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Poster sessions

Introduction: We previously described a loss of opportunity for thrombolytic use in acute myocardial infarction (AMI) in Rio de Janeiro, Brazil.

Objective: To describe the experience of a teleconsultation programme (TIET) for evaluating intravenous thrombolytic indication at small local level emergency units and subsequent transfer to a reference coronary care unit (CCU), as part of a programme to decrease thrombolytic use in the public health system of Rio de Janeiro.

Methods: We studied a cohort of 618 AMI patients consecutively admitted in the reference CCU from July 1999 to November 2003. The teleconsultation system consisted of fax analysis of the electrocardiogram sent by the local clinical unit, together with a standard form. The local unit was encouraged to initiate thrombolysis as soon as possible. We performed descriptive statistical analysis and multivariate logistic regression, with estimation of odds ratio (OR) and 95% confidence intervals (95% CI).

Results: Of the 517 patients with ST segment elevation, in hospital mortality was 13%; among 101 AMI cases without ST elevations, mortality was 4%. Of the 359 patients admitted through the TIET programme (58.1% of the total group), 317 had acute ST elevation. The mortality among these 317 patients was 10.4%, versus 17% in the 200 non-TIET group with ST elevation in AMI (OR 0.6;95% CI 0.3 to 0.98; p = 0.04 favouring TIET). Among the TIET group with ST elevation in AMI, 41.3% received thrombolytics, versus 25% in the non-TIET group (OR 2.1; 95% CI 1.4 to 3.1; p = 0.0001). Among the 181 patients who received intravenous thrombolytics, 47% were treated at the local unit. A smaller mortality (7.1%) was associated with patients receiving thrombolytics at the first attendance level (versus 11.5% in those who received the treatment in CCU). The logistic regression showed a tendency to a smaller mortality associated with thrombolytic use (adjusted OR 0.5; 95% CI 0.3 to 1.09; p = 0.08). This tendency was more evident for thrombolysis at the local level (adjusted OR 0.3; 95% CI 0.1 to 1; p = 0.06) than for thrombolysis in the reference CCU (adjusted OR 0.7; 95% CI 0.3 to 1.6; p = 0.43).

Conclusions: The results suggest that the programme favoured a more precocious and safe intervention at the first emergency attendance level, with a possible benefit on survival. The programme proved to be simple and without additional cost for the healthcare system.

002 FACTORS ASSOCIATED WITH CAESAREAN SECTION IN BRAZIL
S. Almeida¹, H. Bettiol¹, M. A. Barbieri¹, A. A. M. Silva², V. M. Azenha¹.¹Faculty of Medicine of Ribeirão Preto/USP, Department of Paediatrics, Ribeirão Preto, SP, Brazil; ²Federal University of Maranhão, Department of Public Health, São Luís, MA, Brazil

Introduction: Brazil has one of the highest rates of caesarean section in the world. The determinants of caesarean section are related to maternal and fetal conditions and also to non-medical reasons such as physician and maternal convenience.

Objective: The objective of the present investigation was to study maternal, social, and medical hospital variables in an attempt to identify the factors responsible for the discrepancy in caesarean section rates in the city of Ribeirão Preto, located in the wealthiest area of southeast Brazil.

Methods: The study design used was a retrospective analysis of all single live births at two hospitals in 1999, corresponding to almost 70% of all the deliveries in the city (5800/8330). Maternity A exclusively provides care for pregnant women covered by the public health system and Maternity B provides care for women belonging to the private system, including patients covered by private health insurance. Data were analysed statistically by the ² test for the comparison of proportions and by univariate and multiple logistic regression analysis to determine the independent variables related to the caesarean deliveries.

Results: The rates of caesarean delivery were 18.9% and 84.3% at A and B, respectively. Maternity A presented higher proportions of more unfavourable indicators such as adolescent mothers (27.6% versus 5.4%), low maternal educational level (77.9% versus 19.4%), mothers without a cohabiting companion (68.3% versus 15.3%), those with a larger number of children, and those with a greater proportion of obstetric diseases compared with Maternity B. A strong association was detected between caesarean section and coverage by private health insurance at maternity B, with higher rates for women of higher educational level and progressively increasing with age at both hospitals. The highest proportion of caesarean deliveries was observed among patients who had received prenatal care and had been delivered by the same doctor who provided the prenatal care. The convenience of a programmed surgical delivery for the doctor was demonstrated at Maternity B by the distribution of deliveries at well defined times (daylight hours) and on weekdays, with a marked reduction during weekends.

Conclusions: These findings suggest the idea that surgical deliveries were mostly performed without a medical indication at Maternity B.

003 CONSUMPTION OF OLIVE OIL AND INCIDENCE OF HYPERTENSION: THE SUN STUDY
A. Alonso¹, E. Fernández-Jarne², C. Fuente¹, R. M. Pajares¹, A. Sánchez-Villegas³, M. A. Martínez-González¹.¹University of Navarra, Department of Epidemiology and Public Health, Pamplona, Spain; ²University of Navarra, Department of Cardiology, University Clinic, Pamplona, Spain; ³University of Las Palmas, Division of Preventive Medicine and Public Health, Las Palmas de Gran Canaria, Spain

Introduction: The intake of some fatty acids has been associated with a decrease in blood pressure. Particularly, n-3 polyunsaturated fatty acids and monounsaturated fatty acids (MUFA) have shown a beneficial effect on blood pressure. MUFA rich olive oil is the major fat source in Mediterranean diets. However, the relationship between olive oil consumption and the risk of hypertension has not been evaluated in large cohort studies.

Objective: We evaluated the association between olive oil consumption and the incidence of hypertension in the SUN Study.

Methods: The SUN (Seguimiento Universidad de Navarra) Study is an open enrolment cohort currently comprising 13 500 university graduates, recruited and followed up through biennial mailed questionnaires. Diet was evaluated at baseline with a semiquantitative food frequency questionnaire, previously validated in Spain. In the initial questionnaire, information about other risk factors for hypertension and cardiovascular disease was collected, as well as the presence of these conditions. In the first follow up questionnaire, information about a new diagnosis of hypertension made by a physician was requested. To assess the relationship between olive oil consumption and risk of hypertension, a Cox proportional hazards model was used, considering quintiles of energy-adjusted olive oil intake as the main exposure and a new diagnosis of hypertension as the outcome. Hazard ratios (HR) and their 95% confidence interval (CI) for quintiles of energy adjusted olive oil consumption were calculated considering the first quintile as the reference category.

Results: The follow up rate for a median of 28.5 months was 88.4% after five mailings. We identified 118 new cases of hypertension among 4825 participants included in this analysis, accounting for a total study base of 11 003 person years. The HR (95% CI) of incident hypertension for the second, third, fourth and fifth quintiles were 0.60 (0.34 to 1.04). 0.70 (0.41 to 1.18). 0.48 (0.27 to 0.86), and 0.79 (0.48 to 1.32) respectively after adjusting for gender, age, physical activity, body mass index, total energy intake, sodium intake, alcohol intake, and other dietary exposures. There was no linear trend among categories of olive oil consumption. When the four upper quintiles were merged in a single category, the HR (95% CI) of hypertension was 0.63 (0.42 to 0.96) compared with the lowest quintile.

Conclusions: Moderate olive oil consumption is inversely associated with the risk of hypertension in a Spanish cohort of university graduates. Our data suggest a threshold effect in the dose–response relationship between olive oil intake and the risk of hypertension.

004 CHILD HEALTH CARE: MATERNAL AND HEALTH PROFESSIONAL ATTITUDES IN VIANA DO CASTELO DISTRICT, PORTUGAL
O. Alves¹, D. Mendonça², A. Maciel-Barbosa³.¹Nursing School, Mental and Public Health, Viana do Castelo, Portugal; ²Biomedical Institute–ICBAS/Porto University, Population Studies/Biometry Unit, Porto, Portugal; ³Local Health Authority, Alto Minho Public Health Services, Viana do Castelo, Portugal

Introduction: The first years of life are considered a prime period for the detection of health problems. In the European Union (EU) for more than 3 decades, there has been a sustained downward trend in perinatal, neonatal, and infant mortality rates, with an apparent levelling off in the most recent years. Portugal experienced a great reduction in all these mortality rates in the same period. The gap between the Portuguese figures and the EU averages was very wide in the 1970s but is now very narrow. Viana do Castelo followed the same trends but still presents a very high level for these indicators compared with the "best" EU countries, thus the Viana do Castelo Health Services need to perform further developments in child care.

Objective: To understand maternal and health professional attitudes regarding child healthcare.

Methods: A cohort study was carried out with a representative sample (n = 453) of Viana do Castelo population of births stratified by municipalities. Data was collected: (a) from health centre child registers, and (b) by interviewing mothers. Mothers were interviewed after delivery to obtain information about antenatal care and 2 years later to ascertain the childcare provided within this period. Adequate care was defined by the local health authorities based on the frequency and number of appointments. Multifactorial analysis (logistic regression) was used to study factors associated with inadequate childcare.

