| 1. |
- Ali, Sadiq Mohammad, et al.
(author)
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Gender differences in daily smoking prevalence in different age strata: A population-based study in southern Sweden.
- 2009
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In: Scandinavian Journal of Public Health. - : SAGE Publications. - 1651-1905 .- 1403-4948. ; 37:2, s. 146-152
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Journal article (peer-reviewed)abstract
- Objectives: To investigate gender differences in daily smoking prevalence in different age groups in southern Sweden. Methods: The 2004 public-health survey in Skåne is a cross-sectional study. A total of 27,757 persons aged 18-80 years answered a postal questionnaire, which represents 59% of the random sample. A logistic regression model was used to investigate the associations between gender and daily smoking according to age. The multivariate analysis was performed to investigate the importance of possible confounders (country of origin, education, snus use, alcohol consumption, leisure-time physical activity, and BMI) on the gender differences in daily smoking in different age groups. Results: 14.9% of the men and 18.1% of the women were daily smokers. Middle-aged respondents were daily smokers to a significantly higher extent than young and old respondents. The prevalence of daily smoking also varied according to other demographic, socioeconomic, health related behaviour, and BMI characteristics. The crude odds ratios of daily smoking were 1.79 (1.42-2.26) among women compared to men in the 18-24 years age group, and 0.95 (0.80-1.12) in the 65-80 years age group. These odds ratios changed to 2.00 (1.49-2.67) and 0.95 (0.76-1.18), respectively, when all confounders were included. CONCLUSIONS: For the first time in Sweden women have a higher prevalence of daily smoking than men. The odds ratios of daily smoking are highest among women compared to men in the youngest age group of 18-24 years and the odds ratios decrease with increasing age. The findings point to a serious public health problem. Strategic interventions targeting young women's tobacco smoking are needed.
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| 2. |
- Chaix, Basile, et al.
(author)
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A GPS-Based Methodology to Analyze Environment-Health Associations at the Trip Level : Case-Crossover Analyses of Built Environments and Walking
- 2016
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In: American Journal of Epidemiology. - : Oxford University Press (OUP). - 0002-9262 .- 1476-6256. ; 184:8, s. 570-578
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Journal article (peer-reviewed)abstract
- Environmental health studies have examined associations between context and health with individuals as statistical units. However, investigators have been unable to investigate momentary exposures, and such studies are often vulnerable to confounding from, for example, individual-level preferences. We present a Global Positioning System (GPS)-based methodology for segmenting individuals' observation periods into visits to places and trips, enabling novel life-segment investigations and case-crossover analysis for improved inferences. We analyzed relationships between built environments and walking in trips. Participants were tracked for 7 days with GPS receivers and accelerometers and surveyed with a Web-based mapping application about their transport modes during each trip (Residential Environment and Coronary Heart Disease (RECORD) GPS Study, France, 2012-2013; 6,313 trips made by 227 participants). Contextual factors were assessed around residences and the trips' origins and destinations. Conditional logistic regression modeling was used to estimate associations between environmental factors and walking or accelerometry-assessed steps taken in trips. In case-crossover analysis, the probability of walking during a trip was 1.37 (95% confidence interval: 1.23, 1.61) times higher when trip origin was in the fourth (vs. first) quartile of service density and 1.47 (95% confidence interval: 1.23, 1.68) times higher when trip destination was in the fourth (vs. first) quartile of service density. Green spaces at the origin and destination of trips were also associated with within-individual, trip-to-trip variations in walking. Our proposed approach using GPS and Web-based surveys enables novel life-segment epidemiologic investigations.
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| 3. |
- Chaix, Basile, et al.
(author)
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An Interactive Mapping Tool to Assess Individual Mobility Patterns in Neighborhood Studies
- 2012
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In: American Journal of Preventive Medicine. - : Elsevier BV. - 0749-3797. ; 43:4, s. 440-450
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Journal article (peer-reviewed)abstract
- As their most critical limitation, neighborhood and health studies published to date have not taken into account nonresidential activity places where individuals travel in their daily lives. However, identifying low-mobility populations residing in low-resource environments, assessing cumulative environmental exposures over multiple activity places, and identifying specific activity locations for targeting interventions are important for health promotion. Daily mobility has not been given due consideration in part because of a lack of tools to collect locational information on activity spaces. Thus, the first aim of the current article is to describe VERITAS (Visualization and Evaluation of Route Itineraries, Travel Destinations, and Activity Spaces), an interactive web mapping application that can geolocate individuals' activity places, routes between locations, and relevant areas such as experienced or perceived neighborhoods. The second aim is to formalize the theoretic grounds of a contextual expology as a subdiscipline to better assess the spatiotemporal configuration of environmental exposures. Based on activity place data, various indicators of individual patterns of movement in space (spatial behavior) are described. Successive steps are outlined for elaborating variables of multiplace environmental exposure (collection of raw locational information, selection/exclusion of locational data, defining an exposure area for measurement, and calculation). Travel and activity place network areas are discussed as a relevant construct for environmental exposure assessment. Finally, a note of caution is provided that these measures require careful handling to avoid increasing the magnitude of confounding (selective daily mobility bias). (Am J Prev Med 2012; 43(4): 440-450) (c) 2012 American Journal of Preventive Medicine
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| 4. |
- Chaix, Basile, et al.
