Background
Methods
Study design
Delphi panel
-
■ Experts with knowledge on multiple dimensions of population healthExperts were defined as researchers from diverse and wide-ranging areas who have substantial knowledge and information, from diverse and wide-ranging areas, on the multiple factors influencing population health and health inequalities at the European level. All of the 51 researchers (from 15 institutions of 12 European Union Member States), participating in the EURO-HEALTHY consortium were eligible and agreed to participate.
-
■ Stakeholders with the ability to influence policyA stakeholder mapping exercise was carried out at the start of the research, with the objective of identifying individuals that might have significant level of power and interest in population health, or considerable knowledge thereof [50]. The identification of potential stakeholders was based on different attributes, namely: i) their ability to influence policy at various decision levels (national, regional and metropolitan), ii) their scope for intervention (public sector, private sector and civil society), iii) their area of work (e.g. environment, public health, urban planning, groups at risk) and iv) geographic location (to reflect Europe’s diversity). Each of the 15 EURO-HEALTHY partners identified at least two stakeholders from the respective country, mainly working in the fields of health, urban planning and environment. Attention was given to stakeholders with comprehensive knowledge of at any at-risk population (e.g. migrants, Roma population) and representing national and regional/metropolitan level of decision. Before sending a formal invitation, each partner asked stakeholders their willingness to participate in the study as part of the Delphi panel. A total of 30 stakeholders were invited and agreed to participate.The Delphi panel was constituted by a total of 81 experts and stakeholders, reflecting a wide range of expertise profiles: Economics and health systems (9 panellists); Environmental health, ecological systems and sustainability (15 panellists); Epidemiology, social medicine and public health (29 panellists) and Health geography, demography and sociology (28 panellists). Furthermore, the panel reflects the Europe’s diversity, with a representation of the different geographical, political and socioeconomic contexts characterizing the regions of: Northern Europe (16 panellists from Sweden and United Kingdom), Western Europe (18 from Belgium, France, Germany and The Netherlands), Eastern Europe (12 from Czechia, Poland and Slovakia) and Southern Europe (35 from Greece, Italy, Portugal and Spain) [57].
Web-Delphi survey
Statistical analysis
Results
Panel participation
Characteristic | No. | No. (% drop-out rate) | ||
---|---|---|---|---|
Invited | Round 1 | Round 2 | Round 3 | |
Total | 81 | 72 (11.1) | 67 (6.9) | 64 (4.5) |
Gender | ||||
Male | 37 | 33 (10.8) | 31 (6.1) | 30 (3.2) |
Female | 44 | 39 (11.4) | 36 (7.7) | 34 (5.6) |
Type of panellist | ||||
Expert | 51 | 49 (3.9) | 47 (4.1) | 47 (0) |
Stakeholder | 30 | 23 (23.3) | 20 (13.0) | 17 (15.0) |
Field of expertise | ||||
Economics and health systems | 9 | 9 (0) | 8 (11.1) | 8 (0) |
Environmental health, ecological systems, sustainability | 15 | 11 (26.7) | 10 (9.1) | 9 (10.0) |
Epidemiology, social medicine and public health | 29 | 26 (10.3) | 23 (11.5) | 22 (4.3) |