Results: This sample comprises a high percentage of mothers with low educational levels (73.9% 10 years of education). Almost all children (99.8%) contacted the health centres, and 97.3% did it with the recommended frequency. The immunisation coverage according to Portuguese schedule was as high as 96.6% at 24 months. Nevertheless, an adequate surveillance in childcare was only reached by 78.9% of the children. The results suggest that inadequate surveillance is associated with maternal and health service characteristics. Women who had inadequate antenatal care also provided their children with less adequate care (adjusted odds ratio (OR) = 2.0; 95% confidence interval (CI) 1.20 to 3.34); multiparous women were identified as having a higher risk of providing inadequate care to their children (parity 3 compared with parity 1: adjusted OR 5.06; 95% CI 2.49 to 10.31); and the children were more likely to have inadequate care when the health professional did not book the next appointment (adjusted OR 2.41; 95% CI 1.16 to 5.03).

Conclusions: Although it is likely that the most significant contributions in reducing health inequalities will be made by improving educational conditions, health services should develop interventions such as improving health education during the antenatal period, with special emphasis on the low educational level group, and organising an appropriate booking system for the next appointment to overcome access barriers and deliver better childcare.

005 INCREASING SOCIOECONOMIC INEQUALITIES IN MORTALITY, ROME 1990–2000
C. Ancona, M. Davoli, M. Arcà, C. Sforza, C. Perucci.ASL-RME, Epidemiology Department, Rome, Italy

Introduction: Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality.

Objective: To analyse time trends of SES differentials of mortality in Rome from 1990 to 2000.

Methods: Rome has a population of approximately 2 800 000 (1991 census). During the study period 274 537 deaths occurred among residents. Age standardised mortality rates (per 100 000) were compared between four SES categories (SES I (very well off) to SES IV (very underprivileged))*. Rate ratios (RRs; IV versus I) and 95% confidence interval (CI) were computed. To analyse temporal trends we used a linear regression model considering a weighted log transformation of RRs as the dependent variable, and the year of death as the independent variable. Regression weights were calculated as the inverse values of each RR standard error. We used two different models for males and females and tested the possible role of age as an effect modifier (age groups 0–24, 25–44, 45–64, 65+ years).

Results: The inverse association between SES and mortality was confirmed: in each period, for both males and females, a strong positive association between total mortality and low SES existed (table 1).

Conclusion: Despite the Italian NHS offering universal coverage, the disparity in mortality rates between people of different SES in Rome are increasing.

1. *Michelozzi P, et al. Inequality in health: socio-economic differentials in mortality in Rome, 1990–95. J Epidemiol Community Health 1999;53:687–693.[Abstract]

006 QUALITY OF LIFE OF PATIENTS WITH ORAL CANCER
F. Andrade¹, J. Antunes¹, M. Durazzo².¹Schools of Dentistry and ²Medicine, University of São Paulo, São Paulo, Brazil

Introduction: Quality of life is a multidimensional construct increasingly incorporated into the evaluation of health status and treatment of patients with different diseases. Oral cancer is a particularly traumatic type of cancer, which involves facial disfigurement and functional disabilities, frequently associated with negative influences on patient isolation and quality of life.

Objective: The current study assessed the self reported quality of life of patients with oral cancer, with the objective of identifying and classifying their main complaints according with several characteristics (age, sex, socioeconomic status, TNM (tumour, nodes, metastases) classification and anatomical site).

Methods: We interviewed patients with oral squamous cell carcinoma at a major Brazilian hospital (Hospital das Clínicas, School of Medicine, University of São Paulo) using the UW-QOL-R (Revised University of Washington Quality of Life Questionnaire, version 3), which addresses the following dimensions: pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder, taste, and saliva. The questionnaire was given to 111 patients at baseline; the follow up of 62 patients 1 year later accounted for the longitudinal assessment of data.

Results: Patients with T3 and T4 tumours (compared with T1 and T2), patients with cancer in posterior anatomical sites (compared with the anterior portion of the mouth), and patients who underwent recent surgery (compared with those in pre-treatment stages and after 6 or more months of surgery) presented a significantly poorer profile (p<0.05) for most items of the questionnaire. Difficulties in chewing (49%) and swallowing (30%) were the most prevalent complaints during the seven days preceding the interview. At follow up, 20 (18%) patients had already died, and the hospital lost contact with 29 (26%) of them. The remaining patients reported a significant reduction in pain and an improved ability in tasting foods. However, difficulties in chewing (52%) and swallowing (27%) remained the most prevalent complaints.

Conclusion: The persistence of a high prevalence of complaints related to chewing and swallowing reinforces the importance of a continuous monitoring of dental status and treatment needs for patients with oral cancer. An effective participation of the dentist in the multiprofessional team assisting these patients can contribute to reduce the harmful consequences of disease and surgery, and improve their overall quality of life during different stages of their treatment. The use of the UW-QOL-R questionnaire allowed identification of the most frequent complaints of patients with oral cancer. This methodology also allowed the identification of factors associated with a poorer profile of quality of life, and configures an important tool for the decision making process as regards the selection and monitoring of treatment and rehabilitation resources.

007 THE SOBRAL SURVEY ON HEALTH, EDUCATION, AND QUALITY OF LIFE OF CHILDREN AGED 5 TO 9 YEARS IN URBAN SETTINGS OF SOBRAL, BRAZIL 1999–2000: LOCAL HEALTH POLICY BASED ON EPIDEMIOLOGICAL EVIDENCE
L. O. M. Andrade¹, A. C. S. Sucupira², A. V. Santiago³, I. C. H. C. Barreto¹, A. Santiago³, J. W. Lima⁴, A. M. Segall-Correa⁵, A. Pereira³, I. W. Filgeiras¹.¹Universidade Federal do Ceará, Faculdade de Medicina de Sobral, Sobral, Brazil; ²Faculdade de Medicina da Universidade de São Paulo, Departamento de Pediatria, São Paulo, Brazil; ³Prefeitura Municipal de Sobral, Secretaria de Desenvolvimento Social e de Saúde, Sobral, Brazil; ⁴Universidade Estadual do Ceará, Centro de Ciências da Saúde, Fortaleza, Brazil; ⁵Faculdade de Ciências Médicas da UNICAMP, Departamento de Medicina Preventiva e Social, Campinas, Brazil

Introduction: Children between 5 and 9 years old are seen as a population of low risk for mortality and morbidity, therefore little attention is given to the health needs of this group, especially in countries of scarce resources. This situation may be improved when health policies are planned based on epidemiological studies raised by the policy makers’ needs towards new healthcare models.

Objective: To identify healthcare needs from the epidemiological profile of children in a low risk age group.

Method: A cross sectional study was designed to interview mothers, preferably, or another adult at home. A stratified probability sample, by year of birth (from 1990 to 1994), allowed the selection of 3444 children aged 5–9 years. The reference population was a dataset of all families with children in this age group, living in the urban area of the city and registered in the city’s family health programme. The community health workers filled out official forms. Only one child per home was allowed to enter the study randomly. From the total sample, a sub-sample of 2795 children was randomly selected for clinical examination and 375 for laboratory examinations. Data was collected from November 1999 to October 2000 by trained interviewers recruited among university students from college courses not related to the healthcare professions. A semi-structured questionnaire was pre-tested in the field, and data entry was performed using Epi-Info software (version 6.04). Epidemiological indicators were: social and demographic characteristics, schooling, nutrition, food consumption, child labour, health services utilisation, and referred morbidity.

Results: Contrasts were found comparing the availability of healthcare facilities, schools, and social urban equipment combined with high prevalence of referred morbidity in the previous 15 days (43.9%) and school dropout rates (8.2%). This disparity increased among low income families and people of colour. The population of children aged 5–9 years in these settings presents a high morbidity prevalence rate, not related to school dropout rates, despite the availability of health services and school facilities.

Conclusion: Local health policy makers should take into account children in this age group. Family health programmes could play an important role to integrate other social sectors to face children’s needs. The community health workers could be the main agents in this process.

008 EVALUATION MATRIX MODEL IN THE SANTOS MENTAL HEALTH SERVICES
S. Andreoli, C. Magalhães, A. Bellemo, A. Filho, S. Araujo, R. Pinho, R. Pinto, D. Martin.UNISANTOS, Public Health, Santos, Brazil

Objective: To apply an evaluation matrix model to the Santos mental health services.

Method: Five studies were designed aiming to gather information for the matrix: (a) psychiatric reform unit history, (c) service network mapping, (c) service classification, (d) epidemiological profile, and (e) quality of life for the patients. The matrix was formed by two axes, geographical and temporal, each one with three levels: (1) country, (2) local, (3) patient, and (A) input, (B) process, (C) results.

