| 1. |
- De Neve, Jan-Walter, et al.
(författare)
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Antiretroviral therapy coverage associated with increased co-residence between older and working-age adults in Africa
- 2018
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Ingår i: AIDS. - 1473-5571. ; 32:14, s. 2051-2057
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: To determine whether national antiretroviral therapy (ART) coverage is associated with changes in the living arrangements of older adults.DESIGN: Retrospective analysis using 103 nationally representative surveys from 28 African countries between 1991 and 2015.METHODS: The sample consisted of individuals aged at least 60 years. We investigated how three measures of living arrangements of older adults have changed with ART coverage: the number of older individuals living without working-age adults, the number of older individuals living with only dependent children (i.e. 'missing generation' households), and the number of working-age adults per household where an older individual lives.RESULTS: Our sample consisted of 297 331 older adults. An increase in ART coverage of 1% was associated with a 0.7 percentage point reduction (P < 0.001) in the probability of an older adult living without working-age adult and a 0.2 percentage point reduction (P = 0.005) in the probability of an older adult living in a 'missing generation' household. Increases in ART coverage were also associated with more working-age adults in households with at least one older adult. In our study countries, representing 75% (749 million) of the sub-Saharan population, an additional 103 000-358 000 older adults could be living with working-age adults as a result of increased ART coverage (1%).CONCLUSION: The scale-up of ART has likely led to substantial increases in co-residence between older and working-age adults in Africa. Returns to investments in HIV treatment will be too low, if the social benefits from these changes in living arrangements of older adults are not taken into account.
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| 2. |
- Karlsson, Omar, et al.
(författare)
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Socioeconomic and gender inequalities in neonatal, postneonatal and child mortality in India : A repeated cross-sectional study, 2005-2016
- 2019
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Ingår i: Journal of Epidemiology and Community Health. - : BMJ. - 0143-005X .- 1470-2738. ; 73:7, s. 660-667
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Tidskriftsartikel (refereegranskat)abstract
- Background: In India, excess female under-5 mortality is well documented. Under-5 mortality is also known to be patterned by socioeconomic factors. This study examines sex differentials and sex-specific wealth gradients in neonatal, postneonatal and child mortality in India. Methods: Repeated cross-sectional study of nationally representative samples of 298 955 children 0-60 months old from the National Family Health Surveys conducted in 2005-2006 and 2015-2016. The study used logistic regression models as well as Cox proportional hazards models. Results: Overall, boys had greater neonatal mortality than girls and the difference increased between 2005-2006 and 2015-2016. Girls had greater postneonatal and child mortality, but the difference decreased between the surveys and was not statistically significant for child mortality in 2015-2016. A negative wealth gradient was found for all mortality outcomes. Neonatal mortality was persistently greater for boys. Girls had higher child mortality than boys at low levels of wealth and greater postneonatal mortality over much of the wealth distribution. The wealth gradient in neonatal mortality increased between surveys. Females had a stronger wealth gradient than boys for child mortality. Conclusion: Not distinguishing between neonatal, postneonatal and child mortality masks important gender-specific and wealth-specific disparities in under-5 mortality in India. Substantial gains towards the Sustainable Development Goals can be made by combating neonatal mortality, especially at low levels of wealth. Although impressive improvements have been made in reducing the female disadvantage in postneonatal and child mortality, concerted engagements are necessary to eliminate the gender gap - especially in poor households and in north India.
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| 3. |
- Kobayashi, Lindsay C., et al.
