Health Indicators Research Articles

Integrating AI in cause-of-death regular statistical production with human and expert system codings

Abstract Background Cause-of-death (CoD) statistics are key indicators in epidemiology and public health. These statistics are derived from death certificates completed by physicians and are usually coded by official statistics authorities according to the standards of the WHO ICD-10 classification to construct time- and cross-country-comparable statistics. For coding causes of death in free-text format in France according to ICD-10, predictions by deep neural networks (DNNs) are employed in addition to fully automatic batch coding by a rule-based expert system and to interactive coding by the coding team. Methods Seq-to-seq DNNs are trained from scratch on previously coded data to ICD-10 code multiple causes and underlying causes of death. Human coding is focused on certificates with a special public health interest or with low confidence in AI prediction quality to maximize the quality of the overall statistics disseminated when human resources are limited. DNNs also directly predict multiple causes and underlying causes of death for part of the certificates. Hence, the coding campaign aims to optimally allocate a coding mode to a given certificate. Results For deaths in 2021, 63% of the certificates are automatically batch coded by the expert system, 14% by the coding team, and 23% by DNNs. Compared to a traditional campaign that would have relied on automatic batch coding and manual coding, the present campaign reaches an accuracy of 95.7% for ICD-10 coding of the underlying cause (97.3% at the European shortlist level). Conclusions The 3-coding mode approach enables timeliness of dissemination of CoD statistics and may lead in the future to more responsive surveillance. Key messages • Deep neural networks trained on already coded data can be integrated into the regular statistical production of the CoD database in a fully controlled way. • The allocation between the different modes of coding can be optimized to achieve best quality and timeliness under the constraint of limited human resources.

Low physical fitness indicates future injury, mental health, menstrual cycle disruptions and burnout in female emergency service personnel and healthcare providers

Musculoskeletal injury (MSKi), depression, anxiety and burnout place a considerable burden on emergency services personnel and healthcare providers (HCP). Physical fitness is related to both mental and physical health in these populations but females in these are hugely underrepresented in this literature. As female representation in first-responder and HCP roles increases, the need for female specific research is needed. This study examines physical fitness as a short-term indicator of future reproductive health, MSKi, and mental health for females employed as first-responders or HCP. Thirteen first-responders and 29 HCP completed an initial health and demographics questionnaire, a comprehensive physical assessment (e.g., bone mineral density, muscular strength, muscular endurance, muscular power, flexibility, and aerobic capacity), and a health questionnaire 6-7 months after the physical testing. We found that i) bone mineral density, relative upper body strength, and lowerbody power were related to sustaining future MSKi, ii) better lower body endurance and flexibility was related to future menstrual cycle disruptions, and iii) low bone mineral density was related future self-reported burnout and Patient Health Questionnaire score >10. Physical fitness characteristics can be helpful indicators of future MSKi risk, menstrual cycle disruptions, and mental health status in females employed in arduous occupations.

7.X.1. Providing BoD estimates on a regional level – necessity in assessing health inequalities

Abstract Burden of disease indicators, such as Disability-adjusted life years (DALY), Years lost due to disability (YLD) and Years lost due to death (YLL) have become standard indicators in public health reporting systems. Due to the combination of morbidity and mortality, the DALY provides valuable information on the burden due to specific diseases. These tools are employed by policymakers to devise intervention programs with the objective of enhancing the collective health of the population. Studies at the subnational level offer a greater added value to the public health information systems. Identifying variations in health outcomes and disease burden across different regions is a key factor when introducing targeted interventions and allocating resources. Health inequalities persist also in countries with good health systems and well-developed welfare state. There are notable contrasts in the political, economic and social environments across Europe. Moreover, the European countries are at different stages of the epidemiological transition, which encompasses a range of factors influencing health and modifiable risk behaviours. These differences are determined by socioeconomic inequalities at national and sub-national level, such as municipalities, counties and others. It is therefore imperative to provide BoD indicators at the most possible detailed regional-level and to link this information with further indicators such as deprivation indexes or Gini coefficients. Obtaining regional-level data for BoD analysis and health inequalities is not straightforward and can pose many challenges. Data availability is usually scarce and may involve significant resources in collecting it. Data quality and data completeness can also pose challenges in the reporting systems, which can result in under-reporting of certain diseases and overlooking health problems in the population. Also, countries with smaller populations are confronted with the challenge of a limited number of cases, which poses difficulties in obtaining regional estimates. The following workshop presents examples from European BoD studies, that have analysed health inequalities at regional level. The first presentation shows a country comparison study of the overall YLL and their association with socioeconomic and geographical inequalities. The second is from an Estonian study, representing a country with a small population that has developed its own methodology for assessing regional health issues. The third presentation from the German BoD study presents results on 96 spatial planning regions, which have been combined with the German index of socioeconomic deprivation. The final presentation brings example from Norway, where the association between YLL and education and income is examined at municipality level. Key messages • By comparing BoD estimates at the regional level, policymakers and public health officials can identify areas with higher disease burdens, indicating potential health inequalities. • Linking information on BoD indicators with data on regional and socioeconomic inequalities is essential when monitoring developments and tailoring strategies in public health outcomes.

