Estonian Population Research Articles

Determinants of Long-Term Health-Related Quality of Life in Young Ischemic Stroke Patients

ObjectivesThis study aimed to assess long-term, health-related quality of life (HRQOL) in a young ischemic stroke cohort, and to identify factors associated with poor HRQOL. Materials and methodsWe conducted a survey with ischemic stroke survivors in Estonia aged 18–54 years at the time of stroke, measuring HRQOL with the three-level version of the five-dimension EuroQol (EQ-5D-3L). The control group comprised the participants of the Health Behavior among Estonian Adult Population study. A tobit regression model with a backward stepwise analysis was used to identify factors associated with low EQ-5D-3L utility scores. ResultsIn total, 352 patients with a mean follow-up time from the qualifying event of 5.7 years and 2304 controls were included. The mean EQ-5D-3L utility score in stroke survivors was significantly lower compared with that in the general population (0.71 vs. 0.87, respectively, p<0.001). However, the subgroup with excellent functional outcome had a significantly higher mean EQ-5D-3L utility score compared with non-stroke counterparts (0.91 v 0.87, respectively, p<0.001). The largest differences between stroke survivors and the general population were in the physical domains. Coronary heart disease at the index event, and higher follow-up duration, functional disability, depressive symptoms, recurrent stroke, and not being fully employed at follow-up, were independently associated with lower HRQOL. ConclusionYoung ischemic stroke survivors have long-term decreased HRQOL, except for those with excellent functional recovery. Our results prioritize motor rehabilitation and highlight the importance of secondary prevention, treatment of depression, and career counselling as potential ways of increasing HRQOL.

An ethno-linguistic dimension in transnational activity space measured with mobile phone data

In addition to permanent migration, different forms of cross-border mobility were on the rise before the COVID-19 pandemic, ranging from tourism to job-related commuting. In this paper ethno-linguistic differences in cross-border mobility using the activity space framework are considered. New segregation theories emphasise that segregation in one part of the activity space (e.g. in residential neighbourhood) affects the segregation in other parts of the activity space (e.g. in workplace), and that spatial mobility between activity locations is equally important in the production and reproduction of ethnic inequalities. Until now, segregation in activity spaces has been studied by focusing on daily activities inside one country. In reality, an increasing number of people pursue their activities across different countries, so that their activity spaces extend beyond state borders, which can have important implications for the functioning of ethno-linguistic communities and the transfer of inequalities from one country to another. This study takes advantage of mobility data based on mobile phone use, and the new avenues provided for the study of ethno-linguistic differences in temporary cross-border mobility. Such data allow the study of different cross-border visitor groups—tourists, commuters, transnationals, long-term stayers—by providing the means to measure the frequency of visits and time spent abroad, and to link together the travel of each person over several years. Results show that members of the ethno-linguistic minority population in Estonia make more trips than members of the ethno-linguistic majority, and they also have higher probability of being tourists and cross-border commuters than the majority population, paying frequent visits to their ancestral homelands. The connections between ethno-linguistic background and temporary cross-border mobility outlined in this study allows for future discussion on how (in)equalities can emerge in transnational activity space and what implications it has for segregation.

Increased pulse wave velocity strongly related to age in apparently healthy people of high cardiovascular risk population