(author)
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Assessment of the magnitude of geographical variations and socioeconomic contextual effects on ischaemic heart disease mortality: a multilevel survival analysis of a large Swedish cohort
- 2007
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In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 61:4, s. 349-355
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Journal article (peer-reviewed)abstract
- Background: In a public health perspective, it is of interest to assess the magnitude of geographical variations in ischaemic heart disease (IHD) mortality and quantify the strength of contextual effects on IHD. Objective: To investigate whether area effects vary according to the individual and contextual characteristics of the population, socioeconomic contextual influences were assessed in different age groups and within territories of differing population densities. Design: Multilevel survival analysis of a 28-year longitudinal database. Participants: 341 048 residents of the Scania region in Sweden, reaching age 50-79 years in 1996, followed up over 7 years. Results: After adjustment for several individual socioeconomic indicators over the adult age, Cox multilevel models indicated geographical variations in IHD mortality and socioeconomic contextual effects on the mortality risk. However, the magnitude of geographical variations and strength of contextual effects were modified by the age of individuals and the population density of their residential area: socioeconomic contextual effects were much stronger among non-elderly than among elderly adults, and much larger within urban territories than within rural ones. As a consequence, among non-elderly residents of urban territories, the socioeconomic contextual effect was almost as large as the effect of individual 20-year cumulated income. Conclusions: Non-elderly residents of deprived urban neighbourhoods constitute a major target for both contextual epidemiology of coronary disease and public health interventions aimed at reducing the detrimental effects of the social environment on IHD.
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| 5. |
- Chaix, Basile, et al.
(author)
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Associations of Supermarket Characteristics with Weight Status and Body Fat: A Multilevel Analysis of Individuals within Supermarkets (RECORD Study)
- 2012
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In: PLoS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 7:4
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Journal article (peer-reviewed)abstract
- Purpose: Previous research on the influence of the food environment on weight status has often used impersonal measures food environment defined for residential neighborhoods, which ignore whether people actually use the food outlets near their residence. To assess whether supermarkets are relevant contexts for interventions, the present study explored between-residential neighborhood and between-supermarket variations in body mass index (BMI) and waist circumference (WC), and investigated associations between brands and characteristics of supermarkets and BMI or WC, after adjustment for individual and residential neighborhood characteristics. Methods: Participants in the RECORD Cohort Study (Paris Region, France, 2007-2008) were surveyed on the supermarket (brand and exact location) where they conducted their food shopping. Overall, 7 131 participants shopped in 1 097 different supermarkets. Cross-classified multilevel linear models were estimated for BMI and WC. Results: Just 11.4% of participants shopped for food primarily within their residential neighborhood. After accounting for participants' residential neighborhood, people shopping in the same supermarket had a more comparable BMI and WC than participants shopping in different supermarkets. After adjustment for individual and residential neighborhood characteristics, participants shopping in specific supermarket brands, in hard discount supermarkets (especially if they had a low education), and in supermarkets whose catchment area comprised low educated residents had a higher BMI/WC. Conclusion: A public health strategy to reduce excess weight may be to intervene on specific supermarkets to change food purchasing behavior, as supermarkets are where dietary preferences are materialized into definite purchased foods.
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| 6. |
- Chaix, Basile, et al.
(author)
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Children's exposure to nitrogen dioxide in Sweden: investigating environmental injustice in an egalitarian country.