Health geography, demography and sociology | 28 | 26 (7.1) | 26 (0) | 25 (3.8) |
Region of Europe | ||||
Northern Europe | 16 | 13 (18.8) | 12 (7.7) | 11 (8.3) |
Western Europe | 18 | 15 (16.7) | 15 (0) | 14 (6.7) |
Eastern Europe | 12 | 11 (8.3) | 10 (9.1) | 10 (0) |
Southern Europe | 35 | 33 (5.7) | 30 (9.1) | 29 (3.3) |
Indicators
Area of concern and dimension | Proposed | Group agreement | No agreement | |
---|---|---|---|---|
Approved | Rejected | |||
Economic and social environment (ESE) | 23 | 12 | 1 | 10 |
Employment | 4 | 3 | 0 | 1 |
Income & living conditions | 7 | 4 | 0 | 3 |
Social protection | 4 | 1 | 0 | 3 |
Education | 3 | 3 | 0 | 0 |
ICT access & use | 1 | 0 | 0 | 1 |
Governance | 3 | 0 | 1 | 2 |
Security | 1 | 1 | 0 | 0 |
Demographic change | 11 | 5 | 0 | 6 |
Migration | 5 | 2 | 0 | 3 |
Ageing | 3 | 3 | 0 | 0 |
Population change | 3 | 0 | 0 | 3 |
Lifestyle and health behaviours | 10 | 8 | 0 | 2 |
Physical environment | 22 | 6 | 0 | 16 |
Pollution | 16 | 6 | 0 | 10 |
Extreme weather events | 6 | 0 | 0 | 6 |
Built environment | 20 | 12 | 0 | 8 |
Housing conditions | 6 | 5 | 0 | 1 |
Land use and transport | 2 | 0 | 0 | 2 |
Water and sanitation | 5 | 4 | 0 | 1 |
Waste management | 3 | 0 | 0 | 3 |
Road safety | 4 | 3 | 0 | 1 |
Healthcare services | 12 | 11 | 0 | 1 |
Healthcare resources | 6 | 6 | 0 | 0 |
Healthcare access | 2 | 1 | 0 | 1 |
Healthcare utilization | 1 | 1 | 0 | 0 |
Healthcare expenditure | 3 | 3 | 0 | 0 |
Health outcomes | 32 | 26 | 0 | 6 |
Length of life (Mortality) | 25 | 20 | 0 | 5 |
Quality of life (Morbidity) | 7 | 6 | 0 | 1 |
Total | 130 | 80 | 1 | 49 |
Area of concern | A1-A | A2-A | A2-B | A3-B | R1-A |
---|---|---|---|---|---|
Economic and social environment | 4 | 0 | 8 | 0 | 1 |
Demographic change | 0 | 0 | 5 | 0 | 0 |
Lifestyle and health behaviours | 4 | 2 | 2 | 0 | 0 |
Physical environment | 0 | 2 | 3 | 1 | 0 |
Built environment | 0 | 5 | 6 | 1 | 0 |
Healthcare services | 0 | 1 | 9 | 1 | 0 |
Health outcomes | 12 | 6 | 7 | 1 | 0 |
Total | 20 | 16 | 40 | 4 | 1 |
Level of agreement by area of concern
Dimension | Indicator | Aggregated responses (%) |
Pi
| Group majority decision rule | ||||
---|---|---|---|---|---|---|---|---|
SD | D | NAD | A | SA | ||||
Economic and social environment | ||||||||
Employment | Unemployment rate (%) | 1.4 | 1.4 | 2.8 | 30.6 | 63.9 | 0.50 | A1-A |
Youth unemployment rate (%) | 0.0 | 3.0 | 9.0 | 49.3 | 38.8 | 0.39 | A2-B | |
Long-term unemployment rate (%) | 1.4 | 4.2 | 4.2 | 25.0 | 65.3 | 0.49 | A1-A | |
Income & living conditions | Disposable income of private households per capita (€) | 0.0 | 3.0 | 11.9 | 50.7 | 34.3 | 0.38 | A2-B |
People at risk of poverty or social exclusion (%) | 1.4 | 1.4 | 4.2 | 20.8 | 72.2 | 0.56 | A1-A | |
Severe material deprivation rate (%) | 2.8 | 2.8 | 4.2 | 38.9 | 51.4 | 0.41 | A1-A | |
Disposable income ratio - S80/S20 | 1.5 | 4.5 | 16.4 | 34.3 | 43.3 | 0.32 | A2-B | |
Social protection | Expenditure on care for elderly (% of GDP) | 0.0 | 9.0 | 14.9 | 47.8 | 28.4 | 0.33 | A2-B |
Education | Population aged 25–64 with lower secondary education attainment (%) | 0.0 | 14.9 | 7.5 | 46.3 | 31.3 | 0.33 | A2-B |
Population aged 25–64 with upper secondary or tertiary education attainment (%) | 0.0 | 9.0 | 10.4 | 52.2 | 28.4 | 0.36 | A2-B | |
Early leavers from education and training (%) | 0.0 | 9.0 | 13.4 | 41.8 | 35.8 | 0.32 | A2-B | |