Abstract Introduction Pulse wave velocity (PWV) as a measure of arterial stiffness is associated with CVD morbidity and mortality. CVD mortality rates show Estonia (capital Tallinn) as being among high cardiovascular (CV) risk countries. Our study aimed to investigate the prevalence of increased PWV in Tallinn adults aged 20–65, apparently healthy (AH) at primary medical examination, and also to evaluate the association of increased PWV with age and biochemical cardiovascular risk factors at levels indicative of CV risk. Methods PWV measured by Arteriograph and biochemical CV risk factors by Cobas Roche 6000 analyzer were investigated in 805 responders of a cross-sectional population-based study of Tallinn adults aged 20–65, randomly selected from the Estonian Population Register by age decade and sex. Apparently healthy conditions were defined at primary visit as absence of hypertension (SBP &amp;lt;140 and DBP &amp;lt;90 mmHg), diabetes, obesity (BMI &amp;lt;30 kg/m2), a history of known heart disease and medication usage against hyperlipidaemia. Statistical analysis was performed by MedCalc version 14.8.1. Results 445 people (men=180, women=265) were in AH conditions with median values (95% central range) of SBP, DBP, and BMI: 115 (94–137) mmHg, 73 (55–87) mmHg, and 24 (18–29) kg/m2. 27.4% of AH adults were smokers. Medians (95% central range) and indicative of CV risk level (with crude prevalence at this level) of other investigated CV risk factors were: PWV 6.2 (4.5–11.3), ≥9.7 m/s (24.7%); age 39 (23–62), ≥50 years (24.7%); total cholesterol 5.2 (3.7–7.2), &amp;gt;5.0 mmol/L (57.1%); triglycerides 1.0 (0.5–2.7), ≥1.7 mmol/L (14.8%); apolipoprotein B 3.0 (1.7–4.7), &amp;gt;2.6 /2.3 μmol/L for men/women (76.6%); HDL cholesterol 1.6 (1.0–2.6), &amp;lt;1.0/1.3 mmol/L for men/women (7.0%); LDL cholesterol 3.2 (1.7–5.2), ≥3.0 mmol/L (82.7%); homocysteine 11.8 (7.1–20.2), ≥12.0 μmol/L (49%); lipoprotein (a) 0.1 (0.1–1.2), &amp;gt;0.3 g/L (23.6%); high-sensitivity C-reactive protein 0.9 (0.2–6.8), &amp;gt;3.0 mg/L (10.1%). Categorization of PWV values as indicative of CV risk (increased PWV) was made according to their interpretation by Arteriograph software as increased or abnormal. Stepwise logistic regression analysis of increased PWV along with age and biochemical risk factors revealed statistically significant and strong association only with age ≥50. Overall model fit p was &amp;lt;0.0001, c-statistic 0.838, odds ratio 29.3. Conclusions Despite total cholesterol, apolipoprotein B, LDL cholesterol and homocysteine being at indicative of CV risk level in over 50% of AH people, increased PWV was observed only in about 6% of them. The study showed that being 50 years of age or older in a high risk population means 29 times greater probability of increased arterial stiffness than in younger ages, even without having hypertension, diabetes or obesity. This knowledge is important for preventive CVD strategy in this population group. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Estonian Ministry of Education and Research under institutional research financing

Bottled water consumption habits in Estonian residents and their opinions of possible health hazards

Abstract Human needs about 28-15 mL/kg body weight of water daily (National Institute for Health Development). The sources of drinking water are either tap water, private wells or bottled water. According to the Health Board of Estonia, 89.13% of Estonian population used tap water in 2016 and 88.87% in 2017. Of all the consumers, 99.2% used water, for which the microbiological, chemical and indicator parameters did not exceed any normative (except for radiological parameters) (Joogivee..., 2017). However, more and more people are consuming bottled water and this trend is global (Kodumaine..., 2016). For example, in Estonia 72% of consumers used bottled water in 2007 (Noop &amp; Riivits-Arkonsuo, 2007). Different authors bring out that convenience, purity, better taste, better odour and quality were the main reasons for consuming the bottled water (Foote, 2011; Akpinar &amp; Gul 2014). Some studies have shown that socio-demographic factors influence bottled water consumptions (Rothwell, 2006; Dupont et al, 2010). The aim of this research was to determine the bottled water consumption habits of Estonian residents and their subjective assessment of the potential health impact of bottled water. The sample of this research were Estonian residents (n = 869) who agreed to take the online questionnaire through 21.11.2016-20.01.2017. For statistical analysis, X2 - test was used. The conclusions of the research were: 1. Most of the respondents use bottled water and the main reasons are convenience and good taste or odour. 2. Factors as gender, income, education or having children do not affect the consumption of bottled water, but age and marital status do as younger and single or married/in relationship respondents buy bottled water more frequently. 3. About half of the respondents could not tell if the consumption of bottled water can affect health or not. Those respondents who thought that it could, mentioned carcinogenicity, digestive problems, toxicity and bad influence on teeth. Key messages Most of the respondents use bottled water, even if the tap water is of good quality, safe and cheaper, and the main reasons are convenience and good taste or odour. About half of the respondents could not tell if the consumption of bottled water can affect health or not.

