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1.
  • Hallqvist, Johan, 1950-, et al. (author)
  • How to evaluate interaction between causes : a review of practices in cardiovascular epidemiology.
  • 1996
  • In: Journal of Internal Medicine. - : Wiley. - 0954-6820 .- 1365-2796. ; 239:5, s. 377-82
  • Journal article (peer-reviewed)abstract
    • To increase the knowledge of interaction or synergy between risk factors in an important task in medical research. Still, current literature in cardiovascular epidemiology reflects major misconceptions as how to evaluate interaction. This paper presents Rothman's model of causation from which strict empirical criteria of interaction can be derived. In principle, the method to apply consists of comparing risk differences for one risk factor of interest across strata of the other. Commonly used but incorrect approaches are exemplified and discussed. These include reporting risk of disease among those with combined exposure, comparing relative risks for one exposure after stratification by level of the other, and including an interaction term in the regression model and drawing conclusions from its P-value.
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2.
  • Sariaslan, Amir, et al. (author)
  • The impact of neighbourhood deprivation on adolescent violent criminality and substance misuse : A longitudinal, quasi-experimental study of the total Swedish population.
  • 2013
  • In: International Journal of Epidemiology. - : Oxford University Press (OUP). - 0300-5771 .- 1464-3685. ; 42:4, s. 1057-1066
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: A number of studies suggest associations between neighbourhood characteristics and criminality during adolescence and young adulthood. However, the causality of such neighbourhood effects remains uncertain.METHODS: We followed all children born in Sweden from 1975-1989 who lived in its three largest cities by the age of 15 years and for whom complete information was available about individual and contextual factors (N = 303 465). All biological siblings were identified in the sample (N = 179 099). Generalized linear mixed-effects models were used to assess the effect of neighbourhood deprivation on violent criminality and substance misuse between the ages of 15 and 20 years, while taking into account the cross-classified data structure (i.e. siblings in the same families attending different schools and living in different neighbourhoods at age 15).RESULTS: In the crude model, an increase of 1 SD in neighbourhood deprivation was associated with a 57% increase in the odds of being convicted of a violent crime (95% CI 52%-63%). The effect was greatly attenuated when adjustment was made for a number of observed confounders (OR 1.09, 95% CI 1.06-1.11). When we additionally adjusted for unobserved familial confounders, the effect was no longer present (OR 0.96, 95% CI 0.84-1.10). Similar results were observed for substance misuse. The results were not due to poor variability either between neighbourhoods or within families.CONCLUSIONS: We found that the adverse effect of neighbourhood deprivation on adolescent violent criminality and substance misuse in Sweden was not consistent with a causal inference. Instead, our findings highlight the need to control for familial confounding in multilevel studies of criminality and substance misuse.
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3.
  • Sundström, Johan, Professor, 1971-, et al. (author)
  • Risk factors for subarachnoid haemorrhage : a nationwide cohort of 950 000 adults
  • 2019
  • In: International Journal of Epidemiology. - : Oxford University Press. - 0300-5771 .- 1464-3685. ; 48:6, s. 2018-2025
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: Subarachnoid haemorrhage (SAH) is a devastating disease, with high mortality rate and substantial disability among survivors. Its causes are poorly understood. We aimed to investigate risk factors for SAH using a novel nationwide cohort consortium.METHODS: We obtained individual participant data of 949 683 persons (330 334 women) between 25 and 90 years old, with no history of SAH at baseline, from 21 population-based cohorts. Outcomes were obtained from the Swedish Patient and Causes of Death Registries.RESULTS: During 13 704 959 person-years of follow-up, 2659 cases of first-ever fatal or non-fatal SAH occurred, with an age-standardized incidence rate of 9.0 [95% confidence interval (CI) (7.4-10.6)/100 000 person-years] in men and 13.8 [(11.4-16.2)/100 000 person-years] in women. The incidence rate increased exponentially with higher age. In multivariable-adjusted Poisson models, marked sex interactions for current smoking and body mass index (BMI) were observed. Current smoking conferred a rate ratio (RR) of 2.24 (95% CI 1.95-2.57) in women and 1.62 (1.47-1.79) in men. One standard deviation higher BMI was associated with an RR of 0.86 (0.81-0.92) in women and 1.02 (0.96-1.08) in men. Higher blood pressure and lower education level were also associated with higher risk of SAH.CONCLUSIONS: The risk of SAH is 45% higher in women than in men, with substantial sex differences in risk factor strengths. In particular, a markedly stronger adverse effect of smoking in women may motivate targeted public health initiatives.
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4.
  • Söderman, Anne-Charlotte Hessén, et al. (author)
  • Stress as a trigger of attacks in Menière's disease. A case-crossover study.
  • 2004
  • In: The Laryngoscope. - : Wiley. - 0023-852X .- 1531-4995. ; 114:10, s. 1843-8
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: Menière's disease is defined as the presence of recurrent, spontaneous episodic vertigo, hearing loss (HL), aural fullness, and tinnitus. The occurrence of attacks is unpredictable. The etiology is still unknown, but the disease has a pathologic correlate in hydropic distension of the endolymphatic system. Earlier studies have shown increased incidence of stress on the same day as vertigo attacks, but it has not been determined whether stress occurring on the day of the vertiginous episode came before or after the onset of the vertigo. METHODS: A case-crossover study including 46 patients with active Menière's disease. MAIN OUTCOME MEASURE: Relative risks with 95% confidence intervals (CI). FINDINGS: During the study period, 153 Menière's attacks were reported. Twenty-four (52%) of the 46 patients reported attacks. Twelve of the 153 (8%) attacks occurred within 3 hours after exposure to emotional stress. The relative risk of having an attack was 5.10 (95% CI 2.37-10.98) during 3 hours after being exposed to emotional stress. Twenty-nine percent of the patients with attacks had at least one attack after exposure to emotional stress. For mental stress, the relative risk was 4.16 (95% CI 1.46-11.83) and the hazard period 1 hour, but only five attacks were exposed. No excess risk was found after physical stress. INTERPRETATION: Being exposed to emotional stress increases the risk of getting an attack of Menière's disease during the next hour, and the hazard period is possibly extended up to 3 hours.
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5.
  • Agardh, Emilie E, et al. (author)
  • Burden of type 2 diabetes attributed to lower educational levels in Sweden
  • 2011
  • In: Population Health Metrics. - : Springer Science and Business Media LLC. - 1478-7954. ; 9, s. 60-
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: Type 2 diabetes is associated with low socioeconomic position (SEP) in high-income countries. Despite the important role of SEP in the development of many diseases, no socioeconomic indicator was included in the Comparative Risk Assessment (CRA) module of the Global Burden of Disease study. We therefore aimed to illustrate an example by estimating the burden of type 2 diabetes in Sweden attributed to lower educational levels as a measure of SEP using the methods applied in the CRA.METHODS: To include lower educational levels as a risk factor for type 2 diabetes, we pooled relevant international data from a recent systematic review to measure the association between type 2 diabetes incidence and lower educational levels. We also collected data on the distribution of educational levels in the Swedish population using comparable criteria for educational levels as identified in the international literature. Population attributable fractions (PAF) were estimated and applied to the burden of diabetes estimates from the Swedish burden of disease database for men and women in the separate age groups (30-44, 45-59, 60-69, 70-79, and 80+ years).RESULTS: The PAF estimates showed that 17.2% of the diabetes burden in men and 20.1% of the burden in women were attributed to lower educational levels in Sweden when combining all age groups. The burden was, however, most pronounced in the older age groups (70-79 and 80+), where lower educational levels contributed to 22.5% to 24.5% of the diabetes burden in men and 27.8% to 32.6% in women.CONCLUSIONS: There is a considerable burden of type 2 diabetes attributed to lower educational levels in Sweden, and socioeconomic indicators should be considered to be incorporated in the CRA.
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6.
  • Agardh, Emilie E, et al. (author)
  • Explanations of socioeconomic differences in excess risk of type 2 diabetes in Swedish men and women.