Results: For 13 years, the Santos psychiatric reform unit has been considered as an example for the country. A critical history review showed an unstable establishment marked by the dismantling of the psychiatric hospital. Alongside this revolution, a services network was built in such a way that nowadays it presents promising results, such as the wide coverage and low inpatient tax. At present, there are serious difficulties, because it is not an important political concern, which has resulted in an insufficient number of professionals for the large demand, and little specialised assistance.

Conclusion: The matrix model is useful in understanding the holistic assistance comprehension, not relying exclusively on patients¹ outcome information, but recognising and including a wider perspective, such as the historical and the political background.

009 INSUFFICIENT BIRTH WEIGHT: STUDY OF ASSOCIATED FACTORS IN TWO COHORTS OF NEWBORN INFANTS FROM RIBEIRÃO PRETO, BRAZIL, SEPARATED BY A 15-YEAR INTERVAL
V. Azenha, H. Bettiol, M. Barbieri.University of São Paulo, Department of Paediatrics/Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil

Introduction: In many developed countries, insufficient birth weight (IBW; 2500–2999 g) has been decreasing, but in developing countries these rates continue to be high, and very few studies have assessed the factors associated with IBW infants and their long term consequences.

Objective: To investigate the possible factors associated with IBW in two cohorts of singleton newborn infants from Ribeirão Preto, Brazil, the first study in 1978/79 and the second in 1994, and to identify the causes of the increase in IBW that occurred during this period.

Methods: A total of 6223 deliveries were studied in 1978/79 and 2552 in 1994, with data collected at all maternity hospitals in Ribeirão Preto, after exclusion of low birth weight infants (<2500 g). The variables were: maternal age, mother working outside the home, previous abortions, previous stillbirths, number of children, maternal smoking, maternal educational level, occupational group, marital status, number of prenatal visits, type of delivery, category of admission to the hospital, family income, type of hospital, gestational age, and newborn sex. The association between IBW and the above independent variables was first analysed by calculation of the crude odds ratio (OR) and of the 95% confidence interval (95% CI). Multivariate analysis was then performed using the multiple logistic regression models to test the confounding effect of the independent variables. The level of significance was set at 0.05.

Results: IBW increased from 22.4% in 1978/79 to 28.7% in 1994. After adjustment, seven variables were implicated in IBW in 1978/79: maternal age of less than 20 years (p = 0.030), fewer than four prenatal visits (p = 0.003), family income <5 times the minimum wage (p = 0.030), vaginal delivery (p<0.001), newborn female sex (p<0.001), maternal smoking (p<0.001) and preterm delivery (p<0.001). In 1994 4 variables were implicated: mother working outside the home (p = 0.020), newborn female sex (p<0.001), smoking habit (p<0.001) and preterm delivery (p<0.001).

Conclusions: The socioeconomic variables that acted in 1978/79 disappeared in 1994, except for newborn sex, smoking habit, and prematurity, which were the main causes of IBW during both periods studied. As maternal smoking was reduced between the two studies and since there was no change in the proportion of female newborns, the most plausible explanation for the increase in IBW seems to be the large increase in premature deliveries between the two studies, from 7.6% to 13.6%. This increase was largely determined by the increase in delivery by caesarean section (from 30.3% to 51.1%), mostly due to non-medical reasons, which provoked a reduction in mean birth weight between the two studies (from 3293 to 3185 g) and a leftward shift for the birth weight curve for the 1994 cohort compared with the 1978/79 curve, with an increase in both low and insufficient birth weights.

010 EFFECTIVENESS OF RESPITE CARE TO DECREASE THE PSYCHOLOGICAL DISTRESS OF DEMENTIA CAREGIVERS
J. Ballesteros¹, M. Llano², N. Ibarra², M. Martin-Carrasco².¹University of the Basque Country, Department of Neuroscience, Leioa, Spain; ²Maria Josefa Recio Foundation, Institute for Psychiatric Research, Bilbao, Spain

Objective: To combine evidence from experimental and/or observational studies on the effectiveness of respite care on the psychological distress of dementia caregivers.

Methods: Using appropriate terms, we searched PubMed and The Cochrane Library. Secondary citations from retrieved papers and former reviews on caregiver burden were also searched to trace relevant studies. Effectiveness was assessed by reported changes on scores from validated psychiatric scales (GHQ-30, CES-D, MADRS) in the caregivers whose relatives used respite care services compared with controls. A random effect hierarchical Bayesian model with non-informative priors was used to combine the individual standardised mean differences (SMD). WinBUGS estimates were extracted after 5000 iterations once convergence was achieved (burn in of 1000 iterations).

Results: Seventeen independent papers (over a total of 166) were initially selected. Four studies (only one experimental design) were finally considered appropriate for the meta-analysis. The random effect combined estimate supports a small to moderate effect for respite care programmes (SMD = –0.28; 95% confidence interval = –0.58 to 0.01).

Conclusions: High levels of psychological distress in caregivers have been associated with the decision to institutionalise their relatives with dementia. Current evidence, even if scant, favours the effectiveness of respite care programmes to decrease the psychological distress of dementia caregivers, hence the usefulness of developing these type of community services for people with dementia.

011 EVOLUTION OF WINTER MORTALITY 1969–2001 IN VIANA DO CASTELO, PORTUGAL
A. Barbosa¹, C. Faia¹, L. Freixo¹, I. Gonçalves¹, G. Lima¹, A. López¹, M. Losada¹, E. Paixão², C. Pinheiro¹.¹Serviço de Saúde Pública do Alto-Minho, Gabinete de Administração em saúde e Epidemiologia, Viana do Castelo; ²Instituto Nacional de Saúde Dr. Ricardo Jorge, Observatório Nacional de Saúde, Lisboa

Introduction: Recent studies show that Portugal is the country in Europe where seasonal variation of mortality is greatest. A study made in Viana do Castelo district (250 000 inhabitants) showed that 73.3% of annual variation of mortality in the years 1969–1985 was associated with mean monthly temperature. There was a clear U shaped curve due to the excess cold related mortality in the 65 years and older group.

Objective: This study reports on the evolution of seasonal mortality variation since then, for the period 1986–2001, by sex, age, and cause.

Methods: Monthly indices of mortality were calculated after adjustment for 30 days, for each year of 1986–2001. Coefficients of variation of monthly adjusted mortality were calculated for the period. Excess winter mortality was calculated using deaths from December to March minus the average of deaths in the preceding August to November and the following April to July. Results from the previous study referred are used.

Results: Moving average of annual coefficient of variation of mortality showed a negligible decrease from 1969 to 2001. Comparing the periods 1969–1985 and 1986–2001, the U shaped pattern of annual variation of mortality remained unchanged, with excess deaths from December to March. No pattern of variation was find for the under 65 years of age. The U shaped line became deeper as the age group went up: 65–74; 75–84; 85+ years. For these age groups, the variation was larger for females than for males. For the period 1986–2001 there was an excess mortality of 3.87% (mean seven deaths per year) for the under 65 years group and of 39.4% for the 65 years and over group (mean 273 deaths per year). For the 65 years and over group there was no U shaped line of variation for neoplasm; instead, it was clearly U shaped for mortality from cerebrovascular disease, ischaemic heart disease, and respiratory disease.

Conclusions: The evolution of cold related mortality from 1969 to 2001 in the district of Viana do Castelo shows a negligible decrease. The 65 years and over age group remain at increased risk of dying from cerebrovascular, ischaemic heart, and respiratory causes during winter. All the epidemiological knowledge that has been acquired more recently on this issue could help to reduce the winter excess of deaths in this district.

012 PREVALENCE OF PHYSICAL INACTIVITY AND ASSOCIATED VARIABLES: A POPULATION BASED STUDY IN BRAZILIAN ADULTS
E. Baretta¹, M. Baretta¹, K. Peres².¹UNOESC, Physical Education, Brazil; ²UNOESC, Department of Community Health, Brazil

Introduction: Regular practice of physical activity (PA) has been associated with a lower risk of obesity and chronic degenerative diseases, and with longevity. Consequently, measuring the PA level becomes very important from a public health point of view.

Objective: To estimate the prevalence of physical inactivity and the associated variables in the adult population resident in a small city in southern Brazil.

Methods: A cross sectional study was carried out in Joaçaba, southern Brazil, in 2003. A representative random sample of 579 adults between 20 and 59 years old was interviewed at home, weighed, and measured with calibrated scales. The International Physical Activity Questionnaire (IPAQ) was developed to assess PA, supported by World Health Organization (WHO) and Centers for Disease Control (CDC), and is the tool of choice for interviews conducted in person in developing countries. To assess physical inactivity level, the official Portuguese short version of the IPAQ was applied, recalling information on the last 7 days. The physical activity score was obtained as the sum of minutes spent in fast and moderate walking, moderate activity, and vigorous activity, this last one multiplied by 2. Those people who presented a score below 150 minutes/week according to CDC recommendation were considered as physically inactive. The main explanatory variables investigated were family income, schooling, gender, age, body mass index, self- perception of quality of life, alcohol and smoking habits, and partner status (living with or without a partner). These variables were collected through a pre-tested questionnaire. Simple and multiple logistic regression analyses were performed for the physical inactivity (Yes/No), the outcome investigated.