(författare)
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Education modifies the relationship between height and cognitive function in a cross-sectional population-based study of older adults in Rural South Africa
- 2019
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Ingår i: European Journal of Epidemiology. - : Springer. - 0393-2990 .- 1573-7284. ; 34:2, s. 131-139
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Tidskriftsartikel (refereegranskat)abstract
- We aimed to estimate the relationship between height (a measure of early-life cumulative net nutrition) and later-life cognitive function among older rural South African adults, and whether education modified this relationship. Data were from baseline in-person interviews with 5059 adults40years in the population-based Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) study in Agincourt sub-district, South Africa, in 2015. Linear regression was used to estimate the relationship between height quintile and latent cognitive function z-score (representing episodic memory, time orientation, and numeracy), with adjustment for life course covariates and a height-by-education interaction. Mean (SD) height was 162.7 (8.9) cm. Nearly half the sample had no formal education (46%; 2307/5059). Mean age- and sex-adjusted cognitive z-scores increased from -0.68 (95% CI: -0.76 to -0.61) in those with no education in the shortest height quintile to 0.62 (95% CI: 0.52-0.71) in those with at least 8years of education in the tallest height quintile. There was a linear height disparity in cognitive z-scores for those with no formal education (adjusted =0.10; 95% CI: 0.08-0.13 per height quintile), but no height disparity in cognitive z-scores in those with any level of education. Short stature is associated with poor cognitive function and may be a risk factor for cognitive impairment among older adults living in rural South Africa. The height disparity in cognitive function was negated for older adults who had any level of education.
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| 4. |
- Merlo, Juan, et al.
(författare)
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General and specific contextual effects in multilevel regression analyses and their paradoxical relationship : A conceptual tutorial
- 2018
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Ingår i: SSM - Population Health. - : Elsevier. - 2352-8273. ; 5, s. 33-37
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Tidskriftsartikel (refereegranskat)abstract
- To be relevant for public health, a context (e.g., neighborhood, school, hospital) should influence or affect the health status of the individuals included in it. The greater the influence of the shared context, the higher the correlation of subject outcomes within that context is likely to be. This intra-context or intra-class correlation is of substantive interest and has been used to quantify the magnitude of the general contextual effect (GCE). Furthermore, ignoring the intra-class correlation in a regression analysis results in spuriously narrow 95% confidence intervals around the estimated regression coefficients of the specific contextual variables entered as covariates and, thereby, overestimates the precision of the estimated specific contextual effects (SCEs). Multilevel regression analysis is an appropriate methodology for investigating both GCEs and SCEs. However, frequently researchers only report SCEs and disregard the study of the GCE, unaware that small GCEs lead to more precise estimates of SCEs so, paradoxically, the less relevant the context is, the easier it is to detect (and publish) small but "statistically significant" SCEs. We describe this paradoxical situation and encourage researchers performing multilevel regression analysis to consider simultaneously both the GCE and SCEs when interpreting contextual influences on individual health.
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| 5. |
- Merlo, Juan, et al.
(författare)
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The tyranny of the averages and the indiscriminate use of risk factors in public health : The case of coronary heart disease
- 2017
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Ingår i: SSM - Population Health. - : Elsevier BV. - 2352-8273. ; 3, s. 684-698
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Tidskriftsartikel (refereegranskat)abstract
- Modern medicine is overwhelmed by a plethora of both established risk factors and novel biomarkers for diseases. The majority of this information is expressed by probabilistic measures of association such as the odds ratio (OR) obtained by calculating differences in average "risk" between exposed and unexposed groups. However, recent research demonstrates that even ORs of considerable magnitude are insufficient for assessing the ability of risk factors or biomarkers to distinguish the individuals who will develop the disease from those who will not. In regards to coronary heart disease (CHD), we already know that novel biomarkers add very little to the discriminatory accuracy (DA) of traditional risk factors. However, the value added by traditional risk factors alongside simple demographic variables such as age and sex has been the subject of less discussion. Moreover, in public health, we use the OR to calculate the population attributable fraction (PAF), although this measure fails to consider the DA of the risk factor it represents. Therefore, focusing on CHD and applying measures of DA, we re-examine the role of individual demographic characteristics, risk factors, novel biomarkers and PAFs in public health and epidemiology. In so doing, we also raise a more general criticism of the traditional risk factors' epidemiology. We investigated a cohort of 6103 men and women who participated in the baseline (1991-1996) of the Malmö Diet and Cancer study and were followed for 18 years. We found that neither traditional risk factors nor biomarkers substantially improved the DA obtained by models considering only age and sex. We concluded that the PAF measure provided insufficient information for the planning of preventive strategies in the population. We need a better understanding of the individual heterogeneity around the averages and, thereby, a fundamental change in the way we interpret risk factors in public health and epidemiology.
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| 6. |
- Mulinari, Shai, et al.