Vascular adaptations following an eight-week sprint interval training intervention in healthy men.

Sprint interval training (SIT) has been shown to improve many indices of cardiovascular risk. The effect of SIT on emerging indicators of cardiovascular health, including arterial stiffness and carotid intima media thickness, remains unclear. Thus, the purpose of this study was to assess changes in augmentation index at 75 beats per minute (AIx@75), pulse wave velocity (cfPWV), and carotid intima media thickness (CIMT) at three time points of an 8-week SIT intervention. Eighteen sedentary men (age: 24.7±5.1 years, BMI: 26.7±5.8 kg/m2) participated in the study. Subjects trained 3 times a week for 8 weeks. Training consisted of 3-6 consecutive 30-second bouts of maximal intensity cycling, with 4.5 minutes of active recovery between bouts. Baseline, 4-week, and 8-week vascular assessments were performed. Training effects were analyzed using repeated measures ANOVA. Pearson correlations were used to determine the relationship between baseline values and the change scores (baseline to 8 weeks) of each vascular measure. AIx@75 (BL: -3.6±10.9%, 4W: -5.6±8.3%, 8W: -3.2±9.5%), cfPWV (BL: 5.6±1.0 m/s, 4W: 5.8±0.9 m/s, 8W: 5.6±0.7 m/s), and CIMT (BL: 0.51±0.08 mm, 4W: 0.52±0.08 mm, 8W: 0.51±0.08 mm) did not significantly change (all P>0.05). Baseline cfPWV and AIx@75 were negatively correlated to their change from baseline to 8 weeks (P<0.05). These findings demonstrate that 8 weeks of SIT is an insufficient stimulus to reduce cfPWV, AIx@75, or CIMT in a group of young, healthy men. Baseline arterial stiffness may modulate vascular adaptations to SIT.

Heterogeneity in health and lifestyle among preschool children with migrant background in Sweden

Abstract Background Parental country of birth and socioeconomic status affect children’s health, lifestyle, and access to care. But inequality patterns may vary depending on the outcome and indicator being studied. While prior studies have focused on single health outcomes, this study assessed the relationship between parental migrant status and a range of health and lifestyle indicators among 3-year-old children. Methods Using an outcome-wide approach, we analyzed data from cross-sectional population-based surveys of 3-year-old (2014-2018) in Northern Sweden, which included 9,099 children aged 33-42 months. The surveys were administered to parents. Logistic and linear regressions were performed to examine the association between parents’ place of birth and outcome indicators. Additionally, we controlled for parents’ income and education using multiple regression models. Results Children with at least one migrant parent were perceived by their parents to have poorer health (OR:1.5, CI:1.01-2.36) and more socio-emotional problems (OR: 2.8, CI: 2.20-3.59) compared to those with two Swedish parents. While there were no significant differences in estimated BMI, lifestyle indicators showed that these children consumed more sweets (OR:4.5, CI: 3.02-6.58), less milk (OR: 1.3, CI: 1.09-1.55), fewer vegetables (OR:1.6; CI: 1.22-2.05) and brushed their teeth less frequently (OR: 2.8, CI: 2.17-3.53). However, they spent more time playing outdoors on weekdays (OR:1.6, CI:1.22-2.00) and weekends (OR: 1.5, CI: 1.18-1.94), but screen time remained consistent between weekdays and weekends. Conclusions Parental migrant status has varying impacts on children’s health and lifestyle, with some indicators showing worse outcomes for children with migrant parents compared to those with Swedish parents, while others do not. An outcome-wide approach is crucial for targeted actions to strengthen protective factors and mitigate risk factors, and ultimately reduce inequalities in early childhood. Key messages • The link between parental migrant status and children’s well-being is complex. Not all indicators show worse outcomes, inequality patterns vary based on the specific outcome and indicator measured. • An outcome-wide approach is crucial to identify action areas for targeted interventions to reinforce protective factors and mitigate risk factors, and ultimately reduce inequalities during childhood.

