International Journal of Epidemiology, 2015, 300–323
doi: 10.1093/ije/dyu256
Original article
Global Status of Epidemiology
Population health and status of epidemiology in
Western European, Balkan and Baltic countries
Adele Seniori Costantini,1* Federica Gallo,2 Frank Pega,3,4,5
Rodolfo Saracci,6 Piret Veerus7 and Robert West8
1
Cancer Prevention and Research Institute (ISPO), Florence, Italy, 2Centre for Cancer Epidemiology
and Prevention, AOU City of Health and Science, Turin, Italy, 3Burden of Disease Epidemiology, Equity
and Cost-Effectiveness Programme and 4Health Inequalities Research Programme, University of
Otago, Wellington, New Zealand, 5Department of Social and Behavioral Sciences, Harvard School of
Public Health, Boston, MA, USA, 6Institute of Clinical Physiology (IFC), National Research Council,
Pisa, Italy, 7National Institute for Health Development, Tallinn, Estonia and 8Wales Heart Research
Institute, Cardiff University, Cardiff, UK
*Corresponding author. Cancer Prevention and Research Institute (ISPO), via Cosimo il Vecchio n. 2, 50139 Florence,
Italy. E-mail: [email protected]
Accepted 1 December 2014
Abstract
Background: This article is part of a series commissioned by the International
Epidemiological Association, aimed at describing population health and epidemiological
resources in the six World Health Organization (WHO) regions. It covers 32 of the 53
WHO European countries, namely the Western European countries, the Balkan countries
and the Baltic countries.
Methods: The burdens of mortality and morbidity and the patterns of risk factors and
inequalities have been reviewed in order to identify health priorities and challenges.
Literature and internet searches were conducted to stock-take epidemiological teaching,
research activities, funding and scientific productivity.
Findings: These countries have among the highest life expectancies worldwide.
However, within- and between-country inequalities persist, which are largely due to
inequalities in distribution of main health determinants. There is a long tradition of epidemiological research and teaching in most countries, in particular in the Western
European countries. Cross-national networks and collaborations are increasing through
the support of the European Union which fosters procedures to standardize educational
systems across Europe and provides funding for epidemiological research through
framework programmes. The number of Medline-indexed epidemiological research publications per year led by Western European countries has been increasing. The countries
accounts for nearly a third of the global epidemiological publication.
Conclusions: Although population health has improved considerably overall, persistent withinand between-country inequalities continue to challenge national and European health institutions.
More research, policy and action on the social determinants of health are required in the region.
C The Author 2015; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association
V
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Epidemiological training, research and workforce in the Baltic and Balkan countries should be
strengthened. European epidemiologists can play pivotal roles and must influence legislation concerning production and access to high-quality data.
Key words: Epidemiology, health status, risk factors, teaching and research, health inequalities, Europe
Key Messages
• The WHO European region is one of the wealthiest in the world. Even though total population health has improved
considerably in many countries of the region over the past decades, persistent inequalities between and within countries represent a challenge for governments, health institutions and health professionals.
• Strengthening prevention programmes that effectively reach low-educated groups and guaranteeing equitable access
to good-quality health care are needed.
• There is long-standing tradition in epidemiology. Nowadays, important research in epidemiology is undertaken and
relevant training in epidemiology is offered in most of countries of the region.
Introduction
This article, commissioned by the International
Epidemiological Association (IEA), is part of a series of
eight papers on population health and the status of epidemiology in the six World Health Organization (WHO)
regions. The WHO European region includes 53 countries
on the European and Asian continents [http://who.int/
about/regions/en]. This paper describes population health
and stock-takes the status of epidemiology in 32 countries
belonging to Northern, Western and Southern Europe according to the United Nations (UN) geographical classification,1 herein called the ‘UN32 countries’. A previous
paper has considered the other 21 countries in Eastern
Europe, Western Asia and South-Central Asia.2
Culturally, economically and politically, Europe is not a
homogeneous region. To better describe patterns of mortality
and morbidity we have not adhered strictly to the UN geographical classification but have considered the following
three country groupings: (i) 18 ‘Western European countries’
which have been linked by economic and cultural roots since
ancient times and have developed economic and political
bonds during the second half of the 20th century, i.e. Austria,
Belgium, Denmark, Finland, France, Germany, Greece,
Iceland, Ireland, Italy, Luxembourg, The Netherlands,
Norway, Portugal, Spain, Sweden, Switzerland and the
United Kingdom [UK]; (ii) the seven Balkan countries, i.e.
Albania, Bosnia Herzegovina, Croatia, The Former Yugoslav
Republic of Macedonia (TFYR Macedonia), Montenegro,
Serbia and Slovenia; and (iii) the three Baltic countries, i.e.
Estonia, Latvia and Lithuania. Data are provided for Malta.
Some information about Andorra, Monaco and S. Marino,
countries with fewer than 100 000 residents, is available at
[www.euro.who.int/hfadb/]. A partnership, the European
Union (EU), was founded in 1957.3 By the early 1990s, all
Western European countries (except Iceland, Norway and
Switzerland) had become members. More recently Croatia,
Estonia, Latvia, Lithuania, Malta and Slovenia have joined.
In 2013, the World Bank classified these and the 18 Western
European countries as ‘high-income’. Albania, Bosnia
Herzegovina, TFYR Macedonia, Montenegro and Serbia are
‘upper-middle-income’.4
The main data sources contributing to this report are as
follows: ‘Health for All’ and ‘European Health for All
Mortality’ databases provided online by the WHO
Regional Office for Europe; WHO World Health
Statistics; EUROSTAT statistics; EU Commission (EC) and
WHO reports concerning the burden of disease, main risk
factors and inequalities; the ‘EUCAN’ database; and the
‘EUCORDIS’ database. Medline-indexed academic journal
articles and websites of epidemiological and public health
associations, universities and health institutions were accessed to describe epidemiological activity.
Demographic Outlines
The population of the European region has increased over
time, reaching nearly 900 million inhabitants in 2010.5
The population of the European region is ageing. By 2010,
about 15% of the European population was aged 65 years
and over, and this group is projected to represent more
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Figure 1. Life expectancy at birth in (a) Western, (b) Balkan and (c) Baltic countries, 1970–2010. Source of data: World Health Organization. European
Health for All Database (HFA-DB)5.
than 25% by 2050.6 Ageing occurred earlier than elsewhere in the Scandinavian countries where the percentage
of the population aged 65 years and over peaked around
the end of the 1980s. As of now, the countries with the oldest populations are Germany, Italy, Greece and Portugal,
with people aged 65 years and over representing 20.6%,
20.2%, 19.1% and 18.4% of the population,
respectively.5 Both declining birth rates and increasing
life expectancy drive this trend. Birth rates declined
substantially after 1970, but have remained relatively stable over the past 20 years. Life expectancy of European
citizens has increased over time, reaching an average of
72.9 years for men and 80.1 for women. From 1980 to
2010, life expectancy has steadily increased in the Western
European and Balkan countries but decreased in the Baltic
countries in the early 1990s (Figure 1). In 2010, the highest
life expectancies were observed in Switzerland (82.8 years),
Italy (82.5) and Spain (82.3), and the lowest for Latvia
International Journal of Epidemiology, 2015, Vol. 44, No. 1
303
Figure 1. Continued.
Figure 2. Life expectancy at birth in N32 countries (data not available for Monaco), men and women, last year available (2006–10). Source of data:
World Health Organization. European Health for All Database (HFA-DB)5.
