Sábado 4 de Octubre / Saturday 4, October

9:00:00 a/to 11:00:00

Moderador/Chairperson:

Julia del Amo

477 RISK OF SUICIDE IN RELATION TO UNEMPLOYMENT IN PEOPLE ADMITTED TO HOSPITAL WITH MENTAL ILLNESS: NESTED CASE-CONTROL STUDY

Esben Agerbo

National Centre for Register-based Research, University of Aarhus, Denmark.

Background: Suicide is more frequent among the unemployed, and policies promoting employment is assumed to diminish the suicide mortality. In the UK, promoting employment of people experiencing mental health problems is suggested as a target for reducing the suicide rate. However, there is little evidence verifying whether employment will prevent suicide among people suffering from mental illness.

Methods: Nested case-control study of the 9011 people aged 25-60 years who committed suicide during 1982-1997 and 180220 matched controls. Using Danish population based routine registers, cases and controls were compared on measures of own and spousal job status, psychiatric history, income, marital status and municipality unemployment rates.

Findings: After adjustment for individual confounders and partly for factors shared by spouses and people living in the municipality, unemployed individuals in the wider population had an increased suicide risk. In contrast, fully employed males and females discharged from a psychiatric hospital within the last year had an increased suicide risk, so that male patients who were unemployed, social benefits recipients, disability pensioners or otherwise marginalized on the labour market had a suicide risk of 1.55 (95% Cl 1.43-1.68), 2.45 (1.94-3.09), 1.72 (1.44-2.04) and 2.08 (1.68-2.58), respectively. Similarly, the suicide risk was increased among patients with higher income.

Interpretation: Employment programs aimed at people suffering from severe mental health illness might not decrease the suicide risk. Alternatively, fully employed individuals who are mentally ill might experience a higher suicide risk. Among never admitted individuals, unemployment and labour market marginalization increase the suicide mortality.

478 HEALTH AND SOCIAL CONDITIONS IN OLDER RUSSIANS

Francesca Perlman*, Martin Bobak*, Michael Marmot*, Richard Rose**

*Epidemiology and Public Health, University College London, London, UK. **Centre for the Study of Public Policy, University of Strathclyde, Glasgow, UK.

Introduction: Despite a well-documented reduction in life expectancy in Russia, the proportion of people aged over 60 in the population has increased. The small amount of research so far suggests that living conditions of older people are often poor. In this paper we aim to describe the socioeconomic conditions of older Russians and their relationship with health.

Method: We analysed data from a 1996 cross-sectional interview study in a multi-stagerandom sample of the Russian population (n=1599, response rate 66%). These analyses are based on 341 respondents aged 60 and above. Logistic regression was used to assess whether socioeconomic factors influenced health.

Results: Many Russians aged 60 and above reported poor health (57%), coronary heart disease (14%) or severe physical limitation (74%). Many were widowed (38%), lived alone (31%), relied solely on statutory sources of support (20%) and on a pension (87%), were often without necessary food, clothing or heating (15%), had low subjective social status (47% in the lowest 3 of 10 categories). 33% had only elementary education. Most preferred the former political (67%) and economic (77%) systems. These characteristics were significantly commoner than in younger adults.

Deprivation, education, widowhood, living alone, low subjective social status and low perceived control were associated with poor self-reported health in both sexes. In multivariate analyses (adjusting for socioeconomic factors) low education, deprivation and sole reliance on statutory support were associated with poor health. Further analysis showed that these associations were only partly mediated by behavioural factors (smoking, alcohol and obesity).

Conclusions: Elderly Russians often live in poor socioeconomic conditions, and these conditions influence health. Many have found adaptation to political and economic upheaval difficult, and appear to be marginalised and unsupported. Policies should focus on improving social support and health and social care and ensuring adequate pensions.

479 THE IMPACT OF ORGANISED VIOLENCE - CHALLENGE FOR PUBLIC HEALTH

Jutta U. Lindert*, Harald C Traue**

*Epidemiology, University, Bielefeld. **Psychology, University, Ulm.

Context: Evidence is emerging that psychiatric disorders are common in populations affected by mass violence. Objectives: To investigate the general health status of refugees and asylum seekers from Kosovo after the war in 1999, and to determine the extent of traumatic experiences and health problems, as well as the relationships between the biographical data and the experiences of violence to both mental health problems and the physical symptoms.

Design: Analysis of a screening survey. Setting: Kosovo-Albanians who lived after the war 19999 in refugee camps in Germany. Subjects: 99 adults and children.

Methods: The main biographical data was collected and symptoms assessed using the "Harvard-Trauma- Questionnaire" (HTQ) and the "Hopkins-Symptom- Checklist" (HSCL-25). Qualitative data is also documented and analyzed. *Hermeneutical and statistical methods are triangulated in order to analyze the data from an explicit intercultural perspective. Each item of the standardized instrument is analyzed quantitatively and qualitatively. Main Outcome Measure: Post-traumatic stress disorder (PTSD), depressiveness, and anxiety diagnoses, based on the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-IV) criteria.