Results: Five hundred and seventy two people answered the questionnaires and were weighed and measured, with a non-response rate of 0.4%. The distribution of physical activity showed positively skewed scores. The prevalence of physical inactivity was 29.6% (95% confidence interval = 25.9 to 33.3%) almost identical in both males and females. Scores equal to 0 minutes of activity per week were observed in 15.4% of men and 10.5% of women (p = 0.102). The maximum number of minutes spent was 5760 and 6900 for men and women, respectively. After multivariate analyses, it was observed that physical inactivity was associated with those people whose schooling was between 4 and 10 years and with smokers. Furthermore, a positive association with age and with overweight people was also identified.

Conclusions: The prevalence of physical inactivity found in this study was lower than most studies reported in the literature and also when compared with the unique, population based study previously developed in Brazil. Further research is necessary to clarify the reasons for this pattern. In spite of this, public health policies might be developed in order to control the variables associated with physical inactivity.

013 RISK FACTORS PREVALENCE OF OVERWEIGHT AND WEIGHT LOSS BEHAVIOURS IN TEENAGERS
A. Barreiro.Ministério da Saúde, Unidade Operativa de Saúde Pública, Braga, Portugal

Introduction: The prevalence of overweight has increased over the last decades and it is now one of the most important health problems during adolescence, both in developed and in developing countries. On the other hand, youngsters show a growing tendency to worry about their weight, and, consequently put weight controlling behaviours into practice, some of which may endanger their health.

Objectives: To assess the prevalence of overweight in teenagers; to study the gender, age, and family economic level as risk factors; and to identify weight loss directed behaviours.

Method: A descriptive study of the prevalence of overweight on a population of teenagers, aged 10 to 18 years from the municipality of Braga, Northern Portugal, in 2003, was carried out. To carry out the sample, the total number of basic and secondary schools was classified in two stratas; one made up by the schools within the city and the other by the schools of the municipality. Subsequently, a conglomerate two stage sample from each stratus was selected, the schools being the units of the first stage and the classes the units of the second stage. A questionnaire was used to obtain information on all variables of interest and the weight and height of the subjects were measured. The criteria of the Centers for Disease Control and Prevention were applied in the definition of overweight, the risk of overweight, and for regular weight and low weight. The gender, age, and economic level effects on overweight was studied through logistic regression for independent data, with the odds ratio (OR) and the corresponding confidence interval (95% CI) being determined.

Results: There were 452 students who participated in this study (54.4% boys and 45.6% girls). The prevalence of overweight was 22.8% (95% CI 18.9% to 26.7%). Gender was not a risk factor for overweight (OR 0.88; 95% = 0.56 to 1.39). Age reduced the risk of overweight by 0.8 times (95% CI 0.77 to 0.95). The economic level was not a risk factor for any of the five categories that were studied (OR 0.30; 95% CI 0.04 to 2.05; OR 0.29; 95% CI 0.04 to 2.02; OR 0.45; 95% CI 0.07 to 2.98; and OR 0.38; 95% CI 0.05 to 2.63 respectively). The proportion of students wanting to lose weight was 40.5%. The proportion of students that had tried to lose weight was 26.8% and of the students that had been on diets was16.6%, with 6.2% being on a diet at the time this study was made. The proportion of students that practised physical exercise to lose weight was 61.5%. The proportion of students that put purgative behaviours into practice and took pills was 5.8%.

Conclusions: The high prevalence of overweight and the practice of unhealthy behaviours to lose weight allows a conclusion on the importance of intervention programmes aimed at the promotion of health and the prevention of overweight and unhealthy behaviours of weight control.

014 TIME TRENDS OF RAILWAY SUICIDES IN GERMANY FROM 1991 UNTIL 2000
J. Baumert¹, N. Erazo², K. H. Ladwig¹.¹GSF-National Research Center for Environment and Health, Institute of Epidemiology, Neuherberg, Germany; ²Technical University of Munich, Klinikum rechts der Isar, Department of Psychosomatic Medicine, München, Germany

Introduction: Railway suicides are a suicidal behaviour that strongly impacts on the psychological and socioeconomic aspects of the railway company, its employees, and possible eyewitnesses. However, only a few studies relating railway suicides with time trends on a population derived basis have been carried out so far.

Objective: To assess the incidence of railway suicides compared with the total burden of suicides in Germany and its time trend over a 10 year observation period on a population based dataset.

Methods: From 1991 to 2000, a total of 8653 fatal railway suicides were recorded by the national central registry of all passenger accidents on the German railway network. The national suicide rates were taken from the German Report on Health Statistics, which are currently available until the year 2000. To assess time trends, the average annual percentage change (AAPC) of the number of suicides was estimated using Poisson regression. In case of overdispersion of the Poisson model, the dispersion parameter was estimated by the ratio of the deviance to its associated degrees of freedom. Adjustments were made for two age groups (<65 years and >65 years) and measures of availability of the railway system.

Results: Railway suicides accounted for 7.0% (annual range 5.0 to 7.9%) of all suicides in Germany. For all suicides, the same time trend direction with a stronger decline in the number of suicides was observed for older subjects. In contrast, for the number of railway suicides, a "qualitative" interaction with age group was observed: for subjects aged 65 years, an AAPC of 1.8% (95% CI 0.1 to 3.4) indicated an increasing time trend whereas fatal incidences for subjects aged >65 years exhibited a strong decrease (AAPC of –6.2 % (95% CI –10.9 to –1.3). For the same age group, the AAPC was 3.2 (95% CI 1.7 to 4.7) adjusted for the track length. No significant time trend was observed by the AAPC related to passenger volume and mileage covered by all trains.

Conclusions: The present study demonstrates different time trends for railway suicides compared with all suicides. It underlines the urgent need for amplified research efforts in the particular field of railway suicides. Further examinations are recommended in particular concerning possible reasons for this method of suicide.

015 ASSOCIATIONS OF CARDIOVASCULAR RISK FACTORS WITH SOLUBLE ADHESION MOLECULES AND CD141
J. Baumert¹, B. Thorand¹, A. Schneider¹, H. Löwel¹, W. Koenig².¹GSF-National Research Centre for Environment and Health, Institute of Epidemiology, Neuherberg, Germany; ²University of Ulm Medical Centre, Department of Internal Medicine II-Cardiology, Ulm, Germany

Introduction: Low grade systemic inflammation and endothelial dysfunction are suggested to be involved in the pathogenesis of cardiovascular diseases and diabetes mellitus. The causes of endothelial dysfunction are not fully understood so far.

Objective: To investigate associations of cardiovascular risk factors with soluble adhesion molecules (E-selectin, sICAM-1) and CD141 as markers of endothelial dysfunction and to assess possible gender differences in these associations.

Methods: The study population consists of a sub cohort of 1,237 subjects aged 35–74 years randomly drawn from three cross sectional population based MONICA/KORA Augsburg surveys conducted between 1984 and 1995. Markers of endothelial dysfunction were natural log-transformed. Multivariable linear regression analysis with stepwise variable selection was used to investigate the association between cardiovascular risk factors (smoking status, alcohol consumption, physical activity, educational level, adiposites, actual hypertension, diabetes, total cholesterol) and E-selectin, sICAM-1 and CD141 in men and women. Age and survey were forced to stay in each model.

Results: All three markers were strongly correlated to each other (Pearsons correlation coefficients for log transformed variables >0.174, p values <0.001). Men had significantly higher (geometric) mean values of E-selectin (53.9 ng/ml), sICAM-1 (826.6 ng/ml) and CD141 (4.6 ng/ml) than women (45.3 ng/ml, 770.1 ng/ml and 4.1 ng/ml) (p <0.001). In multivariable regression analysis, smoking status and adiposites were significantly associated with elevated levels of E-selectin and sICAM-1 in men and women. Alcohol consumption was significantly associated with all three markers of endothelial dysfunction in men and only with CD141 in women. Moreover, current use of hormone replacement therapy had no impact on markers on endothelial dysfunction. In contrast, a significant association of current use of oral contraceptive with lower values of (natural log transformed) E-selectin was observed in a linear regression model adjusted for age, survey, and cardiovascular risk factors.

Conclusions: Only a few cardiovascular risk factors are associated with markers of endothelial dysfunction in multivariable adjusted regression analysis. Smoking status and adiposites have the strongest impact on markers of endothelial dysfunction in men and women.