  • 2004
  • In: Diabetes Care. - : American Diabetes Association. - 0149-5992 .- 1935-5548. ; 27:3, s. 716-21
  • Journal article (peer-reviewed)abstract
    • OBJECTIVE: We investigated to what extent socioeconomic differences in type 2 diabetes risk could be explained by established risk factors (obesity, physical inactivity, smoking, and heredity) and psychosocial factors (low decision latitude at work and low sense of coherence). RESEARCH DESIGN AND METHODS: This cross-sectional study comprised 3,128 healthy Swedish men and 4,821 women, aged 35-56 years, living in the Stockholm area. An oral glucose tolerance test identified 55 men and 52 women with type 2 diabetes. The relative contribution of established and psychosocial factors to socioeconomic differences in diabetes risk was assessed by comparing analyses with adjustment for different sets of these factors. RESULTS: The relative risks (RRs) for type 2 diabetes in middle and low socioeconomic groups in men were 2.4 (95% CI 1.0-5.3) and 2.9 (1.5-5.7), respectively, and in women 3.2 (1.5-6.6) and 2.7 (1.3-5.9), respectively. In men, the RRs decreased to 1.9 (0.8-4.4) and 2.1 (1.0-4.2) after adjustment for established risk factors; no further change was found when psychosocial factors were included. In women, the RRs changed to 2.4 (1.1-5.2) and 1.6 (0.7-3.8) by including established risk factors and to 2.3 (1.0-5.1) and 1.9 (0.8-4.3) by inclusion of psychosocial factors. After adjustment for both established and psychosocial factors, the RRs were 1.4 (0.6-3.6) and 1.0 (0.4-2.5), respectively. CONCLUSIONS: In men, the excess risk of type 2 diabetes was partly explained by established risk factors (36-42%), whereas psychosocial factors had no effect. In women, most of the socioeconomic differences in type 2 diabetes were explained by simultaneous adjustment for established risk factors and psychosocial factors (81-100%).
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7.
  • Agardh, Emilie E, et al. (author)
  • Work stress and low sense of coherence is associated with type 2 diabetes in middle-aged Swedish women.
  • 2003
  • In: Diabetes Care. - : American Diabetes Association. - 0149-5992 .- 1935-5548. ; 26:3, s. 719-24
  • Journal article (peer-reviewed)abstract
    • OBJECTIVE: The risk of type 2 diabetes is suggested to be increased for individuals exposed to stress. We analyzed the association of work stress by high demands, low decision latitude, and job strain (combination of high demands and low decision latitude) with type 2 diabetes. We also studied low sense of coherence (SOC) (a factor for successful coping with stressors) in association with type 2 diabetes. Finally, we investigated the combination of SOC and demands or SOC and decision latitude in association with the disease. RESEARCH DESIGN AND METHODS: This cross-sectional study recruited 4821 healthy Swedish women (aged 35-56 years) residing in five municipalities in the Stockholm area. An oral glucose tolerance test identified 52 women with type 2 diabetes. Relative risks (RRs) with 95% CIs were estimated in a logistic multiple regression analysis. RESULTS: No association was found between high demands and type 2 diabetes (RR 1.1 [CI 0.5-2.2]). Low decision latitude was associated with type 2 diabetes with a RR of 2.2 (1.0-4.8). The RR of type 2 diabetes with low SOC was 3.7 (1.2-11.2). The combination of low SOC and low decision latitude was associated with type 2 diabetes with a RR of 2.6 (1.2-5.7). Homeostasis model assessment revealed an association of 4.2 (1.2-15.0) between low SOC and insulin resistance. CONCLUSIONS: This study provided new evidence that stress factors such as low decision latitude at work and low SOC were associated with type 2 diabetes in middle-aged Swedish women.
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8.
  • Agardh, Emilie, et al. (author)
  • Type 2 diabetes incidence and socio-economic position : a systematic review and meta-analysis
  • 2011
  • In: International Journal of Epidemiology. - : Oxford University Press (OUP). - 0300-5771 .- 1464-3685. ; 40:3, s. 804-818
  • Research review (peer-reviewed)abstract
    • Background We conducted a systematic review and meta-analysis, the first to our knowledge, summarizing and quantifying the published evidence on associations between type 2 diabetes incidence and socio-economic position (SEP) (measured by educational level, occupation and income) worldwide and when sub-divided into high-, middle- and low-income countries. Methods Relevant case-control and cohort studies published between 1966 and January 2010 were searched in PubMed and EMBASE using the keywords: diabetes vs educational level, occupation or income. All identified citations were screened by one author, and two authors independently evaluated and extracted data from relevant publications. Risk estimates from individual studies were pooled using random-effects models quantifying the associations. Results Out of 5120 citations, 23 studies, including 41 measures of association, were found to be relevant. Compared with high educational level, occupation and income, low levels of these determinants were associated with an overall increased risk of type 2 diabetes; [relative risk (RR) = 1.41, 95% confidence interval (CI): 1.28-1.51], (RR = 1.31, 95% CI: 1.09-1.57) and (RR = 1.40, 95% CI: 1.04-1.88), respectively. The increased risks were independent of the income levels of countries, although based on limited data in middle- and low-income countries. Conclusions The risk of getting type 2 diabetes was associated with low SEP in high-, middle- and low-income countries and overall. The strength of the associations was consistent in high-income countries, whereas there is a strong need for further investigation in middle- and low-income countries.
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10.
  • Ahlbom, Anders, et al. (author)
  • Occupational magnetic field exposure and myocardial infarction incidence.
  • 2004
  • In: Epidemiology. - : Ovid Technologies (Wolters Kluwer Health). - 1044-3983 .- 1531-5487. ; 15:4, s. 403-8
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: Studies on healthy volunteers have seen reduced heart rate variability after exposure to extremely low-frequency electric and magnetic fields (EMF). Because reduced heart rate variability has been linked to cardiovascular disease risk, it has been hypothesized that exposure to EMF might increase the risk of cardiovascular disease. One epidemiologic study has shown increased mortality from cardiovascular conditions in utility workers with elevated exposure to magnetic fields, but several other epidemiologic studies have failed to confirm this result. We tested the hypothesis that occupational EMF exposure increases the risk of myocardial infarction in a large population-based case-control study of myocardial infarction, with detailed information on potential confounders. METHODS: We used data from the SHEEP study, which is a population-based case-control study of acute myocardial infarction in Stockholm. Occupational EMF exposure was based on job titles 1, 5, and 10 years before diagnosis. We used 2 approaches to classify exposure: first, specific individual job titles with presumed elevated EMF exposure, and second, classification of subjects according to a job-exposure matrix. RESULTS: We found no increased risk of myocardial infarction in subjects classified as having elevated EMF exposure. For the highest exposure category of > or = 0.3 microT according to the job-exposure matrix, the adjusted relative risk was = 0.57 (95% confidence interval = 0.36-0.89). CONCLUSIONS: The results of this study do not support the hypothesis that occupational EMF exposure increases the risk of myocardial infarction.
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12.
  • Andersson, Sven-Olof, et al. (author)
  • Adverse Childhood Experiences are associated with choice of partner, both partners' relationship and psychosocial health as reported one year after birth of a common child : A cross-sectional study
  • 2021
  • In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 16:1
  • Journal article (peer-reviewed)abstract
    • Adverse Childhood Experiences (ACEs) are common and known to have consequences for individuals' adult health, leading to a higher risk of illness. The aims of the study were to investigate the ACEs in couples, to examine the extent of assortative mating and to investigate the association between the relationship of the load of ACEs within couples and health outcomes, one year after the birth of a common child. At antenatal clinics in Sweden 818 couples were recruited and investigated one year after the birth of a common child answering a questionnaire including the exposure to ten ACE categories and several outcome variables. In total, 59% of both mothers and partners reported exposure to at least one of the ten ACE categories. Among the mothers 11% and among the partners 9% reported exposure to ≥4 ACE categories (p = 0.12). There was a correlation between the numbers of ACE categories reported by the mothers and their partners (Spearman's ρ = 0.18, p<0.001). This association pertained to six of the ten ACE categories. In multiple logistic regression analyses, there were associations between the ACE exposure load and unfavourable outcomes among the mothers, the partners and within the couples. Unfavourable outcomes concerning health were most prominent in couples where both members reported exposures to ≥4 ACE categories (self-rated bad health (OR 13.82; CI 2.75-69.49), anxiety (OR 91.97; CI 13.38-632.07), depression (OR 17.42; CI 2.14-141.78) and perceived stress (OR 11.04; CI 2.79-43.73)). Mothers exposed to ACEs tend to have partners also exposed to ACEs. Exposure to ACEs was associated with bad health and unfavourable life conditions within the couples, especially among couples where both members reported exposure to multiple ACEs. These results should stimulate incentives to find, to support and to treat individuals and couples where both members report multiple ACEs. The consequences for the children should be further studied as well as how these families should be treated in health care and society.
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13.