- 2006
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In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 60:3, s. 234-241
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Journal article (peer-reviewed)abstract
- Study objective: Prior studies have shown that children are particularly sensitive to air pollution. This study examined whether children of low socioeconomic status suffered greater exposure to outdoor nitrogen dioxide than more affluent ones, both at their place of residence and at school, in a country with widespread state intervention for social equity. Design: Local scale data on outdoor nitrogen dioxide obtained from a validated air pollution model were analysed, along with all school children accurately geocoded to their building of residence and school. Participants: All 29 133 children in grades one through nine (aged 7 to 15 years) residing and attending school in Malmo, Sweden, in 2001. Main results: Defining the socioeconomic status of children according to the mean income in their residential building, the spatial scan statistic technique allowed the authors to identify eight statistically significant clusters of low socioeconomic status children, all of which were located in the most polluted areas of Malmo. Four clusters of high socioeconomic status children were found, all of them located in the least polluted areas. The neighbourhood socioeconomic status better predicted the nitrogen dioxide exposure of children than the socioeconomic status of their building of residence. Exposure to nitrogen dioxide at the place of residence and school of attendance regularly increased as the socioeconomic status of a child's neighbourhood of residence decreased. Conclusions: Evidence of environmental injustice was found, even in a country noted for its egalitarian welfare state. Enforcement of environmental regulations may be necessary to achieve a higher level of environmental equity.
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| 7. |
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| 8. |
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| 9. |
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| 10. |
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| 11. |
- Chaix, Basile, et al.
(author)
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Income change at retirement, neighbourhood-based social support, and ischaemic heart disease: Results from the prospective cohort study "Men born in 1914"
- 2007
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In: Social Science and Medicine. - : Elsevier BV. - 1873-5347 .- 0277-9536. ; 64:4, s. 818-829
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Journal article (peer-reviewed)abstract
- Retirement from active life often leads to decreased finances and reduced social contact, which may increase ischaemic heart disease (IHD) risk in individuals. We examined whether income evolution during the decade before retirement has an impact on subsequent IHD, and explored the mediating effect of common risk factors and social support from different sources (marriage/cohabitation, support from friends/relatives, and neighbourhood-based social support). We analyzed data from the 1982-1983 prospective cohort study, "Men born in 1914" (n = 498, follow-up period = 10 years) conducted in Malmo, Sweden, merged with yearly income data for 14 years preceding baseline. Low income 10 years before retirement predicted both higher prevalence of IHD risk factors at retirement, and weaker neighbourhood-based social support. Income 10 years before retirement was a strong predictor of IHD incidence and mortality after retirement, but a significant downward income mobility at retirement did not increase IHD risk. After adjustment, low neighbourhood-based social support increased the risk of IHD incidence and mortality, and mediated 7-8% of the income effect. In conclusion, income 10 years before retirement, but not the subsequent income evolution, was a strong predictor of IHD post-retirement. This socioeconomic gradient was partly mediated by the protective effect of neighbourhood-based social support, which may be particularly important among the elderly in compensating for social disruptions related to retirement.
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| 12. |
- Chaix, Basile, et al.
(author)
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Neighborhood socioeconomic deprivation and residential instability - Effects on incidence of ischemic heart disease and survival after myocardial inforction
- 2007
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In: Epidemiology. - : Ovid Technologies (Wolters Kluwer Health). - 1531-5487 .- 1044-3983. ; 18:1, s. 104-111
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Journal article (peer-reviewed)abstract
- Background: Previous literature has shown that neighborhood socioeconomic position influences the risk of ischemic heart disease, but little is known about the mechanisms linking the residential context to ischemic heart disease incidence and mortality. We examined whether neighborhood socioeconomic position and neighborhood residential stability (as a determinant of social interaction patterns) have an influence on ischemic heart disease risk. Moreover, we investigated whether dissimilar contextual influences operate at different stages of the disease process, ie, on incidence, 1-day case-fatality, and long-term survival after acute myocardial infarction (MI). Methods: Using a large 27-year longitudinal cohort (baseline: 1 January 1996) defined in the Scania region, Sweden, we estimated multilevel survival models adjusted for individual sociodemographic factors and previous diseases of the persons. Results: After adjustment, multilevel survival models indicated that the incidence of ischemic heart disease increased with neighborhood socioeconomic deprivation but was only weakly associated with neighborhood residential instability (for high vs low residential instability, hazard ratio = 1.2; 95% credible interval = t.0-1.4). Conversely, beyond effects of individual and contextual socioeconomic circumstances and distance to the hospital, we saw a markedly higher I-day case-fatality (4.9; 1.8-15) and shorter survival time after MI among individuals still alive 28 days after MI (4.3; 1.2-17) in neighborhoods with a high versus low residential instability. Conclusions: Effects of residential instability on post-MI survival may be mediated by the lower availability of social support in residentially unstable neighborhoods, suggesting a new class of intermediate processes that should be taken into account when investigating contextual influences on ischemic heart disease. Moreover, dissimilar contextual effects may operate at various stages of the disease process (ie, on incidence, case-fatality, and survival after MI).
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| 13. |
- Chaix, Basile, et al.
(author)
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Neighbourhood social interactions and risk of acute myocardial infarction.