Impact of the WELLBASED urban programs on health, well-being, and energy poverty

Abstract Background The WELLBASED project developed and implemented urban programs across six pilot sites to tackle energy poverty. This study aimed to evaluate these programs’ effectiveness on a broad range of health, well-being, and energy poverty indicators. Methods a controlled study was performed in six European pilot sites. Participants in the intervention condition receive the 12-month WELLBASED urban program. Participants were recruited via different methods and provided informed consent to participate in the 18-month study. Self-report questionnaires were completed at baseline, 6-, 12 and 18 months in both research conditions. In the intervention group, monthly health monitoring of e.g. heart rate and blood pressure, and continuous monitoring of indoor CO2, temperature and humidity were performed. Descriptive statistics and regression analyses are performed to assess the impact of the urban programs on health, well-being and energy poverty-indicators Results In the baseline sample (n = 1350; n = 661 intervention group, n = 689 control group) the mean age was 49 years (SD 16), 15.6% was &amp;gt;65 years, 65% were women, and 42% was married. At baseline people reported not feeling comfortable warm in winter (58%) or cool in summer (70%), 43% reported damp or leak. Preliminary findings at 6-month follow-up indicate changes in HR-QoL, subjective well-being and depression/anxiety differ strongly per pilot site location (p &amp;lt; 0.01). In summer 2024 all data will be available for analysis. Conclusions the comprehensive urban programs developed in the WELLBASED project may support public health to tackle energy and improve health and well-being of vulnerable citizens.

The influence of living environments on subjective health literacy in fourth-graders in Germany

Abstract Background Evidence suggests that worse family affluence is related to low health literacy in children. Still, for the targeted promotion of health literacy, a more nuanced understanding is needed of how living environments affect health literacy in early life. This study explores the relationships between health literacy and indicators of living environments in the neighborhood and at home. Methods A representative sample of 4th-graders (age 8-11) was surveyed from Oct. 2022 to Feb. 2023 in North Rhine-Westphalia, Germany. We included the HLS-Child-Q15 to assess subjective health literacy, 4 items about the neighborhood (e.g., “neighborhood is a good place to play outside” or “I often see people smoking in the neighborhood”), and 4 items about home (e.g., “there’s always fruit and vegetables at home” or “it’s important to my parents that I exercise”). The tendency to answer in a socially desirable way was controlled for with a validated scale. Likert-scale items were dichotomized for use in linear regression. Results n = 1085 students are included, 50.3% are female. The mean age is 9.5 years (SD=.6). The regression model explains 17.8% of variability in health literacy (corr. R²). Significant (p&amp;lt;.05) predictors for high health literacy were birthplace (Germany, not Germany), agreement to the statements “I often see people exercising in my neighborhood”, “my parents can answer all my question about health”, “there’s always fruit and vegetables at home”, “it’s important to my parents that I exercise”, but also social desirability scores. Family affluence was not a significant predictor. Conclusions In this sample of 4th-graders, subjective health literacy could not adequately be explained by family affluence. Indicators of living environments seem to be better suited to explore variability in health literacy. These findings can be used to explore entry points for the promotion of health literacy early in life and to identify groups at risk for low health literacy.

Advancing urban health in Portugal: exploring liveability and its association with mental morbidity

Abstract Background As cities face challenges posed by urbanisation, it becomes essential to understand how city planning can contribute to protecting public health. In this study, we aimed to assess the liveability of different areas in Lisbon, Portugal, by developing a liveability index at the parish level. Secondly, we aimed to explore its association with hospitalisation due to mental disorders. Methods The liveability index was built based on the World Health Organisation’s Urban Health Index methodology. We obtained data on liveability related to housing, socio-economic conditions and access to services (e.g. healthcare) from the 2011 census and other open data sources for Lisbon’s parishes (n = 22). Data on hospital admissions due to mental disorders was sourced at the parish level from the national database for hospital morbidity for the period 2013-2016 and sex-age-standardised. Binomial negative regression was employed to estimate the association between the liveability index tertiles and observed hospital admissions. We used the expected number of hospitalisations as the offset variable and tested for spatial autocorrelation among the regression residuals. Results Our analysis showed that living in the most liveable parishes is associated with a significant decrease in the standardised admission ratio due to mental disorders, compared to living in the least liveable areas (Incidence Relative Ratio=0.643; 95% CI: 0.427, 0.967). We did not observe any geographical pattern in the regression residuals (Moran’s I= -0.035, p = 0.427). Conclusions Our findings show disparities in liveability among Lisbon’s parishes and identify a protective association between living in higher liveability areas and hospital admissions due to mental disorders. This work should prompt further studies concerning this subject to inform urban planning policies to improve liveability and equally reduce the risk of mental health-related harm within cities. Key messages • A spatial index to assess liveability in urban areas was developed. The association between the liveability of Lisbon’s parishes and hospital admissions due to mental disorders was explored. • We found a significant protective association between higher liveability and hospital admissions due to mental disorders. This work is relevant to inform the implementation of urban planning policies.

