1.
Mulinari, Shai, et al.
(author)
Categorical and anti-categorical approaches to US racial/ethnic groupings: revisiting the National 2009 H1N1 Flu Survey (NHFS)
2018
In: Critical Public Health. - : Informa UK Limited. - 0958-1596 .- 1469-3682. ; 28:2, s. 177-189
Journal article (peer-reviewed) abstract
Intersectionality theory calls for the understanding of race/ ethnicity, sex/ gender and class as interlinked. Intersectional analysis can contribute to public health both through furthering understanding of power dynamics causing health disparities, and by pointing to heterogeneities within, and overlap between, social groups. The latter places the usefulness of social categories in public health under scrutiny. Drawing on McCall we relate the first approach to categorical and the second to anti-categorical intersectionality. Here, we juxtapose the categorical approach with traditional between-group risk calculations (e.g. odds ratios) and the anticategorical approach with the statistical concept of discriminatory accuracy (DA), which is routinely used to evaluate disease markers in epidemiology. To demonstrate the salience of this distinction, we use the example of racial/ ethnic identification and its value for predicting influenza vaccine uptake compared to other conceivable ways of organizing attention to social differentiation. We analyzed data on 56,434 adults who responded to the NHFS. We performed logistic regressions to estimate odds ratios and computed the area under the receiver operating characteristic curve (AU-ROC) to measure DA. Above age, the most informative variables were education and household poverty status, with race/ ethnicity providing minor additional information. Our results show that the practical value of standard racial/ ethnic categories for making inferences about vaccination status is questionable, because of the high degree of outcome variability within, and overlap between, categories. We argue that, reminiscent of potential tension between categorical and anti-categorical perspectives, between-group risk should be placed and understood in relationship to measures of DA, to avoid the lure of misguided individual-level interventions.
2.
Axelsson Fisk, Sten, et al.
(author)
Understanding the complexity of socioeconomic disparities in smoking prevalence in sweden : A cross-sectional study applying intersectionality theory
2021
In: BMJ Open. - : BMJ. - 2044-6055. ; 11:2
Journal article (peer-reviewed) abstract
Objectives Socioeconomic disparities in smoking prevalence remain a challenge to public health. The objective of this study was to present a simple methodology that displays intersectional patterns of smoking and quantify heterogeneities within groups to avoid inappropriate and potentially stigmatising conclusions exclusively based on group averages. Setting This is a cross-sectional observational study based on data from the National Health Surveys for Sweden (2004-2016 and 2018) including 136 301 individuals. We excluded people under 30 years of age, or missing information on education, household composition or smoking habits. The final sample consisted on 110 044 individuals or 80.7% of the original sample. Outcome Applying intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA), we investigated the risk of self-reported smoking across 72 intersectional strata defined by age, gender, educational achievement, migration status and household composition. Results The distribution of smoking habit risk in the population was very heterogeneous. For instance, immigrant men aged 30-44 with low educational achievement that lived alone had a prevalence of smoking of 54% (95% CI 44% to 64%), around nine times higher than native women aged 65-84 with high educational achievement and living with other(s) that had a prevalence of 6% (95% CI 5% to 7%). The discriminatory accuracy of the information was moderate. Conclusion A more detailed, intersectional mapping of the socioeconomic and demographic disparities of smoking can assist in public health management aiming to eliminate this unhealthy habit from the community. Intersectionality theory together with AIHDA provides information that can guide resource allocation according to the concept proportionate universalism.
3.
Mulinari, Shai, et al.
(author)
Questioning the discriminatory accuracy of broad migrant categories in public health: self-rated health in Sweden
2015
In: European Journal of Public Health. - : Oxford University Press (OUP). - 1101-1262 .- 1464-360X. ; 25:6, s. 911-917
Journal article (peer-reviewed) abstract
BACKGROUND: Differences between natives and migrants in average risk for poor self-rated health (SRH) are well documented, which has lent support to proposals for interventions targeting disadvantaged minority groups. However, such proposals are based on measures of association that neglect individual heterogeneity around group averages and thereby the discriminatory accuracy (DA) of the categories used (i.e. their ability to discriminate the individuals with poor and good SRH, respectively). Therefore, applying DA measures rather than only measures of association our study revisits the value of broad native and migrant categorizations for predicting SRH. DESIGN, SETTING AND PARTICIPANTS: We analyzed 27 723 individuals aged 18-80 who responded to a 2008 Swedish public health survey. We performed logistic regressions to estimate odds ratios (ORs), predicted risks and the area under the receiver operating characteristic curve (AU-ROC) as a measure of epidemiological DA. RESULTS: Being born abroad was associated with higher odds of poor SRH (OR = 1.75), but the AU-ROC of this variable only added 0.02 units to the AU-ROC for age alone (from 0.53 to 0.55). The AU-ROC increased, but remained unsatisfactorily low (0.62), when available social and demographic variables were included. CONCLUSIONS: Our results question the use of broad native/migrant categorizations as instruments for forecasting individual SRH. Such simple categorizations have a very low DA and should be abandoned in public health practice. Measures of association and DA should be reported together whenever an intervention is being considered, especially in the area of ethnicity, migration and health.