Security | Population who reported crime, violence or vandalism in the area of residence (%) | 0.0 | 6.0 | 7.5 | 50.7 | 35.8 | 0.39 | A2-B |
Demographic change | ||||||||
Migration | Immigrants at risk of poverty or social exclusion - born in EU28 countries, excluding the reporting country (%) | 1.49 | 4.5 | 7.5 | 61.2 | 25.4 | 0.44 | A2-B |
Immigrants at risk of poverty or social exclusion - born in non EU28 countries (%) | 0 | 1.5 | 7.5 | 58.2 | 32.8 | 0.44 | A2-B | |
Ageing | At risk of poverty rate of older people - aged 65 years or over (%) | 0 | 1.5 | 4.5 | 50.7 | 43.3 | 0.44 | A2-B |
Ageing index | 0 | 6 | 7.5 | 40.3 | 46.3 | 0.38 | A2-B | |
Age dependency ratio | 0 | 7.5 | 12 | 50.7 | 29.9 | 0.36 | A2-B | |
Lifestyle & health behaviours | ||||||||
Lifestyle and health behaviours | Adults who are obese (%) | 0.0 | 1.4 | 1.4 | 25.0 | 72.2 | 0.58 | A1-A |
Regular daily smokers in the population - aged 15 and over (%) | 2.8 | 4.2 | 4.2 | 22.2 | 66.7 | 0.49 | A1-A | |
Daily smokers - aged 15 and over (%) | 2.8 | 6.9 | 5.6 | 27.8 | 56.9 | 0.40 | A1-A | |
Number of cigarettes smoked per day - daily smokers (No.) | 0 | 6 | 4.5 | 38.8 | 50.7 | 0.40 | A2-A | |
Pure alcohol consumption - aged 15 and over (Liters per capita) | 0.0 | 0.0 | 4.2 | 43.1 | 52.8 | 0.46 | A1-A | |
Population engaged in vigorous or moderate physical activity on 2 or more days a week (%) | 0 | 0 | 4.5 | 50.7 | 44.8 | 0.45 | A2-B | |
Average amount of fruits and vegetables available per person per year (Kg per person) | 0 | 0 | 12 | 55.2 | 32.8 | 0.42 | A2-B | |
Live births by mothers under age of 20 (%) | 0 | 4.5 | 7.5 | 34.3 | 53.7 | 0.41 | A2-A | |
Physical environment | ||||||||
Pollution | Annual mean of the daily PM2.5 concentrations (ug/m3) | 0 | 0 | 13 | 34.3 | 52.2 | 0.40 | A2-A |
Annual mean of the daily PM10 concentrations (ug/m3) | 0 | 0 | 12 | 37.3 | 50.7 | 0.40 | A2-A | |
Transport emissions of air pollutants (%) | 7.46 | 4.5 | 4.5 | 58.2 | 25.4 | 0.40 | A2-B | |
Population exposed to traffic noise - Lden 55-59db, during day (%) | 6.25 | 3.1 | 11 | 73.4 | 6.25 | 0.55 | A3-B | |
Population who reported pollution, grime or other environmental problems in the area of residence (%) | 2.99 | 1.5 | 16 | 43.3 | 35.8 | 0.33 | A2-B | |
Contaminated sites and other land use indicators (hectares) | 1.49 | 1.5 | 15 | 47.8 | 34.3 | 0.36 | A2-B | |
Built environment | ||||||||
Housing conditions | Average number of rooms per person | 1.56 | 6.3 | 16 | 53.1 | 23.4 | 0.36 | A3-B |
Children living in homes with problems of dampness (%) | 0 | 0 | 9 | 53.7 | 37.3 | 0.43 | A2-B | |
Population living in a dwelling with a leaking roof, damp walls, floors or foundation, or rot in window frames of floor (%) | 0 | 3 | 12 | 28.4 | 56.7 | 0.41 | A2-A | |
Households without indoor flushing toilet (%) | 0 | 3 | 9 | 31.3 | 56.7 | 0.42 | A2-A | |
Households without central heating (%) | 0 | 0 | 15 | 23.9 | 61.2 | 0.45 | A2-A | |
Water and sanitation | Population connected to public water supply (%) | 0 | 4.5 | 4.5 | 49.3 | 41.8 | 0.41 | A2-B |
Drinking water quality: microbiological non-compliance (%) | 0 | 4.5 | 3 | 35.8 | 56.7 | 0.44 | A2-A | |
Drinking water quality: chemical non-compliance (%) | 7.46 | 4.5 | 4.5 | 37.3 | 46.3 | 0.35 | A2-B | |
Population connected to wastewater treatment (%) | 0 | 4.5 | 3 | 40.3 | 52.2 | 0.43 | A2-A | |
Road safety | Injury rate due to road traffic accidents, per 100.000 inhabitants | 0 | 4.5 | 7.5 | 40.3 | 47.8 | 0.39 | A2-B |
