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- Trygg Fagrell, Nadja, 1988-
(författare)
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Knowledge diversification in public health through intersectionality
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundKnowledges about health inequalities and their causes are a central concern in public health. Generally, these relate to the social patterning of health and the forces that affect health conditions in daily life. However, public health decision making has been criticized for excluding knowledges of particular importance for health equity. This poses a challenge since knowledges and understandings shape what policies and interventions are viewed as relevant, reasonable or even possible to think of. If certain knowledges are left out, there is a risk that both knowledge making and decision making with respect to health inequalities will exclude important measures.Since intersectionality encompasses a wide range of knowledge-making practices centered around social justice, it may contribute diverse knowledges of importance to health equity. Intersectionality has recently gained traction within public health and represents an important shift in conceptualizing how different dimensions of inequalities, such as sexism, classism and racism, interlock to generate social exclusion and marginalization instead of working separately, one by one.AimThe overall aim of this thesis is to explore the possibility of using intersectionality as a tool for knowledge diversification within public health. The specific research question is:What knowledges and understandings of health inequalities do the inter-categorical (studies I and II) and post-categorical (studies III and IV) approaches to intersectionality contribute and how are such contributions made?Material and methodsThe method of the cover story can be understood as a way of studying science or as a retrospective self-reflection based on the four individual studies, making up the material of the thesis. Specifically, the material was reassembled and retold in order to show how certain intersectional approaches generate different types of knowledges and understandings of health inequalities by involving different ways of operationalizing inequalities and managing categories.In study I, a scoping review of the quantitative international literature was undertaken with the aim of mapping and describing inter-categorical inequalities in mental health. Study II was a quantitative analysis of a population-based survey with the aim of mapping inter-categorical inequalities in mental health in the Swedish adult population. Study III was a policy analysis of a government bill that proposes a national strategy on alcohol, drugs, tobacco and gambling with the study aim to examine the equity-perspective of the bill through an intersectional lens. Study IV was a post-qualitative inquiry based on participatory observations and interviews with the study aim to explore the becoming of social divisions among seniors as they participate in health-promoting activities.ResultsThe inter-categorical approach to intersectionality (applied in studies I and II) generated knowledges about health inequalities as quantitative mean differences between population groups, and highlighted unexpected patterns and unpredictable inequalities in mental health. This implies the importance of building responsive systems that regularly monitor inequalities across different intersectional positions and contexts so that services can be directed and adapted to those most in need.The post-categorical approach to intersectionality (applied in studies III and IV) generated knowledges about health inequalities as processes of marginalization, resistance, exclusion, or inclusion, and highlighted difficult trade-offs with respect to public health policy and practice. This enables a transformative way of thinking by providing the possibility of doing things differently in everyday practices in which marginalization and resistance becomes.ConclusionDifferent approaches to intersectionality contribute diverse knowledges and understandings about health inequalities. This is important since it expands the possibilities for fair decision making and health equity through different outlooks on social justice. Knowledge diversification through intersectionality could be particularly useful to release tension due to the restrictive forces of public health decision making and to increase accountability for the multiple social interests of the population. Thus, it has the potential to make public health decision making more flexible, transparent, reflexive, and democratic.
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| 2. |
- Meili, Kaspar Walter, 1989-
(författare)
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Capability for broader cost-effectiveness in public health and social welfare : developing, valuing, and applyingcapability-adjusted life years Sweden (CALY-SWE)
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Spending in social welfare areas such as healthcare, wider public health, education, and social care consumes a major part of the public budget. Cost-effective resource allocation is a moral obligation towards both taxpayers and beneficiaries: tax money should be used efficiently, and it should be transparently accounted for. After all, economical management of resources is important for sustaining future prosperity and for addressing fundamental challenges such as climate change and demographic shift. In healthcare, cost‐effectiveness using quality-adjusted life years (QALYs) is a well-established tool to inform policymakers. Using cost per QALY implies that health-related quality of life (QoL), and not money, is an end on its own. Moreover, cost per QALY allows one to compare unrelated interventions by measuring the effects on the common QALY scale. However, for actors concerned with broader social welfare, such as the Swedish municipalities, QALYs may be less useful because their measurement focus is largely limited to health. Comparable outcome measures for broader social welfare are still sparsely available and employed, and a context-specific measure for Sweden is lacking. The aim of this thesis was to develop, value, and apply capability-adjusted life years Sweden (CALY‐SWE), a QoL outcome measure conceptually based on the capability approach, for broader social welfare and specific for Sweden.Within study 1, we organized a Delphi panel to select relevant capability attributes and then developed the phrasing for the questionnaire. The resulting questionnaire contains six attributes –health, social relations, financial situation & housing, security, occupation, and political & civil rights – each with three answer levels. The phrasing integrates an implicit threshold so that the sensitivity is focused on the lower range of the scale, thus incorporating equity considerations that relate to sufficientarianism and prioritarianism. In study 2, we developed a value set consisting of all quality weights for the 729 possible CALY-SWE states. We relied on health economic outcome methodology, namely hybrid modelling of discrete choice and time trade-off data that we collected in a cross-sectional web survey with representative sampling. This value set allows to aggregate the CALY-SWE answers into a single quality weight that can be used in cost‐effectiveness analysis to calculate CALYs. In study 3, we applied the CALY-SWE questionnaire and value set to describe the capability distribution in a cross-sectional representative sample of the Swedish population. In a framework of group comparisons, we estimated capability inequalities and shortfalls for different population groups. The results showed that there are capability inequalities for *disadvantage groups* as well as for groups with discriminative inequalities – *plurality groups*, for example between lower and higher education. For study 4, we applied CALY‐SWE in a cost‐effectiveness application to model the effects of a payroll tax reduction in Sweden from 2007 to 2016 (during the financial crisis) on young people not in employment, education, or training (NEET). The intervention was likely cost-effective from a societal perspective, but only with limited probability from a fiscal perspective, although definite statements regarding cost-effectiveness are challenging because a threshold value for a CALY is still lacking. The final chapter discusses the measure’s development, including normative choices, in relation to the Swedish social welfare and policy context, the capability framework as suggested by Amartya Sen, distributive justice, and other outcome measures in cost‐effectiveness evaluations. Important work remains – for example, assessing psychometric properties, developing the conceptualization of the 0 to 1 anchor scale for capability weights, and assessing a threshold value for a CALY. In conclusion, with the questionnaire development, value set elicitation, and demonstration of applications, important steps for CALY‐SWE were accomplished. Cost‐effectiveness evaluations in wider social welfare and public health using CALY-SWE are now possible.