4.
Merlo, Juan, et al.
(author)
God vård på lika villkor vid hjärtinfarkt i dagens Sverige. Geografiska skillnader i dödlighet utan betyd
2005
In: Läkartidningen. - 0023-7205. ; 102:1-2, s. 20-23
Journal article (peer-reviewed) abstract
It is a known fact that the 1990s brought a decrease in mortality after myocardial infarction in Sweden but that differences in mortality rates following myocardial infarction still remain between the Swedish counties. Unresolved, however, are questions as to what these inter-county differences mean for the individual patient and what role hospital care plays in this context. We analysed all patients aged 64-85 years who were hospitalised following diagnosis of myocardial infarction in Sweden during the period 1993-1996. To gain an understanding of the relevance of geographical differences in mortality after myocardial infarction for the individual patient we applied multi-level regression analysis and calculated county and hospital median odds ratios (MORs) in relation to 28-day mortality. For hospitalised patients with myocardial infarction, being cared for in another hospital with higher mortality would increase the risk of dying by 9% (MOR=1.09) in men and 12% in women. If these patients moved to another county with higher mortality the risk would increase by 7% and 3%, respectively. The small geographical differences in 28-day mortality after myocardial infarction found in Sweden suggest a high degree of equality across the country; however, further improvement could be achieved in hospital care, especially for women - an issue that deserves further analysis.
5.
Bjerkeli, Pernilla J., et al.
(author)
Overuse of methylphenidate : an analysis of Swedish pharmacy dispensing data
2018
In: Clinical Epidemiology. - : Dove Press. - 1179-1349. ; 10, s. 1657-1665
Journal article (peer-reviewed) abstract
Purpose: To identify overuse of methylphenidate and to investigate patterns of overuse in relation to sociodemographic and clinical characteristics. Patients and methods: Swedish national, pharmacy dispensing data were analyzed for all 56,922 individuals aged 6-79 years, who filled a methylphenidate prescription between 2010 and 2011. Overuse was defined as having above 150% days covered by the dispensed amount during 365 days from the first prescription fill, assuming use at the maximum recommended daily dose. Results: In total, 4,304 individuals (7.6% of the methylphenidate users) were categorized as overusers. The risk of overuse increased with age (OR for 46-65 years vs 6-12 years 17.5, 95% CI 14.3-21.3), and was higher in men (OR 1.4, 95% CI 1.3-1.5) and individuals with low income (OR 1.1, 95% CI 1.0-1.2), as well as in individuals with an attention deficit hyperactivity disorder (ADHD) diagnosis (OR 1.4, 95% CI 1.3-1.6), health care visits (OR 1.3, 95% CI 1.2-1.4), previous ADHD medication use (OR 2.6, 95% CI 2.4-2.8), and previous diagnosis of mental and behavioral disorders due to psychoactive substance use (OR 2.1 95% CI 2.0-2.3). Conclusion: Among individuals using methylphenidate in Sweden, 7.6% receive amounts that are larger than what they should have a medical need for, assuming that they were using the maximum recommended daily dose 365 days per year. Notably, the prevalence of overuse was associated with previous diagnosis of alcohol and drug misuse. The prevalence was also positively associated with higher age and previous use of ADHD medication. These findings may point toward a link between exposure time and overuse. However, future studies with long-term data are needed to investigate this.
6.
Karlsson, Matilda, et al.