(73.7) and Lithuania (73.6). Women experience higher life
expectancy in all countries (Figure 2).
According to the EC, during 2011 approximately 3 million and 2 million individuals (52% men) migrated, respectively, to and from one of the EU countries.7 The
greatest numbers of immigrants settled in the UK, Spain,
Italy and Germany. Emigrants outnumbered immigrants in
Ireland, Greece, Spain and in the Baltic countries.7 In the
Baltic and Balkan countries, the strong negative migration
rate together with a reduced birth rate have resulted in
decreased population counts and population aging.7–8
Mortality and Morbidity
In Europe, over the past three decades, mortality has
decreased in all countries, for all age groups, in both sexes,
for most causes of death. Mortality is very low during childhood and young adulthood. Infant mortality in Europe has
decreased by 55% over the past 30 years.5–6 In Western
European countries rates have converged, ranging between
2.3 deaths per 1000 births in Finland and 4.3 in the UK in
2010. In the Baltic countries, the rates rose from 1985,
peaked in 1995 and subsequently dropped to between 3.3 in
Estonia and 5.7 in Latvia. In the Balkan countries, the rates
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Figure 3. Infant mortality in (a) Western, (b) Balkan and (c) Baltic countries, 1985–2010. Source of data: World Health Organization. European Health
for All Database (HFA-DB)5.
International Journal of Epidemiology, 2015, Vol. 44, No. 1
range between 2.5 in Slovenia and 7.6 in TFYR Macedonia
(Figure 3). In 2010, over 70% of mortality occurred among
people aged 65 years and over.6 The age-standardized allcause mortality rate (all ages, both genders) was 800 deaths
per 100 000 of population—a 25% reduction over 30 years.5
Rates ranged from 464 deaths per 100 000 of population
(Switzerland) to 591 (Portugal) in Western European countries, from 600 to 948 in the Balkan countries and from 800
to 951 in the Baltic countries. Premature mortality differed
markedly; the 0–64 age-standardized rates ranged from 138
(Sweden) to 189 (Portugal) in Western European countries,
from 199 (Slovenia) to 313 (Serbia) in Balkan countries and
from 314 (Estonia) to 415 (Lithuania) in Baltic countries.
Death rates were higher for men than for women; the rate
ratios for all ages ranged from 1.4 in Greece to 2.2 in
Lithuania, and for the 0–64 year age group from 1.6 in
Switzerland to 3.1 in Lithuania.
Among adults, cardiovascular diseases (CVD) and malignant neoplasms (MN) are the main causes of death in
terms of both rates and absolute numbers.9 Figure 4 shows
the contribution of different causes of death in the UN32
countries. Time trends show considerable reductions in
CVD mortality in Western European countries—approximately 30% over the past 30 years. In the Baltic countries,
CVD mortality increased from late 1980s to mid 1990s
(especially in the under-65s) and subsequently reduced. In
the Balkan countries, there is evidence of a declining trend
in Slovenia and, more recently, in Serbia and Croatia
(Figure 5). Mortality from ischaemic heart disease (IHD),
the most common CVD, demonstrated a similar pattern,
with France, Spain and Greece exhibiting the lowest rates
in the 1970s and France, Spain and The Netherlands showing the lowest rates in 2010. Mortality from stroke also
declined in Western European countries, with Portugal
showing the most dramatic decline but still remaining the
country with the highest rate besides Greece. TFYR
Macedonia, Latvia, Lithuania and Serbia exhibited the
highest rates among the UN32 countries.5
Type 2 diabetes has increased in European adults.
Mortality rates do not account for the whole mortality by
diabetes, further (indirect) mortality resulting from death
due to complications, in particular CVD. Data from
available national registers indicate that the prevalence
of diabetes varies substantially across the European
countries, with the highest being reported for Portugal
(9.4%) and the lowest, at less than 1%, for Albania,
Greece and Iceland.5 Recent estimates indicate an overall
prevalence of 8.5% in 2010 in the 47 European member
states of the International Diabetes Federation Europe
region.10
Mortality rates from MN in Western European countries rose between the 1970s and the early to mid 1990s
305
Figure 4. Causes of death in the UN32 countries, 1999 and 2009
(Andorra, Monaco and S. Marino excluded). Source of data:
World Health Organization, European Health for All Mortality Database
(HFA-MDB)9.
and then fell. Greece, Portugal and Spain showed the lowest mortality in the early 1970s, whereas Finland,
Switzerland and Sweden showed the greatest falls and the
lowest rates towards 2010 (Figure 6). In recent years, the
age-standardized mortality rates for MN surpassed CVD
mortality in men in France, Italy, Spain, Portugal and The
Netherlands5. In Baltic countries, rates peaked in the
1990s and then fell.5 In 2010, the highest all-cancer mortalities were reported for Croatia, Serbia, Latvia and
Slovenia. The most common cancer deaths were those arising from the lung, colorectum, female breast, and stomach.5,11 However, in Western European and Baltic
countries the most frequent cancers in 2012 were those
arising from the large bowel, lung, female breast and also
the prostate for which the increasing incidence has been
correlated to increasing early diagnosis using the prostatespecific antigen (PSA) test.12. For breast and large bowel
cancers, an improved survival, seen especially in Western
European countries, has led to reduced mortality in spite
of increasing incidence.13–14. Figure 7 shows breast cancer
incidence and mortality rates for the year 2012.
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Figure 5. Mortality from cardiovascular diseases in (a) Western, (b) Balkan and (c) Baltic countries, 1970–2010. Source of data: World Health
Organization. European Health for All Database (HFA-DB)5.
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307
Figure 6. Mortality from malignant neoplasms in (a) Western, (b) Balkan and (c) Baltic countries, 1970–2010. Source of data: World Health
Organization. European Health for All Database (HFA-DB)5.
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Figure 7. Incidence and mortality rates of breast cancer in women in (a) Western, (b) Balkan and (c) Baltic countries, 2012. Source of data:
International Agency for Research on Cancer-World Health Organization. EUCAN Database11.
Mortality from mental and neurological diseases has
increased.5 A recent study has estimated that 38% of the
EU population (plus Switzerland, Norway and Iceland)
suffered from mental disorders in 2011.15
External causes represent the leading cause of death in
people aged 15–44 years.5 Rates declined over the past
20 years, in particular for motor vehicle accidents and
suicides, the two most significant causes of death in this
group. In 2010, Greece, Croatia, Latvia and Lithuania
exhibited the highest rates of motor vehicle accidents;
Malta, The Netherlands, Sweden and Switzerland had
the lowest rates.5 Suicides were highest in Latvia,
Lithuania and Finland and lowest in Spain, Italy and
Greece.5
Mortality from communicable diseases decreased in
Europe during the 1970s and 1980s but increased moderately subsequently. This increase may be attributed to
septicaemia among older people and to increasing antimicrobial resistance.6 Concern currently focuses particularly on tuberculosis and HIV/AIDS. Mortality and
incidence rates for tuberculosis have declined generally but
remain high in Bosnia Herzegovina, Latvia and Lithuania.