(författare)
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Categorical and anti-categorical approaches to US racial/ethnic groupings: revisiting the National 2009 H1N1 Flu Survey (NHFS)
- 2018
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Ingår i: Critical Public Health. - : Informa UK Limited. - 0958-1596 .- 1469-3682. ; 28:2, s. 177-189
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Tidskriftsartikel (refereegranskat)abstract
- Intersectionality theory calls for the understanding of race/ ethnicity, sex/ gender and class as interlinked. Intersectional analysis can contribute to public health both through furthering understanding of power dynamics causing health disparities, and by pointing to heterogeneities within, and overlap between, social groups. The latter places the usefulness of social categories in public health under scrutiny. Drawing on McCall we relate the first approach to categorical and the second to anti-categorical intersectionality. Here, we juxtapose the categorical approach with traditional between-group risk calculations (e.g. odds ratios) and the anticategorical approach with the statistical concept of discriminatory accuracy (DA), which is routinely used to evaluate disease markers in epidemiology. To demonstrate the salience of this distinction, we use the example of racial/ ethnic identification and its value for predicting influenza vaccine uptake compared to other conceivable ways of organizing attention to social differentiation. We analyzed data on 56,434 adults who responded to the NHFS. We performed logistic regressions to estimate odds ratios and computed the area under the receiver operating characteristic curve (AU-ROC) to measure DA. Above age, the most informative variables were education and household poverty status, with race/ ethnicity providing minor additional information. Our results show that the practical value of standard racial/ ethnic categories for making inferences about vaccination status is questionable, because of the high degree of outcome variability within, and overlap between, categories. We argue that, reminiscent of potential tension between categorical and anti-categorical perspectives, between-group risk should be placed and understood in relationship to measures of DA, to avoid the lure of misguided individual-level interventions.
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| 7. |
- Palafox, Benjamin, et al.
(författare)
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Wealth and cardiovascular health: a cross-sectional study of wealth-related inequalities in the awareness, treatment and control of hypertension in high-, middle- and low-income countries.
- 2016
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Ingår i: International journal for equity in health. - : Springer Science and Business Media LLC. - 1475-9276. ; 15:1
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Tidskriftsartikel (refereegranskat)abstract
- Effective policies to control hypertension require an understanding of its distribution in the population and the barriers people face along the pathway from detection through to treatment and control. One key factor is household wealth, which may enable or limit a household's ability to access health care services and adequately control such a chronic condition. This study aims to describe the scale and patterns of wealth-related inequalities in the awareness, treatment and control of hypertension in 21 countries using baseline data from the Prospective Urban and Rural Epidemiology study.A cross-section of 163,397 adults aged 35 to 70years were recruited from 661 urban and rural communities in selected low-, middle- and high-income countries (complete data for this analysis from 151,619 participants). Using blood pressure measurements, self-reported health and household data, concentration indices adjusted for age, sex and urban-rural location, we estimate the magnitude of wealth-related inequalities in the levels of hypertension awareness, treatment, and control in each of the 21 country samples.Overall, the magnitude of wealth-related inequalities in hypertension awareness, treatment, and control was observed to be higher in poorer than in richer countries. In poorer countries, levels of hypertension awareness and treatment tended to be higher among wealthier households; while a similar pro-rich distribution was observed for hypertension control in countries at all levels of economic development. In some countries, hypertension awareness was greater among the poor (Sweden, Argentina, Poland), as was treatment (Sweden, Poland) and control (Sweden).Inequality in hypertension management outcomes decreased as countries became richer, but the considerable variation in patterns of wealth-related inequality - even among countries at similar levels of economic development - underscores the importance of health systems in improving hypertension management for all. These findings show that some, but not all, countries, including those with limited resources, have been able to achieve more equitable management of hypertension; and strategies must be tailored to national contexts to achieve optimal impact at population level.
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| 8. |
- Persmark, Anna, et al.
