-DALY data from the Institute for Health Metrics and Evaluation result tool. The annual per cent change (APC) and average annual per cent change (AAPC) from 1990 to 2019 were analyzed in 19 former socialist economies (FSEs) in Europe, including Albania, Belarus, Bosnia and Herzegovina (BH), Bulgaria, Croatia, Czechia, Estonia, Latvia, Lithuania, Montenegro, North Macedonia, Poland, Moldova, Romania, Russia, Serbia, Slovakia, Slovenia, and Ukraine. Results The ASR-DALY decreased in Estonia (APC1994-1997= -5.2%, p = 0.034; APC2013-2019= -0.7%, p = 0.07), Latvia (APC1994-1997= -6.3%, p = 0.03; APC1997-2007= -1%, p = 0.001; APC2007-2011= -3.9%, p = 0.01), BH (APC1995-1998= -13.3%, p = 0.041; APC1998-2019= -0.5%, p = 0.004), Bulgaria (APC1997-2000= -2.5%, p = 0.022), Lithuania (APC2007-2010= -4.9%, p = 0.018), North Macedonia (APC2007-2011= -1.9%, p = 0.023, APC2011-2019= -0.5%, p = 0.005), Czechia (APC2014-2019= -0.6%, p = 0.014), Moldavia (APC1998-2007= -0.6%, p = 0.06), and Ukraine (APC1995-2008= -0.5%, p = 0.035). Slovenia performed the best amongst the FSEs (ASR-DALY2019: 16677.51 for women, 21985.95 for men and 19134.73 for both sexes), Ukraine the worst (ASR-DALY2019: 26154.88 for women, 47983.60 for men and 35852.17 for both sexes). Conclusions Except for Ukraine, all FSEs in the European region achieved health improvement. The most common was a three-year decline in ASR-DALY. Health policy changes, investments in health care, and harmonization with EU regulations were among the factors contributing to improved population health in the FSEs. Key messages • Bosnia and Herzegovina is the only FSE in Europe with a continuous 24-year decline in total ASR-DALY. • Reducing total ASR-DALY significantly in a three-year time frame is possible.

Public Health In Conflict And War: A Response To An Ever Evolving Landscape

Abstract Background The bases for this proposal are the current and ongoing conflict and war situations around the world, causing turmoil for nations and hardship and public health crises for people. We can no longer ignore the critical and time-sensitive need to address issues of Public Health (PH) in conflict and war in our education and training programmes. Objectives To consider appropriate themes and topics in Conflict and War that should be included in PH education and training programmes; and to consider how and where they are best represented. Member schools of the Association of Schools of PH in the European Region (ASPHER) were asked to provide details of their curricula relating PH in Conflict and War. Submissions on this topic were received from over 10 schools. Information was collated into logical themes, to which elements of the curriculum were mapped. In a modified Delphi process, respondents were asked for their level of agreement for inclusion in a curriculum and at what level content should be delivered. Results Findings from the survey allowed identification of seven main themes from topics provided: Contextual Factors; Preventive Strategies; Emergency Preparedness; Impact and Response; Conflict Resolution and Solidarity, Rehabilitation and Recovery. Respondents had high levels of agreement that content should be included in curricula and be delivered at every level in PH education and training. Conclusions PH education and training have been deficient in not including PH in Conflict and War as a subject area in programmes. The knowledge and expertise developed of necessity in some places can be shared across the ASPHER network and beyond to increase awareness of the PH considerations of conflict and war. Key messages • Public health in war and conflict zones is critical due to unique challenges and urgent needs of affected populations. • An Integrated curriculum is vital for addressing conflict’s long-term health impact and preparing skilled workforce for health, resilience, action and laying the path to peace.