HIV infection rates slightly increased until the beginning of
the 2000s in Western European countries; afterwards they
remained relatively stable. Exceptions were Switzerland
and Portugal where rates—the highest in 1990s—have
dropped since 1990 and 2000, respectively. In the Balkan
countries, HIV infection slightly increased. In the Baltic
countries rates peaked at the beginning of the 2000s, in
particular in Estonia and Latvia where the highest rates in
the UN32 countries were seen at the beginning of the
2010s.5 HIV infection is concentrated in populations at
higher risk for unprotected sex and drug injecting, the latter transmission mode being highest in the Baltic
countries.16
Mortality data do not account for the global disease burden.17 In 2004, among the UN32 countries the lowest disability-adjusted life-years (DALYs) per 100 population—a
measure combining the years of life lost due to premature
mortality and years lived in states of disability—were
estimated for Iceland (9.8), Switzerland (10.8) and Malta
(11.1), and the highest for Estonia (18.9), Latvia (19.6) and
Lithuania (18.4) see [http://www.int/healthinfo/globan_bur
den_disease/estimates_country/en/]. Most DALYs have been
ascribed to CVD, MN and neuropsychiatric disorders, but
also to injuries in the Baltic countries.6,18
International Journal of Epidemiology, 2015, Vol. 44, No. 1
Health Behaviours
Tobacco smoking, heavy alcohol drinking, unhealthy diet
and physical inactivity, both directly and through intermediate factors—such as raised blood pressure, overweight
and obesity and high glucose and cholesterol levels—are
the main determinants of health in the European region.19–20 With few exceptions, tobacco smoking has
steadily decreased in European populations over the past
30 years.5,21 The decline was particularly steep in The
Netherlands and Sweden, where the prevalence of smoking
dropped from 43.0% to 20.9% and from 32.4% to
13.6%, respectively, between 1980 and 2010. Smoking
declined steadily among men in all countries, whereas
among females it declined only more recently and
increased in some countries. However, it remained more
common among men than among women except in
Sweden (Table 1). Smoking prevalence in adolescents tends
to be higher among girls than boys in the Western
European and Balkan countries, whereas in the Baltic
countries this pattern is reversed.22–23
In Europe as a whole the proportion of deaths attributable to smoking, based on mortality in 2004, was estimated
be equal to 16% in both genders24 and the tobacco smoking-attributable proportion of total DALYs to be approximately 12%.25 Among men, smoking-attributable deaths
are notably declining in those countries where smoking reduction started earlier, as in Finland (38% in 1970 to 15%
in 2009 in men aged 35–69 years) and the UK (47% in
1970 to 22% in 2009). In contrast, the proportion among
women aged 35–69 years in the Western European countries
has not yet decreased and exceeds the male smokingattributable proportions in Denmark and Sweden.21,26
All EU Member States ratified the Framework
Convention on Tobacco Control (FCTC), the first treaty
negotiated under the auspices of the WHO,27 and almost
all of these have implemented or are currently implementing comprehensive smoking bans in workplaces, indoor
public places and public transport.28
Alcohol consumption has decreased in most Western
European countries over the past two decades, but has
increased in the Baltic countries.5 Consumption and patterns
of drinking vary across Europe. In the Mediterranean region,
alcohol (generally wine) is consumed daily, usually with
meals. In other countries such as Germany, Austria and
Belgium, beer is the beverage of choice, and there is some irregular heavy drinking in countries of Northern Europe, the
British Isles and the Baltic countries.29–30 The estimated alcohol-attributable proportion of all deaths is approximately
7% Europe-wide,24 being greatest in Estonia, Latvia and
Lithuania.30–32 The estimated proportion of total DALYs due
to alcohol is 11% (15.2% in men, and 3.9% in women).25
309
Europe was the first region to develop a wide action plan to
address the harmful use of alcohol.33 In the EU, alcohol policies have been guided by an EU strategy to support Member
States in reducing alcohol-related harm.34 Several actions
have been adopted in the countries covered by this review.35
Dietary habits can influence health. Disparities in dietary
habits, and specifically in fruit and vegetables consumption,
have been described across Europe.36 In Western European
countries, the highest average amount of fruit and vegetables available per person-year were observed for Greece
(although declining in the mid 2000s), Italy, Luxemburg,
Spain and Portugal. In Finland, Iceland, Ireland, Denmark,
Norway and Sweden, as well as in the Baltic and Balkan
countries, fruit and vegetable availability has increased over
the past 20 years.5 The average number of calories available
per person has increased slightly since the 70s in Western
European and in Baltic countries; a steady increase has been
seen over the past two decades in the Balkan countries.5 A
rise of calorific intake has led to an increased prevalence of
overweight and obesity (Table 1). The estimated proportion
of DALYs attributable to overweight and obesity is about
8% in the European region.25
Inter-country inequalities in smoking, alcohol and eating habits have been evidenced to underlie temporal trends
and differences between countries in mortality and
morbidity. The North–South gradient of IHD mortality
has suggested a protective effect of the so-called
Mediterranean diet. The WHO Monitoring Trends and
Determinants in Cardiovascular Disease (MONICA) project and the ‘Seven Countries’ study have evidenced that
the observed declining CVD mortality is associated with
declines in smoking, heavy alcohol drinking and unhealthy
diets.37–38 Recent studies have confirmed the protective effect of healthy eating on CVD39 Differences in lung and
stomach cancer incidence have been attributed to inequalities in dietary behaviours.40–43
Physical activity influences health. The percentage of insufficiently active people varies between countries22 and is
generally higher among women (Table 1). The levels of physical activity among children and adolescents vary by country
but they are generally higher among boys than girls.23
Environment
Air quality is the main environmental determinant of
human health in the region.
Burning of petroleum fuels in transportation is the main
source of air pollution in towns, airports and sea ports.44
The EU has implemented several legislative measures to
improve air quality and has developed a number of
Environment Action Programmes (EAPs) [http://ec.europa.
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Table 1. Main risk factors
Prevalence of
obese adults aged
20 years and
over, 2008
Country
Austria
Belgium
Denmark
Finland
France
Germany
Greece
Iceland
Ireland
Italy
Luxembourg
Netherlands
Norway
Portugal
Spain
Sweden
Switzerland
United Kingdom
Albania
Bosnia and Erzegovina
Croatia
Montenegro
Serbia
Slovenia
TFYR Macedonia
Estonia
Latvia
Lituania
Malta
Men
19.2
21.2
17.1
21.0
16.8
23.1
18.8
23.4
25.7
19.3
24.5
16.1
21.6
20.4
24.9
18.2
18.3
24.4
21.7
22.7
22.8
22.8
25.5
28.1
21.6
20.2
21.5
23.9
26.1
Adult obesity
rate of change
2000–2009
(men þ women)
Women
17.1
16.9
15.4
18.6
14.6
19.2
16.1
20.3
23.3
14.9
22.2
16.1
17.9
22.3
23.0
15.0
11.6
25.2
20.5
25.3
19.4
20.7
20.3
25.9
18.9
17.6
21.8
24.7
26.8
Prevalence of
smokers aged
15 years and over
Last year available
(2006/2010)
Men
33.3
16.7
30.0
36.4
22.2
25.0
...
66.7
36.4
11.1
37.5
33.3
66.7
15.4
23.1
22.2
...
9.5
...
...
...
...
...
...
...
...
...
...
...