  • Bean, Christopher G., 1990-, et al. (author)
  • Group activity participation at age 21 and depressive symptoms during boom and recession in Sweden : a 20-year follow-up
  • 2019
  • In: European Journal of Public Health. - : Oxford University Press (OUP). - 1101-1262 .- 1464-360X. ; 29:3, s. 475-481
  • Journal article (peer-reviewed)abstract
    • Background: Organized group activities (e.g. sports or arts clubs) have long been noted as important developmental settings for youth, yet previous studies on the relationships between participation and mental health outcomes have focused on short-term effects among school-aged adolescents. The subsequent period of life, emerging adulthood, has been largely overlooked despite being another important life stage where individuals face new existential challenges and may benefit from group activity participation. The potential for macroeconomic conditions to modify these relationships has also not been considered. Methods: Participants (n = 1654) comprise two cohorts, born in either 1965 (n = 968) or 1973 (n = 686), from the same middle-sized industrial town in Northern Sweden. Both cohorts completed detailed questionnaires at age 21 (macroeconomic boom for Cohort 65, recession for Cohort 73) and approximately 20 years follow-up (age 43 for Cohort 65, age 39 for Cohort 73). General linear models were used to assess concurrent and prospective associations between regular group activity participation and depressive symptoms, as well as the potential interaction with boom/recession. Results: After controlling for sociodemographic factors, regular group activity participation at age 21 was associated with lower depressive symptoms, both concurrently and at follow-up. Those exposed to recession at age 21 reported higher depressive symptoms at the time but there was no interaction between cohort (boom/recession) and group activity participation. Conclusions: Regular group activity participation during emerging adulthood is associated with lower depressive symptoms uniformly in times of boom and recession. Beneficial effects of such participation may contribute to better mental health over 20 years.
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14.
  • Bean, Christopher, 1990-, et al. (author)
  • Poor peer relations in adolescence, social support in early adulthood, and depressive symptoms in later adulthood : evaluating mediation and interaction using four-way decomposition analysis
  • 2019
  • In: Annals of Epidemiology. - : Elsevier BV. - 1047-2797 .- 1873-2585. ; 29, s. 52-59
  • Journal article (peer-reviewed)abstract
    • Purpose: Supportive social relations are associated with good mental health, yet few studies have considered the prospective importance of adolescent peer relations for adult mental health and the potential mechanisms involved.Methods: Participants (n=941) were sourced from the Northern Swedish Cohort, a prospective study comprising school students aged 16 in 1981. Integrating life course epidemiology with four-way decomposition analysis, this paper considers the controlled direct effect of poor peer relations at age 16 on depressive symptoms at age 43, the pure indirect effect mediated by the availability of social support at age 30, and potential interactions between the exposure and the mediator.Results: After controlling for gender, baseline depressive symptoms and parental socioeconomic position, poor peer relations at age 16 were associated with depressive symptoms at age 43, largely irrespective of social support at age 30. Nonetheless, poor peer relations in adolescence were associated with poorer social support at age 30, and mediation accounted for a modest proportion (pure indirect effect 10%) of the association between poor peer relations and depressive symptoms at age 43.Conclusions: Policies to foster constructive peer relations for adolescents at school are encouraged; such policies may promote both the availability of social support and better mental health across the life course.
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16.
  • Bennet, Anna M, et al. (author)
  • The risk of myocardial infarction is enhanced by a synergistic interaction between serum insulin and smoking.
  • 2002
  • In: European Journal of Endocrinology. - : Oxford University Press (OUP). - 0804-4643 .- 1479-683X. ; 147:5, s. 641-7
  • Journal article (peer-reviewed)abstract
    • OBJECTIVES: To evaluate the relationship between levels of serum insulin, the homeostasis model assessment (HOMA) and IGF-binding protein-1 (IGFBP-1) as factors related to myocardial infarction (MI) risk, and their interaction with lifestyle-related risk factors. DESIGN: The Stockholm epidemiology programme (SHEEP), a case-control study, consisting of 749 first-time MI cases (510 men, 239 women) and 1101 healthy controls (705 men, 396 women) was used. METHODS: The risk of developing MI was assessed by calculating odds ratios (OR) and synergistic interactions (SI) between serum insulin, IGFBP-1, HOMA and other variables related to MI risk (including smoking) in men and women. RESULTS: Subjects with elevated levels of insulin and HOMA (>75th percentile) had increased MI risks when compared with individuals with low levels. ORs for elevated insulin and HOMA (adjusted for age and residential area) for men: insulin 1.6 (95% confidence interval (CI) 1.3-2.1) and HOMA 1.5 (95% CI 1.1-1.9) and for women: insulin 2.1 (95% CI 1.5-2.9) and HOMA 1.9 (95% CI 1.3-2.8). Women with low levels of IGFBP-1 (<10th percentile) showed a tendency towards elevated MI risk even if this was not statistically significant (OR 1.5 (95% CI 0.9-2.6)). Smokers with high levels of serum insulin had greatly increased MI risk (OR for men: 4.7 (95% CI 3.0-7.2) and OR for women: 8.1 (95% CI 4.5-14.8)). SI scores based upon these interactions were statistically significant. CONCLUSIONS: These results might have preventive cardiovascular implications as they clearly suggest that subjects with insulin resistance are particularly susceptible to the hazards of smoking.
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17.
  • Berglind, Niklas, et al. (author)
  • Air Pollution Exposure : A Trigger for Myocardial Infarction?
  • 2010
  • In: International Journal of Environmental Research and Public Health. - : MDPI AG. - 1661-7827 .- 1660-4601. ; 7:4, s. 1486-1499
  • Journal article (peer-reviewed)abstract
    • The association between ambient air pollution exposure and hospitalization for cardiovascular events has been reported in several studies with conflicting results. A case-crossover design was used to investigate the effects of air pollution in 660 first-time myocardial infarction cases in Stockholm in 1993-1994, interviewed shortly after diagnosis using a standard protocol. Air pollution data came from central urban background monitors. No associations were observed between the risk for onset of myocardial infarction and two-hour or 24-hour air pollution exposure. No evidence of susceptible subgroups was found. This study provides no support that moderately elevated air pollution levels trigger first-time myocardial infarction.
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18.
  • Bigert, Carolina, et al. (author)
  • Myocardial infarction among professional drivers.
  • 2003
  • In: Epidemiology. - 1044-3983 .- 1531-5487. ; 14:3, s. 333-9
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: Professional drivers are at an increased risk of myocardial infarction but the underlying causes for this increased risk are uncertain. METHODS: We identified all first events of myocardial infarction among men age 45-70 years in Stockholm County for 1992 and 1993. We selected controls randomly from the population. Response rates of 72% and 71% resulted in 1067 cases and 1482 controls, respectively. We obtained exposure information from questionnaires. We calculated odds ratios (ORs), with and without adjustment for socioeconomic status, tobacco smoking, alcohol drinking, physical inactivity at leisure time, overweight status, diabetes and hypertension. RESULTS: The crude OR among bus drivers was 2.14 (95% confidence interval = 1.34-3.41), among taxi drivers 1.88 (1.19-2.98) and among truck drivers 1.66 (1.22-2.26). Adjustment for potential confounders gave lower ORs: 1.49 (0.90-2.45), 1.34 (0.82-2.19) and 1.10 (0.79-1.53), respectively. Additional adjustment for job strain lowered the ORs only slightly. An exposure-response pattern (by duration of work) was found for bus and taxi drivers. CONCLUSIONS: The high risk among bus and taxi drivers was partly explained by unfavorable life-style factors and social factors. The work environment may contribute to their increased risk. Among truck drivers, individual risk factors seemed to explain most of the elevated risk.
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19.
  • Bigert, C, et al. (author)
  • Time trends in the incidence of myocardial infarction among professional drivers in Stockholm 1977-96.
  • 2004
  • In: Occupational and Environmental Medicine. - : BMJ. - 1351-0711 .- 1470-7926. ; 61:12, s. 987-91
  • Journal article (peer-reviewed)abstract
    • AIMS: To investigate time trends in the incidence of first myocardial infarction (MI) among bus, taxi, and lorry drivers in Stockholm. METHODS: In this population based case-control study, all first events of acute MI among men aged 40-69 in Stockholm County 1977-96 were identified using registers of hospital discharges and deaths. Controls were selected randomly from the general population. National censuses were used for information on occupational titles. A total of 20,364 cases and 136,342 controls were included in the study. Among these, 1183 cases and 6072 controls had worked as drivers. RESULTS: During 1977-84 the MI incidence was higher in all three driver groups than among other manual workers. There was a decline in MI incidence among drivers as well as in the general population during the study period. The decline was greater among drivers than among other manual workers. During 1985-96 the relative risk remained increased compared to other manual workers among taxi and lorry drivers, but not among bus drivers. CONCLUSIONS: Despite a reduced MI incidence for professional drivers in recent years, preventive measures to reduce the risk of MI in these occupational groups, and in particular among taxi and lorry drivers, continue to be of importance.