- 2008
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In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 62:1, s. 62-68
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Journal article (peer-reviewed)abstract
- STUDY OBJECTIVE: Previous studies of neighbourhood effects on ischaemic heart disease (IHD) have used census or administrative data to characterise the residential context, most commonly its socioeconomic level. Using the ecometric approach to define neighbourhood social interaction variables that may be relevant to IHD, neighbourhood social cohesion and safety were examined to see how they related to acute myocardial infarction (AMI) mortality, after adjustment for individual and neighbourhood confounders. DESIGN: To construct social interaction variables, multilevel models were used to aggregate individual perceptions of safety and cohesion at the neighbourhood level. Linking data from the Health Survey in Scania, Sweden, and the Population, Hospital, and Mortality Registers, multilevel survival models were used to investigate determinants of AMI mortality over a three year and nine month period. PARTICIPANTS: 7791 Individuals aged 45 years and over. MAIN RESULTS: The rate of AMI mortality increased with decreasing neighbourhood safety and cohesion. After adjustment for individual health and socioeconomic variables, low neighbourhood cohesion, and to a lesser extent low safety, were associated with higher AMI mortality. Neighbourhood cohesion effects persisted after adjustment for various neighbourhood confounding factors (income, population density, percentage of residents from low-income countries, residential stability) and distance to the hospital. There was some evidence that neighbourhood cohesion effects on AMI mortality were caused by effects on one-day case-fatality, rather than on incidence. CONCLUSIONS: Beyond commonly evoked effects of the physical environment, neighbourhood social interaction patterns may have a decisive influence on IHD, with a particularly strong effect on survival after AMI.
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| 14. |
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| 15. |
- Chaix, Basile, et al.
(author)
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Recent Increase of Neighborhood Socioeconomic Effects on Ischemic Heart Disease Mortality: A Multilevel Survival Analysis of Two Large Swedish Cohorts.
- 2007
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In: American Journal of Epidemiology. - : Oxford University Press (OUP). - 0002-9262 .- 1476-6256. ; 165, s. 22-26
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Journal article (peer-reviewed)abstract
- Studies have shown that the decrease in ischemic heart disease mortality over the past decades was paralleled by an increase in socioeconomic disparities. Using two large Swedish cohorts defined in 1986 and 1996, the authors examined whether the effect of neighborhood socioeconomic position on ischemic heart disease mortality strengthened over the period and whether the relative contribution of individual and neighborhood socioeconomic effects changed over time. Multilevel survival models adjusted for individual factors indicated that neighborhood socioeconomic effects on ischemic heart disease mortality increased markedly between the two periods (hazard ratios for residing in the most vs. least deprived neighborhoods were 1.60 (95% credible interval: 1.36, 1.89) for the 1986 cohort and 2.54 (95% credible interval: 1.99, 3.21) for the 1996 cohort). Comparing the neighborhood socioeconomic effect with the strongly predictive effect of 15-year individual income indicated that the neighborhood effect was two times weaker than the individual effect in the 1986 cohort (-48%, 95% credible interval: -22%, -68%) but of comparable magnitude in the 1996 cohort (-11%, 95% credible interval: -42%, 29%). This increase in the contribution of neighborhood factors to the socioeconomic gradient in ischemic heart disease urges investigation into the exact mechanisms between the residential context and coronary health.
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| 16. |
- Chaix, Basile, et al.
(author)
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Spatial clustering of mental disorders and associated characteristics of the neighbourhood context in Malmo, Sweden, in 2001.
- 2006
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In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 60:5, s. 427-435
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Journal article (peer-reviewed)abstract
- Study objective: Previous research provides preliminary evidence of spatial variations of mental disorders and associations between neighbourhood social context and mental health. This study expands past literature by (1) using spatial techniques, rather than multilevel models, to compare the spatial distributions of two groups of mental disorders (that is, disorders due to psychoactive substance use, and neurotic, stress related, and somatoform disorders); and (2) investigating the independent impact of contextual deprivation and neighbourhood social disorganisation on mental health, while assessing both the magnitude and the spatial scale of these effects. Design: Using different spatial techniques, the study investigated mental disorders due to psychoactive substance use, and neurotic disorders. Participants: All 89285 persons aged 40-69 years residing in Malmo, Sweden, in 2001, geolocated to their place of residence. Main results: The spatial scan statistic identified a large cluster of increased prevalence in a similar location for the two mental disorders in the northern part of Malmo. However, hierarchical geostatistical models showed that the two groups of disorders exhibited a different spatial distribution, in terms of both magnitude and spatial scale. Mental disorders due to substance consumption showed larger neighbourhood variations, and varied in space on a larger scale, than neurotic disorders. After adjustment for individual factors, the risk of substance related disorders increased with neighbourhood deprivation and neighbourhood social disorganisation. The risk of neurotic disorders only increased with contextual deprivation. Measuring contextual factors across continuous space, it was found that these associations operated on a local scale. Conclusions: Taking space into account in the analyses permitted deeper insight into the contextual determinants of mental disorders.