Regional variation of age-related blood pressure trajectories and their association with blood pressure control rates, disability-adjusted life years and death

Abstract Background/Introduction While the relationship between blood pressure (BP) changes and increasing age is well described, age-related BP trajectories may vary substantially across different populations and associated with differential CV risk and outcomes. Purpose The dataset of the May Measurement Month (MMM) international campaigns enables a unique investigation of regional, socio-economic and sex differences in age-BP trajectories and their association with major public-health outcomes. Method Global BP data from more than 4,5 million adult (≥18 years) screenees obtained during the cross-sectional MMM campaigns in 2017, 2018, 2019, and 2021 were used for analysis. Average BP and slopes of BP changes across age groups were calculated within regional, socio-economic and sex strata. BP slopes of individuals between 30 and 70 years of age were derived from adjusted linear regression models, along with baseline BP estimates at young age. These BP slopes were correlated in regression models adjusted for baseline BP at young age with country-specific all-cause rates of DALYs (Disability-Adjusted Life Years), death (both from Global Burden of Disease Study 2019), life expectancy (World Bank data SP.DYN.LE00.IN 2019) and BP control rates (NCD Risk Factor Collaboration). Results Age-related BP changes differed distinctly across global geographic regions, income levels, and between sexes. The steepest increase in BP with age was observed in populations from Africa and Europe, whereas a more gradual rise in BP with increasing age was seen in South-East Asian populations. Women had lower BP levels than men at younger ages (twenties and thirties), but subsequently experienced a more pronounced age-related BP increase resulting in diminishing sex differences across older age groups. Geographically divergent age-related BP trajectories were significantly associated with major national public health indicators. Globally, the steeper the age-related BP slope, the stronger the association with poor BP control (β = -0.46 [95% CI: -0.74; -0.19], p=0.001), increased DALY’s (β = 66155.68 [95% CI: 44847.0; 87464.36], p&amp;lt;0.001) and death rates. (β = 1017.3 [95% CI: 351.72; 1682.89], p=0.003). Conclusion Age-related BP trajectories vary considerably across global populations and contribute considerably to the variability in BP-related risks and adverse outcomes across regions. Effective public health strategies may require region-specific targeting of lifestyle and other factors contributing to adverse BP trajectories to improve health outcomes.Average blood pressure by ageAssiciations with public health metrics

The Africa CDC Guidance for Strengthening NCDI-MH Surveillance Systems: The role of HIS assessments

Abstract Deaths due to NCDs, injuries and mental health conditions are expected to at least triple by 2063 in the region of the African Union. Population-based data for NCDI/MH and their determinants remain scarce in many AU MS; therefore, NCDI/MH surveillance is a flagship initiative in the Africa CDC NCDI/MH Strategy. In a survey conducted by Africa CDC and RKI in 2022 on the impact of COVID-19 on NCDI/MH in 10 AU MS, countries signaled the need for a continental guidance document. In 2023, Africa CDC and RKI performed desk reviews and facilitated peer-to-peer multi-country HIS assessment workshops, based on modified WHO and IANPHI tools. The first workshop took place in Zambia with experts from Botswana, Democratic Republic of Congo/DRC, Kenya and Zambia. The second workshop was hosted in Ghana and included DRC, Ghana, Morocco, Nigeria, Senegal and Sierra Leone. Participants came i.a. from ministries of health, national public health institutes or academia. The process included a virtual introductory meeting as well as half-day training sessions at the physical meeting for participants to familiarize themselves with the tools. Peer-to-peer assessment sessions took place on days 2 and 3. Day 4 was reserved for site visits to (public) health institutions of the hosting countries. On day 5, participants presented their findings to the plenary, which included high-level representations from host countries. The combined results from the survey, desk reviews and workshops informed the development of the continental Africa CDC Guidance for strengthening surveillance for NCDI/MH, launched at the 3rd Conference on Public Health in Africa. In four chapters, the Guidance covers recommendations on indicators, data sources and data types; surveillance system capacities; surveillance integration with existing systems; and data use. Implementation of the Guidance, including development of core health indicators, has been initiated by Africa CDC in 2024.