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20.
  • Björkenstam, C., et al. (author)
  • School grades, parental education and suicide : a national register-based cohort study
  • 2010
  • In: Journal of Epidemiology and Community Health. - : BMJ. - 0143-005X .- 1470-2738.
  • Journal article (peer-reviewed)abstract
    • Background To investigate whether school performance is a risk factor for suicide death later in life and, if so, to what extent this is explained by intergenerational effects of parental education. Methods This population-based cohort study comprises national birth cohorts between 1972 and 1981 in Sweden. We followed 898 342 students, graduating between 1988 and 1997 from the 9 years of compulsory school, equivalent to junior high school, until 31 December 2006, generating 11 148 758 person-years and 1490 suicides. Final school grades, in six categories, and risk of suicide were analysed with Poisson regression. Results The incidence rate ratio (RR) for suicide death for students with the lowest grades was 4.57 (95% CI 2.82 to 7.40) for men and 2.67 (1.42 to 5.01) for women compared to those with highest grades after adjustment for a number of sociodemographic and parental morbidity variables, such as year of graduation, parental education, lone parenthood, household receiving social welfare or disability pension, place of schooling, adoption, maternal age and parent's mental illness. Students with grades in the middle categories had RRs in between. These relationships were not modified by parental education. Conclusions The strong association between low school grades and suicide in youth and young adulthood emphasises the importance of both primary and secondary prevention in schools.
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21.
  • Björkenstam, Emma, et al. (author)
  • Juvenile delinquency, social background and suicide-a Swedish national cohort study of 992 881 young adults
  • 2011
  • In: International Journal of Epidemiology. - : Oxford University Press (OUP). - 0300-5771 .- 1464-3685. ; 40:6, s. 1585-1592
  • Journal article (peer-reviewed)abstract
    • Background As the suicide rates in young adults do not show a clear decline, it is important to elucidate possible risk factors. Juvenile delinquency has been pointed out as a possible risk behaviour. Methods This register-based cohort study comprises the birth cohorts between 1972 and 1981 in Sweden. We followed 992 881 individuals from the age of 20 years until 31 December 2006, generating 10 210 566 person-years and 1482 suicides. Juvenile delinquency was defined as being convicted of a crime between the ages of 15 and 19 years. Estimates of risk of suicide were calculated as incidence rate ratio (IRR) with 95% confidence intervals (CIs) using Poisson regression analysis with adjustment for potential confounding by their own and their parents' mental illness or substance abuse, parental education, single parenthood, social assistance, adoption and foster care. Results Among females, 5.9%, and among males, 17.9%, had at least one conviction between the ages 15 and 19 years. In the fully adjusted model, females with one conviction had a suicide risk of 1.7 times higher (95% CI 1.2-2.4), the corresponding IRR for men was 2.0 (95% CI 1.7-2.4) and 5.7 (95% CI 2.5-13.1) and 6.6 (95% CI 5.2-8.3), for women and men with five or more convictions. The effect of severe delinquency on suicide was independent of parental educational level. Conclusions This study supports the hypothesis that individuals with delinquent behaviour in late adolescence have an increased risk of suicide as young adults. Regardless of causality issues, repeated juvenile offenders should be regarded by professionals in health, social and correctional services who come into contact with this group as a high-risk group for suicide.
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22.
  • Björkenstam, Emma, et al. (author)
  • Quality of medical care and excess mortality in psychiatric patients : a nationwide register-based study in Sweden
  • 2012
  • In: BMJ Open. - : BMJ. - 2044-6055. ; 2:1, s. e000778-
  • Journal article (peer-reviewed)abstract
    • OBJECTIVE: To assess overall and cause-specific mortality and the quality of somatic care among psychiatric patients.DESIGN: A register-based cohort study.SETTING: All individuals aged 20-79 years in Sweden in 2005.PARTICIPANTS: In total 6 294 339 individuals.PRIMARY OUTCOME MEASURE: The individuals were followed for mortality in 2006 and 2007, generating 72 187 deaths. Psychiatric patients were grouped according to their diagnosis in the National Patient Register. Mortality risk of psychiatric patients was compared with that of non-psychiatric patients. Estimates of RR of mortality were calculated as incidence rate ratios (IRRs) with 95% CIs using Poisson regression analysis. Psychiatric patients were compared with non-psychiatric patients for three healthcare quality indicators: the proportion of avoidable hospitalisations, case death rate after myocardial infarction and statin use among diabetic patients.RESULTS: Compared with individuals with no episodes of treatment for mental disorder, psychiatric patients had a substantially increased risk of all studied causes of death as well as death from conditions considered amenable to intervention by the health service, that is, avoidable mortality. The highest mortality was found among those with another mental disorder, predominantly substance abuse (for women, an IRR of 4.7 (95% CI 4.3 to 5.0) and for men, an IRR of 4.8 (95% CI 4.6 to 5.0)). The analysis of quality of somatic care revealed lower levels of healthcare quality for psychiatric patients, signalling failures in public health and medical care.CONCLUSION: This study shows a marked increase in excess mortality, suggesting a lower quality of somatic healthcare in psychiatric patients.
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23.
  • Bohman, Tony, et al. (author)
  • Healthy lifestyle behaviour and risk of long-duration troublesome neck pain among men and women with occasional neck pain : results from the Stockholm public health cohort
  • 2019
  • In: BMJ Open. - : BMJ. - 2044-6055. ; 9:11
  • Journal article (peer-reviewed)abstract
    • OBJECTIVES: The effect of a healthy lifestyle on the prognosis of neck pain is unknown. This study aimed to investigate if a healthy lifestyle behaviour influences the risk of long-duration troublesome neck pain among men and women with occasional neck pain.DESIGN: Longitudinal cohort study.SETTINGS: General population, and a subsample of the working population, in Stockholm County, Sweden.PARTICIPANTS: This study involved 5342 men and 7298 women, age 18 to 84, from the Stockholm Public Health Cohort, reporting occasional neck pain at baseline in 2006.MEASURES: Baseline information about leisure physical activity, smoking, alcohol consumption and consumption of fruits and vegetables were dichotomised into recommendations for healthy/not healthy behaviour. The exposure, a healthy lifestyle behaviour, was categorised into four levels according to the number of healthy behaviours (HB) met. Generalised linear models were applied to assess the exposure on the outcome long-duration troublesome neck pain (activity-limiting neck pain ≥2 days/week during the past 6 months), at follow-up in 2010.RESULTS: The adjusted risk of long-duration troublesome neck pain decreased with increasing adherence to a healthy lifestyle behaviour among both men and women (trend test: p<0.05). Compared with the reference category, none or one HB, the risk decreased by 24% (risk ratio 0.76, 95% CI 0.58 to 0.98) among men and by 34% (0.66, 0.54 to 0.81) among women, with three or four HBs. The same comparison showed an absolute reduction of the outcome by 3% in men (risk difference -0.03, 95% CI -0.05 to -0.01) and 5% in women (-0.05,-0.08 to -0.03). Similar results were found in the working population subsample.CONCLUSION: Adhering to a healthy lifestyle behaviour decreased the risk of long-duration troublesome neck pain among men and women with occasional neck pain. The results add to previous research and supports the importance of promoting a healthy lifestyle behaviour.
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24.
  • Bohman, Tony, et al. (author)
  • Influence of work ability and smoking on the prognosis of long-duration activity-limiting neck/back pain : A cohort study of a Swedish working population
  • 2022
  • In: BMJ Open. - : BMJ. - 2044-6055. ; 12:4
  • Journal article (peer-reviewed)abstract
    • OBJECTIVES: Long-duration activity-limiting neck/back pain is common, but the knowledge of what work and lifestyle factors that influence the prognosis is sparse. The objective was therefore to evaluate if two factors, good self-perceived work ability and no daily smoking, are associated with a favourable prognosis of long-duration activity-limiting neck/back pain in a working population, and if these exposures have a synergistic prognostic effect.DESIGN: A prospective cohort study based on three subsamples from the Stockholm Public Health Cohort.SETTINGS: A working population in Stockholm County, Sweden.PARTICIPANTS: Individuals, 18-61 years old, reporting long-duration activity-limiting neck/back pain the previous 6 months at baseline in 2010 (n=5177).MEASURES: The exposures were: self-perceived work ability (categorised into good, moderate and poor) and daily smoking (no/yes). The outcome in 2014 was 'absence of long-duration activity-limiting neck/back pain' the previous 6 months representing a favourable prognosis of reported problems at baseline in 2010. Risk ratios (RRs) and risk differences (RDs) with 95% CI was estimated by general linear regressions, and the synergistic effect was estimated by the synergy index (SI) with 95% CI.RESULTS: Participants with moderate or good work ability, respectively, had an adjusted RR for a favourable prognosis of 1.37 (95% CI 1.11 to 1.69), and 1.80 (1.49 to 2.17) in comparison with participants with poor work ability. The corresponding adjusted RD were 0.07 (0.02 to 0.11) and 0.17 (0.12 to 0.22). Participants not smoking on daily basis had an adjusted RR of 1.21 (1.02 to 1.42), and an adjusted RD of 0.05 (0.01 to 0.10) for a favourable outcome compared with daily smokers. The adjusted SI was 0.92 (0.60 to 1.43).CONCLUSION: For participants with long-duration activity-limiting neck/back pain, moderate or good self-perceived work ability and not being a daily smoker were associated with a favourable prognosis but having both exposures seemed to have no synergistic prognostic effect.