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| 17. |
- Lynch, Kristian, et al.
(author)
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Context and disease when disease risk is low: the case of type 1 diabetes in Sweden
- 2010
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In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 64:9, s. 789-795
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Journal article (peer-reviewed)abstract
- Background Several European studies have found significant small area variation in the risk of childhood onset (type 1) diabetes (T1D) which has been interpreted as evidence for contextual determinants of T1D. However, this conclusion may be fallacious since the limited number of newborn infants and the low risk for T1D is a source of spurious variability not properly handled by usual statistical methods. This study investigates the existence of contextual effects in the genesis of T1D, compares conclusions in previous reports with results obtained in a multilevel regression framework and highlights analysis of variance as a useful approach in public health. Methods All singletons born in Sweden between 1987 and 1991 were identified in the Medical Birth Registry (n=560 766) and followed for diabetes until age 14 using the Hospital Discharge Registry. Area variation in the cumulative incidence of T1D was estimated by different statistical methods including multilevel logistic regression. Results The risk of T1D ranged from 4.3 to 6.5 per 1000 newborns across the counties (n=24) and from 0.0 to 19.2 per 1000 newborns across the municipalities (n=284). These differences were significant in standard statistical tests (counties, p=0.02; municipalities, p=0.007). However, according to multilevel analyses, the risk of T1D ranged from 4.7 to 5.7 and from 4.4 to 6.0 per 1000 newborns in counties and municipalities, respectively, and the area variation was small and without practical relevance (counties, sigma(2)=0.006; municipalities, sigma(2)=0.017). Conclusions Previous reports based on standard statistical tests are misleading. According to multilevel analysis, administrative areas have minor relevance for individual risk of T1D in Sweden.
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| 18. |
- Merlo, Juan, et al.
(author)
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A brief conceptual tutorial of multilevel analysis in social epidemiology: linking the statistical concept of clustering to the idea of contextual phenomenon.
- 2005
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In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 59:6, s. 443-449
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Journal article (peer-reviewed)abstract
- Study objective: This didactical essay is directed to readers disposed to approach multilevel regression analysis (MLRA) in a more conceptual than mathematical way. However, it specifically develops an epidemiological vision on multilevel analysis with particular emphasis on measures of health variation (for example, intraclass correlation). Such measures have been underused in the literature as compared with more traditional measures of association (for example, regression coefficients) in the investigation of contextual determinants of health. A link is provided, which will be comprehensible to epidemiologists, between MLRA and social epidemiological concepts, particularly between the statistical idea of clustering and the concept of contextual phenomenon. Design and participants: The study uses an example based on hypothetical data on systolic blood pressure (SBP) from 25 000 people living in 39 neighbourhoods. As the focus is on the empty MLRA model, the study does not use any independent variable but focuses mainly on SBP variance between people and between neighbourhoods. Results: The intraclass correlation (ICC = 0.08) informed of an appreciable clustering of individual SBP within the neighbourhoods, showing that 8% of the total individual differences in SBP occurred at the neighbourhood level and might be attributable to contextual neighbourhood factors or to the different composition of neighbourhoods. Conclusions: The statistical idea of clustering emerges as appropriate for quantifying "contextual phenomena" that is of central relevance in social epidemiology. Both concepts convey that people from the same neighbourhood are more similar to each other than to people from different neighbourhoods with respect to the health outcome variable.
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| 19. |
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| 20. |
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| 21. |
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| 22. |
- Merlo, Juan, et al.
(author)
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Individual and collective bodies: using measures of variance and association in contextual epidemiology.