Multiple behavioural risk factors and mental health complaints among adults in Estonia

Abstract Background Behavioural risk factors are inter-related and often coincide, resulting in potentially worse mental health outcomes. This study explores the association between multiple behavioural risk factors and mental health among adults in Estonia. Methods We used nationally representative survey data from 2020 (n = 6404) to study the co-occurrence of lifestyle risk factors (smoking, alcohol consumption, physical inactivity, unhealthy diet, drug use, and high screen time) in relation to mental health indicators. Latent class analysis (LCA) was used to identify lifestyle risk profiles, while regression analysis was used to examine associations. Results Mental health outcomes were more frequent among females and younger respondents, but 54.4% of respondents reported having at least one mental health problem. Using LCA, three lifestyle classes were identified: multiple risk factors (17.9% of respondents), healthy lifestyle (76.1%), and drug use lifestyle (5.9%). Compared to individuals in healthy lifestyle class, respondents in multiple risk factors had higher odds for experiencing depressiveness (OR 1.46; CI 1.24-1.72), stress (OR 1.26; CI 1.06-1.49), and suicidal thoughts (OR 1.50; CI 1.26-1.80), as well as self-reported diagnoses of depression and insomnia, and using medications, such as antidepressants, hypnotics and sedatives. Respondents in drug use lifestyle had 1.5-2.5 times higher odds for all mental health items compared to healthy lifestyle class with largest difference found for suicidal thoughts (OR 2.46; CI 1.92-3.16) and medication use (OR 2.58; CI 1.91-3.47). Conclusions The current data highlights the importance of preventive measures targeting multiple behavioural risk factors, given that these factors often coincide. Moreover, the study showed a high proportion of individuals with at least one mental health problem, highlighting the necessity to continue efforts in preventive and interventive methods. Key messages • The study highlights the significant association between multiple behavioural risk factors and mental health outcomes. • The study also emphasizes the importance of focused interventions targeting multiple behavioural risk factors to address the increased risk of mental health problems.

The relationship between sleep quality and emotional eating during the pandemic in Croatian adults

Abstract Background Social isolation during pandemics has adverse effects on sleep quality which in connection with COVID-19 distress facilitates the development of emotional eating patterns in various populations. This study aimed to evaluate the interconnection between sleep quality and emotional eating in the Croatian adult population during the COVID-19 pandemic. Methods This cross-sectional questionnaire study was conducted from February to June 2021 period. A validated, anonymous questionnaire that contained questions regarding demographic data, data on eating habits, and the Pittsburgh Sleep Quality Index (PSQI), was self-administered to a convenient sample of Croatian adults from central and northwestern Croatia. Results The study sample included 939 subjects with, a median age of 42 years (interquartile range 35-48), 35.4% males, and 64.6% females. At the PSQI 22.6% of subjects presented sleep disturbances. Sleep disturbances were more frequent among females (p &amp;lt; 0.001), and inhabitants of the Croatian capital Zagreb (p = 0.001). Subjects with sleep disturbances detected by PSQI during pandemics consumed a larger amount of food than usual (p &amp;lt; 0.001), consumed snacks more frequently (p &amp;lt; 0.001), and cooked more in their households (p = 0.006). Conclusions Poor sleep quality caused by the COVID-19 pandemic led to emotional eating patterns in the Croatian adult population. Health promotion programs directed toward healthy lifestyle choices need to be implemented to successfully tackle observed poor health indicators in the studied population. Key messages • Following the COVID-19 pandemic the obvious deterioration of sleep quality and eating habits is seen in the Croatian general population. • Comprehensive health promotion programs directed toward healthy lifestyle choices adoption are needed.