Spatiotemporal variability of flash floods and their human impacts in the Czech Republic during the 2001–2023 period

Abstract. Flash floods, characterized by their sudden onset, extreme discharge, short duration, material damage, and human loss, represent a significant natural hazard. Not well covered by standard hydrological observations, flash flood data can primarily be derived from various types of documentary evidence. This evidence served as the main data source for creating a flash flood database for the Czech Republic from 2001 to 2023. This database enabled detailed analysis of different aspects of flash floods. The annual series of 233 flash flood events, 160 flash flood days, and 424 affected municipalities showed significant inter-annual variability but no linear trends. The triggering rainfall that generates flash floods was analyzed with respect to 1–3-hourly and daily precipitation totals and circulation types from the objective classification. While flash floods can occur anywhere, they were more frequently recorded at the foots of mountain slopes, often coinciding with “critical points” where built-up areas meet concentrated surface runoff pathways. The division of material damage caused by flash floods into eight categories indicated that the highest proportion of damage was to streets and communications (24.3 %), to houses (21.7 %), and to their cellars and basements (18.3 %). There were also 36 recorded fatalities. The understanding of flash floods in the Czech Republic aligns generally well with studies of flash floods in other European regions.

Increasing trends in hypertension-related mortality in European Union 27 countries from 2011 to 2019

Abstract Background Arterial Hypertension (HT) is one of the most common chronic cardiovascular disease in adults and a leading cause of disability and mortality worldwide. However, update data regarding the HT-related mortality trends in Europe are lacking. Therefore, we assess the age- and sex- specific trends in HT-related mortality in the 27 European Union Member States (EU-27) between years 2011 and 2029. Methods Data were retrieved from the free publicly available EUROSTAT death certificate database to examine age-adjusted HT-related mortality rates (AAMR) (per 100.000 people) and relative average annual percentage change (AAPC) across all European Union 27 countries (EU27) from 2011 to 2019 using the International Classification of diseases, Tenth Revision (ICD-10) codes I10-I13 and I15. To calculate annual trends in HT-related mortality, we assessed the average annual percent change (AAPC) and relative 95% confidence intervals (CIs) using Joinpoint regression analysis. Results Over the study period, 254.540 HT-related deaths (157,081 males) were listed in EU27. Age-adjusted HT-related death increased from 9.12 to 10.7 per 100,000 people [AAPC: +1.5% (95% CI: 0.8-2.0), p<0.001]. Specifically, the HT-related mortality increased in males [AAPC: +1.8 (95% CI: 0.9-2.6) while decreased in women [AAPC: -1.1 (95% CI: -2.0 to 0.2), p=0.001]. Additionally, the HT-related mortality rates increased in northern [+1.5 (95% CI: 0.7 to 2.3), p<0.001] and eastern [AAPC: +3.9 (95% CI: 2.3 to 5.4), p<0.001] EU-27 states. Conversely, the AAMR plateaued in southern [AAPC: -0.1 (95% ci: 0.6 to 0.7), p=0.96)] and western EU-27 countries [AAPC: 1.0 (95% CI: -0.1 to 2.1, p=0.07] over the same period. Conclusions In EU27, HT-related mortality increased from 2011 to 2019, especially in men. However, significant disparities in HT-related mortality rates still exist between different European regions.

2.Y.1. Communication in participatory health research with refugees and migrants

Abstract Innovative approaches are needed to transform public health research and address health inequities. Participatory Health Research (PHR) is one such approach, which aims to maximize the participation of those whose life or work is the subject of the research in all stages of the research process. PHR has advantages for both research outcomes, including increased relevance, meaningfulness and impact of research, as well as for those involved, in terms of ownership and empowerment to address their health priorities. PHR with migrants has potential to reduce health inequities through the active involvement of migrants in research about their health. In a framework for refugee and migrant health in the WHO European Region, MacFarlane et al. (2022) recommend the research field of migration and health to adopt PHR as the norm, for ethical reasons and to support effective research-policy-practice translation. PHR with migrants is increasingly used but is still rare and adhoc in the field of migration health research. There are also potential practical and ethical challenges that warrant critical reflection. One persistent challenge is communication, where differences in culture, language and knowledge areas need to be considered in multiple ways, for example, in the development of participatory partnerships, in the conduct of data collection that takes place as a result of such participatory partnerships and in dissemination processes. The aim of the workshop is to share different approaches on PHR with migrants and propose solutions to common challenges in communication. The workshop will be structured in a first part where presenters will draw upon their experience in PHR with refugees and migrants covering a broad range of topics relating to communication, and a second part of open discussion with presenters and the audience. The workshop will address two key questions: what challenges have we experienced, and lessons learnt. Anne MacFarlane presents emerging evidence about music and singing as culturally attuned arts based methods that can create innovative opportunities for communication for partnership building, fieldwork and dissemination. Ana Gama presents on using idea-generation workshops with vignettes representing migrants with diverse health-literacy profiles and its potential to address communication challenges. Key messages • Participatory health research with migrants warrants critical reflection around communication, ethics and partnership-building. • In participatory health research, using innovative and creative methods can create opportunities to overcome communication barriers and build meaningful collaborations. Speakers/Panelists Anne MacFarlane University of Limerick, Limerick, Ireland Ana Gama IHMT, Universidade Nova de Lisboa, Lisbon, Portugal