Differences in local population history at the finest level: the case of the Estonian population

Several recent studies detected fine-scale genetic structure in human populations. Hence, groups conventionally treated as single populations harbour significant variation in terms of allele frequencies and patterns of haplotype sharing. It has been shown that these findings should be considered when performing studies of genetic associations and natural selection, especially when dealing with polygenic phenotypes. However, there is little understanding of the practical effects of such genetic structure on demography reconstructions and selection scans when focusing on recent population history. Here we tested the impact of population structure on such inferences using high-coverage (~30×) genome sequences of 2305 Estonians. We show that different regions of Estonia differ in both effective population size dynamics and signatures of natural selection. By analyzing identity-by-descent segments we also reveal that some Estonian regions exhibit evidence of a bottleneck 10–15 generations ago reflecting sequential episodes of wars, plague and famine, although this signal is virtually undetected when treating Estonia as a single population. Besides that, we provide a framework for relating effective population size estimated from genetic data to actual census size and validate it on the Estonian population. This approach may be widely used both to cross-check estimates based on historical sources as well as to get insight into times and/or regions with no other information available. Our results suggest that the history of human populations within the last few millennia can be highly region specific and cannot be properly studied without taking local genetic structure into account.

Households and families in Estonian population

The statistical distribution of households and families by their size and structure can be received from population and household censuses, but it is also important to know this information between the censuses, as changes during the ten-year period can be quite remarkable. It is demonstrated that, since the last census in Estonia in 2011, the share of older age-groups has increased and the rate of children – decreased. The age at first marriage has increased for men and women respectively by 3 and 4 months per year. Consequently, the share of young people living without a partner has increased, but the process is different in men and women. The number of divorces has dropped, but this seems to be caused by the decline of marriages during the last decades. The age of women giving birth has also increased. During the last years, the number of third children has increased, but the number of first children has decreased. The distribution of households by their types was also studied and is presented in Table 1. It is evident that about one-sixth of the population lives alone; single-person households form the most numerous household type in present-day Estonia. From all households containing a couple, somewhat more than two-thirds are households with a married couple, others are households with a cohabiting couple. In average, the first ones are much older than the second ones. The number of households where two or more generations live together is marginal.

How to Demonstrate Freedom from African Swine Fever in Wild Boar-Estonia as an Example.

Estonia has been combatting African swine fever (ASF) for six years now. Since October 2017, the disease has only been detected in the wild boar population, but trade restrictions had to remain in place due to international regulations. Yet, the epidemiological course of the disease has changed within the last few years. The prevalence of ASF virus (ASFV)-positive wild boar decreased steadily towards 0%. In February 2019, the last ASFV-positive wild boar was detected. Since then, positive wild boar samples have exclusively been positive for ASFV-specific antibodies, suggesting the possible absence of circulating ASFV in the Estonian wild boar population. However, as the role of seropositive animals is controversially discussed and the presence of antibody-carriers is regarded as an indication of virus circulation at EU and OIE level, Estonia remains under trade restrictions. To make the disease status of a country reliable for trading partners and to facilitate the process of declaration of disease freedom, we suggest to monitor the prevalence of seropositive wild boar in absence of ASFV-positive animals. The possibility to include ASF in the list of diseases, for which an official pathway for recognition of disease status is defined by the OIE should be evaluated.

Genetic diversity in Siberian flying squirrel (Pteromys volans) in its western frontier with a focus on the Estonian population

The Siberian flying squirrel population is experiencing a continuous decline in Estonia and Finland. Hence, the flying squirrel is listed in Annexes II and IV of the EU Habitat directive and is regarded as a priority species for protection by the European Community. So far, only a limited number of genetic studies have been conducted on this species—all using invasively collected tissue samples and most focusing on the Finnish population only. Our aim was to describe the genetic diversity of the Estonian flying squirrel population and its relatedness to the nearest populations from Finland and Karelia by using, for the first time, non-invasively collected faecal samples. Based on mitochondrial markers’ analysis, the Estonian population appeared more homogenous in comparison with the other two populations. Mitochondrial markers did not reveal essential genetic dissimilarities between Estonian, Finnish, and Karelian populations as they all shared the same mitochondrial haplotypes. Combined data from both mitochondrial and microsatellite markers indicated that the flying squirrel population in Estonia is genetically less diverse compared with the other populations. Finally, signs of inbreeding and heterozygote deficiency were detected in the Estonian flying squirrel population.

