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1.	Adlercreutz, Emma, et al. (author) Perinatal risk factors increase the risk of being affected by both type 1 diabetes and celiac disease. 2015 In: Acta Pædiatrica. - : Wiley. - 1651-2227 .- 0803-5253. ; 104:2, s. 178-184 Journal article (peer-reviewed)abstract This study investigated whether perinatal factors influenced the risk of a double diagnosis of type 1 diabetes and celiac disease.
2.	Ali, Sadiq Mohammad, et al. (author) Gender differences in daily smoking prevalence in different age strata: A population-based study in southern Sweden. 2009 In: Scandinavian Journal of Public Health. - : SAGE Publications. - 1651-1905 .- 1403-4948. ; 37:2, s. 146-152 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.
3.	Ali, Sadiq Mohammad, et al. (author) Social capital, the miniaturisation of community, traditionalism and first time acute myocardial infarction: A prospective cohort study in southern Sweden. 2006 In: Social Science and Medicine. - : Elsevier BV. - 1873-5347 .- 0277-9536. ; 63:8, s. 2204-2217 Journal article (peer-reviewed)abstract This longitudinal study investigates the impact of social participation, trust and the combinations of social participation and trust on the incidence of first time acute myocardial infarction (AMI) in the population of Scania, southern Sweden. It is based on the cross-sectional 2000 public-health survey in Scania with a 59% participation rate and 13,604 participants, and prospective morbidity/mortality data collected for three years (January 2000-December 2002). The study cohort was followed prospectively to examine first ever AMI Hazard rate ratios (HRR) for first time AMI in the social participation, trust and social participation/trust combinations were calculated in a Cox regression model with adjustments for age, sex, education, economic stress, daily smoking, leisure time physical activity, body mass index (BMI), and self-reported health. The prevalence of low social participation was 32.8% among men and 31.5% among women. The prevalence of low trust was 40.0% among men and 44.2% among women. The three-year first time AMI rate was significantly higher among people with higher age, low education, daily smoking, poor self-reported health (among men), low social participation, and the combinations of low social participation/high trust and low social participation/low trust. The results show that low social participation but not trust was significantly associated with first time AMI after adjustment for age and sex. The positive association between low social participation and myocardial infarction remained significant after further adjustments for education, economic stress, daily smoking, physical activity and BMI, and became not significant only after additional adjustment for self-reported health, HRR 1.3 (0.9-2.0). High trust in combination with low social participation as well as low social capital (low trust/low social participation) were significantly associated with AMI, but after multiple adjustments only the low social participation/high trust category remained significant, HRR 1.6 (1.0-2.6).
4.	Ammirati, Enrico, et al. (author) Acute Myocarditis Associated With Desmosomal Gene Variants 2022 In: JACC. Heart failure. - : ELSEVIER SCI LTD. - 2213-1779 .- 2213-1787. ; 10:10, s. 714-727 Journal article (peer-reviewed)abstract BACKGROUND The risk of adverse cardiovascular events in patients with acute myocarditis (AM) and desmosomal gene variants (DGV) remains unknown.OBJECTIVES The purpose of this study was to ascertain the risk of death, ventricular arrhythmias, recurrent myocarditis, and heart failure (main endpoint) in patients with AM and pathogenic or likely pathogenetic DGV.METHODS In a retrospective international study from 23 hospitals, 97 patients were included: 36 with AM and DGV (DGV[+]), 25 with AM and negative gene testing (DGV[-]), and 36 with AM without genetics testing. All patients had troponin elevation plus findings consistent with AM on histology or at cardiac magnetic resonance (CMR). In 86 patients, CMR changes in function and structure were re-assessed at follow-up.RESULTS In the DGV(+) AM group (88.9% DSP variants), median age was 24 years, 91.7% presented with chest pain, and median left ventricular ejection fraction (LVEF) was 56% on CMR (P = NS vs the other 2 groups). Kaplan-Meier curves demonstrated a higher risk of the main endpoint in DGV(+) AM compared with DGV(-) and without genetics testing patients (62.3% vs 17.5% vs 5.3% at 5 years, respectively; P < 0.0001), driven by myocarditis recurrence and ventricular arrhythmias. At follow-up CMR, a higher number of late gadolinium enhanced segments was found in DGV(+) AM. CONCLUSIONS Patients with AM and evidence of DGV have a higher incidence of adverse cardiovascular events compared with patients with AM without DGV. Further prospective studies are needed to ascertain if genetic testing might improve risk stratification of patients with AM who are considered at low risk. (J Am Coll Cardiol HF 2022;10:714-727) (c) 2022 by the American College of Cardiology Foundation.