(författare)
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Intersectional inequalities and the U.S. opioid crisis : challenging dominant narratives and revealing heterogeneities
- 2019
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Ingår i: Critical Public Health. - : Taylor & Francis. - 0958-1596 .- 1469-3682. ; 30:4, s. 398-414
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Tidskriftsartikel (refereegranskat)abstract
- Dominant narratives of prescription opioid misuse (POM) in the U.S. have portrayed it as an issue primarily affecting White communities. In this study we explore POM as reported in data from the 2015 National Survey on Drug Use and Health, using an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). We map the risk of POM through a series of multilevel models with individuals (N = 43,409) nested within strata formed by the intersections of gender, race/ethnicity, income, and age. We find meaningful heterogeneity between and within strata. The ten strata with the greatest risk for POM were comprised of individuals identifying as White, African American, and non-White Hispanic, and included individuals of low, medium, and high income. We uncover intersections of social position with high risk for POM that are often excluded from dominant narratives, including young high-income African American women. Intersectional approaches are essential for advancing our understanding of health inequalities and unfolding epidemics such as that of POM in the U.S.
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| 9. |
- Persmark, Anna, et al.
(författare)
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Precision public health: mapping socioeconomic disparities in opioid dispensations at Swedish pharmacies by Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA)
- 2019
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Ingår i: PLoS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; , s. 1-21
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundIn light of the opioid epidemic in the United States, there is growing concern about the use of opioids in Sweden as it may lead to misuse and overuse and, in turn, severe public health problems. However, little is known about the distribution of opioid use across different demographic and socioeconomic dimensions in the Swedish general population. Therefore, we applied an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA), to obtain an improved mapping of the risk heterogeneity of and socioeconomic inequalities in opioid prescription receipt. Methods and FindingsUsing data from 6,846,106 residents in Sweden aged 18 and above, we constructed 72 intersectional strata from combinations of gender, age, income, cohabitation status, and presence or absence of psychological distress. We modelled the absolute risk (AR) of opioid prescription receipt in a series of multilevel logistic regression models distinguishing between additive and interaction effects. By means of the Variance Partitioning Coefficient (VPC) and the area under the receiver operating characteristic curve (AUC), we quantified the discriminatory accuracy (DA) of the intersectional strata for discerning those who received opioid prescriptions from those who did not. The AR of opioid prescription receipt ranged from 2.77% (95% CI 2.69¬–2.86) among low-income men aged 18–34, living alone, without psychological distress, to 28.25% (95% CI 27.95–28.56) among medium-income women aged 65 and older, living alone, with psychological distress. In a model that conflated both additive and interaction effects, the intersectional strata had a fair DA for discerning opioid users from non-users (VPC=13.2%, AUC=0.68). However, in the model that decomposed total effects into additive and interaction effects, the VPC was very low (0.42%) indicating the existence of small interaction effects for a number of the intersectional strata. ConclusionsThe intersectional MAIHDA approach aligns with the aims of precision public health, through improving the evidence base for health policy by increasing understanding of both health inequalities and individual heterogeneity. This approach is particularly relevant for socioeconomically conditioned outcomes such as opioid prescription receipt. We have identified intersections of social position within the Swedish population at greater risk for opioid prescription receipt.
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| 10. |
- Stenholm, S., et al.
(författare)
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Patterns of weight gain in middle-aged and older US adults from 1992-2010
- 2015
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Ingår i: Epidemiology. - 1044-3983 .- 1531-5487. ; 26:2, s. 165-168
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Tidskriftsartikel (refereegranskat)abstract
- Background: Cross-sectional analyses of national data have found that persons with high baseline body mass index (BMI) gain weight faster than persons at the median and that those whose weight was below the median gain very little weight. However, it is not clear whether these population-level changes reflect patterns at the individual level. Methods: We examined longitudinal changes in BMI in initially underweight, normal-weight, overweight, and obese US men and women using individual-level repeat data from the Health and Retirement Study (n = 15,895; age range, 40-69 years at baseline). Linear mixed-effect regression was used to model 6-year change in self-reported BMI during 4 study periods (1992/1994-1998/2000, 1996/1998-2002/2004, 2000/2002-2006/2008, and 2004-2010). Results: In the first 6-year period, the mean increase in BMI was greatest among persons who were initially normal weight (0.3 kg/m(2) [95% confidence interval = 0.2 to 0.4]) and overweight (0.2 kg/m(2) [0.1 to 0.3]). Weight gain accelerated in these groups with each subsequent period. Weight gain was less for initially class-I obese participants, and a net decrease in BMI was observed for class-II obese participants. Conclusion: These analyses suggest that the change in mean BMI among middle-aged and older US adults between 1992 and 2010 resulted mainly from accelerated weight gain among persons who were initially normal weight and overweight.