Results: The population is heterogeneous as regards education, region of origin and duration of flight. Serious forms of violence were reported. 40.2 % suffered symptoms of post-traumatic stress disorder, 80.3% suffered symptoms of depression and 80% suffered symptoms of anxiety. Gender is not related to outcome rates. Spending less time in forced flight is associated with a less likelihood of symptoms. To be especially considered is the fact that the refugees who cannot give information about their flight show a significantly increased number of symptoms; declarable and non-declarable memory can be distinguished -Anxiety correlates with age, with a peak between 30-50 years; a decreasing amount of symptoms are shown by the elder refugees.

Conclusión: The symptom level found among Kosovo-Albanian refugees living in Germany was particularly high. A very great part of the refugees experienced several traumatic events. There is an evidence-based need for research by public health in order to prevent the accumulation of future and actual health problems. Further research is necessary to understand the associations amongst depression, anxiety, PTSD, age- andculture- bound symptoms and migration status. Outlook war and forced flight are revealed as a serious threat to and thus a serious challenge for public health. Preventing war, and respecting refugees by offering culture-adequate health structure in their homeland as well as in the host country, should be on the agenda of public health organizations and in the practice of public health professionals. The need for an international data-based epidemiological violence survey are discussed.

480 SELECTED ELEMENTS OF THE QUALITY OF LIFE OF OLDER WOMEN (KRAKOW STUDY)

Beata Tobiasz-Adamczyk, Jadwiga Bajka, Piotr Brzyski

Department of Medical Sociology, Faculty of Medicine Jagiellonian University, Cracow, Poland.

Introduction: Feminization of the senior age leaves open the question of factors responsible for the quality of life (objective and subjective aspects) of women during that time, determined by factors from earlier stages of their life. In social epidemiology integrating the bio-medical and socio-medical models allows to determine the status of elderly women in view of changes on their health and family, professional, economic and social status. Additionally such an approach allows to see the complexity of this process in Poland, where apart from changes due to the aging process and its psycho-social consequences, there are also changes due to the transformation process.

The aim of the study was to assess the role of social resources (family status, satisfaction with family life, occupational position in the past, socio-economic status, social support, frequency and quality of social ties) in the health related quality of life in Polish women at the beginning of senior age.

Methods and Results: Preliminary results coming from cohort study performed in the sample of 65 yr. female citizens of Krakow (N=234) compared to control group (men - N=186), showed that general self-rating health was influenced by previous professional position (B=0,08), changes in health status in last year (B=0,27), number of chronic conditions (B=-0,06), and level of independence (index ADL and IADL (B=0,05) and mental well-being (B=0,08)). Such factors like satisfaction with previous occupational activity (B=2,43), lack of stressful events in the family (B=-0,92), satisfaction with present life (B=0,50 in women vs B=0,82 in men), lack of depression (B=-1,14 vs B=-0,57), independence in ADL and IADL (B=-0,48 vs B=0,30) and self-perceiving as a healthy person (B=0,97) influenced mental well-being.

Conclusions: Result should be used by public health practitioners to develop the program of healthy ageing as well as by family doctors in routine evaluation of determinants of general well-being of old patients.

481 ONE-YEAR POSTPARTUM INTIMATE PARTNER VIOLENCE

Lúcia Rocha, Henrique Barros

Hygiene and Epidemioogy, University of Porto Medical School, Porto, Portugal.

Introduction: Violence is an extremely complex phenomenon with deep roots in gender power imbalances and life cycle culturally determined patterns. Pregnancy could be regarded as a major life event influencing intimate partner abuse However, little is known in Europe regarding this major public health problem, both describing pregnancy or postpartum related events. The present investigation aimed to determine the occurrence - incidence, number and severity of incidents - of physical abuse during the 12 months postpartum.

Participants and methods: A cohort of 923 women delivered at the Obstetrics Department of a large University Hospital was assembled and 829 (89.9%) were surveyed 12 months after delivery. The 94 women lost to follow-up at that moment showed no statistically significant differences regarding social, demographic and reproductive characteristics when compared with those that participate in the study. Follow-up information was obtained face to face, by telephone or mail, using a structured questionnaire, and according to a previously random allocation of the mode of interview. The frequency, the severity and information on the perpetrator were obtained using a Portuguese version of the Abuse assessment Screen.

Results: During the first postpartum year 72 (8.7%) women reported to be physically abused. Of these women 61 corresponded to cases of moderate or severe violence continuing that experienced during the index pregnancy. The remaining 11 women reported physical abuse for the first time during the postpartum period. Compared to the pregnancy period, 13 women declared to be no longer victim of physical abuse because they abandoned the relationship (9 women), the partner seemed to change attitude (3 women) and in one case the perpetrator husband was arrested. Physical abuse acts were described as slapping or pushing with no permanent injuries, in 45.8%, and bruises, cuts, pushing or kicking with lasting pain in the remaining. Approximately half abused women were repeatedly aggressed and most cases of partner abuse occurred early after delivery, 62.5% women being abused during the first month. The most frequent reasons given to remain on an abusive relation were the family bond (the perpetrator was the baby father) and economical constraints.