5.	Austin, Peter C, et al. (author) Intermediate and advanced topics in multilevel logistic regression analysis 2017 In: Statistics in Medicine. - : Wiley. - 1097-0258 .- 0277-6715. ; 36:20, s. 3257-3277 Journal article (peer-reviewed)abstract Multilevel data occur frequently in health services, population and public health, and epidemiologic research. In such research, binary outcomes are common. Multilevel logistic regression models allow one to account for the clustering of subjects within clusters of higher-level units when estimating the effect of subject and cluster characteristics on subject outcomes. A search of the PubMed database demonstrated that the use of multilevel or hierarchical regression models is increasing rapidly. However, our impression is that many analysts simply use multilevel regression models to account for the nuisance of within-cluster homogeneity that is induced by clustering. In this article, we describe a suite of analyses that can complement the fitting of multilevel logistic regression models. These ancillary analyses permit analysts to estimate the marginal or population-average effect of covariates measured at the subject and cluster level, in contrast to the within-cluster or cluster-specific effects arising from the original multilevel logistic regression model. We describe the interval odds ratio and the proportion of opposed odds ratios, which are summary measures of effect for cluster-level covariates. We describe the variance partition coefficient and the median odds ratio which are measures of components of variance and heterogeneity in outcomes. These measures allow one to quantify the magnitude of the general contextual effect. We describe an R(2) measure that allows analysts to quantify the proportion of variation explained by different multilevel logistic regression models. We illustrate the application and interpretation of these measures by analyzing mortality in patients hospitalized with a diagnosis of acute myocardial infarction. © 2017 The Authors. Statistics in Medicine published by John Wiley & Sons Ltd.
6.	Austin, Peter C, et al. (author) Measures of clustering and heterogeneity in multilevel Poisson regression analyses of rates/count data 2018 In: Statistics in Medicine. - : Wiley. - 1097-0258 .- 0277-6715. ; 37:4, s. 572-589 Journal article (peer-reviewed)abstract Multilevel data occur frequently in many research areas like health services research and epidemiology. A suitable way to analyze such data is through the use of multilevel regression models. These models incorporate cluster-specific random effects that allow one to partition the total variation in the outcome into between-cluster variation and between-individual variation. The magnitude of the effect of clustering provides a measure of the general contextual effect. When outcomes are binary or time-to-event in nature, the general contextual effect can be quantified by measures of heterogeneity like the median odds ratio or the median hazard ratio, respectively, which can be calculated from a multilevel regression model. Outcomes that are integer counts denoting the number of times that an event occurred are common in epidemiological and medical research. The median (incidence) rate ratio in multilevel Poisson regression for counts that corresponds to the median odds ratio or median hazard ratio for binary or time-to-event outcomes respectively is relatively unknown and is rarely used. The median rate ratio is the median relative change in the rate of the occurrence of the event when comparing identical subjects from 2 randomly selected different clusters that are ordered by rate. We also describe how the variance partition coefficient, which denotes the proportion of the variation in the outcome that is attributable to between-cluster differences, can be computed with count outcomes. We illustrate the application and interpretation of these measures in a case study analyzing the rate of hospital readmission in patients discharged from hospital with a diagnosis of heart failure.
7.	Austin, Peter C., et al. (author) The median hazard ratio : a useful measure of variance and general contextual effects in multilevel survival analysis 2017 In: Statistics in Medicine. - : WILEY. - 0277-6715 .- 1097-0258. ; 36:6, s. 928-938 Journal article (peer-reviewed)abstract Multilevel data occurs frequently in many research areas like health services research and epidemiology. A suitable way to analyze such data is through the use of multilevel regression models (MLRM). MLRM incorporate cluster-specific random effects which allow one to partition the total individual variance into between-cluster variation and between-individual variation. Statistically, MLRM account for the dependency of the data within clusters and provide correct estimates of uncertainty around regression coefficients. Substantively, the magnitude of the effect of clustering provides a measure of the General Contextual Effect (GCE). When outcomes are binary, the GCE can also be quantified by measures of heterogeneity like the Median Odds Ratio (MOR) calculated from a multilevel logistic regression model. Time-to-event outcomes within a multilevel structure occur commonly in epidemiological and medical research. However, the Median Hazard Ratio (MHR) that corresponds to the MOR in multilevel (i.e., 'frailty') Cox proportional hazards regression is rarely used. Analogously to the MOR, the MHR is the median relative change in the hazard of the occurrence of the outcome when comparing identical subjects from two randomly selected different clusters that are ordered by risk. We illustrate the application and interpretation of the MHR in a case study analyzing the hazard of mortality in patients hospitalized for acute myocardial infarction at hospitals in Ontario, Canada. We provide R code for computing the MHR. The MHR is a useful and intuitive measure for expressing cluster heterogeneity in the outcome and, thereby, estimating general contextual effects in multilevel survival analysis.