016 RESULTS OF A CASE–CONTROL STUDY ON POTENTIAL RISK FACTORS FOR THE DEVELOPMENT OF STROKE AMONG FACTORS OF NON-COMPLIANCE WITH THE THERAPEUTIC REGIMEN IN THE GAZA STRIP
B. Baune¹, Y. Aljeesh², R. Bender³, A. Kraemer².¹University of Muenster, Mental Health Epidemiology; Department of Psychiatry, Muenster, Germany;n ²University of Bielefeld, School of Public Health Department of Public Health Medicine, Bielefeld, Germany; ³Johannes-Gutenberg-University Mainz, Department of Medical Biometry, Epidemiology & Informatics, Mainz, Germany

Introduction: Hypertensive patients are more likely to have a stroke than patients with normal blood pressure. Besides hypertension, other factors such as smoking, overweight, and poor diet (high in fat and salt), may increase the risk of stroke. Antihypertensive medication, weight control, restriction of sodium, physical activity, regular medical follow up and psychological factors such as emotional disturbance each contribute to a certain extent to a normal blood pressure in hypertensive patients.

Objectives: To study potential risk factors among factors of non-compliance with the therapeutic regimen for the development of stroke.

Methods: A paired case–control study among 112 patients, who had been hospitalised for acute stroke with history of hypertension, and 224 controls with history of hypertension matched by age, sex, start of therapeutic regimen, and enrolment location, was carried out. A structured interview on compliance with medication, diet, weight reduction, exercise, follow up healthcare, and smoking was used for data collection. Conditional logistic regression models were used for data analysis.

Results: Significant risk factors for stroke were excessive usage of salt (OR 4.512), excessive usage of fat (OR 4.671), high level of stress (OR 2.779) and medication not taken as prescribed (OR 6.073). Regular physical exercise (OR 0.269) was found to be a protective factor. Smoking was a significant risk factor only if interaction terms (psychological stress) were considered. Further potential interaction terms were analysed.

Conclusions: The results indicate that non-compliance with the therapeutic regimen increases the risk for the development of stroke in Gaza. Further studies are needed to explain knowledge and misconceptions of patients with hypertension in Gaza, which might lead to a better understanding of non-compliance with the therapeutic regimen.

017 ESTIMATION OF EFFECTIVENESS OF GENERAL VERSUS SELECTIVE SCREENING OF SYPHILIS AMONG DRUG USERS IN INPATIENT SETTINGS
B. Baune¹, R. Mikolajczyk², N. Scherbaum³.¹University of Muenster, Mental Health Epidemiology; Department of Psychiatry, Muenster, Germany; ²University of Bielefeld, Department of Public Health Medicine, Bielefeld, Germany; ³University of Essen, Department of Psychiatry and Psychotherapy, Essen, Germany

Introduction: The number of syphilis cases has decreased in general during the last decades in Germany, and therefore syphilis screening is no longer a routine procedure at admission to psychiatric hospitals. Opiate users are a high risk group for syphilis infection. Owing to a lack of epidemiological data, there are no recommendations as to whether syphilis screening should be routinely performed in opiate users admitted to medical treatment, or only selectively in patients with an increased risk for syphilis.

Methods: Using a standardised questionnaire regarding patterns of drug use and sexual behaviour, 1186 patients admitted to eight detoxification units in North Rhine-Westphalia, Germany, in 2000–01 were interviewed by the physicians. A TPHA-test was carried out in each patient and in the case of a reactive test a FTA-ABS IgM for syphilis was performed.

Results: TPHA positive tests were found in 39 (3.3%) of 1186 drug users (97% of whom where opiate users) and seven (0.6%) were IgM positive. Female patients were 4.45 (95% confidence interval (CI) 2.40 to 8.25) times more likely to have a positive TPHA test than males. Female patients who regularly had sex for drugs or money were 14.0 (95% CI 7.9 to 25.0) more likely to have reactive TPHA test than remaining patients. Immigration status and patterns of drug use were not associated with TPHA reactivity.

Conclusions: In view of the low overall prevalence of syphilis even in the sample of drug users, and the strong association between positive syphilis serology and female gender and regular sex for drugs or money, a selective screening strategy restricted to this group should be advocated.

018 EFFECTIVENESS OF ACUPUNCTURE TREATMENT FOR CHRONIC NECK PAIN: THE ACUPUNCTURE IN ROUTINE CARE (ARC) STUDY
C. Becker-Witt¹, S. Jena¹, B. Brinkhaus¹, D. Selim¹, B. Liecker², S. Willich¹.¹Charité University Medical Centre, Social Medicine, Epidemiology and Health Economics, Berlin, Germany; ²Techniker Krankenkasse, Hamburg, Germany

Introduction: Acupuncture is widely used by patients suffering from chronic neck pain.

Objective: To evaluate the effectiveness of treatment with versus without acupuncture in patients with chronic neck pain in routine care.

Methods: Patients (18 years) with chronic neck pain were randomised either to an acupuncture group (ACU) or a control group (CON). Patients who disagreed with randomisation were monitored in a third group, which also received acupuncture (NR-ACU). Over a period of 3 months, the ACU nd NR-ACU groups received up to 15 acupuncture treatments, whereas the CON received no acupuncture. For all treatment groups, usage of routine medical care was permitted. Patients received standardised questionnaires including socio-demographic data, neck pain and disability (Neck Pain and Disability Scale; NPDS) and health related quality of life (SF-36) at baseline and 3 months.

Results: Of a total of 13 846 patients included in the study 3451 (69% female, 49.2 (12.7) years; 31% male, 53.5 (12.9) years) agreed to be randomised. After 3 months of treatment we found a higher improvement in neck pain in the ACU compared with the CON (NPDS baseline to 3 months: ACU 56.4 (15.2) to 39.6 (17.5); CON 54.5 (15.8) to 51.2 (17.7), p<0.001). After 3 months, quality of life on the mental and the physical component scale differed significantly between the treatment groups (p<0.001), again in favour of ACU. There were no significant differences between ACU and NR-ACU for the NPDS and quality of life after 3 months.

Conclusion: In patients with chronic neck pain acupuncture in addition to routine care showed a significant and relevant improvement of pain, disability, and quality of life compared with treatment without acupuncture.

019 SELF REPORTED TRAFFIC DENSITY AND ATOPIC DISEASE IN CHILDREN
T. Behrens¹, D. Taeger¹, W. Maziak², H. Duhme¹, P. Rzehak³, S. Weiland³, U. Keil¹.¹University of Münster, Institute of Epidemiology and Social Medicine, Germany; ²Syrian Centre for Tobacco Studies, Syria; ³University of Ulm, Department of Epidemiology, Germany

Introduction: Positive associations between traffic exposure and atopic respiratory disorders in children have been described in several studies.

Methods: We analysed data related to self reported truck traffic density and several symptoms and diagnoses of asthma and hay fever (12 month wheezing and rhinitis symptoms, diagnoses of asthma and hay fever) from the ISAAC Phase III survey in Muenster, Germany, using core written and video questionnaires. Data were collected from representative school-based samples (n = 7345) of 6–7 and 13–14 year olds.

Results: In 13–14 year olds categorised according to exposure levels into rare, frequent, and constant, with the "never" category used as reference, the sex adjusted prevalence ratios were 1.29 (95% CI 1.08 to 1.53), 1.58 (1.29 to 1.94), and 1.57 (1.18 to 2.10) for wheeze in the previous 12 months, and 1.20 (1.06 to 1.34), 1.35 (1.17 to 1.55), and 1.69 (1.42 to 2.0) for rhinitis symptoms in the previous 12 months. Prevalence ratios in 6-7 year olds and results for a diagnosis of asthma were less consistent, while no positive association was detected between hay fever and truck traffic in both age groups. When analyses were based on a more general traffic indicator (self reported traffic noise), no consistent associations were observed.

Conclusions: Our data provide support for the hypothesis that residential exposure to truck traffic may adversely affect the health of children.

020 DIFFICULTIES IN THE QUANTIFICATION OF RF EXPOSURE FROM APPLIANCES IN ANALYTICAL EPIDEMIOLOGICAL STUDIES
T. Behrens¹, C. Terschüren², W. Hoffmann².¹University of Bremen, Bremer Institut für Präventionsforschung und Sozialmedizin, Germany; ²University of Greifswald, Institute for Community Medicine, Germany

Introduction: Although evidence is still limited, possible adverse health effects after exposure to radiofrequency (RF) emitting appliances have been a major concern in experimental and epidemiological research.

Objective: To assess the quality of exposure estimates based on interviews in a large epidemiological case–control study.

Methods: The Northern Germany Leukaemia and Lymphoma Study, conducted 1997–2002, recorded lifetime use of a pre-selected array of RF emitting appliances (cellular and cordless phones, baby monitors, and TV headphones) in standardised, face to face computer assisted interviews. Exposure assessment comprised three levels of precision: ever use, gross/net appliance years, and lifelong cumulative exposure hours.