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25.
  • Boström, G, et al. (author)
  • Socioeconomic differences in smoking in an urban Swedish population. The bias introduced by non-participation in a mailed questionnaire.
  • 1993
  • In: Scandinavian journal of social medicine. - 0300-8037. ; 21:2, s. 77-82
  • Journal article (peer-reviewed)abstract
    • Stockholm Health of the Population Study is a cross-sectional study carried out from 1984-85. Postal questionnaires, telephone interviews and health interviews were used to get information from a sample of 5,199 persons, 18-64 years of age, on health status, risk exposures, healthcare consumption and social factors. Non-participation with respect to the postal questionnaire was 36.8%. With subsequent telephone interviews and an invitation to a health interview, non-participation was reduced to 17.8%. The estimated prevalence of daily smoking increased from 36.1% to 38.7. The non-responders had a higher prevalence of daily smoking in all sub-groups. This effect of the efforts to reduce non-participation differed socially. The prevalence of smoking for men, 40-64 years of age, who were reached by telephone was 60.3%. Male professionals and intermediate non-manual workers, 40-64 years of age reached by telephone had a prevalence of smoking, which was twice as high as for the responders of the questionnaire (62.5 and 26.8%, respectively). In the younger age-group, non-responders had the same socioeconomic pattern in smoking as the responders. Independent of socioeconomic group, there was a tendency of ill or disabled smokers to respond more quickly than healthy smokers. Using a postal questionnaire with a high non-response rate might lead to an overestimation of socioeconomic differences and an underestimation of smoking prevalence.
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26.
  • Carlsson, Lars, et al. (author)
  • Motivation for return to work and actual return to work among people on long-term sick leave due to pain syndrome or mental health conditions
  • 2019
  • In: Disability and Rehabilitation. - : Informa UK Limited. - 0963-8288 .- 1464-5165. ; 41:25, s. 3061-3070
  • Journal article (peer-reviewed)abstract
    • Purpose: The purpose of this study was to investigate associations between motivation for return to work and actual return to work, or increased employability among people on long-term sick leave.Materials and methods: Data by responses to questionnaires was collected from 227 people on long-term sick leave (mean = 7.9 years) due to pain syndrome or mild to moderate mental health conditions who had participated in a vocational rehabilitation intervention. The participants’ motivation for return to work was measured at baseline. At 12-month follow-up, change in the type of reimbursement between baseline and at present was assessed and used to categorise outcomes as: “decreased work and employability”, “unchanged”, “increased employability”, and “increased work”. Associations between baseline motivation and return to work outcome were analysed using logistic and multinomial regression models.Results: Motivation for return to work at baseline was associated with return to work or increased employability at 12-month follow-up in the logistic regression model adjusting for potential confounders (OR 2.44, 95% CI 1.25–4.78).Conclusions: The results suggest that motivation for return to work at baseline was associated with actual chances of return to work or increased employability in people on long-term sick leave due to pain syndrome or mild to moderate mental health conditions.Implication for rehabilitationHigh motivation for return to work seems to increase the chances of actual return to work or increased employability in people on sick leave due to pain syndrome or mild to moderate mental health conditions.The potential impact of motivation for return to work is suggested to be highlighted in vocational rehabilitation.Rehabilitation professionals are recommended to recognise and take into consideration the patient’s stated motivation for return to work.Rehabilitation professionals should be aware of that the patient’s motivation for return to work might have an impact on the outcome of vocational rehabilitation.
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27.
  • Diderichsen, Finn, et al. (author)
  • Differential vulnerability and susceptibility : how to make use of recent development in our understanding of mediation and interaction to tackle health inequalities
  • 2019
  • In: International Journal of Epidemiology. - : Oxford University Press (OUP). - 0300-5771 .- 1464-3685. ; 48:1, s. 268-274
  • Journal article (peer-reviewed)abstract
    • This paper discusses the concepts of vulnerability and susceptibility and their relevance for understanding and tackling health inequalities. Tackling socioeconomic inequalities in health is based on an understanding of how an individual's social position influences disease risk. Conceptually, there are two possible mechanisms (not mutually exclusive): there is either some cause(s) of disease that are unevenly distributed across socioeconomic groups (differential exposure) or the effect of some cause(s) of disease differs across groups (differential effect). Since differential vulnerability and susceptibility are often used to denote the latter, we discuss these concepts and their current use and suggest an epidemiologically relevant distinction. The effect of social position can thus be mediated by causes that are unevenly distributed across social groups and/or interact with social position. Recent improvements in the methodology to estimate mediation and interaction have made it possible to calculate measures of relevance for setting targets and priorities in policy for health equity which include both mechanisms, i.e. equalize exposure or equalize effects. We finally discuss the importance of differential susceptibility and vulnerability for the choice of preventive strategies, including approaches that target high-risk individuals, whole populations and vulnerable groups.
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28.
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29.
  • Diderichsen, F, et al. (author)
  • Trends in occupational mortality among middle-aged men in Sweden 1961-1990.
  • 1997
  • In: International Journal of Epidemiology. - : Oxford University Press (OUP). - 0300-5771 .- 1464-3685. ; 26:4, s. 782-7
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: Many European countries have in recent decades reported growing socioeconomic differentials in mortality. While these trends have usually paralleled high unemployment and increasing income disparities, Sweden had low unemployment and narrowing income differences. This study describes trends, 1961-1990, in total and cardiovascular mortality among men, 45-69 years of age, in major occupational classes in Sweden. METHODS: From census data four cohorts were created from those enumerated in 1960, 1970, 1980 and 1985. Through record linkage with the Swedish cause of death registry the mortality in each cohort was followed for 5-10 years. Age-standardized mortality trends 1961-1990 were calculated for occupational groups, categorized according to sector of the economy. RESULTS: The increase in mortality among middle-aged men in Sweden 1965-1980 was mainly a result of increasing cardiovascular mortality among industrial workers and farmers. In the 1980s the trend for these groups changed into a last decrease in mortality similar to that for non-manual occupations for the whole period. Consequently the rate ratio for industrial workers in comparison with men having a professional/managerial type of occupation increased from 0.98 to 1.43. The slowest decrease is now found among unqualified occupations in services and transportation. CONCLUSIONS: While Sweden, during the period studied, had narrowing income differentials and low unemployment this result points to the importance of working conditions in understanding trends and distribution of male adult mortality.
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30.
  • Drevin, Jennifer, et al. (author)
  • Childhood abuse and unplanned pregnancies : a cross-sectional study of women in the Norwegian Mother and Child Cohort Study
  • 2020
  • In: British Journal of Obstetrics and Gynecology. - : Wiley. - 1470-0328 .- 1471-0528. ; 127:4, s. 438-446
  • Journal article (peer-reviewed)abstract
    • Objective To study if childhood emotional, physical and sexual abuse are determinants for having an unplanned pregnancy, if the categories of abuse interact, and if a potential bias due to the selection of the participants (collider stratification bias) could explain the effect of childhood abuse.Design A cross-sectional study.Setting The study is based on the Norwegian Mother and Child Cohort Study (MoBa) and uses data from the Medical Birth Registry of Norway.Sample Women participating in the MoBa for the first time, >= 18 years of age who responded to questions regarding childhood abuse and pregnancy planning (n = 76 197).Methods Data were collected using questionnaires. We conducted analyses using modified Poisson regressions and the relative excess risks due to interaction (RERI). Sensitivity analyses were performed.Main outcome measure An unplanned pregnancy (yes/no).Results Exposure to childhood emotional (adjusted relative risk (RR) 1.14, 95% CI 1.10-1.19), physical (adjusted RR 1.11, 95% CI 1.04-1.18) and sexual (adjusted RR 1.20, 95% CI 1.14-1.27) abuse increased the risk of having an unplanned pregnancy. The effects could not be explained by the collider stratification bias. The different combinations of categories of abuse did not show any interaction effects.Conclusions Childhood emotional, physical and sexual abuses separately increase the risk of having an unplanned pregnancy. The results indicate that victims of childhood abuse are in greater need of support to achieve their reproductive goals. Tweetable abstract Childhood abuse increases the risk of having an unplanned pregnancy. #reproductivehealth #epitwitter.