Conclusion: This study showed that pregnancy and childbearing related physical abuse is an unacceptably frequent situation in this relatively wealthy population, that can occur any time in life and that tend to present a repetitive pattern. Our findings emphasize the need for considering the investigation of threats and physical violence as part of every clinical encounter.

482 DEPRESSION AMONG GENDER GROUPS OF THE POLISH URBAN ELDERLY

Tomasz Knurowski, Beata Tobiasz-Adamczyk

Medical Sociology, Chair of Epidemiology and Preventive Med., Collegium Medicum, Jagiellonian University, Krakow, Poland.

Introduction: Numerous reports and research outcomes publications identify depression as an important clinical, epidemiological and public health concern. Epidemiological studies show that 8-15% of the general elderly population has clinically significant depressive symptomatology. Unrecognized depression can cause disability and increase mortality. These observations suggest that research on depression should focus on approaches improving recognition and treatment to prevent onset or recurrence of geriatric depression. It may be especially important among Central and Eastern European countries, where elderly had suffered on transitional changes and there is a high prevalence of widowed females among this vulnerable social group. Considering gender differences, we aimed at determining which socio-economic and medical factors have the greatest impact on depression among these elderly.

Methods: The database consisting of 528 questionnaires collected among randomly chosen, noninstitutionalized elderly age 65-85 living in Krakow was analysed using SPSS v. 10 package (Chi2 and logistic regression). Presence of depressive symptoms was evaluated using HADS scale, with cut-off point of 11 and more considered as high probability of depression. Sociodemographic (gender, age, living lonely, marital status, educational level, social isolation) as well as health status measures (self-rated health, functional status, prevalence of 19 chronic conditions and comorbidity) were applied in the analysis.

Results: Unidimensional analysis revealed strong relation of self-rated health, social isolation and stroke or it's consequences, neurological diseases (such as Parkinson's disease or epilepsy) with depression among males and females. Additionally, educational level and functional status had significant relation with depression among females and pain in legs among males. The results of multidimensional analysis (separate models for each of the chronic conditions adjusted for sociodemographic and health status measures) show that stroke or it's consequences increase the risk of depression among males (also social isolation and comorbidity increase the risk in this group). Among females, the risk of depression is increased in case of neurological diseases, bad self-rated health and social isolation.

Conclusions: The results indicate that medical staff should be sensitive to any signs of depressive symptomatology in elderly patients suffering from stroke or it's consequences in males and neurological diseases in females in order to prevent the onset of depression. The significance of social isolation should also be noticed and taken into account. Gender differences in evaluation of health between males and females are visible, where the number of chronic conditions is a predictor of depression among males and bad self-rated health is a risk factor of depression among females.

483 PEOPLE LIVING WITH SICK CO-RESIDENTS ARE AT INCREASED RISKS OF UNDERCONSULTATION

Basile Chaix, Pierre Chauvin

Research Unit in Epidemiology and Information Sciences, National Institute of Health and Medical Research, Paris, France.

Introduction: Many studies from the caregiving literature demonstrated that, due to the difficulty of their task, family caregivers experience stress, distress, depressive symptoms, subjective and objective burden, and disruptions in their daily lives. Furthermore, as the resources available in the household first benefit to the individuals with the most urgent health needs, we hypothesized in the present study that people living with sick co-residents may be put at increased risks of underuse of healthcare services.

Methods: We used French data collected in 2000 by the French National Institute of Statistics and Economic Studies through a face-to-face interview survey. The sample, representative of the French population, consisted of 9817 individuals from 5413 households.

Focusing on specialist physicians, logistic multilevel models adjusted for a large set of sociodemographic factors were used to investigate if living with sick co-residents decreased one's odds of consulting over the previous 12 months.

Results: After adjustment, a dose-response relationship indicated that the odds of consulting a specialist decreased when the rated health of one's co-resident worsened (OR=0.75, 95% CI: 0.62, 0.90 for a fair, OR=0.64, 95% CI: 0.52, 0.80 for a bad rated health vs. a good rated health of the co-resident). Furthermore, the odds of consulting decreased when the number of co-residents with a bad rated health increased (OR=0.76, 95% CI: 0.59, 0.98 and OR=0.62, 95% CI: 0.40, 0.97 for living respectively with one or two co-resident(s) with a bad rated health). Such effects were found to be dramatically stronger among people who had a poor insurance status: among them, the ORs for living with respectively one or two co-residents with a bad rated health were 0.19 (95% CI: 0.06, 0.60) and 0.03 (95% CI: <0.01, 0.34).

Conclusions: We discussed the potential causal pathways which may explain that living with sick co-residents lead to decreased odds of consulting a specialist (financial limitations, disruptions in daily life). If further research confirms this effect, it may be worthwhile including recommendations and specific warnings in health professionals' guidelines: they should be reminded to turn their attention to the people living with their particularly ill patients, in order to avoid underconsultation among them.