A cross-sectional study of data linkage and artificial intelligence practices across European countries

Abstract Background The availability of different data sources is increasing with the possibility to link them with each other. However, linked administrative data can be complex to use and may require advanced expertise and skills in statistical analysis. The main objectives of this study were to describe the use of data linkage and artificial intelligence (AI) in routine public health activities and the constraints to linking different data sources. Methods A cross-sectional survey was performed across European countries to explore the current practices applied by national institutes of public health, health information and statistics for innovative use of data sources (i.e., the use of data linkage and/or AI). Results In Europe, the use of data linkage and AI at national institutes of public health, health information and statistics varies. The use data linkage in routine by applying a deterministic method or a combination of two types of linkages (i.e., deterministic &amp; probabilistic) for public health surveillance and research purposes is common in majority of European countries. The use of AI to estimate health indicators is not frequent among these institutes. The complex data regulation laws, lack of human resources, skills and problems with data governance, were reported by European countries as main constraints to routine data linkage for public health surveillance and research. Conclusions Our study showed that the majority of European countries have integrated data linkage in their routine public health activities but only a few use AI. A sustainable national health information system allowing to link different data sources are essential to contribute to public health research. Moreover, it supports evidence-informed health policy making processes with an overview of various aspects affecting population health and may contribute to European pandemic preparedness.

Comparison of hospital treatments of the Roma settlements’ inhabitants in Slovenia

Abstract Background Roma ethnic minority in Slovenia was recognized as a vulnerable group with worse health indicators and significantly shorter life expectancy. The vast majority of Roma population in Slovenia have health insurance. We were investigating the use of hospital services in Roma population according to their age and comparing it with the rest of the population. Methods We determined the inhabitants of Roma settlements from the Slovenian register on residents. The data on hospital treatments used were from Slovenian national register on hospital treatments for the period 2018 to 2022. We compared different ratios according to certain hospital treatments within age categories of patients and co-pared those two groups. The frequency statistics, ANOVA and comparison of column proportion tests were used (p-value&amp;lt;0.005, 95% CI). Results Inhabitants of Roma settlements were more often treating in hospitals that rest of population. If comparing the frequency of hospital treatments between age groups only in Roma population, the percentage of hospital treatments steeply declines with age as well as the number of persons in age groups. The highest percentages and numbers of services are in the youngest age group of 0-15 years, and the lowest in the oldest group (75+). Therefore, significantly higher ratios of hospital treatments were detected in younger then in older age groups. Conclusions Roma children and youngsters (0-15 years old) had the highest rate of hospital treatments and it declined with the age. It was consistent with age pyramid of Roma as young population as well as emphasized care for children in culture. The steady decline rate of hospital treatments with age could be explain with delayed seeking of health care services in adult age and higher premature mortality that leads to smaller adult population. Additional and in-depth research is necessary to explain the root causes of higher premature mortality and use of primary and preventive health services. Key messages • Higher use of hospital treatments was caused by higher morbidity. It is necessary to explore the leading causes of hospital treatments and premature mortality. • It is necessary to explore the use of primary health care service, preventive service and level of health literacy of inhabitants of Roma settlements.

Clustering Portuguese municipalities based on population health indicators

Abstract Background The large number of publicly available health-related indicators poses challenges in health planning to policymakers. Identifying patterns among municipalities may assist these processes, by grouping similar contexts and pointing out relevant differences among neighbouring locations. The aim of this work was to define clusters of municipalities based on health-related indicators. Methods All health-related indicators available at municipality level for the year 2021 were obtained from the Portuguese National Statistics Office website. Missing values were imputed with the closest available year or excluded. Indicators were standardized and K-means clustering was applied. Elbow criterion was used to select the optimal number of clusters. Sensitivity analysis was performed with a priori exclusion of indicators less directly associated with health outcomes. Results The clustering analysis revealed five distinct clusters of municipalities. Clusters were associated with specific socio-demographic patterns, providing insights into common health challenges and strengths within each group. Interestingly, geographic profiles emerged (e.g. coastal vs inland), despite no geographic information being specifically provided. One outlier municipality was identified (Lisbon), highlighting a need for special consideration. Conclusions Clustering techniques provide a data-driven approach to inform public health planning. Our findings show previously unrecognized patterns and relationships between municipalities. Using these clusters, policymakers may implement interventions based on what has been proven to work in similar contexts, enhance collaboration opportunities and promote a tailored policy development, contributing to an overall improvement of public health outcomes. Key messages • Clustering machine learning techniques provide a data-driven approach to inform public health planning. • Identifying comparable municipalities based on health-related indicators allows targeted public health interventions.