27.3
24.0
20.0
23.2
32.4
26.4
38.0
14.5
28.0
29.6
27.0
23.1
19.0
30.8
31.2
12.5
22.0
21.0
60.0a
17.6
33.8b
36.7
30.7
22.4
40.0c
36.8
47.4
34.2
25.6
Adult smoking
rate of change
(1995–99) - 2006/2010
(men þ women)
Women
19.4
18.0
20.0
15.7
26.0
17.6
26.1
14.1
26.0
17.1
20.0
18.8
19.0
11.8
21.3
14.7
17.0
20.0
18.0a
11.3
21.7b
29.0
22.6
15.5
32.0c
18.7
20.7
14.4
15.8
Prevalence of
insufficiently
active adults,
aged 15 years
and older, 2008
Men
22.0
25.4
39.1
19.4
8.2
40.0
16.2
45.9
13.6
7.4
23.3
40.4
42.1
15.6
20.4
33.9
41.4
26.0
9.0
...
16.1
...
...
26.6
...
11.8
12.3
1.2
9.0
30
40
35
41
28
28
17
...
48
50
50
21
43
48
47
44
...
58
...
30
26
...
63
27
...
16
28
20
71
Women
39
45
35
35
37
29
15
...
59
60
46
15
45
54
53
44
...
69
...
37
21
...
73
34
...
19
36
25
73
Sources of data: (i) Obesity 2008: World Health Organization, Global Health Observatory (GHO), Data Repository,22 Obesity rate of change 2000–09:
Health at a Glance. 2011 OECD Indicators. released on November 2011 (http://www.oecd.org/health/healthataglance); (ii) Smoking 2006/2010: WHO HFA DB,5 Smoking 1995–99 average value: Nichols M, Townsend N, Scarborough P, et al. (eds). European Cardiovascular Disease Statistics 2012, European Heart
Network, European Society of Cardiology (http://www.escardio.org/about/documents/eu-cardiovascular-disease-statistics-2012.pdf); (iii) Physical activity as
prevalence of insufficiently active adults (% of defined population attaining less than 5 times 30 mins of moderate activity per week or less than 3 times 20 min of
vigorous activity per week or equivalent). 2008: World Health Organization. Global Health Observatory (GHO). Data Repository.22
a
Data 2000.
b
Data 2003.
c
Data 1999.
eu/environment/newprg/]. The European Environmental
Agency, established in 1990 [www.eea.europa.eu/], collects data from 38 European countries, allowing monitoring of pollutants across the region. The levels of sulphur
dioxide, carbon monoxide and benzene have substantially
reduced over the past 20 years, whereas nitrogen oxides
(NOx), particulate matter (PM), and ozone (O3) still remain at high levels. The EU limit and target values for
PM10 and PM2.5 were widely exceeded over the period
2001–10 except in Denmark, Finland, Ireland and
Luxembourg.45 The EU target value for O3 was not attained in most countries, in particular Italy, Greece and
Slovenia. It has been estimated that in the period 2008–10,
18–21% of the EU urban population was exposed to concentrations of PM10 in excess of the EU reference value.
The proportion of the urban population exposed to PM10
levels exceeding the stricter WHO Air Quality Guidelines
(AQG) limit was approximately 81%.45 Many studies
International Journal of Epidemiology, 2015, Vol. 44, No. 1
involving European populations have demonstrated shortand long-term adverse health effects of exposure to PM,
NOx and O3.46–50
In the WHO’s Review of Evidence on Health Aspects of
Air Pollution (REVIHAAP) and Health Risks of Air
Pollution in Europe (HRAPIE) projects, the group of experts who reviewed the scientific evidence for the adverse
effects on health of air pollution concluded that the effects in some cases occur at air pollution concentrations
lower than the WHO AQG limits.49–50 Recently the
International Agency for Research on Cancer (IARC) has
classified air pollution and PM as carcinogenic agents to
humans with robust evidence [http://www.iarc.fr/en/publications/books/sp161/index.php], thus posing further arguments for the improvement of air quality in Europe.
Recent climate change represents another important environmental stressor.51–52 Europe’s average temperature is
projected to continue to increase throughout the 21st century, especially in winter over North-Eastern Europe and
in summer over Southern Europe.53
Work
Work is an important determinant of health; it influences exposure to a range of hazards, but also provides income and
determines social position in society. The current increasing
unemployment poses a serious concern in many countries in
the region (Figure 8). The European Framework Directive on
Safety and Health at Work [https://osha.europa.eu/it/legislation/directives/the-osh-framework-directive/1] represented a
milestone in improving occupational safety across EU
Member States. However, flaws in the Directive’s application
hinder the achievement of its potential [osha.europa.eu/en/le
gislation/directives/the-osh-framework-directive/the-osh-fram
ework-directive-introduction]. The European Agency for
Safety and Health at Work sets European occupational health
standards, together with the WHO Headquarters in Geneva
[https://osha.europa.eu/]. Unhealthy working conditions are
estimated to contribute to at least 1.6% of the total burden
of disease in the European region [http://www.euro.who.int/
en/health-topics/environment-and-health/occupational-health/
data-and-statistics].
Social Determinants and Health Inequalities
The cultural, environmental, social and economic diversity
within and between European countries, together with the
high-quality data available on both individual-level socioeconomic status (SES) (e.g. education, employment, income
and occupation) and structural factors (e.g. welfare regimens, public policies and political factors) have made
311
Europe fertile ground for studying social determinants of
health (SDH) and health inequalities.54–55
The European region, one of the wealthiest in the world,
has undergone substantial socioeconomic development over
the second half of the 20th century. This economic growth
has been linked to the observed decline in mortality, especially in Western European countries.56 In 2010, per capita
annual gross domestic product (GDP) in the European region was just under US$23,000, but with large betweencountry variation.5 An association between national income
and life expectancy has been reported.55 Figure 9 shows life
expectancy by GDP. Incomes have grown faster for high-income groups than for low-income groups.57 According to
Eurostat, in 2011 in the EU 17% the population lived in or
at risk of poverty (meaning that their disposable income
was less than 60% of the national median income) with
more than 20% in Spain, Greece, Croatia and Lithuania7.
Moreover, child poverty has increased recently in many
countries, including some high-income countries.58 Health
services expenditure differs across countries. Most Western
European countries have invested by building a welfare state
modelled on those developed by the Scandinavian countries
and the UK over the second half of the past century. Total
health expenditures, as a percentage of GDP, have risen
over the past decades, reaching a country average of 8.5%
in 2010. Richer countries allocate higher percentages, ranging from 11.7% in France compared with 6.0% in
Albania.5 Government expenditure as a percentage of total
health expenditures is generally high, exceeding 80% in
Denmark, Iceland, Luxembourg, Norway, Sweden and the
UK, but are lower than 20% in the Baltic and Balkan countries (Figure 10). Out-of-pocket (OOP) payments (additional costs paid directly by the patients) represent an
important financing mechanism in the latter countries.
Association between social welfare spending and life expectancy has been reported.59
The English Black Report in 1980 (http://www.sochealth.co.uk/resources/public-health-and-wellbeing/poverty-and-inequality/the-black-report-1980/) marked an
important step in drawing attention to health inequalities.
This report demonstrated that, although health had improved overall since the introduction of the welfare state,
it had not benefited all citizens equally. Numerous epidemiological studies have since shown that European men
and women with lower education, occupational status or
income carry greater disease burden (including from earlier in life) and die earlier from chronic diseases as well as
from infectious diseases and intentional and non-intentional injuries.60–65 National census-linked mortality and
cross-sectional studies have shown that mortality rate
ratios between lower and higher SES groups range from
below 2 in Sweden, Norway, Denmark, Belgium, Italy,
312
International Journal of Epidemiology, 2015, Vol. 44, No. 1
Figure 8. Unemployment rate, annual average, men and women, 2012. Source of data: European Commission. Eurostat, Statistics Database.7.