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31.
  • Engström, Karin, et al. (author)
  • Contextual social capital as a risk factor for poor self-rated health : a multilevel analysis
  • 2008
  • In: Social Science and Medicine. - : Elsevier BV. - 0277-9536 .- 1873-5347. ; 66:11, s. 2268-2280
  • Journal article (peer-reviewed)abstract
    • In this study, we critically examine whether contextual social capital (CSC) is associated with self-rated health, with an emphasis on the problem of confounding. We also examine different components of CSC and their association with self-rated health. Finally, we look at differences in susceptibility between different socio-demographic groups. We use the cross-sectional base line study of the Stockholm Public Health Cohort, conducted in 2002. A postal questionnaire was answered by 31,182 randomly selected citizens, 18-84 years old, in Stockholm County. We used four measures of social capital: horizontal (civic trust and participation), vertical (political trust and participation), cognitive (civic and political trust) and structural (civic and political participation). CSC was measured at parish level from aggregated individual data, and multilevel regression procedures were employed. We show a twofold greater risk of poor self-rated health in areas with very low CSC compared with areas with very high CSC. Adjustments for individual socio-demographic factors, contextual economic factors and individual social capital lowered the excess risk. Simultaneous adjustment for all three forms of confounding further weakened the association and rendered it insignificant. Cognitive and structural social capital show relatively similar associations with self-rated health, while horizontal CSC seems to be more strongly related to self-rated health than vertical CSC. In conclusion, whether there is none or a moderate association between CSC and self-rated health, depends on the extent to which individual social capital is seen as a mediator or confounder. The association with self-rated health is similar independent of the measure of CSC used. It is also similar in different socio-demographic groups.
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32.
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33.
  • Grann, Martin, et al. (author)
  • Methodological development : structured outcome assessment and community risk monitoring (SORM)
  • 2005
  • In: International Journal of Law and Psychiatry. - : Elsevier BV. - 0160-2527 .- 1873-6386. ; 28:4, s. 442-456
  • Journal article (peer-reviewed)abstract
    • This paper describes an effort to develop a clinical tool for the continuous monitoring of risk for violence in forensic mental health clients who have left their institutions and who are dwelling in the community on a conditional release basis. The model is called Structured Outcome Assessment and Community Risk Monitoring (SORM). The SORM consists of 30 dynamic factors and each factor in SORM is assessed in two ways: The current absence, presence or partial och intermittent presence of the factors, which is an actuarial (systematized and 'objective') assessment. Secondly, the risk effect, i.e. whether the presence/absence of factors currently increases, decreases or is perceived as unrelated to violence risk, is a clinical (or impressionistic) assessment. Thus, the factors considered via the SORM can be coded as risk factors or protective factors (or as factors unimportant to risk of violence) depending on circumstances that apply in the individual case. Further, the SORM has a built-in module for gathering idiographical information about risk-affecting contextual factors. The use of the SORM and its potential as a risk monitoring instrument is illustrated via preliminary data and case vignettes from an ongoing multicenter project. In this research project, patients leaving any of the 9 participating forensic hospitals in Sweden is assessed at release on a variety of static background factors, and the SORM is then administered every 30 days for 2 years.
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34.
  • Gray, Linsay, et al. (author)
  • International differences in self-reported health measures in 33 major metropolitan areas in Europe
  • 2012
  • In: European Journal of Public Health. - : Oxford University Press (OUP). - 1101-1262 .- 1464-360X. ; 22:1, s. 40-47
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: The increasing concentration of populations into large conurbations in recent decades has not been matched by international health assessments, which remain largely focused at the country level. We aimed to demonstrate the use of routine survey data to compare the health of large metropolitan centres across Europe and determine the extent to which differences are due to socio-economic factors.METHODS:Multilevel modelling of health survey data on 126 853 individuals from 33 metropolitan areas in the UK, Republic of Ireland, Sweden, Norway, Finland, Spain, Belgium and Germany compared general health, longstanding illness, acute sickness, psychological distress and obesity with the average for all areas, accounting for education and social class.RESULTS:We found some areas (Greater Glasgow; Greater Manchester, Cheshire and Merseyside; Northumberland, Tyne and Wear and South Yorkshire) had significantly higher levels of poor health. Other areas (West Flanders and Antwerp) had better than average health. Differences in individual socio-economic circumstances did not explain findings. With a few exceptions, acute sickness levels did not vary.CONCLUSION:Health tended to be worse in metropolitan areas in the north and west of the UK and the central belt and south east of Germany, and more favourable in Sweden and north west Belgium, even accounting for socio-economic composition of local populations. This study demonstrated that combining national health survey data covering different areas is viable but not without technical difficulties. Future comparisons between European regions should be made using standardized sampling, recruitment and data collection protocols, allowing proper monitoring of health inequalities.
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35.
  • Gustavsson, P, et al. (author)
  • A population-based case-referent study of myocardial infarction and occupational exposure to motor exhaust, other combustion products, organic solvents, lead, and dynamite. Stockholm Heart Epidemiology Program (SHEEP) Study Group.
  • 2001
  • In: Epidemiology. - : Ovid Technologies (Wolters Kluwer Health). - 1044-3983 .- 1531-5487. ; 12:2, s. 222-8
  • Journal article (peer-reviewed)abstract
    • This case-referent study investigated the risk of myocardial infarction from occupational exposure to motor exhaust, other combustion products, organic solvents, lead, and dynamite. We identified first-time, nonfatal myocardial infarctions among men and women 45-70 years of age in Stockholm County from 1992 through 1994. We selected referent subjects from the population to match the demographic characteristics of the cases. A lifetime history of occupations was obtained by questionnaire. The response rate was 81% for the cases and 74% for the referents, with 1,335 cases and 1,658 referents included in the study. An occupational hygienist assessed occupational exposures, coding the intensity and probability of exposure for each subject. We adjusted relative risk estimates for tobacco smoking, alcohol drinking, hypertension, diabetes mellitus, overweight, and physical inactivity at leisure time. The relative risk of myocardial infarction was 2.11 (95% confidence interval = 1.23-3.60) among those who were highly exposed and 1.42 (95% confidence interval = 1.05-1.92) among those who were intermediately exposed to combustion products from organic material. We observed an exposure-response pattern, in terms of both maximum exposure intensity and cumulative dose. Exposure to dynamite and organic solvents was possibly associated with an increased risk. The other exposures were not consistently associated with myocardial infarction.
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36.
  • Hallqvist, Johan, 1950-, et al. (author)
  • Can we disentangle life course processes of accumulation, critical period and social mobility? An analysis of disadvantaged socio-economic positions and myocardial infarction in the Stockholm Heart Epidemiology Program.
  • 2004
  • In: Social Science and Medicine. - 0277-9536 .- 1873-5347. ; 58:8, s. 1555-62
  • Journal article (peer-reviewed)abstract
    • The accumulation hypothesis would propose that the longer the duration of exposure to disadvantaged socio-economic position, the greater the risk of myocardial infarction. However there may be a danger of confounding between accumulation and possibly more complex combinations of critical periods of exposure and social mobility. The objective of this paper is to investigate the possibility of distinguishing between these alternatives. We used a population based case-control study (Stockholm Heart Epidemiology Programme) of all incident first events of myocardial infarction among men and women, living in the Stockholm region 1992-94. The analyses were restricted to men 53-70 years, 511 cases and 716 controls. From a full occupational history each subject was categorized as manual worker or non-manual at three stages of the life course, childhood (from parent's occupation), at the ages 25-29 and 51-55, resulting in 8 possible socio-economic trajectories. We found a graded response to the accumulation of disadvantaged socio-economic positions over the life course. However, we also found evidence for effects of critical periods and of social mobility. A conceptual analysis showed that there are, for theoretical reasons, only a limited number of trajectories available, too small to form distinct empirical categories of each hypothesis. The empirical task of disentangling the life course hypotheses of critical period, social mobility and accumulation is therefore comparable to the problem of separating age, period, and cohort effects. Accordingly, the interpretation must depend on prior knowledge of more specific causal mechanisms.
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37.