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| 11. |
- Vaezghasemi, Masoud, et al.
(författare)
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Households, the omitted level in contextual analysis : disentangling the relative influence of households and districts on the variation of BMI about two decades in Indonesia
- 2016
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Ingår i: International Journal for Equity in Health. - : Springer Science and Business Media LLC. - 1475-9276. ; 15
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Tidskriftsartikel (refereegranskat)abstract
- Background: Most of the research investigating the effect of social context on individual health outcomes has interpreted context in terms of the residential environment. In these studies, individuals are nested within their neighbourhoods or communities, disregarding the intermediate household level that lies between individuals and their residential environment. Households are an important determinant of health yet they are rarely included at the contextual level in research examining association between body mass index (BMI) and the social determinants of health. In this study, our main aim was to provide a methodological demonstration of multilevel analysis, which disentangles the simultaneous effects of households and districts as well as their associated predictors on BMI over time.Methods: Using both two- and three-level multilevel analysis, we utilized data from all four cross-sections of the Indonesian Family life Survey (IFLS) 1993 to 2007-8.Results: We found that: (i) the variation in BMI attributable to districts decreased from 4.3 % in 1993 to 1.5 % in 1997-98, and remained constant until 2007-08, while there was an alarming increase in the variation of BMI attributable to households, from 10 % in 2000 to 15 % in 2007-08; (ii) ignoring the household level did not change the relative variance contribution of districts on BMI, but ignoring the district level resulted in overestimation of household effects, and (iii) households' characteristics (socioeconomic status, size, and place of residence) did not attenuate the variation of BMI at the household-level.Conclusions: Estimating the relative importance of multiple social settings allows us to better understand and unpack the variation in clustered or hieratical data in order to make valid and robust inferences. Our findings will help direct investment of limited public health resources to the appropriate context in order to reduce health risk (variation in BMI) and promote population health.
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| 12. |
- Vaezghasemi, Masoud, et al.
(författare)
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Inter-individual inequality in BMI : an analysis of Indonesian Family LifeSurveys (1993–2007)
- 2016
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Ingår i: SSM - Population Health. - : Elsevier. - 2352-8273. ; 2, s. 876-888
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Tidskriftsartikel (refereegranskat)abstract
- Widening inequalities in mean Body Mass Index (BMI) between social and economic groups are well documented. However, whether changes in mean BMI are followed by changes in dispersion (or variance) and whether these inequalities are also occurring within social groups or across individuals remain understudied. In addition, a substantial body of literature exists on the global increase in mean BMI and prevalence of overweight and obesity. However, whether this weight gain is shared proportionately across the whole spectrum of BMI distribution, also remains understudied. We examined changes in the distribution of BMI at the population level over time to understand how changes in the dispersion reflect between-group compared to within-group inequalities in weight gain. Moreover, we investigated the entire distribution of BMI to determine in which percentiles the most weight gain is occurring over time. Utilizing four waves (from 1993 to 2007) of Indonesian Family Life Surveys (IFLS), we estimated changes in the mean and the variance of BMI over time and across various socioeconomic groups based on education and households’ expenditure per capita in 53,648 men and women aged 20–50 years. An increase in mean and standard deviation was observed among men (by 4.3% and 25%, respectively) and women (by 7.3% and 20%, respectively) over time. Quantile-Quantile plots showed that higher percentiles had greater increases in BMI compared to the segment of the population at lower percentiles. While between socioeconomic group differences decreased over time, within-group differences increased and were more prominent among individuals with poor education and lower per capita expenditures. Population changes in BMI cannot be fully described by average trends or single parameters such as the mean BMI. Moreover, greater increases in within-group dispersion compared with between-group differences imply that growing inequalities are not merely driven by these socioeconomic factors at the population level.
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| 13. |
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- 2019
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Tidskriftsartikel (refereegranskat)
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