Figure 9. Life expectancy by per capita (GDP) (in US$), 2010. Source of data: World Health Organization. European Health for All Database (HFA-DB)5.
International Journal of Epidemiology, 2015, Vol. 44, No. 1
313
Figure 10. Per capita health expenditures (in US$) by source of financing: Public, Private and ‘Out_of_pocket’ (OUP), 2010. Source of data: World
Health Organization. European Health for All Database (HFA-DB)5.
Portugal and Spain to above 3 in Estonia (and in some
Eastern European countries).66 Epidemiological research
demonstrates that inequalities in health are largely explained by inequalities in behaviours (e.g. smoking, alcohol drinking, physical activity and diet).67–72 For
example, SES inequalities in lung cancer mortality are
relatively large in The Netherlands and the UK, where the
prevalence of smokers in high SES classes declined earlier,
but are smaller in France, Spain, Italy and in particular in
Portugal, where smoking cessation started later and
where inequalities in smoking by SES are smaller.71–72 A
study of 10 Western European countries estimated that
smoking accounted for 50% of educational inequalities in
lung cancer risk.67 People of lower SES also have less access to high-quality health care and prevention services,
with implications for mortality from CVD and some
cancers.73–75
Health inequalities have remained or even widened over
recent decades. In many Western European countries,
whereas total mortality has declined, absolute inequalities
by SES have been fairly stable but relative inequalities have
widened.76 Increasing unemployment, recent austerity
measures and weaker social protection appear to partially
explain this phenomenon.77–78 An inverse ‘U’-shaped trend
in mortality occurred in the Baltic countries around the
mid 1990s. Over this period, mortality rates declined only
in the high educational groups, whereas the huge increase
occurred among the lower educated groups and has been
ascribed to risky health behaviours associated with
increased levels of poverty and marginalization.79–80
Epidemiological Research, Education,
Scientific Productivity, Personnel
In all countries of the region, epidemiological research is
undertaken and epidemiological education is offered both
by universities where research and teaching are strictly correlated and by national (governmental) health institutions.
Education
Across the region universities are leaders in education in epidemiology. Examples of institutions providing considerable
epidemiological education are the London School of Hygiene
and Tropical Medicine, which is part of London University,
and the Erasmus University in Rotterdam, as they attract students from other European and non-European countries.
During the past decades the EU has fostered restructuring
procedures to standardize educational systems across Europe.
In 1999, the Bologna Declaration started a process to overcome the segmentation of the European higher education sector. This led to the establishment of the European Higher
314
Education Area (EHEA) which aims to ensure more comparable degrees and encourage student mobility and employability across European countries.81 All countries included in this
paper are EHEA members and have remodelled or are currently remodelling their higher educational systems. The EU
is strongly committed to standardization of education in epidemiology, as demonstrated by the establishment of
programmes for the European Public Health Master [www.
europubhealth.org], the EU Master of Science in
Epidemiology [www.lsht.ac.uk/study/cpd/eu_mse.html] and
the European Master and Doctorate of Science in Advanced
Epidemiology [http://madeineur.eu]. All three programmes
are (partially) supported by the EC and they represent an example of joint masters, i.e. they are offered by a consortium
of universities across Europe. The Association of Schools of
Public Health in the European Region (ASPHER) was
founded in 1966 as part a worldwide initiative to establish
Associations of Schools in every WHO region, to support
public health education. During late 1980s, ASPHER laid the
foundations for a European Master in Public Health. Today
it aims to enhance epidemiological teaching and training of
professionals in public health and it has over 100 institutional
members located throughout Europe, with all countries
included in this review, except Luxembourg, BosniaHerzegovina, Montenegro and Malta, having at least one
[www.aspher.org/].
To define the consistency of educational courses in epidemiology, searches of universities’/professional societies’
websites were performed and an e-mail survey on teaching
activities was carried out among professional societies.
Education in public health was also considered because
public health is probably the principal practical application
of epidemiology. So not considering educational courses
labelled as ‘public health’ would have led to a bias in the
total educational offer. In total 118 institutions were identified that provide postgraduate education in the region
(see Supplementary data 1, available at IJE online). The
quality and comprehensiveness of this information may be
biased by inaccurate and/or dated internet sources and
relatively low survey response (50%). Master degree
courses are the primary qualification for professionals and
designed to cover five ‘core’ disciplines: epidemiology,
biostatistics, environmental health, health policy, and social and behavioural sciences. A master degree usually
takes 2 years of full-time study and requires the candidate
to conduct and present in a thesis an original research project. Doctors of Philosophy (PhD) and postdoctoral
programmes comprise advanced professional degrees with
an average duration of 4 or 5 years, that aim to develop
integrated interdisciplinary expertise and include original
research cumulating in a doctoral dissertation (Table 2).
All Western European countries except Luxembourg
International Journal of Epidemiology, 2015, Vol. 44, No. 1
provide epidemiological postgraduate education, with
eight countries (Belgium, Denmark, Germany, Italy, The
Netherlands, Spain, Sweden and the UK) offering considerable curricula, i.e. at least five national universities offer
educational programmes in epidemiology and public
health. To these countries, France has to be added, where
the Institut de Santé Publique, d’Épidémiologie et de
Dévelopement (ISPED) actively cooperates with universities to implement teaching in epidemiology/public health
nationwide. Within the Baltic and Balkan countries the
offer is less extensive. Nevertheless, in the Baltic countries
at least one university offers a masters course (in Lithuania
two courses). The offer is similar in the Balkan countries,
with the exception of Montenegro. Serbia offers epidemiological education at two universities; particular emphasis is
given to public health as it is taught within medicine masters degrees and PhD courses.
Advanced training for health professionals and statisticians with an interest in epidemiology is quite consistent in
the Balkan, Baltic and Western European countries.
Also in these activities, the EU acts as a promoter.
The European Programme for Intervention Epidemiology
Training (EPIET)—which is included in the Training
Programmes in Epidemiology and Public Health
Interventions Network (TEPHINET) and is carried out by
the European Centre for Diseases Prevention and Control
(ECDC) seated in Stockolm [www.ecdc.europa.eu/]—
provides professional training and practical experience in
intervention epidemiology, for public health professionals
and medical practitioners. Also, the International Agency
for Research on Cancer (IARC) [www.iarc.fr/], the
WHO’s specialized cancer agency based in Lyon, France,
offers training courses in cancer epidemiology.
In the Baltic and Balkan countries, developments in
public health education have occurred in recent years
through international networks. In particular, the Open
Society Institute (OSI) Network Public Health programme
has developed training for public health professionals from
Central and Eastern Europe and the former Soviet Union
[http://health.accel-it.lt/en/about_us/]. Erasmus–Western
Balkans (ERAWEB) is a joint mobility programme offered
by eight Western Balkan universities and six EU universities, aimed at promoting research in medicine and health
sciences and to promote students’/faculty members’ mobility [http://erasmus-westernbalkans.eu/].
The European Educational Programme in Epidemiology
[www.eepe.org/] held in Florence since 1988 is the first
epidemiological summer school established in the region,
with a faculty drawn from globally leading institutions.