  • Hallqvist, Johan, 1950-, et al. (author)
  • Does heavy physical exertion trigger myocardial infarction? A case-crossover analysis nested in a population-based case-referent study.
  • 2000
  • In: American Journal of Epidemiology. - : Oxford University Press (OUP). - 0002-9262 .- 1476-6256. ; 151:5, s. 459-67
  • Journal article (peer-reviewed)abstract
    • To study possible triggering of first events of acute myocardial infarction by heavy physical exertion, the authors conducted a case-crossover analysis (1993-1994) within a population-based case-referent study in Stockholm County, Sweden (the Stockholm Heart Epidemiology Program). Interviews were carried out with 699 myocardial infarction patients after onset of the disease. These cases represented 47 percent of all cases in the study base, and 70 percent of all nonfatal cases. The relative risk from vigorous exertion was 6.1 (95% confidence interval: 4.2, 9.0). The rate difference was 1.5 per million person-hours, and the attributable proportion was 5.7 percent. The risk was modified by physical fitness, with an increased risk being seen among sedentary subjects as in earlier studies, but the data also suggested a U-shaped association. In addition, the trigger effect was modified by socioeconomic status. Premonitory symptoms were common, and this implies risks of reverse causation bias and misclassification of case exposure information that require methodological consideration. Different techniques (the use of the usual-frequency type of control information, a pair-matched analysis, and a standard case-referent analysis) were applied to overcome the threat of misclassification of control exposure information. A case-crossover analysis in a random sample of healthy subjects resulted in a relative risk close to unity, as expected.
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38.
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39.
  • Hallqvist, Johan, 1950-, et al. (author)
  • Is the effect of job strain on myocardial infarction risk due to interaction between high psychological demands and low decision latitude? Results from Stockholm Heart Epidemiology Program (SHEEP).
  • 1998
  • In: Social Science and Medicine. - : Elsevier BV. - 0277-9536 .- 1873-5347. ; 46:11, s. 1405-15
  • Journal article (peer-reviewed)abstract
    • The objectives are to examine if the excess risk of myocardial infarction from exposure to job strain is due to interaction between high demands and low control and to analyse what role such an interaction has regarding socioeconomic differences in risk of myocardial infarction. The material is a population-based case-referent study having incident first events of myocardial infarction as outcome (SHEEP: Stockholm Heart Epidemiology Program). The analysis is restricted to males 45-64 yr of age with a more detailed analysis confined to those still working at inclusion. In total, 1047 cases and 1450 referents were included in the analysis. Exposure categories of job strain were formed from self reported questionnaire information. The results show that high demands and low decision latitude interact with a synergy index of 7.5 (95% C.I.: 1.8-30.6) providing empirical support for the core mechanism of the job strain model. Manual workers are more susceptible when exposed to job strain and its components and this increased susceptibility explains about 25-50% of the relative excess risk among manual workers. Low decision latitude may also, as a causal link, explain about 30% of the socioeconomic difference in risk of myocardial infarction. The distinction between the interaction and the causal link mechanisms identifies new etiologic questions and intervention alternatives. The specific causes of the increased susceptibility among manual workers to job strain and its components seem to be an interesting and important research question.
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40.
  • Hallqvist, Johan, 1950-, et al. (author)
  • Socioeconomic differences in risk of myocardial infarction 1971-1994 in Sweden : time trends, relative risks and population attributable risks.
  • 1998
  • In: International Journal of Epidemiology. - : Oxford University Press (OUP). - 0300-5771 .- 1464-3685. ; 27:3, s. 410-5
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: The general trend in incidence of myocardial infarction (MI) in the Stockholm area changed from increasing to decreasing around 1980. The objective of this study is to examine time trends in incidence in major socioeconomic strata, relative risk between socioeconomic groups and population risk attributable to socioeconomic differences during this period. METHODS: All cases of MI from 1971 to 1986 were identified from hospital discharge and cause-of-death registers. Person-years for each year of follow-up were calculated from the population register in the Stockholm region 1971-1986. Census registers were used for information on socioeconomic status. Register information was individually linked through the Swedish personal identification number. Supplementary information for 1992-1994 was taken from the case-control study SHEEP (Stockholm Heart Epidemiology Program). RESULTS: The decline in MI risk among male high- and middle-level employees started in 1976 and in male manual workers in 1981. For women incidence increased from 1971 to 1986 among manual workers and decreased among high- and middle-level employees. The increase over time of the relative risk from low socioeconomic position continued into the 1990s. Despite the reduction of the category of manual workers, the population attributable risk from socioeconomic differences also increased over time. The process of social change influencing the size of the socioeconomic groups contributes to the change in time trends of MI morbidity. CONCLUSIONS: The increase over time of relative and population attributable risks of MI from low socioeconomic status add to the public health importance of social inequity.
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41.
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42.
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43.
  • Hansson, J, et al. (author)
  • Use of snus and risk for cardiovascular disease : results from the Swedish Twin Registry
  • 2009
  • In: Journal of Internal Medicine. - : Wiley. - 0954-6820 .- 1365-2796. ; 265:6, s. 717-724
  • Journal article (peer-reviewed)abstract
    • OBJECTIVETo study the association between snus use and the risk for cardiovascular disease, i.e. ischemic heart disease and stroke. DESIGNCohort study. SETTINGSweden. SUBJECTSSixteen thousand six hundred and forty-two male Swedish twins participating in the Screening Across the Lifespan Twin Study, conducted in 1998- 2002, were followed for incident cardiovascular disease. Participants were without a history of cardiovascular disease at baseline and incident cases were identified via the Swedish Cause of Death Register and Hospital Discharge Register.RESULTSOverall, there was no association between use of snus and risk for cardiovascular disease. Current snus users, without a smoking history, had a relative risk of 1.00 (95% confidence interval 0.69-1.46) for cardiovascular disease as compared to non users. Corresponding relative risks for ischemic heart disease and stroke were 0.85 (95% confidence interval 0.51-1.41) and 1.18 (95% confidence interval 0.67-2.08), respectively. In smoking adjusted models, risk estimates for ischemic heart disease in relation to snus use were all close to unity regardless of timing or intensity of snus use. However, current heavy snus users (consuming more than four cans week(-1)) had a relative risk for stroke of 1.75 (95% confidence interval 0.95-3.21). CONCLUSIONThese data do not support any strong association between snus use and risk for cardiovascular disease.
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44.
  • Hermansson, Jonas, et al. (author)
  • Interaction between Shift Work and Established Coronary Risk Factors
  • 2019
  • In: International Journal of Occupational and Environmental Medicine. - : IJOEM. - 2008-6520 .- 2008-6814. ; 10:2, s. 57-65
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: Shift work is associated with increased risk of cardiovascular disease, but the causes have not yet been fully established. It has been proposed that the coronary risk factors are more hazardous for shift workers, resulting in a potential interaction effect with shift work.OBJECTIVE: To analyse interaction effects of work schedule and established risk factors for coronary artery disease on the risk of myocardial infarction.METHODS: This analysis was conducted in SHEEP/VHEEP, a case-control study conducted in two counties in Sweden, comprising all first-time cases of myocardial infarction among men and women 45-70 years of age with controls stratified by sex, age, and hospital catchment area, totalling to 4648 participants. Synergy index (SI) was used as the main outcome analysis method for interaction analysis.RESULTS: There was an interaction effect between shift work and physical inactivity on the risk of myocardial infarction with SI of 2.05 (95% CI 1.07 to 3.92) for male shift workers. For female shift workers, interaction effects were found with high waist-hip ratio (SI 4.0, 95% CI 1.12 to 14.28) and elevated triglycerides (SI 5.69, 95% CI 1.67 to 19.38).CONCLUSION: Shift work and some established coronary risk factors have significant interactions.
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45.
  • Hermansson, J., et al. (author)
  • Shift work, parental cardiovascular disease and myocardial infarction in males
  • 2018
  • In: Occupational Medicine. - : Oxford University Press. - 0962-7480 .- 1471-8405. ; 68:2, s. 120-125
  • Journal article (peer-reviewed)abstract
    • Background Shift work has been associated with an increased risk of cardiovascular disease (CVD). However, there is a need for more studies to determine whether there is an interaction between shift work and other risk factors of CVD, thereby increasing the risk of CVD in shift workers. Aims To discern whether shift work and parental mortality from myocardial infarction (MI) or sudden cardiac death (SCD) interact to increase the risk of MI in men. Methods A case-control dataset was used to assess interaction between shift work and parental history of CVD, using death from MI or SCD, or death before age 65, on an additive scale. Results were reported as relative excess risk due to interaction, attributable proportion due to interaction (AP) and synergy index (SI). Results There was an interaction between shift work and paternal mortality from MI or SCD, when both factors were present [SI = 2.39; 95% confidence interval (CI) 1.02. 5.6 and AP = 0.4; 95% CI 0.08. 0.73]. Conclusions Paternal mortality from MI or SCD interacts with shift work to increase the risk of MI in men.