11.Q. Round table: A Guide for creating a code of ethics for public health professionals and institutions

Abstract The professional discipline of public health is driven by its values. Public health professionals face decisions that have far-reaching ethical implications. Our norms, values, beliefs and the way we see the world, as individuals, communities and institutions which serve us, do matter and fundamentally affect our decisions, behaviours, policies, and practice. The ability to be aware and reflect on norms and values when taking decisions, is a decisive professional virtue in public health practice. The World Health Organisation (WHO) and Association of Schools of Public Health in the European Region (ASPHER) Roadmap for the professionalisation of the public health workforce, has highlighted ethics as an essential pillar for professionalisation, a core competency, and the need for a Code of Ethics and Professional Conduct for good public health practice. In order to further advance the issue the Global Network for Academic Public Health (GNAPH), ASPHER, the European Public Health Association (EUPHA), the UK Faculty of Public Health and other partners set up an expert international joint working group on public health ethics and law (PHELWG). The PHEL expert working group - which includes senior public health professionals, ethicists, lawyers and academics - has been working to carry out research and develop a guide for creating a Code of Ethics and Professional Conduct for public health professionals and institutions. This has included consideration of the competencies, principles and values for good public health practice. The project has involved literature review, research and the wide professional experience of the international group of experts who have been working on the issue.The development of a guide for creating a code of ethics for public health professionals and institutions is part of the overall objective of the PHELWG to build a ethico-legal competency, capacity and resilience of public health workforce. The proposed Guide and related resources will be a timely resource, practical tool and support for public health professionals, organisations, or regulatory bodies to develop their own local country code of ethics and build further ethico-legal capacity of their public health professional workforce and institutions. Purpose of the roundtable workshop will be to: - present the guide on creating a code of ethics for public health public health professionals and institutions, which will be launched at that time - Share the proposed ethical competencies/skills, principles and values for good public health practice, with particular consideration of Indigenous knowledge and world views - reflect and consult with the workshop participants around the guide and the proposed pilot sites for implementing the Codes in various centres. Key messages • Development of Code of ethics and professional conduct is a key requirement for public health professionalization. • The Guide for creating code of ethics by international expert group provides significant resource for development of codes locally. Speakers/Panelists Kasia Czabanowska Maastricht University, Maastricht, Netherlands Farhang Tahzib Faculty of Public Health, Haywards heath, UK Paul Athanasopoulos Public Health Department, Stirling, UK

A Good Practice for Learning with Public Health Professionals Globally: Humphrey Fellowship Program

Abstract Background International collaborations are valuable yet often undervalued assets that enhance the quality of public health education and bolster the development of the public health workforce. Objectives The Humphrey Fellowship Program, part of the Fulbright Exchange Program, facilitates mid-career professionals’ visits to US-based host universities for an academic year. Fellows engage in a semi-structured fellowship period to achieve self-defined goals, emphasizing professional development, expanded experience, and intercultural exchange. This study advocates for the program’s contribution to enhancing public health education. Results Currently, two universities host fellows in public health. Over decades, fellows have engaged with faculty and professionals, participated in classes and meetings, visited institutions for development purposes, and completed US-based affiliations, contributing significantly to their own and the public health workforce’s advancement. This interaction-based learning approach aids in navigating social and ethical challenges by fostering a deeper understanding of public and global health issues across countries. Conclusions The Humphrey Fellowship Program in public health stands as a commendable model. Similar initiatives could be beneficially replicated in the European region, leveraging local and global successes to strengthen ties with public health education institutions, student communities, and beyond. Key messages • Programs that facilitate international interactions can enhance public health professionals’ understanding of global perspectives. • The Humphrey Fellowship Program in the US stands as a commendable practice for mid-career public health professionals, contributing significant value to the education at host universities.