Over two 2000 students have attended the programme
since its inception. Today, epidemiological summer schools
are held by universities and public health institutions in
International Journal of Epidemiology, 2015, Vol. 44, No. 1
315
Table 2. Number of institutions giving post-graduate training
in epidemiology and public health
Countries
Type of epidemiological
training
Master Philosophy Post-doctoral
degrees doctorates programmes
Western European countries
Austria
3
Belgium
5
Denmark
4
Finland
2
Francea
6
Germany
10
Greece
1
Iceland
2
Ireland
1
Italy
8
Luxembourg
–
Netherlands
5
Norway
1
Portugal
2
Spain
10
Sweden
7
Switzerland
4
United Kingdom
18
Baltic countries
Estonia
1
Latvia
1
Lithuania
2
Balkan countries
Albania
1
Bosnia-Herzegovina
1
Croatia
1
TFYR Macedonia
1
Montenegro
–
Slovenia
1
Serbia
1
Other countries
Malta
1
Total
number of
Institutions
2
3
1
1
2
4
1
2
2
7
–
4
–
1
2
4
3
5
1
–
–
1
–
2
–
1
–
2
–
–
–
–
–
1
1
2
4
6
5
2
4
14
2
2
2
11
–
5
1
3
11
8
4
21
–
–
–
–
–
–
1
1
2
–
–
1
–
–
–
2
–
–
–
–
–
–
–
1
1
1
1
–
1
2
1
–
1
a
The Institute of Public Health (ISPED) provides epidemiological
education, in collaboration with universities nationwide.
many countries (Austria, Denmark, Finland, France,
Germany, Greece, Italy, Lithuania, The Netherlands,
Spain, Slovenia, Sweden, Switzerland and the UK).
The established academic tradition in epidemiology of
Western European countries is also reflected in the number
of European textbooks and reference works. Two of the
world’s leading publishing companies in science and health
information, Elsevier and Springer, have headquarters in
The Netherlands and Germany, respectively. In 2008,
Springer also acquired BioMed Central, becoming the largest open-access publisher in the world. The British Oxford
and Cambridge University Presses, the world’s oldest
publishing houses, are also based in the region and have
specialized sections for life sciences and for epidemiology,
biometrics and biostatistics.
Research institutions and funding
In all Western European countries (except Switzerland), all
Baltic countries and Croatia, Slovenia and Malta, national
health institutions are involved in surveillance of and research in communicable diseases. These bodies are affiliated to the European Centre for Disease Prevention and
Control (ECDC), the EU agency aimed at strengthening
Europe’s defences against infectious diseases [http://www.
ecdc.europa.eu/en/Pages/home.aspx].
No scientific research institution for all noncommunicable diseases exists at European level (nor, in
fact, worldwide). IARC is a unique institution carrying out
research in the fields of cancer biology, epidemiology and
prevention, and management of the IARC biobank, one of
the largest biobanks in the world. The European Cancer
Observatory is an EC-funded project developed at the
IARC in partnership with the European Network of
Cancer Registries within the Europe against Cancer:
Optimisation of the Use of Registries for Scientific
Excellence in research (EUROCOURSE) project. The observatory provides comprehensive information on cancer
burden in Europe through three websites [www.eco.iarc.fr/
eucan/Default.aspx; www.eco.iarc.fr/eureg/Default.aspx;
www.eco.iarc.fr/eurocim/Default.aspx].
High-quality population-based and disease-oriented
biobanks have been established in many European
countries.82
A particular, large expertise has been developed by
European epidemiologists in the field of cancer screening
programme monitoring and evaluation, in particular in
Western European countries in most of which populationbased screening is undertaken (Supplementary data 2,
available at IJE online).
The European Monitoring Centre for Drugs and Drug
Addiction (EMCDDA), an agency of the EU, was established in 1993 in Lisbon (Portugal) [http://www.emcdda.
europa.eu/].
The Cochrane Collaboration is an international independent network, in official relationship with the WHO—
and supported by national governments, international
governmental and non-governmental organizations,
universities, hospitals, private foundations and personal
donations—which promotes systematic reviews to inform
healthcare decisions. It was founded in the UK and currently includes working groups of experts from more than
120 countries. Over 5000 reviews are available online in
the Cochrane Library [www.thecochranelibrary.com/].
316
Out of the 16 ‘methods groups’, 8 are placed in Europe as
well as 7 of the 11 ‘fields and networks’ and 37 of the 53
‘review groups’ [http://www.cochrane.org/contact].
National statistical organizations are active in all countries and cooperate with EUROSTAT, the EU statistical office that provides demographic, economic, social and
health statistics (ec.europa.eu/eurostat).
Health research priorities and strategies are defined by
national governments with support from international organizations, principally the WHO Regional Office for
Europe that provides all 53 European countries with statistics on demography, mortality, morbidity, risk factors and
health services. The EC is aimed at harmonizing the health
status of citizens in member states through two structures,
the Directorate for Research and Innovation and the
Directorate for Health and Consumers (DG SANCO), of
which the latter has national contact points in all 18
Western countries, in the Baltic countries, and in Croatia,
Slovenia and Malta. The Public Health Innovation and
Research in Europe (PHIRE) project has evidenced that
health research strategies were present in 15 EU member
states and that public health research was identified in
three national strategies.83 The EU European Medical
Research Council [www.esf.org/] and Science Europe
[www.scienceeurope.org/] further boost biomedical research and assist between-country collaborations.
Funding for biomedical and public health research is
provided mainly by national governments. The EC promotes and funds research in any field of science through
multi-annual programmes settled by the DirectorateGeneral for Research and Innovation [http://ec.europa.eu/
research/index.cfm]. Besides public funding, a relevant
number of non-governmental organizations provide funds
for biomedical and public health research. The contribution of industry is generally limited to funding clinical
trials.
To determine the areas covered by EU-funded epidemiological research, we have analysed the Community
Research and Development Information Service (CORDIS)
database provided by the EU publications office [http://
cordis.europa.eu/], which includes all research projects
supported under the 5th, 6th and 7th Framework
Programmes. We searched the database for ‘epidemiological’ projects defined as disease modelling, aetiological
studies, clinical trials (excluding phase I), intervention
trials, data mining and biobanking, epidemiological
surveillance, health promotion, health policy evaluation
and health service research. The exact strategy is described
in Supplementary data 3 (available at IJE online).
Approximately 50% of CORDIS-indexed ‘epidemiological’ projects concerned non-communicable diseases,
20% communicable diseases, 10% evaluated health
International Journal of Epidemiology, 2015, Vol. 44, No. 1
policies or services and 10% specifically addressed older
people. Just over a quarter of projects investigated causes
of diseases, of which approximately one-third focused on
genetic and environmental determinants and about 20%
on gene-environment interactions. Project objectives
ranged over deepening knowledge on disease aetiology, improving diagnostic tools and treatment, disseminating
knowledge and covering the gap between science and its
applications in prevention and clinical treatment. Over
90% of ‘epidemiological’ projects were led by a Western
country. The UK coordinated approximately a quarter of
projects, followed by The Netherlands, Germany, France
and Italy. The UK, Germany, Italy, The Netherlands,
France, Spain and Sweden were the most frequent project
participants. The Baltic and Balkan countries participated
in 11% and 10% of the projects, respectively. Other
European countries were included in about 40% of projects and non-European countries in about 18%.