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| 3. |
- Månsdotter, Anna, 1965-
(författare)
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Health, economics, and feminism : on judging fairness and reform
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: The point of departure in this thesis is that women live longer than men, while men have more power, influence and resources, and probably better health-related quality of life, than women. In order to judge and act from this situation, the classical idea that both facts and values are needed for conclusion is adopted. The diverse positions of the sexes are mainly assumed to depend on the gender system, i.e. the societal structure organising human activities and relations, ultimately privileges and burdens, by sex. Hence, abolition of gender is held to be associated with decreased differences in health. The handling of facts and values is divided into two principal questions: 1) how to compare women and men within a particular state of the world, and 2) how to choose from their positions between states. Aims: The overall aim is to propose a public health framework for judging fairness and change from the positions of women and men. The specific aims are to: illustrate how the choice of normative approach affects judgements on fairness and resource allocation (I), explor public health views regarding various ethical principles (II), study the relationship between aspects of gender equality in public/domestic and health (III), estimate costs, savings and health gains, associated with the Swedish parental insurance reform (IV). Methods: The methods used are: ethical analysis based on the normative theories of welfarism, extrawelfarism, egalitarianism, and feminism; and the notions of justice by separate spheres, equity as choice and attainment/shortfall principles (I), survey among public health workers regarding within-state and between-states ethical views (II), epidemiologic study on death and sickness leave among traditional, equal, and untraditional Swedish couples who had their first child in 1978 (III), cost-effectiveness analysis based on men who took paternity leave 1978-1979 (IV). Results: The selected normative theories are likely to claim different opinions on fairness regarding women and men, and different proposals on resource allocations (I). Most public health workers support the idea of judging fairness by separate spheres, end-points, and shortfall equity. The rejection of health maximisation, and support for equality in life span and income, are convincing; although females and males differ significantly in judging societal change (II). In comparison to being equal in the public sphere, traditional women have lower risks of death and sickness, while traditional men tend to have higher risks. Being equal in the domestic sphere seems to be associated with lower risks among both sexes (III). Men who took paternity leave run significant lower death risks than other men. Base case cost-effectiveness of the reform is 6,000 EUR, and worst case 40,000 EUR, per gained QALY (IV). Conclusions: A public health framework for judging fairness and reform by women and men could look as follows: 1) identify facts at present and from past, 2) ask whether the situation is fair by within-state rules, 3) claim or refuse change, 4) identify consequences from reform, 5) consider whether the change was satisfying by between-states rules. The gains from more ethical analyses of public health based on sex/gender should overcome the many tricky issues involved. Since there is no common understanding on how to judge fairness and change from female/male differences in health and wealth, added research and exchange of views are called for. At Swedish state of gender (in)equality, it seems public health relevant to support further similarity in child-care. Provided an effective fraction of 25 percent, the entitlement to paternity leave is probably approved of by common welfarist, egalitarian, and feminist goals.
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| 4. |
- Meili, Kaspar Walter, et al.
(författare)
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Eliciting a value set for the Swedish capability-adjusted life years instrument (CALY-SWE)
- 2024
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Ingår i: Quality of Life Research. - : Springer Nature. - 0962-9343 .- 1573-2649. ; 33:1, s. 59-72
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: Our aim was to elicit a value set for Capability-Adjusted Life Years Sweden (CALY-SWE); a capability-grounded quality of life instrument intended for use in economic evaluations of social interventions with broad consequences beyond health.Methods: Building on methods commonly used in the quality-adjusted life years EQ-5D context, we collected time-trade off (TTO) and discrete choice experiment (DCE) data through an online survey from a general population sample of 1697 Swedish participants. We assessed data quality using a score based on the severity of inconsistencies. For generating the value set, we compared different model features, including hybrid modeling of DCE and TTO versus TTO data only, censoring of TTO answers, varying intercept, and accommodating for heteroskedasticity. We also assessed the models’ DCE logit fidelity to measure agreement with potentially less-biased DCE data. To anchor the best capability state to 1 on the 0 to 1 scale, we included a multiplicative scaling factor.Results: We excluded 20% of the TTO answers of participants with the largest inconsistencies to improve data quality. A hybrid model with an anchor scale and censoring was chosen to generate the value set; models with heteroskedasticity considerations or individually varying intercepts did not offer substantial improvement. The lowest capability weight was 0.114. Health, social relations, and finance and housing attributes contributed the largest capability gains, followed by occupation, security, and political and civil rights.Conclusion: We elicited a value set for CALY-SWE for use in economic evaluations of interventions with broad social consequences.
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