The applicability of web-based solutions in headache epidemiology research

BackgroundEpidemiological research of headache is vital but resource consuming prerequisite for evidence-based development in the field. Rapid evolution of information technology may provide new opportunities for population-based surveys. The aim of this study was to evaluate the applicability of web-based solutions in epidemiological studies of primary headaches.MethodsAn online survey was conducted among 20–64 year old Estonian citizens, using a previously validated headache questionnaire. The participants were accessed through most popular portals and e-mail domains to get the maximum coverage of Estonian digital community. The resulting one-year headache prevalences were compared to those acquired in parallel from a population-based cross-sectional person-to-person study in Estonia.ResultsFive thousand seven hundred eight entries were made by 5347 participants in the online study. Of the participants, 3896 (72.9%) had no headache, 1436 (26.8%) had only one and 15 (0.3%) had more than one type of headache. The study sample demographics were statistically significantly different from Estonian population and the prevalences were adjusted by age, gender, education and habitat. The proportion of headache sufferers was smaller in the online study sample (23.1% vs 41.0% in the population-based parallel person-to-person study). Among the headache sufferers the proportions of different headache diagnoses were similar across the two studies with the exceptions of episodic migraine and episodic tension-type headache. There were less migraine and more tension-type headache sufferers in the online study sample.DiscussionThis is the first study addressing applicability of web-based solutions in headache related large epidemiological studies. Online approach presents a much faster means of data collection, larger samples, has mechanisms of avoiding data contamination and distinguishes the proportions of most primary headache disorders among the headache sufferers. However, the present online survey was significantly biased towards the people without headache, leading to underestimation of headache prevalence. This stems from the shortcomings related to method of sampling, access and engagement.ConclusionOnline headache epidemiology research could be a resource saving alternative to person-to-person studies, however, further research is needed to overcome the problems related to methods of sampling, access and engagement.

Testing the efficacy of a minimal-guidance online self-help intervention for alcohol misuse in Estonia: study protocol of a randomized controlled trial

BackgroundDespite an initial steep decrease in alcohol misuse among Estonians through structural intervention means and the scaling up of alcohol counselling in the mid-2000’s, most of the country’s alcohol misuse indicators remain clearly higher than European averages. Consequently, an online self-help program was launched as part of an initial behavioral intervention initiative to foster progress in alcohol prevention on a population level.MethodsA two-arm randomized controlled trial (RCT) has been designed to compare the efficacy of a culturally-adapted minimal-guidance online self-help program, the 8-week “Selge” online program against a control condition that consists of a self-administered test of alcohol use and advice regarding usual treatment in Estonia. A target sample of 600 individuals will be recruited and randomly assigned to either condition. The program will contain 10 modules based on principles of cognitive behavioural therapy (CBT) and motivational interviewing (MI). Participants in the control group will have access to the full treatment after they complete their final follow-up assessment. The primary outcome will be change in the Alcohol Use Disorders Identification Test (AUDIT) score between the 6-month follow-up and baseline assessments. Secondary outcomes will include the number of standard drinks consumed and alcohol-free days, drinking motives and motivation for change, as well as changes in mental health. Assessments will be completed at baseline, at the end of treatment, and at 6 months follow-up. Data analysis will follow the intention-to-treat principle and employ (generalised) linear mixed models.DiscussionThe “Selge” program is the first and only internet program for the intervention of alcohol misuse in Estonia. If proven effective, it will foster progress in the intervention of alcohol misuse in the Estonian population and be implemented as a standard program amidst the continuum of intervention and care.Trial registrationCurrent Controlled Trials ISRCTN48753339 registered 04/06/2019 retrospectively.

Changes in therapy and survival of metastatic renal cell carcinoma in Estonia

BackgroundBefore the era of targeted therapies, cytokines were the main therapy for metastatic renal cell carcinoma (mRCC). Our aim was to analyze the changes in treatments and overall survival (OS) of all mRCC patients in Estonia in relation to the introduction of new medications.MethodsAll patients with mRCC who started medical therapy in Estonia during the years 2004–2012 were identified using the database of the Estonian Health Insurance Fund. Tumor and treatment data were gathered from medical records. Vital status data were obtained from the Estonian Population Registry. The only available therapy before 2008 was interferon alpha-2A (INFa2A), targeted agents added from 2008. For survival analysis, patients were divided into 2 groups: INFa therapy only (group 1) and INFa followed by targeted agents or targeted agents therapy only (group 2).ResultsOut of 416 identified patients, 380 were eligible for analysis. The most common 1st-line treatments were INFa (55%), sunitinib (32%) and INFa+bevacizumab (13%). 28% of patients received 2nd-line therapies and 15% 3rd-line treatments. Median survival of all patients was 13.7 months [95% confidence interval (CI) 11.3–16.2]; 7.6 months (CI 6.4–8.6) for group 1 and 19.8 months (CI 15.6–22.9) for group 2. In multivariate analysis, group 1 had nearly four times higher risk of dying than group 2 [hazard ration (HR) 3.88, 95% CI 2.64–5.72].ConclusionsThe implementation of targeted therapies significantly changed the outcomes of mRCC in Estonia: it prolonged median survival, reduced the risk of death and also enlarged the proportion of patients who received medical therapy.