Results: Weighted kappa coefficients for gross versus net appliance years in men ranged between 0.59 (95% confidence limits 0.46 to 0.71) for baby monitors and 0.98 (0.97 to 0.99) for cordless phones. In women, kappa coefficients were 0.68 (0.56 to 0.79) and 0.97 (0.94 to 0.98), respectively. Weighted kappa values were considerably lower when net appliance years and lifelong cumulative exposure hours were compared. For baby monitors the two exposure measures were almost uncorrelated for both sexes.

Conclusions: We demonstrated in our data that interview information on the use of RF emitting appliances can result in misclassification when measured with different levels of precision, which may eventually lead to biased risk estimates.

021 MULTI-SOURCES INFORMATION SYSTEM AND EPIDEMIOLOGICAL FOLLOW UP OF CHRONIC DISEASE
M. Said, C. Mugnier, L. Le Mignot, J. Richard, J. Jais, P. Landais.Hopital Necker Enfants Malades, Laboratoire de Biostatistique et d’Informatique Medicale, Paris, France

Introduction: The absence of systematic and continuous data collection about the nature and the evolution of the demand of care penalises the appropriateness of the supply of care for endstage renal diseases. In order to respond to the information needs, an information system based on the Internet, integrating the data of renal dialysis and transplantation was recommended.

Methods: The multi-source information system (MSIS) was designed following an "n tiers" architecture model. Lightweight universal clients in the client tier interact through a web browser with a dynamic web server in the middle tier. The dynamic web server in turn interacts with the databases located in the information system tier. The patient data are first collected in the production database, then consolidated, exported, and historicised in a data warehouse. MSIS deployment in the regions fits within a framework agreement, which brings together decision makers including representatives of the health ministry, social security institution, health professionals, epidemiologists, and patients. A clinical research assistant ensures the control of exhaustiveness and quality of the patient data. The position of the clinical research assistant is complementarily financed by the national project network and by the region.

Results: This MSIS is currently in production in three regions: Limousin, Languedoc-Roussillon and Champagne-Ardenne. The production database includes more than 3000 patient files. Deployment in new regions (Provence-Alpes-Cote-d’Azur, Centre) is underway starting in January 2004.

Discussion: The use of the MSIS in the regions helped in testing its ergonomics, portability, ubiquity, and acceptability among users as well as the respect of confidentiality (authorisation of the National Commission of Informatics and Freedom). The system usability in providing pertinent descriptors for the care demand and supply, and for their adequacy was validated at the regional and the national level. In addition, the MSIS supports the analysis of the patient’s trajectory through the healthcare procedures: dialysis and transplantation and provides the basis for a geographic information system.

Conclusion: An MSIS via Internet including a data warehouse is an adapted tool for describing the endstage renal diseased population at regional and national level. This model allows a better approach to developing knowledge about the care demand and the existing supply, and about methods to improve their adequacy.

022 NON-MELANOMA SKIN AND BLADDER CANCER INCIDENCE IN RELATION TO ARSENIC EXPOSURE: 20 YEARS OF OBSERVATION
V. Bencko¹, P. Franek¹, M. Götzl³, J. Rame².¹Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic; ²European Centre for Medical Informatics, Statistics and Epi, Centre Cardio, Prague, Czech Republic; ³District Hospital of Bojnice, Department of Oncology, Slovakia

Introduction: The subject of our analysis was a database of 1503 non-melanoma skin cancer (NMSC) cases (756 in men and 747 in women) and 230 bladder cancer cases (187 in men and 43 in women) collected from 1977 to 1996 in a region polluted by emissions of a power plant arising from burning of coal with a high arsenic content, ranging between 900 and 1500 g per metric ton of dry coal.

Exposure assessment: Exposure assessment of the local population of the district was based on biological monitoring. Determination of arsenic was done in groups of 10 year old boys as samples of a non-occupationally exposed general population by analysing hair and urine samples at different localities situated up to the distances of 30 km from the local power plant. The district was split in two areas marked off by a 7.5 km circle around the power plant. The criterion of higher exposure was arsenic content exceeding hair concentrations of 3 µg/g of arsenic. In a 7.5 km radius of the exposed region live about two-tenths of the district population, which was considered as "exposed"; the rest of the district served as the control population.

Methods: Basic epidemiological data of the cancer cases were obtained by a questionnaire, which covered basics of personal, family, residential, and occupational history. Our study base represents 1328 men/year and 1334 women/year of a population of approximate size of 125 000 inhabitants.

Results: The age standardised incidence of non-melanoma skin cancer (each confirmed by histological examination) in non-occupational settings ranged from 45.9 to 93.9 in men and from 34.6 to 81.4 in women. Relevant data for bladder cancer (each confirmed by biopsy or autopsy histological examination) ranged from 10.2 to 21.1 in men and from 0.0 to 3.7 in women per 100 000.

Conclusions: Analysis of our data demonstrates a positive correlation between human cumulative exposure to arsenic and incidence of NMSC, which adds further confirmation to the long held clinical and epidemiological experiences with non-melanoma skin cancer and exposure to arsenic. Owing to the relatively small numbers, analysis of our database does not confirm the suspected relationship between exposure to arsenic and bladder cancer incidence.

Acknowledgement: The presented data resulted from the EC supported INCO Copernicus Expascan project grant ERB IC 15 CT98-0325. Analysis of the last 5 year interval of our database was supported by project grant LN 00B107 from the Ministry of Education, Czech Republic.

023 IS A COHORT STUDY ON WORKERS EXPOSED TO HIGH FREQUENCY RADIATION FEASIBLE?
G. Berg¹, J. Breckenkamp¹, E. Boehler², J. Schuz², B. Schlehofer³, M. Blettner².¹University of Bielefeld, School of Public Health, Bielefeld, Germany; ²University of Mainz, Institute of Medical Biometry, Epidemiology and Informatics, Mainz, Germany; ³German Cancer Institute, Department of Epidemiology, Heidelberg, Germany

Introduction: There are numerous studies on the effects of electromagnetic fields on cancer mortality; however, specific studies focusing on high frequency (HF) radiation are rare and their results are inconsistent.

Objective: The aim of this German feasibility study was to find an occupational cohort to analyse health effects of HF radiation.

Method: In a first step, a literature review was performed. Nine existing cohort studies on high frequency exposure during work were found. They mainly examined cancer mortality. In the next step, contacts were made with government organisations, commissions, professional organisations, and companies to find possible cohorts for occupational HF radiation exposure. At the same time, criteria were developed for assessment of the exposure, building up of the cohort, and follow up.

Results: In total, 26 occupations were collected. Three were selected for evaluation according to the criteria catalogue compiled by our working group: engineers and technicians of medium wave and short wave transmitting plants, amateur radio operators, and workers on HF dielectric heat sealers. However, all three cohorts exhibit deficits in one or another criterion. The greatest number of disadvantages were found for the cohort of workers on HF dielectric heat sealers, although the exposure was the most distinct. The other two cohorts exhibited the same number of strengths and weaknesses. The strength of the amateur radio operators lies in the large number of subjects that can be approached in a uniform way. The high quality of the retrospective exposure estimation is the strength of the workers in the short and medium wave transmitters’ cohort.

Discussion: Mortality studies should be performed in a historical approach as for example the amateur radio operator or engineers and technicians of medium wave and short wave transmitting plants. Cohort studies on morbidity, particular for Germany, are only practicable in a prospective follow up design, which might take a long time. Clinical parameters should also be investigated in a small sub-group. In all, the vast majority of occupational groups that we had considered from literature reviews had to be excluded from further consideration owing to small numbers of exposed subjects or exposure levels only marginally higher than for the general public.

024 HEALTH IMPACT ASSESSMENT (HIA) OF A MUNICIPAL WASTE INCINERATOR NEAR FLORENCE, ITALY
F. Bianchi¹, S. Arniani², S. Bartolacci², A. Barchielli³, A. Corti⁴, L. Lombardi⁵, E. Buiatti².¹IFC-National Research Council, Unit of Epidemiology, Pisa, Italy; ²Tuscany Health Agency, Epidemiology Observatory, Florence, Italy; ³Local Health Unit 10, Service of Epidemiology, Florence, Italy; ⁴University, Centre for Complex System, Siena, Italy; ⁵University, Department of Energetic, Florence, Italy

Introduction: In 2002, the Province of Florence administration entrusted the Tuscany Health Agency with producing a health impact assessment (HIA) study of a municipal waste incinerator to be located in the west area of Florence.

Objective: To help decision makers to decide whether one out of the three proposed locations could be selected or none of them.

Methods: HIA was designed on the basis of British and Canadian experiences. Study area included a portion of three municipalities with approximately 100 000 residents. For the HIA screening stage, all ICD-9 groups and subgroups of causes of mortality and discharge hospital records at the municipality level over 1996–1999 were analysed. Atmospheric diffusion models were performed to obtain current values of existing pollution also to compare in terms of annual mean and peak concentrations the present situation with a perspective scenario including an incinerator. According to the estimated values of the highest pollutants fallout, a circular area of 2.5 km radius was selected. For the HIA appraisal stage, selected causes of mortality and hospital discharge records of populations residing within 2.5 km of the proposed sites were considered. Resident population and health events were georeferenced using a geographic information system. SMRs for mortality, morbidity, and mortality plus morbidity were calculated using the province of Florence as standard. The Cuzick-Edwards case–control method for clustering and Kulldorff’s method for cluster identification were applied in specific situations.