2.G. Practice session: Africa and Europe: peer-to-peer HIS assessments for NCD, mental health and injuries surveillance

Abstract Public health surveillance is the basis for evidence-informed decision-making and health (systems) research, globally. Without robust data, public health challenges cannot be tackled. NCDs, mental health conditions and injuries (NCDI/MH) are among the biggest global public health challenges. Their risk and protective factors, including social, political and commercial determinants of health, transcend borders and require multi-disciplinary, multi-stakeholder and long-term responses. Since 2006, comparable national data on NCDI/MH are being collected in Europe on the basis of European Core Health Indicators (ECHI) and the European Health Interview Survey (EHIS). Currently, EU and WHO EURO are working together to set up a new Health Information Network. At EU level, a sustainable health information infrastructure is still lacking, despite extensive preparations in EU-funded projects. Part of these project activities were health information system (HIS) assessments, applying the WHO EURO Support tool to strengthen health information systems for peer-to-peer assessments. In the African region, the Africa Centres for Disease Control and Prevention (Africa CDC), founded in 2017, made NCDI/MH prevention and control a strategic priority. In 2021, it launched its first continental NCDs, Injuries Prevention and Control and Mental Health Promotion Strategy (2022-26) under which the organization supports its Member States. At the 3rd International Conference on Public Health in Africa (Zambia, Nov. 2023), Africa CDC presented a continental Guidance to strengthen NCDI/MH surveillance. The Guidance was developed in collaboration with Robert Koch Institute (RKI) and is based on desk reviews, surveys and national HIS assessments. Both Europe and Africa performed HIS assessments to strengthen NCDI/MH surveillance; standardized tools from WHO EURO and from the International Association of National Public Health Institutes (IANPHI) were used and adapted to fit peer-to-peer approaches and regional contexts. This workshop will present and discuss methodological approaches, experiences and lessons learned, thereby initiating knowledge exchange across continents. The presentations will address the following points: - From top-down to peer-to-peer: methods &amp; tools used in HIS assessments - From paper to practice: the importance of site visits in HIS assessments - From educated guesses to evidence: outcomes of HIS assessments at country level - From evidence to action: translation of HIS assessment outcomes into HIS improvements - From pilot to scale-up: challenges, lessons learned, sustainability of HIS developments To our knowledge, this workshop is the first one at the EPH to bring together practitioners in HIS strengthening for NCDI/MH from Africa and Europe. The workshop offers a unique opportunity to engage with the audience and to explore options for international collaboration. Key messages • Interregional collaboration helps reduce health information inequalities, facilitating better global management of high burden health challenges, such as NCDs, mental health conditions and injuries. • Peer-to-peer HIS assessments in Africa and Europe strengthen NCDI/MH surveillance. They build evidence for policy advice, research and health education and add the benefit of forging expert networks.

Evaluating the feasibility of an Adapted Physical Activity intervention among breast cancer patients

Abstract Adapted physical activity (PA) programs have shown promising results to reduce physical, psychological and social side effects associated with breast cancer (BC), but the extent to which they can be effectively adopted, implemented and maintained is unclear. The aim of this study is to use the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework to evaluate RIPOSTE (Reconstruction, Image de soi, Posture, Oncologie, Santé, Thérapie, Escrime), an innovative intervention focused on improving the quality of life (QoL) of BC surgery patients through fencing. A convergent mixed-methods pilot study was conducted to evaluate the RE-AIM dimensions of RIPOSTE. 24 participants who have just undergone surgery for invasive BC were randomly allocated either in the “RIPOSTE” group (starting immediately after their inclusion), or the “Delayed RIPOSTE” group (starting at 3 months following their inclusion). They answered to questionnaires at inclusion and at the end of the program on QoL, shoulder functional capacity, fatigue, anxiety-depression and PA. Interviews were conducted with 10 participants, 3 sports physicians and 1 fencing master. RIPOSTE program was able to reach mainly young and dynamic participants, attracted by the originality of fencing and keen to improve their physical condition. Regarding effectiveness, our results suggest a trend to the improvement of health indicators, even without any significant differences between the two groups. The cooperation, exchanges and cohesion within the group greatly facilitated the adoption of the program, whereas interruptions during vacations were the main barriers. Maintenance analyses showed that most participants continued to practice PA after the program. RIPOSTE is an acceptable and effective program for involving BC survivors in PA, that needs to be tested at larger scale to investigate its effectiveness, but has the potential to be transferred and scaled up worldwide. Key messages • These results would help to enrich the literature on how to best intervene to enhance treatment and recovery among patients and facilitate transfer from a research program to a field daily practice. • By highlighting complexities of RIPOSTE effectiveness and implementation, this study could lead to a more complete program that addresses issues related to improving external and internal validity.