(author)
Intimate Partner Violence against Women in the EU : A Multilevel Analysis of the Contextual and Individual Impact on Public Perceptions
2022
In: Women & Criminal Justice. - : Routledge. - 0897-4454 .- 1541-0323. ; 32:5, s. 417-430
Journal article (peer-reviewed) abstract
Intimate partner violence against women (IPVAW) poses severe threats to women’s health and rights. This study investigates the role of country context and gender equality in shaping individual perceptions of the severity of IPVAW. Multilevel logistic regression analyses of a Eurobarometer survey on attitudes toward IPVAW from 27 EU states showed that male gender, young age, low education, low self-assessed social position and particularly perceiving IPVAW as uncommon were associated with perceiving IPVAW as less severe. The likelihood of perceiving IPVAW as less severe was higher in countries with low gender equality. Between-country variance accounted for 14% of the variability, while country-level gender equality accounted for 22% of the between-country variance. We conclude that efforts toward strengthening perceptions of IPVAW as a severe issue should focus on awareness-raising and on increasing country-level gender equality.
7.
Carlsson, Frida, et al.
(author)
Representativity of a postal public health questionnaire survey in Sweden, with special reference to ethnic differences in participation
2006
In: Scandinavian Journal of Public Health. - : SAGE Publications. - 1651-1905 .- 1403-4948. ; 34:2, s. 132-139
Journal article (peer-reviewed) abstract
AIM: Non-participation in health surveys is a common phenomenon. When differences between participants and non-participants are considerable, the external validity of the sample survey may decrease and false conclusions might be drawn about the health status of the population. For this reason, the authors aimed to investigate the representativity of a postal questionnaire survey performed in the county of Scania, Sweden, in 1999-2000. The survey, which was based on an 18- to 80-year-old population sample, had a 58% response rate (n = 13 604).METHODS: For some variables, the information obtained using the questionnaire was compared with information obtained from a population register that covers all the population in the county (for the 18- to 80-year-old group, n = 850 476). The population register includes, among other data, information on age, gender, educational level, country of birth, and healthcare expenditure.RESULTS: Men, individuals with a low level of education, and immigrants were under-represented in the survey. However, except for immigrants, the under-representation was not large. Among immigrants, particularly those born in former Yugoslavia, the Arabic-speaking countries, and Poland were very significantly under-represented in the study. By contrast, immigrants born in other Nordic countries had responded to almost the same extent as respondents born in Sweden. The survey sample had about the same healthcare utilization costs as did the general population.CONCLUSIONS: In summary, the "Health Survey for Scania, 2000" seems largely representative of the total Scanian population. A major concern, however, is the under-representation of the immigrant population.
8.
Ericsson, Lovisa, et al.
(author)
Revisiting socio-economic inequalities in sedentary leisure time in Sweden : An intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA)
2023
In: Scandinavian Journal of Public Health. - : Sage Publications. - 1403-4948 .- 1651-1905. ; 51:4, s. 570-578
Journal article (peer-reviewed) abstract
Aims: Swedish public health reports have repeatedly provided information about socio-economic inequalities in sedentary leisure time, despite that, in the interest of health equity, physical activity should be equally distributed in the population. Such public health reports, however, neither consider the intersection of multiple socio-demographic factors nor the individual heterogeneity around group averages. Drawing on intersectionality theory, this study aimed to revisit previous findings on sedentary leisure time from Swedish public health surveys and demonstrate how the analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can be used for analysing complex health inequalities.Methods: Using data from Swedish national public health surveys (2004–2015), we applied the AIHDA to define 72 intersectional groups by categories of age, gender, educational achievement, migration status and household composition. We then calculated (a) the absolute and relative risk of sedentary leisure time and (b) the discriminatory accuracy (DA) of the intersectional grouping.Results: The average risk of sedentary leisure time ranged from 5.8% among native-born, highly educated, young women living alone to 41.0% among immigrated young men, living alone, with low education. The risk was higher in strata comprising immigrated people with low education and lower in strata including native-born, highly educated people. However, the DA of the grouping was poor, indicating a substantial overlap of individual risk between groups.Conclusions: Using the AIHDA and drawing on intersectionality, this study provides an improved mapping of the socio-economic distribution of sedentary leisure time in Sweden, with the poor DA suggesting universal rather than targeted physical activity interventions.
9.
Bjerkeli, Pernilla J., et al.