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46.
  • Hultin, Hanna, et al. (author)
  • Low level of adjustment latitude : a risk factor for sickness absence
  • 2010
  • In: European Journal of Public Health. - : Oxford University Press (OUP). - 1101-1262 .- 1464-360X. ; 20:6, s. 682-688
  • Journal article (peer-reviewed)abstract
    • Background: The prerequisite for obtaining sickness benefit is reduced work ability for medical reasons in combination with work demands which cannot be adjusted accordingly. The aim of this study was to investigate if low levels of adjustment latitude, defined as the possibility to temporarily adjust work demands in case of ill health, influence sickness absence. Methods: A prospective cohort study of 1420 employees (47% participation, aged 19-68; 56% women) was conducted at six Swedish workplaces. Exposure to two general and nine specific types of adjustment latitude was ascertained at baseline. Outcome was defined as the first new employer-reported sick-leave spell during a follow-up of 3-12 months. Hazard ratios (HR) of sick leave, with 95% confidence intervals (CI), were estimated by Cox proportional hazards regression. Results: The incidence of sickness absence was 2.85/1000 person-days. The self-reported reasons for sick leave were mainly minor complaints such as colds, influenzas and headaches. Employees lacking adjustment latitude had an adjusted HR of sickness absence of 1.51 (95% CI 1.08-2.11). Among specific adjustment latitude types, those not having the possibility to work from home generated an HR of 1.86 (95% CI 1.31-2.64). The effects of lack of adjustment latitude were similar for men and women but seemed to vary between different occupations. Conclusion: A low level of adjustment latitude at work is a risk factor for sickness absence.
  •  
47.
  • Hultin, Hanna, et al. (author)
  • Low Workload as a Trigger of Sick Leave Results From a Swedish Case-Crossover Study
  • 2012
  • In: Journal of Occupational and Environmental Medicine. - : Lippincott, Williams and Wilkins. - 1076-2752 .- 1536-5948. ; 54:2, s. 202-209
  • Journal article (peer-reviewed)abstract
    • Objectives: To investigate if exposure to an unusually low workload when ill can trigger taking sick leave. Methods: A case-crossover design was applied to 546 sick-leave spells obtained from a cohort of 1430 employees within six Swedish workplaces. New sick-leave spells were reported from the workplaces during 3 to 12 months follow-up. Exposure was assessed in structured participant interviews at sick leave. Case and control periods from the same individual were sampled according to the matched-pair and usual-frequency approaches. Results are presented as odds ratios with surrounding 95% confidence intervals. Results: The odds ratio of sick leave on a day with an unusually low workload was 2.57 (confidence interval, 1.07-6.16). Conclusions: Becoming ill on a day with a lower workload than usual can trigger the decision to take sick leave.
  •  
48.
  • Hultin, Hanna, et al. (author)
  • Work-related psychosocial events as triggers of sickleave – results from a Swedish case-crossover study
  • 2011
  • In: BMC Public Health. - : BMC. - 1471-2458. ; 11:175
  • Journal article (peer-reviewed)abstract
    • Background Although illness is an important cause of sick leave, it has also been suggested that non-medical risk factors may influence this association. If such factors impact on the period of decision making, they should be considered as triggers. Yet, there is no empirical support available. The aim was to investigate whether recent exposure to work-related psychosocial events can trigger the decision to report sick when ill. Methods A case-crossover design was applied to 546 sick-leave spells, extracted from a Swedish cohort of 1 430 employees with a 3-12 month follow-up of new sick-leave spells. Exposure in a case period corresponding to an induction period of one or two days was compared with exposure during control periods sampled from workdays during a two-week period prior to sick leave for the same individual. This was done according to the matched-pair interval and the usual frequency approaches. Results are presented as odds ratios (OR) with 95% confidence intervals (CI). Results Most sick-leave spells happened in relation to acute, minor illnesses that substantially reduced work ability. The risk of taking sick leave was increased when individuals had recently been exposed to problems in their relationship with a superior (OR 3.63; CI 1.44-9.14) or colleagues (OR 4.68; CI 1.43-15.29). Individuals were also more inclined to report sick on days when they expected a very stressful work situation than on a day when they were not under such stress (OR 2.27; CI 1.40-3.70). Conclusions Exposure to problems in workplace relationships or a stressful work situation seems to be able to trigger reporting sick. Psychosocial work-environmental factors appear to have a short-term effect on individuals when deciding to report sick.
  •  
49.
  • Janszky, Imre, et al. (author)
  • Alcohol and long-term prognosis after a first acute myocardial infarction : the SHEEP study
  • 2008
  • In: European Heart Journal. - : Oxford University Press (OUP). - 0195-668X .- 1522-9645. ; 29:1, s. 45-53
  • Journal article (peer-reviewed)abstract
    • CONTEXTFew studies have investigated the relation between alcohol consumption, former drinking, and prognosis after an acute myocardial infarction (AMI), particularly for non-fatal outcomes.OBJECTIVETo investigate the prognostic importance of drinking habits among patients surviving a first AMI.DESIGN, SETTINGS, AND PATIENTSA total of 1346 consecutive patients between 45-70 years with a first non-fatal AMI underwent a standardized clinical examination and were followed for over 8 years.MAIN OUTCOME MEASURESTotal and cardiac mortality and hospitalization for non-fatal cardiovascular disease in relation to individual alcoholic beverage consumption at the time of AMI and 5 years before inclusion, assessed by a standardized questionnaire administered during hospitalization.RESULTSWe recorded 267 deaths, and 145 deaths from cardiac causes, during the follow-up period. After adjustment for several potential confounders, hazard ratios for total and cardiac mortality were 0.77 (0.51-1.15) and 0.61 (0.36-1.02) for those drinking >0-<5 g per day, 0.77 (0.50-1.18) and 0.62 (0.36-1.07) for those drinking 5-20 g per day, and 0.89 (0.56-1.40) and 0.69 (0.38-1.25) for those drinking over 20 g per day. Risk of hospitalization for recurrent non-fatal AMI, stroke, or heart failure generally showed a similar pattern to that of total and cardiac mortality. Recent quitters at the time of AMI had a hazard ratio of 4.55 (2.03-10.20) for total mortality. Measures of insulin sensitivity appeared to be the strongest mediators of this association.CONCLUSIONSModerate alcohol drinking might have beneficial effects on several aspects of long-term prognosis after an AMI. Our findings also highlight that former drinkers should be examined separately from long-term abstainers. The potential mechanisms that underlie this association still need to be elucidated.
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50.
  • Janszky, I, et al. (author)
  • Chocolate consumption and mortality following a first acute myocardial infarction : the Stockholm Heart Epidemiology Program
  • 2009
  • In: Journal of Internal Medicine. - : Wiley. - 0954-6820 .- 1365-2796. ; 266:3, s. 248-257
  • Journal article (peer-reviewed)abstract
    • OBJECTIVESTo assess the long-term effects of chocolate consumption amongst patients with established coronary heart disease.DESIGNIn a population-based inception cohort study, we followed 1169 non-diabetic patients hospitalized with a confirmed first acute myocardial infarction (AMI) between 1992 and 1994 in Stockholm County, Sweden, as part of the Stockholm Heart Epidemiology Program. Participants self-reported usual chocolate consumption over the preceding 12 months with a standardized questionnaire distributed during hospitalization and underwent a health examination 3 months after discharge. Participants were followed for hospitalizations and mortality with national registries for 8 years.RESULTSChocolate consumption had a strong inverse association with cardiac mortality. When compared with those never eating chocolate, the multivariable-adjusted hazard ratios were 0.73 (95% confidence interval, 0.41-1.31), 0.56 (0.32-0.99) and 0.34 (0.17-0.70) for those consuming chocolate less than once per month, up to once per week and twice or more per week respectively. Chocolate consumption generally had an inverse but weak association with total mortality and nonfatal outcomes. In contrast, intake of other sweets was not associated with cardiac or total mortality.CONCLUSIONSChocolate consumption was associated with lower cardiac mortality in a dose dependent manner in patients free of diabetes surviving their first AMI. Although our findings support increasing evidence that chocolate is a rich source of beneficial bioactive compounds, confirmation of this strong inverse relationship from other observational studies or large-scale, long-term, controlled randomized trials is needed.
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