Victims in road accidents - injured and killed, per 100.000 inhabitants | 0 | 7.5 | 15 | 32.8 | 44.8 | 0.33 | A2-B | |
Fatality rate due to road traffic accidents, per 1.000 victims | 0 | 6 | 12 | 37.3 | 44.8 | 0.35 | A2-B | |
Healthcare services | ||||||||
Healthcare resources | Health personnel (general practitioners), per 100.000 inhabitants | 1.49 | 1.5 | 3 | 52.2 | 41.8 | 0.44 | A2-B |
Curative care beds, per 100.000 inhabitants | 0 | 9.4 | 13 | 57.8 | 20.3 | 0.39 | A3-B | |
Long-term care beds in nursing and residential care facilities, per 100.000 inhabitants | 1.49 | 3 | 18 | 47.8 | 29.9 | 0.34 | A2-B | |
Medical doctors, per 100.000 inhabitants | 1.49 | 3 | 12 | 32.8 | 50.7 | 0.37 | A2-A | |
Health personnel (nurses and midwives, dentists, pharmacists and physiotherapists), per 100.000 inhabitants | 1.49 | 3 | 12 | 35.8 | 47.8 | 0.36 | A2-B | |
Medical Technology (e.g. mammography, PET scanners, CT scanners) per 100.000 inhabitants | 1.49 | 4.5 | 12 | 50.7 | 31.3 | 0.36 | A2-B | |
Healthcare access | Population living to more than 60 min from Urgent Care/Emergency unit (%) | 0 | 6 | 9 | 40.3 | 44.8 | 0.36 | A2-B |
Healthcare utilization | Hospital discharges due to diabetes, hypertension and asthma per 100.000 inhabitants | 0 | 3 | 10 | 55.2 | 31.3 | 0.41 | A2-B |
Healthcare expenditure | Health care expenditure by all financing agents per inhabitant, in Purchasing Power Standards (PPS) | 2.99 | 1.5 | 10 | 56.7 | 28.4 | 0.41 | A2-B |
Health care expenditure by private household out-of-pocket expenditure per inhabitant, in PPS | 0 | 0 | 12 | 55.2 | 32.8 | 0.42 | A2-B | |
Governmental (except social security funds) expenditure in providers of health care in health care per capita, in PPS | 1.49 | 0 | 12 | 46.3 | 40.3 | 0.38 | A2-B | |
Health outcomes | ||||||||
Length of life (Mortality) | Life expectancy at birth (years) | 0.0 | 0.0 | 0.0 | 25.4 | 74.6 | 0.62 | A1-A |
Sex ratio of life expectancy at birth | 0 | 9.4 | 13 | 57.8 | 20.3 | 0.39 | A3-B | |
Life expectancy at 65 years of age (years) | 0.0 | 0.0 | 4.2 | 31.0 | 64.8 | 0.51 | A1-A | |
Infant mortality, per 1.000 live births | 0.0 | 2.8 | 4.2 | 18.3 | 74.6 | 0.59 | A1-A | |
Perinatal mortality, per 1.000 live births | 0 | 3 | 11 | 28.8 | 57.6 | 0.42 | A2-A | |
Neonatal mortality, per 1.000 live births | 0 | 3 | 12 | 28.8 | 56.1 | 0.40 | A2-A | |
Premature mortality, SDR per 100.000 inhabitants | 0.0 | 1.4 | 9.9 | 23.9 | 64.8 | 0.48 | A1-A | |
Amenable deaths to health, SDR per 100.000 inhabitants | 0 | 1.5 | 14 | 42.4 | 42.4 | 0.37 | A2-B | |
Preventable deaths, SDR per 100.000 inhabitants | 0.0 | 1.4 | 5.6 | 42.3 | 50.7 | 0.43 | A1-A | |
Deaths related to infectious disease, SDR per 100.000 inhabitants | 0 | 1.5 | 4.5 | 40.9 | 53 | 0.44 | A2-A | |
Deaths related to land transport accidents, SDR per 100.000 inhabitants | 1.52 | 6.1 | 11 | 40.9 | 40.9 | 0.34 | A2-B | |
Deaths from diseases of the circulatory system, SDR per 100.000 inhabitants | 0.0 | 0.0 | 8.5 | 33.8 | 57.7 | 0.45 | A1-A | |
Deaths from diseases of the respiratory system, SDR per 100.000 inhabitants | 0.0 | 0.0 | 5.6 | 38.0 | 56.3 | 0.46 | A1-A | |
Deaths from cancer (malignant neoplasms), SDR per 100.000 inhabitants | 0 | 0 | 3 | 42.4 | 54.5 | 0.47 | A2-A | |
Death due to ischaemic heart disease, SDR per 100.000 inhabitants | 0.0 | 0.0 | 4.2 | 39.4 | 56.3 | 0.47 | A1-A | |