Assessing progress towards viral hepatitis B and C elimination in prisons in the European region

Abstract Background In 2016 the WHO launched the global health sector strategy for the elimination of viral hepatitis, alongside a dedicated monitoring&evaluation (M&E) framework to assess progress at national, regional and global levels. Despite being a priority setting for viral hepatitis elimination in Europe, prisons are rarely integrated into national monitoring efforts. Besides, prisons are particular contexts with a high viral hepatitis prevalence, where it is possible to utilize adequate micro-elimination strategies. Objectives We aimed to assess available metrics of viral hepatitis burden and coverage of prevention and control interventions in prison settings in Europe using routine sources of data. Methods We adapted the WHO M&E framework for viral hepatitis elimination to the prison context. The resulting M&E framework has 49 indicators of which 10 are defined as core. Data were sourced from available European prison surveillance systems at European level, namely: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and WHO Health in Prisons European Database (HIPED). Results In total 38 countries in the European region provided data to either data sources for 2020. For WHO-HIPED, among core indicators, 3 out of 10 could be calculated for HCV, and covered prevalence, HCV treatment availability and treatment outcome. Concerning HBV, 3 core indicators out of 10 could be calculated and covered prevalence, screening availability and treatment coverage in prison. With EMCDDA surveillance system we could calculate 4 HCV core indicators and 6 HBV core indicators. Lessons Availability of health data from prison settings is scarce, hampering the current capacity to monitor the progress in the viral hepatitis elimination within prisons contexts strategies and its relative contribution to global health goals achievement. A coordinated and standardised M&E framework tailored to this specific setting is needed to foster data collection and systematic monitoring. Key messages • Micro-elimination strategies in prison context contribute to the global health goals achievement. • A coordinated and standardized M&V framework, adapted to the prison context, is needed to foster data collection and monitoring of the viral hepatitis elimination strategy.

3.X.1. Health literacy in Europe: Building a comparative database for shaping public health policy

Abstract Health literacy (HL) is a key determinant of health and a lever for health equity. It refers to the extent to which individuals are able to deal with health-related information, communicate with health professionals, and navigate the health care system to restore, maintain, protect, and improve their health and well-being. It is the result of an interplay between personal motivation, individual competencies and the health information and service environment. HL is strongly related to health behaviors and issues such as obesity, the social determinants of health, and the use of health systems, which have been under pressure since COVID-19. The development and implementation of targeted public health interventions to promote HL in the European Region require reliable and comparable data on population HL to identify the main HL challenges and the most affected population groups. The WHO Action Network on Measuring Population and Organizational Health Literacy (M-POHL) has started monitoring population HL and conducted the first M-POHL Health Literacy Survey (HLS19) in 17 countries in the WHO European Region between 2019 and 2021. In preparation for the 2nd M-POHL Health Literacy Survey (2024-2026; HLS24), the HLS19 instruments were further improved and supplemented by a new measure on mental HL. These instruments are also of interest to the European Joint Action PreventNCD with its specific task on HL and non-communicable diseases (7.4). The workshop will provide insights into the M-POHL HLS24, the largest HL survey in Europe, and the HL instruments used. It consists of four presentations, one describing the M-POHL HLS24 project and three on specific HL instruments used to assess different aspects of HL in the European general population: HLS24-DIGI for digital HL; HLS24-COM-P for communicative HL; HLS24-NAV for navigational HL. Each presentation will describe the revised item set and results from pretests. We invite the audience to ask questions and to engage in a (cross-cutting) discussion with the presenters. Expected impact: The presentations will provide a comprehensive overview of the advanced family of instruments used in the HLS24 study, their quality, and the expected HL data for Europe. They will provide a deeper understanding of how HL will be measured in the M-POHL HLS24 project. Key messages • The advanced family of HL instruments used in the M-POHL HLS24 project enables comprehensive HL monitoring in Europe. • The data collected in HLS24 will provide a solid database for shaping public health policy to strengthen population HL and promote health equity in Europe.