- 2009
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In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 63, s. 1043-1048
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Journal article (peer-reviewed)abstract
- BACKGROUND: Social epidemiology investigates both individuals and their collectives. While the limits that define the individual bodies are very apparent, the collective body's geographical or cultural limits (e.g., "neighbourhood") are more difficult to discern. Also, epidemiologists normally investigate causation as changes in group means. However, many variables of interest in epidemiology may cause a change in the variance of the distribution of the dependent variable. In spite of that, variance is normally considered a measure of uncertainty or a nuisance rather than a source of substantive information. This reasoning is also true in many multilevel investigations, whereas understanding the distribution of variance across levels should be fundamental. This means-centric reductionism is mostly concerned with risk factors and creates a paradoxical situation, since social medicine is not only interested in increasing the (mean) health of the population, but also in understanding and decreasing inappropriate health and health care inequalities (variance). METHODS: Critical essay and literature review. RESULTS: The present essay promotes (a) the application of measures of variance and clustering to evaluate the boundaries one uses in defining collective levels of analysis (e.g., neighbourhoods), (b) the combined use of measures of variance and means-centric measures of association, and (c) the investigation of causes of health variation (variance-altering causation). CONCLUSIONS: Both measures of variance and means-centric measures of association need to be included when performing contextual analyses. The variance approach, a new aspect of contextual analysis that cannot be interpreted in means-centric terms, allows us to expand our perspectives.
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| 23. |
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| 24. |
- Merlo, Juan, et al.
(author)
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Revisiting causal neighborhood effects on individual ischemic heart disease risk: A quasi-experimental multilevel analysis among Swedish siblings.
- 2013
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In: Social Science and Medicine. - : Elsevier BV. - 1873-5347 .- 0277-9536. ; 76, s. 39-46
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Journal article (peer-reviewed)abstract
- Neighborhood socioeconomic disadvantage is associated to increased individual risk of ischemic heart disease (IHD). However, the value of this association for causal inference is uncertain. Moreover, neighborhoods are often defined by available administrative boundaries without evaluating in which degree these boundaries embrace a relevant socio-geographical context that condition individual differences in IHD risk. Therefore, we performed an analysis of variance, and also compared the associations obtained by conventional multilevel analyses and by quasi-experimental family-based design that provides stronger evidence for causal inference. Linking the Swedish Multi-Generation Register to several other national registers, we analyzed 184,931 families embracing 415,540 full brothers 45-64 years old in 2004, and residing in 8408 small-area market statistics (SAMS) considered as "neighborhoods" in our study. We investigated the association between low neighborhood income (categorized in groups by deciles) and IHD risk in the next four years. We distinguished between family mean and intrafamilial-centered low neighborhood income, which allowed us to investigate both unrelated individuals from different families and full brothers within families. We applied multilevel logistic regression techniques to obtain odds ratios (OR), variance partition coefficients (VPC) and 95% credible intervals (CI). In unrelated individuals a decile unit increase of low neighborhood income increased individual IHD risk (OR = 1.04, 95% CI: 1.03-1.07). In the intrafamilial analysis this association was reduced (OR = 1.02, 95% CI: 1.02-1.04). Low neighborhood income seems associated with IHD risk in middle-aged men. However, despite the family-based design, we cannot exclude residual confounding by genetic and non-shared environmental factors. Besides, the low neighborhood level VPC = 1.5% suggest that the SAMS are a rather inappropriate construct of the socio-geographic context that conditions individual variance in IHD risk. In contrast the high family level VPC = 20.1% confirms the relevance of the family context for understanding IHD risk.
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| 25. |
- Ohlsson, Henrik, et al.
(author)
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Socioeconomic position and secondary preventive therapy after an AMI.
- 2010
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In: Pharmacoepidemiology and Drug Safety. - : Wiley. - 1053-8569 .- 1099-1557. ; 19, s. 358-366
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Journal article (peer-reviewed)abstract
- PURPOSE: To investigate the association between socioeconomic position and use of lipid-lowering drugs and ACE-inhibitors after an acute myocardial infarction (AMI) when simultaneously considering participation in the national quality register RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive care Admissions), age, sex and previous hospitalizations of the patients. METHODS: Population-based prospective cohort study included all 1346 AMI patients cared in the county of Scania, Sweden during 2006 of whom 1061 were register at the RIKS-HIA. Treatment with lipid-lowering and ACE-inhibiting therapy in relation to income was investigated with Cox and logistic regression modelling. RESULTS: In the whole population of AMI patients, high income patients had a higher adherence to guidelines for pharmacological secondary prevention than low income patients (HR(lipid-lowering drug): 1.29; 95%CI: 1.12-1.49 and HR(ACE-inhibitor therapy): 1.22; 95%CI: 1.04-1.43). Among RIKS-HIA participants, patients with high income presented a better adherence to lipid-lowering treatment than patients with low income (HR: 1.15; 95%CI: 0.98-1.34). CONCLUSION: Our investigation reveals that the Swedish goal of access to health care on equal terms and according to needs is still not fully accomplished. Moreover, since this pattern of inequity in pharmacological secondary prevention may lead to the recurrence of heart disease, these inequities are not only a matter of fairness and social justice, but also a potential (and modifiable) source of ineffectiveness and inefficiency in health care. Copyright (c) 2010 John Wiley & Sons, Ltd.