(author)
Sociodemographic patterns in pharmacy dispensing of medications for erectile dysfunction in Sweden
2018
In: European Journal of Clinical Pharmacology. - : Springer. - 0031-6970 .- 1432-1041. ; 74:2, s. 209-218
Journal article (peer-reviewed) abstract
PURPOSE: The purpose of this study is to investigate the relationship between sociodemographic factors and pharmacy dispensing of medications for erectile dysfunction (ED) in the general population of middle-aged and elderly men. By considering a number of medical conditions that could promote or contraindicate use of ED medication, the analysis could help capture prescription patterns that might not be explained by medical needs.METHODS: Individual-level pharmacy dispensing data from 2006 for a population-based cohort of 216,148 men aged 45-79 years in the county Scania, Sweden, were analysed. Multiple logistic regression was applied, and area under the receiver operating characteristic curve (AUC) was calculated to quantify the discriminatory accuracy (DA) of the associations. National trends in pharmacy dispensing of ED medication between 2006 and 2016 were also analysed.RESULTS: Pharmacy dispensing of ED medication increased between 2006 and 2016, particularly among men aged 65-79 years (from 6.8 to 9.2%). Dispensing of ED medication was positively associated with higher socioeconomic position, and divorced and widowed men were more likely to fill a prescription with ED medication than married men. These associations remained after adjusting for medical conditions. The DA of the associations was, however, rather low (AUC = 0.69 among 45-64 year olds and AUC = 0.65 among 65-79 year olds).CONCLUSIONS: Pharmacy dispensing of ED medication seem linked to the individuals socioeconomic position, age and marital status suggesting sociodemographic disparities in the pharmacy dispensing targeting sexual function. However, the low DA of the associations shows the limited capacity of these factors to predict ED medication use at the individual level.
10.
Merlo, Juan
(author)
Pharmacoepidemiologic studies on cardiovascular drugs - with special reference to the effectiveness and safety of blood pressure lowering drugs
1998
Doctoral thesis (other academic/artistic) abstract
Background: Ischaemic heart disease (IHD) and stroke are the main causes of morbidity and mortality in developed countries and hence constitute a large public health problem. Cardiovascular drugs are used in an effort to prevent (e. g. blood pressure lowering drugs (BPLD) and lipid lowering drugs) and palliate (e. g. nitrates) these disorders. The efficacy and safety of these drugs have been evaluated in randomised clinical trials. However, conclusions from these trials are not representative of patients in general. This necessitates epidemiologic studies to evaluate the long-term effectiveness and risk of cardiovascular drugs in routine care. Methods: 283 Swedish municipalities were studied during 1989 - 1993 by multivariate Poisson regression at the ecologic level. Drug utilisation was categorised into four equal-size groups by quartiles and compared with mortality from IHD and stroke. The relation between stroke mortality and utilisation of BPLD was also analysed in 49 municipalities by correlation of direct age standardised (equivalent average rate method) rates. At the individual level, the incidence of ischaemic cardiac events and stroke in relation to the use of BPLD and blood pressure level was analysed in a prospective population based cohort of 500 men born 1914 and living in Malmö in 1982-83 by multivariate 10-year survival analysis. Results: Compared with the municipalities within the lowest fourth of drug utilisation, mortality from IHD and stroke was reduced in the three other fourths of lipid-lowering drugs utilisation. Only the municipalities within the uppermost BPLD utilisation had a lower IHD (-5%) and stroke mortality (-10%). Utilisation of nitrates was associated with a gradually increased risk of mortality from stroke (+3%, +7%, +11%) and an increased risk of mortality from IHD (+10%, +9%, +13%). At the individual level, use of BPLD was associated with increased incidence of ischaemic cardiac events both in those with diastolic blood pressure above, and in those at or below, 90 mmHg. However, after adjustment for confounders the two-fold risk increase among the former disappeared, whereas the four-fold risk increase among the latter remained. Systolic blood pressure <160 mmHg conveyed a lower risk of stroke, but this benefit was only seen in untreated men. In men being treated with BPLD the opposite was true, the risk of stroke being increased almost threefold. Main conclusions: Both BPLD and lipid lowering drugs seemed to be effective in the general population, but the effectiveness of routine treatment with BPLD appeared to be low; reduced IHD and stroke mortality was reached in only one fourth of the municipalities. This need not indicate a suboptimal utilisation level of BPLD but rather that various factors may counteract their effects in routine care. The safety of nitrates should be further analysed as they might enhance the risk of IHD and stroke mortality. A plausible explanation of the increased risk in BPLD users with low blood pressure is that it was confined to a subgroup of subjects not represented in randomised clinical trials in whom lowering of blood pressure could be detrimental (the J-curve phenomenon).