Low genetic polymorphism in the re-introduced Eurasian beaver (Castor fiber) population in Finland: implications for conservation

BackgroundReduction of genetic diversity can lead to reduced fitness of species, such as the loss of adaptability to changing environments. The native Eurasian beaver (Castor fiber) was hunted to extinction from Finland and many other countries in Europe in the nineteenth century. In Finland, the species was re-introduced in the 1930s with only a few individuals from Norway. Re-introductions were performed also in other countries of northern Europe and as a result, Eurasian beaver populations have undergone population bottlenecks leading to low levels of genetic diversity.Materials and MethodsHere, 200 Eurasian beaver samples from Finland, Estonia, Lithuania, and Russian Karelia were investigated using 12 microsatellite markers to examine the level of genetic diversity and relationship between the populations.ResultsWhile Russian and Estonian populations were genetically the closest, the Finnish population was clearly distinct from all others and had the lowest genetic variability among the study populations. This may be deleterious to the population especially in a changing environment.ConclusionsGenetic rescue could be the best solution to increase the genetic diversity and improve the future prospects of the population, although more studies are required to resolve the optimal source population.

Doing statistics, enacting the nation: The performative powers of categories.

It has been widely acknowledged in debates about nationalism and ethnicity that identity categories used for classifying people along the lines of culture, race, and ethnicity help to enact, that is, bring into being, the collective identities they name. However, we know little about how categories acquire their performative powers. The contribution of this paper is twofold: first, it proposes a conceptual framework based on concepts and insights from science and technology studies for investigating the performative powers of statistical identity categories and possibly also other domains. Second, it demonstrates, through an empirical study of two examples from Estonian and Dutch official population statistics, that statistical identity categories enact more than the groups to which they refer. We argue that they also enact national identities and notions of national belonging of majoritarian groups in the host countries. Therefore, statistical identity categories can be used as analytical lenses to study nationalism and processes of nation‐building.

Giving Teachers a Voice: A Study of Actual Game Use in the Classroom

The adoption of games in the classroom has been studied from different angles, such as the readiness of teachers to use games or the barriers encountered. However, actual classroom practices with regard to the use of games have not been examined on a larger scale. With this research, we gave teachers a voice to report on their actual practices. We examined the current practices of a large sample of Estonian teachers (N = 1258, which constitutes almost 9% of the total Estonian teacher population) in primary and secondary education in 2017. We found that most of the teachers use games on a regular basis. Mainly, they use the games for motivation and alternation, but they also use them to consolidate and teach new skills. While awareness and motivation are high and experimentation on using games is widespread, practices appear fragmentary and not widely sustained. As a result of this study, we suggest the creation of an evidence base and a better integration of social support structures into teacher education. This is the first large-scale study to look into Estonian teacher’s actual practices, and although Estonian teachers have relatively high autonomy and technical skills, we believe that these results and further investigations are applicable in other contexts as well.

Mortality in young adult patients with acute ischaemic stroke.

This study aimed to determine short- and long-term mortality, clinical determinants and causes of death in young patients with ischaemic stroke. We performed a hospital-based study of 18- to 54-year-old consecutive patients with ischaemic stroke, who were treated in the two largest hospitals in Estonia from 2003 to 2012. All cases were reviewed by the authors. Survival data and causes of death were obtained from the Estonian Population Registry and the Causes of Death Registry, respectively. Logistic regression and Cox proportional hazard models with backwards stepwise analysis were used to identify determinants of mortality. We identified 738 patients, of whom 124 died during the 5-year follow-up. Cumulative mortality rates at 30days and 5years were 4.5% (95% confidence interval [CI], 3.0%-6.0%) and 16.8% (95% CI, 14.1%-19.5%), respectively. The proportion of deaths due to vascular causes was 87.9% at 1month and 54.6% at 5years. Thirty-day mortality was independently associated with severe stroke, with a National Institutes of Health Stroke Scale (NIHSS) score >15, and post-stroke infections. The determinants of 5-year mortality were post-stroke infections, structural cardiac diseases and moderate stroke severity with NIHSS score of 7-15. The mortality rate among young patients with ischaemic stroke in Estonia is higher than that reported in previous studies and is associated with increased stroke severity, post-stroke infections and structural cardiac diseases. These results emphasize the need for more effective preventive strategies in these patient groups.