The UFair-Questionnaire: Perceived university fairness and its association with mental health

Abstract Introduction University students face different stressors that might jeopardise their mental health. Hitherto, mainly general stress perceptions were assessed, which appeared inappropriate to indicate stress directly linked to the university or for deriving specific preventative measures. The aim of this study was to adapt the concept of organisational justice to universities, develop and validate a corresponding questionnaire (UFair: University Fairness Questionnaire), and estimate its association with mental health. Methods In total, 1,105 students (average age: 25.5 years [SD: 5.43]; female: 50.1%; university: 67.2%, university of applied sciences: 32.8%) were surveyed online. Perceived unfairness at the university was measured using the newly developed 20 item UFair Questionnaire. Mental health was measured using the Patient Health Questionnaire (PHQ-8, depression) and Maslach Burnout Inventory for Students (MBI-SS, burnout). Linear regression models estimated the adjusted (age, gender, type of university, lifestyle factors) relationship between perceived university injustice and mental health indicators. Results The UFair questionnaire showed good psychometric properties (Cronbach’s alpha = .960) and a unidimensional factor structure. There was a considerable association with depression (beta = .485; p &amp;lt; .001; R2 = .261) and burnout (beta = .481; p &amp;lt; .001; R2 = .250). Conclusions Perceived injustice represents not only a stressor at the workplace but also in the university setting, showing a considerable relationship with students’ mental health. University justice includes the perception of organisational aspects, the treatment of students, and consideration of the individual situation of students. The relevance of these aspects to the health of students should be recognised and taken into account by universities. The valid measurement by the UFair Questionnaire represents the basis for possible preventive approaches and interventions. Key messages • Organisational injustice exists not only in the workplace but also among students in the university setting. • Perceived unfairness among students is associated with depression and burnout.

Cross-sectoral interventions to promote health-supportive urban environments

Abstract Background As dealing with the complexity of urban living conditions becomes more and more evident and urgent, it is fundamental to promote cross-sectoral interventions that allow cities to become more inclusive and supportive of health. The Emilia-Romagna region, Italy, has promoted a participatory initiative to structurally integrate health into urban planning tools, identifying a framework of tailored urban indicators linked to locally perceived population health issues. Methods Through internal discussion and systematic literature research, a set of urban planners, epidemiologists, and public health experts from regional offices, local health services, universities, and environmental protection agencies identified the urban and health dimensions most suitable for embedding population health into city planning. The result was summarised in a preliminary working paper, which included a matrix of associations between urban features and health dimensions framed according to the DPSEEA framework. Its applicability was then tested in a participatory process (March-May 2024) involving urban planners and public health departments of 7 different sized municipalities. Results A group of epidemiologists identified local-level computable indicators for the health dimensions already included in the matrix or added at request. Each municipality focused on specific topics based on local priorities: 3 groups assessing their already-approved urban plans and looking for computable urban indicators; the others integrating their under-construction plans with local health indicators. Conclusions The need for professional contamination and cross-sectoral interventions is significant. Epidemiological support is pivotal in integrating different professional languages and reading health data. The outputs of this experience will contribute to a technical document outlining how to incorporate health promotion into urban planning tools and practice while actively considering the local context. Key messages • Although the development of a common vocabulary can be difficult, multidisciplinary collaboration is essential in promoting a model for integrating health promotion into urban planning. • Local municipalities’ involvement in the experimentation can improve the model’s applicability by taking into account territorial specificities.

Mapping geographic health disparities in 11 high-income nations

Abstract Health care delivery faces a myriad of challenges globally with well-documented health inequities based on geographic location. Yet, researchers and policy makers have a limited understanding of the frequency of geographic health disparities. In this survey study, we analyzed results from the 2020 Commonwealth Fund International Health Policy (IHP) Survey-a nationally representative, self-reported, and cross-sectional survey of adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK, and the US. Eligible adults older than age 18 years were included by random sampling. Survey data were compared for the association of area type (rural or urban) with 10 health indicators across 3 domains: health status and socioeconomic risk factors, affordability of care, and access to care. Across the 11 countries and 10 health indicators and 3 domains (health status and socioeconomic risk factors, affordability of care, access to care), there were 21 occurrences of geographic health disparities. The indicators with the most occurrences of geographic health disparities were in the access to care domain. Differences in number of disparities reported by country suggest that health policy and decision makers in the US should look to Canada, Norway, and the Netherlands to improve geographic-based health equity.