Publications
We conducted a systematic search of Medline-indexed
journal articles to estimate publication activity, mainly in
the period 1993–2012.84 An epidemiological publication
about a country/countries was defined as a Medlineindexed paper with ‘epidemiology’ appearing as a Medical
Subject Heading (MeSH) or ‘epidemiol*’ appearing in the
title or abstract of the publication, ‘humans’ appearing as a
MeSH heading and the country/countries appearing as a
MeSH heading or in the title or abstract. This definition is
comparable with that used in the majority of articles in this
series.2 The exact strategy is available from authors on
request.
Approximately one-third (32.4%) of 1993–2012 epidemiological publications about any country in the world
concerned one of the UN32 countries, with the great majority (96.4%) reporting about a Western European country. Growth in epidemiological publications about Western
European countries was particularly strong, moving from
an average of 41 publications per year in 1950–69 to 1966
in 2000–12. A similar pattern was observed for the Baltic
countries (from 1 per year in 1950–69 to 20 in 2000–12)
and Balkan countries (from less than 1 to 62). The UK,
Italy, France and Germany were the countries on which
the largest numbers of epidemiological publications reported (Figure 11). However, the 1993–2012 country publication rate per million of population, a summary measure
over many years of research activity, were highest for
Iceland (793), Denmark (308) Bosnia-Herzegovina (321)
and Sweden (262).
An additional Medline search was conducted to determine each epidemiological publication’s country of
International Journal of Epidemiology, 2015, Vol. 44, No. 1
317
Figure 11. Number of publications (1970–99) and publication rate (1993–2012) of Medline-indexed epidemiological papers, by decreasing rate within
different groups of countries. Publication rate is defined as the ratio of number of epidemiological papers published in 1993–2012 to population size
in 2008, expressed per million of inhabitants. Population data refer to 2008, source: United Nations, Department of Economic and Social Affairs.
World Population Prospectus: The 2008 Revision. New York, NY: United Nations, 2008. Data for Macedonia refer to 2010 and data for Montenegro
refer to 2011, source: World Health Organization. World Health Statistics. Geneva: World Health Organization, 2012. The search was based on the
word ‘epidemiol*’ appearing in the title or abstract of the paper. As this term is not always included, the number of identified papers could to be an
underestimate of the total number. However, this search strategy included ‘epidemiology’ as a MeSH term, allowing all papers labelled as epidemiological by a Medline indexer, through objective inclusion/exclusion criteria, to be included in this analysis. Because this analysis does not take into account citation indices such as the journal’s impact factor or the researcher’s h-index, it is unable to differentiate high- or low-quality publications or to
quantify relevance and impact of epidemiological contributions.85.
(principal) origin. More than half (57.7%) of the total
1993–2012 epidemiological publications about Western
European, Baltic and Balkan countries were principally authored by a researcher affiliated to an institution in these
countries. In absolute terms, the largest number of epidemiological papers was principally authored by researchers from institutions located in the UK, followed by
Italy, France and Spain (Table 3). Estonia and Croatia
were the most productive among the Baltic and Balkan
countries, respectively. When considering the scientific
productivity of each country regardless of which country/
countries epidemiological publications reported on, it
emerged that about one-third of epidemiological publications of which the principal author was affiliated to an institution in any country of the world was principally
authored by a researcher affiliated to an institution in the
WHO region. In particular, the UK leads publication activity, accounting for 24.3% of 59 671 epidemiological publications in the period 1993–2012, followed by France
(13.4%), Italy (11.8%) and Germany (10.0%).
Of all the epidemiological papers for 1993 to 2012,
63% could be classified as belonging to one of: communicable diseases; maternal, perinatal and nutritional
conditions; cancer; CVD; other non-communicable diseases; and injuries. The percentages of such publications
about communicable diseases (25%), maternal, perinatal,
and nutritional conditions (3%), cancer (23%), CVD
(11%), other non-communicable diseases (48%), and injuries (15%) weakly corresponded with the burden of disease
in the region (estimated from mortality data).
Western European, Baltic and Balkan countries also
publish several epidemiological journals. The Journal
R 85
Citation ReportsV
categorizes scientific journals according to the main subjects of published articles. We searched
for scientific journals falling into categories that mainly
included public health, general medicine and epidemiological research, finding that 174 (41%) of the indexed 420
journals originated in a country of the region. Out of these
174, 89 were published in the UK, 11 in France and
Germany and 10 in Italy and The Netherlands.
Personnel
Although formal statistics of the number of epidemiologists are not available, it is well known that epidemiological workforces vary across countries. Some Western
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International Journal of Epidemiology, 2015, Vol. 44, No. 1
Table 3. Quantity of epidemiological papers concerning the
country which are principally authored by a researcher
affiliated with an institution in the country, 1993_2012. To
determine each epidemiological publication’s country of
(principal) origin, the condition that countries appeared in the
search field containing the institutional affiliation of the
paper’s principal author has been included
Country
Number of
epidemiological
papers about
the country
Western European countries
Austria
514
Belgium
694
Denmark
1687
Finland
1319
France
4358
Germany
3701
Greece
767
Iceland
256
Ireland
649
Italy
4260
Luxembourg
36
Netherlands
1680
Norway
1061
Portugal
468
Spain
3726
Sweden
2422
Switzerland
996
United Kingdom
6022
Baltic countries
Estonia
155
Latvia
69
Lithuania
118
Balkan countries
Albania
65
Bosnia and
121
Herzegovina
Croatia
389
TFYR Macedonia
31
Montenegro
70
Serbia
153
Slovenia
128
Other countries
Malta
57
Total
35972
Number of
epidemiological
papers
principally
authored by a
researcher
affiliated
with an
institution in
the country
247
358
1015
808
2565
1731
570
101
284
2621
20
1269
633
258
1872
1602
452
3808
64
15
52
10
2
243
20
5
74
82
26
20807
% of
epidemiological
papers principally
authored
by a researcher
affiliated
with an
institution
in the country
58.4
48.1
51.6
60.2
61.3
58.9
46.8
74.3
39.5
43.8
61.5
55.6
75.5
59.7
55.1
50.2
66.1
45.4
63.2
38.3
41.3
21.7
44.1
45.6
15.4
1.7
62.5
64.5
7.1
48.4
64.1
45.6
45.6
57.8
European countries, including the UK, Denmark, France,
Germany, Italy, The Netherlands and Spain, have the
benefit of a long tradition of epidemiological activities.
They have a highly qualified epidemiological workforce
available in academia and in their national health services
and, in some countries such as Germany, Finland, Italy,
Denmark, Ireland, France and Latvia, within institutes
devoted to other disciplines, such as environmental protection agencies, institutes for food and nutrition and institutes for economics. In the IEA-Europe member register,
albeit a very crude measure of the number of epidemiologists, Western European epidemiologists represent about
90% of the whole European memberships. In the Balkan
and Baltic countries, the role of epidemiologists is not yet
fully exploited. Recently, efforts to develop the workforce
as well as research and education in epidemiology and public health have commenced, facilitated by a number of
international projects implemented around the turn of the
millennium.86 Professional associations are active in most
countries (Supplementary data 4, available at IJE online).
These societies play important roles in education, in knowledge-sharing and in fostering debate within the scientific
community. The European Epidemiology Federation of the
IEA includes 16 national societies and the European
Young Epidemiologists network. It sponsors European regional conferences held by an affiliated society in its respective countries on a rotating basis [www.iea-europe.
org/].