Deaths due to cerebrovascular diseases, SDR per 100.000 inhabitants | 0.0 | 0.0 | 7.0 | 36.6 | 56.3 | 0.45 | A1-A | |
Deaths due to colorectal cancer, SDR per 100.000 inhabitants | 0.0 | 0.0 | 7.0 | 42.3 | 50.7 | 0.43 | A1-A | |
Deaths due to larynx, trachea, bronchus and lung cancer, SDR per 100.000 inhabitants | 0.0 | 0.0 | 8.5 | 40.8 | 50.7 | 0.42 | A1-A | |
Deaths due to breast cancer, SDR per 100.000 inhabitants | 0.0 | 2.8 | 7.0 | 39.4 | 50.7 | 0.41 | A1-A | |
Deaths due to prostate cancer, SDR per 100.000 inhabitants | 1.52 | 6.1 | 4.5 | 39.4 | 48.5 | 0.39 | A2-B | |
Quality of life (Morbidity) | People who reported having a long-standing illness or health problem (%) | 0 | 3 | 6.1 | 37.9 | 53 | 0.42 | A2-A |
Self-perceived health less than good (%) | 0 | 7.6 | 14 | 31.8 | 47 | 0.34 | A2-B | |
Self-reported unmet needs for medical examination (%) | 1.52 | 6.1 | 17 | 47 | 28.8 | 0.32 | A2-B | |
Age-standardized Disability-Adjusted Life Year (DALY) rate | 1.52 | 1.5 | 9.1 | 24.2 | 63.6 | 0.46 | A2-A | |
Low birth-weight (%) | 0 | 6.1 | 12 | 42.4 | 39.4 | 0.34 | A2-B | |
Preterm birth (%) | 0 | 6.1 | 15 | 37.9 | 40.9 | 0.33 | A2-B |
Stability and group opinion variance
Area of concern | Round 1 | Round 2 | Round 3 | ||||||
---|---|---|---|---|---|---|---|---|---|
Wilks’ Lambda | F value | P-value | Wilks’ Lambda | F value | P-value | Wilks’ Lambda | F value | P-value | |
Economic and social environment | 0.159 | 1.703 | 0.004a | 0.235 | 1.596 | 0.016a | 0.563 | 1.082 | 0.366 |
Demographic change | 0.609 | 0.952 | 0.548 | 0.584 | 0.952 | 0.549 | 0.642 | 1.469 | 0.108 |
Lifestyle and health behaviours | 0.640 | 0.953 | 0.542 | 0.584 | 0.952 | 0.549 | 0.927 | 0.764 | 0.600 |
Physical environment | 0.140 | 1.994 | 0.000a | 0.199 | 1.370 | 0.066 | 0.306 | 1.263 | 0.147 |
Built environment | 0.364 | 0.989 | 0.508 | 0.400 | 0.791 | 0.846 | 0.690 | 0.765 | 0.790 |
Healthcare services | 0.509 | 1.206 | 0.215 | 0.510 | 1.097 | 0.341 | 0.859 | 1.552 | 0.167 |
Health outcomes | 0.116 | 1.191 | 0.188 | 0.210 | 1.481 | 0.033 | 0.453 | 2.312 | 0.002a |
Round | Area of concern | Indicator | Field of expertise | |||
---|---|---|---|---|---|---|
EHS | EHESS | ESMPH | HGDS | |||
1 | ESE | Population who reported crime, violence or vandalism in the area of residence | ● | ● | ||
PHE | Annual mean concentrations of Particulate Matter - PM2.5 (ug/m3) | ●|□ | ● | □ | ||
PHE | Annual mean concentrations of Particulate Matter - PM10 (ug/m3) | ●|□ | ● | □ | ||
PHE | Annual mean ozone concentrations | ●|□|▲|♦ | □ | ▲ | ♦ | |
PHE | Annual mean Nitrogen Dioxide concentration | ●|□ | ● | ▲ | □|▲ | |
PHE | Annual mean Sulphur Dioxide concentration | ●|□ | ● | ▲ | □|▲ | |
PHE | Number of high temperature days | ●|□ | ●|▲ | ▲|♦ | □|♦ | |
PHE | Number of low temperature days | ● | ● | |||
PHE | Number of warm nights | ●|□ | ● |▲ | ▲|♦ | □|♦ | |
PHE | Number of heatwaves | ●|□ | ● |▲ | ▲|♦ | □|♦ | |
PHE | Heating degree days | ● | ●|□ | □|♦ | ♦ | |
2 | ESE | Gross Domestic Product, per capita in Purchasing Power Standards (PPS) | ● | ● | ||
ESE | Early leavers from education and training (%) | ● | ● | |||
3 | HO | Sex ratio of life expectancy at birth | ● | □ | ●|□ | |
HO | Sex ratio of premature mortality | ● | □ | ●|□ | ||
HO | Sex ratio of amenable mortality | ● | ● | |||
HO | Deaths related to dementias including Alzheimer’s disease, SDR per 100.000 inhabitants | ● | ● |