Results: Screening stage: Although the general mortality and morbidity and the majority of causes in the three municipalities had similar results to the standard, some excesses were noteworthy, particularly for lung cancer, non-Hodgkin lymphomas, and selected congenital malformations. Appraisal stage: One of the three sites (site C) had a smaller population residing in the area (17 213) compared with site A (27 744) and B (30 913). Differences were more marked when considering a 1.5 km radius area (site A: 1067, site B: 3175, site C: 114). A statistically significant pulmonary disease (ICD9 518) excess in the southern part of the 1.5–2.0 km site A crown (SMR 168) emerged. In addition, excesses of pulmonary diseases in adults (SMR 122) and asthma (ICD9 493) in children aged 0–14 years (SMR 169) living near a heavy traffic road area were found. This area showed also a cluster of 34 events versus 16.3 expected for the same group of respiratory diseases.

Conclusions: Excesses for respiratory diseases in adults and children in the area around site C were detected. A few steps are still needed to conclude the HIA (risk assessment, recommendations, monitoring programme). However, first results lead the administration authority to an environmental requalification programme (traffic, cogenerating power plants, territory bioremediation) that is currently ongoing.

025 FAMILY DOCTORS’ JOB SATISFACTION AND CONDITIONS OF PROFESSIONAL PRACTICE
A. Biscaia¹, P. Ferrinho², M. Colaço³.¹Associaçâo para o Desenvolvimento e Cooperaçâo Garcia de Orta, Unidade de Sistemas de Saúde do Instituto de Higiene e Medicina Tropical, Centro de Saúde de Cascais, Portugal; ²Associaçâo para o Desenvolvimento e Cooperaçâo Garcia de Orta, Unidade de Sistemas de Saúde do Instituto de Higiene e Medicina Tropical, Unidade de Epidemiologia da Facuidcde de Faculdade de Medicina de Lisboa, Portugal; ³Centro de Saúde da Cova da Piedade, Portugal

Introduction: Job satisfaction is acknowledged as being associated with satisfaction with life in general, with mental well-being and with professional performance. It is defined as a positive individual attitude towards the profession and the conditions of its execution.

Objective: In this study we report on a study of job satisfaction of family physicians in the Health Region of Lisbon and the Tagus Valley, with the following research objectives: determining the conditions in which professional practice takes place in the health centres; determining the level of family doctors’ job satisfaction; determining the physicians’ motivation for change (of profession, of career and from the health centre); and physicians’ self-perceptions of health.

Methods: Twenty-four health centres were randomly selected. A validated job satisfaction questionnaire was personally presented to all the family doctors in each of the selected health centres. Conditions of professional practice were determined by a questionnaire applied to the Directors of the health centres and by direct observation, using a standard schedule, by a Technical Commission of the Medical Council and the Regional Health Authority. Data was analysed using SPSS, with recourse to the Pearson ² test (with the Yates correction where appropriate), Fisher’s exact test, the likelihood ratio test, or Student’s t test where applicable. The study was carried out during 2002 and 2003.

Results: From 448 family doctors, 307 (69%) answered the questionnaire. The average level (on a Likert scale) of job satisfaction is neutral. Negative evaluations of job satisfaction are associated with pressure at work, poor work conditions at the health centre, and the type of incentives received. Positive evaluations of job satisfaction are associated with commitment to the work, feeling adequate to perform the expected tasks, and the relationships with colleagues and chiefs at work. These vary among health centres. Specific aspects of work conditions that affect family doctors’ job satisfaction were, among others, the need to share a consultation room, the proportion of nurses to doctors, the proportion of administrative staff to doctors, the proportion of patients in the practice to doctors, and the number of overtime hours. Being dissatisfied is associated with a desire to change. Nine percent of the respondents would not have chosen a medical profession if they had to make that choice today, 34% would not choose being a family physician, and 25% would not choose the same health centre.

Conclusions: This study illustrates the importance of using the epidemiological method in health services research. It helps to identify factors that can be addressed by managers and policy makers in order to correct job dissatisfaction as a determinant of poor performance.

026 ACUTE EFFECTS OF AIR POLLUTION ON HUMAN HEALTH IN AN INDUSTRIALISED URBAN AREA IN ITALY
L. Bisceglia¹, M. A. Vigotti², V. M. R. Muggeo³, S. Minerba⁴, V. Semeraro⁵, G. Assennato¹.¹University, Internal Medicine and Public Health, Bari, Italy; ²University and IFC-CNR, Environmental Epidemiology, Pisa; ³University, Statistics, Palermo; ⁴Local Health Unit, Unit of Prevention, Taranto; ⁵Meteorological Observatory, Taranto

Introduction: The town of Taranto in Southern Italy was included by the World Health Organization among areas at high risk of environmental crisis because of the presence of heavy industries (steel plant including coke oven shops, oil refinery and cement plant) and descriptive epidemiology showing excessive cancer deaths in the general population.

Objective: Within the projects developed by local regional government, an ecological study on short term effects of air pollution on general population was designed. Some of these data will be evaluated within the context of the national multicentre project MISA2, which includes about 20 Italian towns.

Methods: Daily measures of airborne pollutants, started in 1998, come from a network of six monitoring stations. Climate data are drawn from the local Meteorological Observatory. Health data are recruited from the mortality files of the local health unit and from the hospital discharge files of the regional epidemiological observatory. Only natural mortality (excluding traumatic deaths) has been examined among residents who have died in the city. Poisson regression, allowing for overdispersion and autocorrelation, was used to evaluate the percent change in daily deaths or hospital admissions associated with variations of air pollution measures, taking into account meteorological and other possible confounding variables.

Results and Conclusions: In November 2003, a first preliminary analysis for the period May1998–December 2001 was conducted. The update through December 2002 has been recently completed. An overall evaluation of the air pollution in Taranto shows that data are in compliance with legal requirements, with the exception of total suspended particles (TSP), values of which exceed the guideline data (according to Law 203/1988). The situation is worse in the area closer to industrial area (mean (SD) (median) 81.2 (26.6) (78) mg/m³) compared with the city centre (average 55.3 (21.9) (51) mg/m³). Temporal trend of airborne pollutants shows little seasonality and no high background levels, but there are some elevated spike values, typical of areas with industrial emissions. Even mortality seems to be influenced by the presence of heavy industrial plants, cancer being the major cause of death in age classes 2–64 and 65–74 years, especially among males. Preliminary results on acute effects of air pollutants levels at selected time lags: lag₂, lag_0–3, and lag_0–5, show an association between natural mortality and TSP at lag₂, NO₂ at lag_0–5, and CO at all lags, the latter suggesting a prominent role of vehicular traffic. More definitive results will be presented on the on going analyses to verify the hypothesis of association between air pollution and adverse acute effects on health in this area of southern Italy, characterised by a low socioeconomic level and by a developmental model based on a wide industrial area very close to the city.

027 PREVALENCE OF PACIFIER AND NURSING BOTTLE USE IN CHILDREN LESS THAN 1 YEAR OLD IN QUEIMADOS CITY
C. Boccolini, N. Maximiniano, P. Augusto.Secretaria Municipal de Saúde de Queimados, Departamento de Saúde Coletiva, Queimados, Rio de Janeiro, Brazil

Introduction: The use of pacifiers and nursing bottles by children can interfere with milk suction and is associated with high incidences of tooth decay. The Brazilian health ministry does not recommend these practices and has a specific legislation that obliges the pacifier and nursing bottle industries to print on those products a warning about the harm that can be inflicted.

Objectives: To verify the prevalence of pacifier and nursing bottle use in children less than 1 year old living at Queimados city/Rio de Janeiro (RJ) state.

Methods: The subjects were children less than 1 year old living in Queimados city, Rio de Janeiro, whose parents or relatives were questioned with a specific questionnaire, I think ’formulary’ equates to ’questionnaire’ developed by the Instituto de Saúde da SES/SP, about the use of pacifiers and nursing bottles in the previous 24 hours. The research was carried out on 14 June, 2003, together which the national vaccination campaign, and was promoted by Secretaria Estadual de Saúde do Rio de Janeiro and executed by the Área Técnica de Alimentação e Nutrição and Programa de Atenção Integral da Saúde da Mulher, Criança e Adolescentes of Queimados city, Rio de Janeiro.

Results: The study comprised 666 children less than 1 year old, of which 54.71% (n = 354, missing cases = 19) used pacifiers and 63.05% (n = 418, missing cases = 3) received any sort of foods by nursing bottle in the 24 hours preceding the research.