Challenges and Perspectives
Within the limits of this paper which generally surveys the
epidemiological profile and the status of the epidemiological research in 32 countries, it emerges that differences
exist among European countries in health profile as well as
in knowledge of the health status of the population and in
health research strategies. The WHO European policy
framework ‘Health 2020’ aims at supporting actions to
‘significantly improve the health and well-being of populations, reduce health inequalities, ensure people-centred,
equitable and of high quality health systems’ [http://www.
euro.who.int/en/health-topics/health-policy/health-2020the-european-policy-for-health-and-wellbeing].
The overarching aims of the EU Third Health
Programme for 2014–20 are aligned to promote health,
prevent diseases and facilitate access to better and safer
health care for EU citizens. Measuring population health
and implementing cost-effective, evidence-based interventions have been emphasized as ‘core aspects’ of the health
research in the EU programme ‘Horizon 2020’ [http://ec.
europa.eu/programmes/horizon2020/en]. Epidemiologists,
therefore, might make a substantial contribution to setting
priorities and planning actions for monitoring and improving population health. Western European countries have
a long-standing tradition of epidemiological research.
In these countries, the dialogue with health planners begins
International Journal of Epidemiology, 2015, Vol. 44, No. 1
to produce interesting results in some fields such as communicable diseases monitoring, health promotion and cancer screening.
However, the planning of teaching and training and the
definition of competency frameworks for public health
workforce development would require more emphasis on
epidemiological skills development. The currently high
level of epidemiological research activity and productivity
represents a valuable and rich resource for society, which
should be maintained and enhanced. In the Baltic and
Balkan countries, education in the discipline is relatively
less developed. Stronger teaching and training programmes
and dedicated funding initiatives are needed to raise the
level of epidemiological work, in particular in the field of
non-communicable diseases monitoring and prevention,
healthy behaviour promotion and intervention policy
evaluation.
An exemplary collaborative project primarily aiming at
producing an overview of public health research was the
3-year Strengthening Public Health Research in Europe
(SPHERE) collaboration of 16 partners. This was founded
under the leadership of the UK Faculty of Public Health of
the Royal College of Physicians with funding from the EU
Commission’s Sixth Framework Programme, and evidenced a relative underinvestment in national structures
and health research strategies in some countries, notably in
the Baltic and Balkan countries [http://www.who.int/nmh/
publications/ncd_report2010/en/]. Countries need to make
their research competencies and tools available through
high level, international cooperation, to examine the similarities and differences in risk factor distribution and disease occurrence and evaluate the performance of the
healthcare and prevention services.
There is a need to link epidemiological profiles on
health and health determinants with information on policies at national and European levels and to measure how
much policies affect the projected trends. Encouraging
results have been evidenced on the effects of tobacco
control policies and alcohol and smoking restriction on
peoples’ behaviours.87,88
Even though total population health has improved
considerably in many countries of the region, persistent
within- and between-country inequalities continue to challenge national governments and European institutions.
The results of epidemiological studies suggest that inequalities in mortality most likely reflect inequalities in disease
incidence and risk factors. They also suggest that policies
and public health interventions can impact differently with
regard to SES,75,89–91 and that reducing inequalities in
health requires the implementation of health and social
policies that address the SDH and effectively favour the
adoption of healthy behaviours in disadvantaged groups of
319
population. Intersectorial policynmaking that adopts
‘health in all policies’ and ‘health equity in all policies’
approaches is recommended.55 The health system plays a
central role for improving health and health equity through
addressing differences in risk factors (e.g. through smoking
cessation programmes targeted at disadvantaged groups)
and guaranteeing access to high-quality health care, including medical innovation for all population groups. This
requires monitoring of access to services and the development of good performance indicators.55 In particular, the
Baltic countries would benefit from placing a greater focus
on SDH, health promotion and disease prevention, addressing people of lower SES.79 Further research is also
required on factors that have not received sufficient attention in the region, such as indigeneity, ethnicity, migrant
status, gender identity and sexual orientation.
Recently all the European countries have committed to
the principles of universal access, equity and solidarity as
core values of European societies. Additional research on
structural SDH such as welfare regimens, social and health
investments, and individual policies is a priority. The paradox that inequalities have persisted or even widened during
the expansion of the welfare states and increased during
the recent global economic crisis underlines the necessity
and urgency of this research domain.92–94
Improving data collection and data quality and comparability across countries is indispensable to guarantee individual and population health. A proposal for a personal
data protection regulation that would permit the use of an
individual’s data only with the explicit consent of that individual has passed the EU Parliament and is currently
debated within the EU Council. Many epidemiological and
public health associations, including the European Public
health Association (EUPHA) and IEA, foresee difficulties
for epidemiological and public health research arising from
this proposed regulation. Limiting the use of an individual’s personal health-related data only to cases of ‘high
public interest’—as stated in the regulation’s article concerning health research—would probably make large sections of epidemiological work impossible, at least in some
countries.
In conclusion, epidemiologists can contribute considerably to improving population health and health equity in
Europe. The dialogue between epidemiologists and health
planners needs to be strengthened to guarantee translation
of epidemiological evidence into cost-effective policies.
The importance of epidemiological research must be further explained to legislators, when rules are formulated
that regulate the production, maintenance and sharing of
data, in order for legislators to better understand the potential of epidemiological resources to contribute to the
health of European citizens.
320
Supplementary Data
Supplementary data are available at IJE online.
Funding
Funding by the International Epidemiological Association is
acknowledged.
Acknowledgements
We thank colleagues who have contributed to the survey on teaching
and training: Ellen Aagaard Nøhr, University of Aarhus (Denmark);
David Batty, University College London (UK); Biljana Danilovska,
Center for Public Health - Skopje (TFYR Macedonia); Livia
Giordano, AOU City of Health and Science, Turin, Italy; Eva Grill,
University of München (Germany); Andrej Gribovski, Norwegian
Institute of Public Health, Oslo (Norway); Biljana Kocic, University
of Niš (Serbia); Alessio Petrelli, National Institute for Health,
Migration and Poverty, Rome (Italy); Alberto Ruano, University of
Santiago de Compostela (Spain); Laufey Tryggvadóttir, Icelandic
Cancer Registry, Reykjavı́k (Iceland); Maurice Zeegers, Maastricht
University (The Netherlands).
We thank for their comments and suggestions: Roberto Bertollini,
WHO, Geneva (Switzerland); Francesco Forastiere, Regional Health
Authority of Lazio, Roma (Italy); Livia Giordano, AOU City of
Health and Science, Turin, Italy; Giuseppe Gorini, Cancer
Prevention and Research Institute, Florence (Italy); Katrin Lang,
University of Tartu (Estonia); Gavino Maciocco, University of
Florence (Italy); Giovanna Masala, Cancer Prevention and Research
Institute, Florence (Italy); Mati Rahu, National Institute for Health
Development, Tallinn (Estonia); Marco Zappa, Cancer Prevention
and Research Institute, Florence (Italy).
We thank Nigel Barton for analysing the CORDIS database;
Simona Gallo Mosala for collation of questionnaires and
internet searches on teaching institutions and Lucia Castellucci for
editing.
We thank Cesar Victora for guidance in the preparation of the
article.
Contributors: A.S.C. conceived the structure of the paper and wrote
the manuscript. F.P. performed the bibliometric research. F.G. performed the survey on education. A.S.C. and F.G. performed the analysis of the CORDIS database. F.G., F.P., R.S., P.V. and R.W.
contributed in revising critically the manuscript and providing it
with suggestions on the design and relevant contents. F.G., F.P. and
R.W. contributed to revising and editing the final version. All the authors approved the version to be published.
Conflict of interest: None declared.
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