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| 26. |
- Ohlsson, Henrik, et al.
(author)
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Therapeutic traditions, patient socioeconomic characteristics and physicians' early new drug prescribing-a multilevel analysis of rosuvastatin prescription in south Sweden.
- 2009
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In: European Journal of Clinical Pharmacology. - : Springer Science and Business Media LLC. - 1432-1041 .- 0031-6970. ; Oct 4., s. 141-150
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Journal article (peer-reviewed)abstract
- PURPOSE: To investigate the role that both patient and outpatient factors related to health care practice (HCP) play in physicians' early adoption of rosuvastatin. MATERIALS AND METHODS: Generalized estimation equations (GEEs) and alternating logistic regression (ALR) with pair-wise odds ratios (PWORs) were used to measure similarities in rosuvastatin prescription within HCPs for all individuals with statin prescriptions in Skåne region, Sweden. RESULTS: After 12 months, 53% of the HCPs had adopted the new statin. Rosuvastatin prescriptions co-occured within certain HCPs 3.56 times more often than one would have expected based on a random distribution. Private HCPs had four times higher probability of prescribing rosuvastatin than public HCPs. CONCLUSION: Contextual characteristics of the HCP seem to be relevant for understanding physicians' motivation to adopt rosuvastatin. Moreover, our study reveals inequity in health care as the socioeconomic status of the patients appears to influence the prescribing behavior of the physicians irrespective of medical reasons.
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| 27. |
- Rosvall, Maria, et al.
(author)
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Auditing patient registration in the Swedish quality register for acute coronary syndrome.
- 2010
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In: Scandinavian Journal of Public Health. - : SAGE Publications. - 1651-1905 .- 1403-4948. ; May 4, s. 533-540
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Journal article (peer-reviewed)abstract
- AIMS: The present study aims to quantify non-participation in the RIKS-HIA register during 2005 and to compare acute myocardial infarction (AMI) patients registered and not registered in RIKS-HIA, in relation to sociodemographic factors, prevalent disease, and 7-day and 30-day survival. METHODS: We linked information on sociodemographic characteristics, treatments, morbidity, and mortality from the LOMAS (Longitudinal Multilevel Analysis in Scania) database with the RIKS-HIA register. The study population consisted of individuals younger than 85 years living in Scania by 31 December 2004 who had one or more AMI during 2005 (n = 2968). RESULTS: The 70% of the AMI patients included in the register were generally younger, more often men, generally more healthy, more often had AMI as the main diagnosis, and more often underwent revascularisation procedures than AMI patients not included. Among both men (ORadjusted = 0.19; 95% CI 0.14-0.27) and women (ORadjusted = 0.30; 95% CI 0.20-0.44), registered patients had a lower 30-day mortality than patients not registered in RIKS-HIA. CONCLUSIONS: Even though RIKS-HIA conveys a clear quality improvement for the care of patients with acute coronary syndrome in Sweden, it is important to be aware that the register does not include the entire AMI population, but rather a selected and healthier population of AMI patients. This circumstance decreases the external validity of the information obtained from the RIKS-HIA register. Such an effect might be reduced over time and data from 2006 shows an inclusion rate of 76% among AMI patients aged less than 80 years.
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| 28. |
- Rosvall, Maria, et al.
(author)
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Contribution of main causes of death to social inequalities in mortality in the whole population of Scania, Sweden
- 2006
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In: BMC Public Health. - : Springer Science and Business Media LLC. - 1471-2458. ; 6:79
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Journal article (peer-reviewed)abstract
- Background: To more efficiently reduce social inequalities in mortality, it is important to establish which causes of death contribute the most to socioeconomic mortality differentials. Few studies have investigated which diseases contribute to existing socioeconomic mortality differences in specific age groups and none were in samples of the whole population, where selection bias is minimized. The aim of the present study was to determine which causes of death contribute the most to social inequalities in mortality in each age group in the whole population of Scania, Sweden. Methods: Data from LOMAS ( Longitudinal Multilevel Analysis in Skane) were used to estimate 12-year follow-up mortality rates across levels of socioeconomic position (SEP) and workforce participation in 975,938 men and women aged 0 to 80 years, during 1991 - 2002. Results: The results generally showed increasing absolute mortality differences between those holding manual and non-manual occupations with increasing age, while there were inverted u-shaped associations when using relative inequality measures. Cardiovascular diseases (CVD) contributed to 52% of the male socioeconomic difference in overall mortality, cancer to 18%, external causes to 4% and psychiatric disorders to 3%. The corresponding contributions in women were 55%, 21%, 2% and 3%. Additionally, those outside the workforce (i.e., students, housewives, disability pensioners, and the unemployed) showed a strongly increased risk of future mortality in all age groups compared to those inside the workforce. Even though coronary heart disease (CHD) played a major contributing role to the mortality differences seen, stroke and other types of cardiovascular diseases also made substantial contributions. Furthermore, while the most common types of cancers made substantial contributions to the socioeconomic mortality differences, in some age groups more than half of the differences in cancer mortality could be attributed to rarer cancers. Conclusion: CHD made a major contribution to the socioeconomic differences in overall mortality. However, there were also important contributions from diseases with less well understood mechanistic links with SEP such as stroke and less-common cancers. Thus, an increased understanding of the mechanisms connecting SEP with more rare causes of disease might be important to be able to more successfully intervene on socioeconomic differences in health.