Continuing expansion of non-indigenous crayfish species in Northern Europe: first established spiny-cheek crayfish Faxonius limosus (Refinesque, 1817) population in Estonia

Continuing expansion of non-indigenous crayfish species in Northern Europe: first established spiny-cheek crayfish Faxonius limosus (Refinesque, 1817) population in Estonia

Factors associated with incidence of depressiveness among the middle-aged and older Estonian population.

Objective:Relatively scant research among older Estonian population describes factors associated with the incidence of depressive symptoms. This study identifies factors associated with the incidence of depressiveness among middle-aged and older Estonians over 2- and 4-year periods.Method:In this cross-sectional analysis, logistic regression models are used to identify the factors associated with the incidence of depressiveness over 2- and 4-year periods. The data were drawn from the Survey of Health, Ageing and Retirement in Europe (SHARE) 2011–2015 which included Estonian population aged 53 years and older in 2013. After excluding those younger than 53 years, not interviewed 2 years later, those with depressive symptoms at baseline in 2013, and missing values for depressiveness or other variables, our analytical sample comprised 2513 people.Results:Among those who were not depressive in 2013, 21.9% became depressive within 2 years; 16.1% of non-depressive individuals since 2011 became depressive by 2015. No age differences in incidence remained in adjusted models. Women have almost 50% higher odds of becoming depressive. A previous history of depressiveness and the presence of everyday activity limitations were important factors increasing the incidence of depression.Discussion:Changes related to the individual’s unique ageing experience are important explanatory factors related to the likelihood of developing depressive symptoms, rather than age itself. To diminish the incidence of depressive symptoms among older Estonian population, public health interventions should attempt to address factors which complicate existing health problems and facilitate continued independence and community involvement, both of which contribute to overall satisfaction with life.

Finding opportunities to induce growth of medication history usage: evidence from Estonian population level panel data

E-services in the health sector have promised to improve treatment quality and administrative capabilities. Yet, studies have shown a paradoxical situation, in which implementing new e-services exacerbates existing social cleavages. The aim of this study is to examine, how medication history e-service has diffused among different age and gender groups, over time and between first-time and returning users. Estonian population level panel data was used for the purposes of this study, which covered the time span from the launch of the service in 2010 until the end of 2015, including information for approximately 180,000 unique users. Results of this study show that while digital divide for older populations was evident on first-time usage level, older users who did use the service were significantly more likely to become repeat users. This indicates that digital divide is conditional, depending on first-time access to e-services.

На пути к эстонской государственности. Временное правительство и административные преобразования в Эстляндской губернии» в 1917 году: историографические и источниковедческие аспекты

The activity of Estonian political elites increased after the Provisional Government came to power in 1917. In the spring of 1917, social and political figures of the Governorate of Estonia began to actively demand alterations of the boundaries of the province. They sought to consolidate the Estonian population within the borders of a single province. The Provisional Government adopted the Regulation "On the temporary structure of administration and local self-government of the Governorate of Estonia", which changed not only the borders of the province, but the system of local government. Soviet historians assessed the actions of the Provisional Government as forced ones. After the collapse of the USSR, Estonian historians also shared this position. The key event that forced the Provisional Government to support the Estonian demands was what the majority of Estonian historians call the demonstration of Estonians in Petrograd on March 26, 1917.

Finding opportunities to induce growth of medication history usage: evidence from Estonian population level panel data

E-services in the health sector have promised to improve treatment quality and administrative capabilities. Yet, studies have shown a paradoxical situation, in which implementing new e-services exacerbates existing social cleavages. The aim of this study is to examine, how medication history e-service has diffused among different age and gender groups, over time and between first-time and returning users. Estonian population level panel data was used for the purposes of this study, which covered the time span from the launch of the service in 2010 until the end of 2015, including information for approximately 180,000 unique users. Results of this study show that while digital divide for older populations was evident on first-time usage level, older users who did use the service were significantly more likely to become repeat users. This indicates that digital divide is conditional, depending on first-time access to e-services.