Conclusion: The high prevalence of pacifier and nursing bottle use by children less than 1 year old in Queimados city, Rio de Janeiro, reinforces the need for an effective public health policy that can promote information about risks of pacifier and nursing bottle use.

028 COFFEE AND GASTRIC CANCER: A COMMUNITY BASED CASE–CONTROL STUDY AND A META-ANALYSIS OF PUBLISHED DATA
F. Botelho, N. Lunet, H. Barros.University of Porto Medical School, Hygiene and Epidemiology Department, Porto, Portugal

Introduction: Few studies have addressed the effect of coffee in gastric cancer, and these have yielded inconsistent results. with most individual articles showing non-statistically significant associations. This led us to complement the results of an unpublished community based case–control study performed in Portugal with a meta-analysis of published data.

Methods: Three hundred and two histologically confirmed cases and 518 controls completed a face to face structured questionnaire, including sociodemographic, dietary, and lifestyle characteristics, including detailed coffee consumption habits. Age, sex, education, and smoking adjusted odds ratios (OR) and 95% confidence intervals (CI) were computed. Our results were combined with those from 15 studies identified in a PubMed® based search, providing quantitative estimates of the association between coffee and gastric cancer (relative risk or OR) and respective precision estimates, considering the highest versus the lowest exposure. We present the combined ORs, 95% CIs, and the results for heterogeneity tests, calculated through the fixed effects method with Stata® software.

Results: In our case–control study, and using never drinkers as reference, the OR for gastric cancer was 1.4 (95% CI 0.64 to 2.96) for ex-drinkers for more than 5 years, 3.1 (95% CI 1.40 to 6.63) for those stopping coffee consumption in the previous 5 years, and 1.4 (95% CI 0.88 to 2.08) for current drinkers. Although changes in coffee consumption can be expected in gastric cancer patients, no previously published case–control study considered the category of ex-drinkers. The overall combined OR estimate for the highest versus the lowest exposure was 1.03 (95% CI 0.92 to 1.16) for all 16 studies (heterogeneity test p = 0.24), 1.48 (95% CI 1.00 to 2.20) for three cohort studies, 0.99 (95% CI 0.82 to 1.20) for five population based case–control studies (heterogeneity test p = 0.08), 1.00 (95% CI 0.87 to 1.16) for seven hospital based case–control studies (heterogeneity test p = 0.68), 1.22 (95% CI 0.97 to 1.54) for four case–control studies considering coffee consumption in a period of 5 or more years prior to interview, and 0.94 (95% CI 0.82 to 1.07) for nine case–control studies assessing coffee consumption at diagnosis or in the previous 2 years (heterogeneity test p = 0.34).

Conclusion: When all studies were combined, no association was found between coffee and gastric cancer, but when considering studies with a stronger design to test the aetiological hypothesis (cohort or population based case–control studies addressing coffee consumption several years prior to interview) a small positive association was observed. As coffee drinking is very common, even small increases in risk might have a large population impact.

029 SURVEY OF RISK FACTORS FOR CARDIOVASCULAR DISEASES AMONG PUBLIC SCHOOL TEENAGERS
J. S. Botelho, A. A. Ferrari, M. Fisberg.Universidade Federal de São Paulo, Centro de Atendimento e Apoio ao Adolescente, São Paulo, Brazil

Introduction: Nowadays there is rising concern about cardiovascular disease (CVD). The cardiovascular diseases are the main cause of death around the world. In Brazil, because of the morbidity and mortality rates, cardiovascular disease is considered a public health problem. In many studies, the early lesions of arteriosclerosis can be seen even in youth.

Objective: The present study aims knowing the presence of cardiovascular disease risk factors in adolescents.

Methods: The study was conducted with 2047 students of both sexes, ages ranging from 14 years to 19 years and 11 months, all students at a technical school located in city of São Paulo. We applied a tested and validated form that measured the following cardiovascular disease risk factors: familiar history and dyslipidemia, diabetes mellitus, arterial hypertension, defined as systolic arterial pressure over than 133 mmHg and diastolic arterial pressure below 86 mmHg, obesity (body mass index greater than 95th centile for age and sex), smoking habits (more than five a day), oral contraceptive use, and physical activity.

Results: The students showed overweight or obesity in 14.5%, diabetes mellitus in 0.6%; familiar history and dyslipidemia 41.2%; 23.3% were sedentary; 3.8% mentioned use of oral contraceptives; 9.6% had arterial hypertension or pressure over the 95th centile during the test, and 9.6% declared themselves smokers. Through the obtained information on CVD risk factors, 36.7% of the students presented at least one risk factor, 27.8% from two to three, and 16.7% presented four or more risk factors.

Conclusion: This prevalence of the CVD risk factors presence is similar to that found in the literature, justifying more attention to this age range.

030 A NEW METHOD FOR CARIES PREVENTION IN PUBLIC HEALTH: EFFICACY OF AN ANTISEPTIC MOUTHRINSE PREPARED WITH ALECRIM-PIMENTA ESSENTIAL OIL (LIPPIA SIDOIDES CHAM)
M. Botelho¹, F. Matos², M. Passeggi³, A. Linhares¹, F. Mattos, K. Ferrer.¹Federal University of Ceará, Department of Community Health, Fortaleza, Brazil; ²Federal University of Ceará, Natural Products Laboratory, Fortaleza, Brazil; ³Federal University of Rio Grande do Norte, Department of Education, Natal, Brazil

Introduction: The northeast popular culture of Brazil has aboriginal origins that lead the population of the interior to favour natural, alternative ways to attenuate its illnesses. Medical and dental assistance in emergent countries such as Brazil still has gaps that favour the indifference of the public sector to primary attention in healthcare.

Objective: In order to devise a new method and practical alternatives for programmes in public health, the present study had as its main objective to evaluate the antibacterial action of the essential oil and extract of a plant, Lippia sidoides Cham, against Streptococcus mutans and S. mitis. Lippia sidoides Cham, popularly known in the state of the Ceará as alecrim-pimenta, is a plant of the family Verbenaceae, a finely branched shrub of regularly spaced twigs and short leaves. For the effective relief of toothache, it is customary for the provincial population to make and to smoke small cigarettes made from its falling leaves. From this information, the group of researchers started to evaluate the possible phytotherapeutic chemical effects present in the extract and the essential oil of alecrim-pimenta F-930.

Methods: Intending to develop a new buccal preventive method based on natural substances extracted from plants, samples were obtained from patients in the odontopaediatric clinics of The Federal University of the Ceará by getting them to chew a piece of wax. The subjects were distributed into two groups based on the mouth rinse they used: control and alecrim-pimenta. Both mouth rinses were applied by the subjects every 2 days for 2 weeks. At day 0 and day 15, the scores for bacteria plaque and gingivitis were evaluated in a blinded fashion.

Results: The results indicated that those subjects in the alecrim-pimenta group had significantly decreased (p<0.05) total number counts of S. mutans and S. mitis compared with the other group, thus the extract and essential oil shows antimicrobial activity. This effect may be determined by its chemical composition, which is rich in thymol and carvacrol, two powerful phenolic substances.

Conclusion: These results present alecrim pimenta mouth rinse as an alternative way for caries control and this new method could be used in the Brazilian Government programme Saúde da Família. The extract and the essential oil of alecrim-pimenta could be an effective and cheap potential alternative in the context of community dental assistance in Brazil. The use of this new method could represent a new educational stimuli for poor communities not regularly assisted in health programmes.

031 POPULAR EDUCATION: SYNCRETISM AND REPRESENTATIONS IN BRAZILIANS’ PUBLIC HEALTH
M. Botelho¹, M. Passeggi², A. Linhares¹, R. Gapski³.¹Federal University of Ceará, Community Health Department, Fortaleza, Brazil; ²Federal University of Rio Grande do Norte, Educational Department, Natal, Brazil; ³University of Missouri-Kansas City, Department of Periodontics, Kansas City, USA

Introduction: The use of white as a colour in clothing such as tunics, sacramental vestments, and mantles has taken root in the history of humanity as symbol of expertise: either of wisdom, royalty, a high degree of spirituality, or superior purity. Among the old Brahmans, Egyptians, Christians, and Hindus, white symbolised connecting links between the body and the spirit. However, the use of white is not limited only to religious inheritances; it extends to health practices. In the Brazilian popular imagination, the image of white is associated with two areas—health and religion—especially for Afro-Brazilians, in the figure of the Pai de Santo of Umbanda.

Objective: This paper presents the first results of a research in progress carried out in a fishing village of Mundaú Beach (northeast Brazil), in the context of public health programmes and population education, observing how representations of the dentist are reassigned during and after the intervention process.

Methods: We adopted the principle that human actions are not determined by the objective components of a situation but by the representations of this situation. The study was designed on a qualitative basis and presents the point of view of the informers for the interpretation of the observed phenomena. The instruments of data collection used were the participants’ comment and semi-structured intervi