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| 29. |
- Rosvall, Maria, et al.
(author)
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Similar support for three different life course socioeconomic models on predicting premature cardiovascular mortality and all-cause mortality
- 2006
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In: BMC Public Health. - : Springer Science and Business Media LLC. - 1471-2458. ; 6
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Journal article (peer-reviewed)abstract
- Background: There are at least three broad conceptual models for the impact of the social environment on adult disease: the critical period, social mobility, and cumulative life course models. Several studies have shown an association between each of these models and mortality. However, few studies have investigated the importance of the different models within the same setting and none has been performed in samples of the whole population. The purpose of the present study was to study the relation between socioeconomic position (SEP) and mortality using different conceptual models in the whole population of Scania. Methods: In the present investigation we use socioeconomic information on all men (N = 48,909) and women ( N = 47,688) born between 1945 and 1950, alive on January, 1(st), 1990, and living in the Region of Scania, in Sweden. Focusing on three specific life periods (i.e., ages 10 - 15, 30 - 35 and 40 - 45), we examined the association between SEP and the 12-year risk of premature cardiovascular mortality and all-cause mortality. Results: There was a strong relation between SEP and mortality among those inside the workforce, irrespective of the conceptual model used. There was a clear upward trend in the mortality hazard rate ratios (HRR) with accumulated exposure to manual SEP in both men ( p for trend < 0.001 for both cardiovascular and all-cause mortality) and women ( p for trend = 0.01 for cardiovascular mortality) and ( p for trend = 0.003 for all-cause mortality). Inter- and intragenerational downward social mobility was associated with an increased mortality risk. When applying similar conceptual models based on workforce participation, it was shown that mortality was affected by the accumulated exposure to being outside the workforce. Conclusion: There was a strong relation between SEP and cardiovascular and all-cause mortality, irrespective of the conceptual model used. The critical period, social mobility, and cumulative life course models, showed the same fit to the data. That is, one model could not be pointed out as "the best" model and even in this large unselected sample it was not possible to adjudicate which theories best describe the links between life course SEP and mortality risk.
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| 30. |
- Rosvall, Maria, et al.
(author)
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The association between socioeconomic position, use of revascularization procedures and five-year survival after recovery from acute myocardial infarction
- 2008
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In: BMC Public Health. - : Springer Science and Business Media LLC. - 1471-2458. ; 8:44
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Journal article (peer-reviewed)abstract
- Background: Patients living under better socioeconomic circumstances often receive more active treatments after an acute myocardial infarction ( AMI) compared to less affluent patients. However, most previous studies were performed in countries with less comprehensive coverage for medical services. In this Swedish nation- wide longitudinal study we wanted to evaluate long- term survival after AMI in relation to socioeconomic position ( SEP) and use of revascularization. Methods: From the Swedish Myocardial Infarction Register we identified all 45 to 84- year- old patients ( 16,041 women and 30,366 men) alive 28 days after their first AMI during the period 1993 to 1996. We obtained detailed information on the use of revascularization, cumulative household income from the 1975 and 1990 censuses and 5- year survival after the AMI. Results: Patients with the highest cumulative income ( adding the values of the quartile categories of income in 1975 and 1990) underwent a revascularization procedure within one month after their first AMI two to three times as often as patients with the lowest cumulative income and had half the risk of death within five years. The socioeconomic differences in the use of revascularization procedures could not be explained by differences in co- morbidity or type of hospital at first admission. Patients who underwent revascularization showed a similar lowered mortality risk in the different income groups, while there were strong socioeconomic differences in long- term mortality among patients who did not undergo revascularization. Conclusion: This nationwide Swedish study showed that patients with high income had a better long- term survival after recovery from their AMI compared to patients with low income. Furthermore, even though the use of revascularization procedures is beneficial, low SEP groups receive it less often than high SEP groups.
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