8.	Axelsson Fisk, Sten, et al. (author) Absolute rather than relative income is a better socioeconomic predictor of chronic obstructive pulmonary disease in Swedish adults 2017 In: International Journal for Equity in Health. - : Springer Science and Business Media LLC. - 1475-9276. ; 16:1 Journal article (peer-reviewed)abstract BACKGROUND: While psychosocial theory claims that socioeconomic status (SES), acting through social comparisons, has an important influence on susceptibility to disease, materialistic theory says that socioeconomic position (SEP) and related access to material resources matter more. However, the relative role of SEP versus SES in chronic obstructive pulmonary disease (COPD) risk has still not been examined.METHOD: We investigated the association between SES/SEP and COPD risk among 667 094 older adults, aged 55 to 60, residing in Sweden between 2006 and 2011. Absolute income in five groups by population quintiles depicted SEP and relative income expressed as quintile groups within each absolute income group represented SES. We performed sex-stratified logistic regression models to estimate odds ratios and the area under the receiver operator curve (AUC) to compare the discriminatory accuracy of SES and SEP in relation to COPD.RESULTS: Even though both absolute (SEP) and relative income (SES) were associated with COPD risk, only absolute income (SEP) presented a clear gradient, so the poorest had a three-fold higher COPD risk than the richest individuals. While the AUC for a model including only age was 0.54 and 0.55 when including relative income (SES), it increased to 0.65 when accounting for absolute income (SEP). SEP rather than SES demonstrated a consistent association with COPD.CONCLUSIONS: Our study supports the materialistic theory. Access to material resources seems more relevant to COPD risk than the consequences of low relative income.
9.	Axelsson Fisk, Sten, et al. (author) Chronic Obstructive Pulmonary Disease in Sweden: an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy 2018 In: SSM - Population Health. - : Elsevier BV. - 2352-8273. ; 4, s. 334-346 Journal article (peer-reviewed)abstract Socioeconomic, ethnic and gender disparities in Chronic Obstructive Pulmonary Disease (COPD) risk are well established but no studies have applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) within an intersectional framework to study this outcome. We study individuals at the first level of analysis and combinations of multiple social and demographic categorizations (i.e., intersectional strata) at the second level of analysis. Here we used MAIHDA to assess to what extent individual differences in the propensity of developing COPD are at the intersectional strata level. We also used MAIHDA to determine the degree of similarity in COPD incidence of individuals in the same intersectional stratum. This leads to an improved understanding of risk heterogeneity and of the social dynamics driving socioeconomic and demographic disparities in COPD incidence. Using data from 2,445,501 residents in Sweden aged 45–65, we constructed 96 intersectional strata combining categories of age, gender, income, education, civil- and migration status. The incidences of COPD ranged from 0.02% for young, native males with high income and high education who cohabited to 0.98% for older native females with low income and low education who lived alone. We calculated the intra-class correlation coefficient (ICC) that informs on the discriminatory accuracy of the categorizations. In a model that conflated additive and interaction effects, the ICC was good (20.0%). In contrast, in a model that measured only interaction effects, the ICC was poor (1.1%) suggesting that most of the observed differences in COPD incidence across strata are due to the main effects of the categories used to construct the intersectional matrix while only a minor share of the differences are attributable to intersectional interactions. We found conclusive interaction effects. The intersectional MAIHDA approach offers improved information to guide public health policies in COPD prevention, and such policies should adopt an intersectional perspective.
10.	Axelsson Fisk, Sten, et al. (author) Understanding the complexity of socioeconomic disparities in smoking prevalence in sweden : A cross-sectional study applying intersectionality theory 2021 In: BMJ Open. - : BMJ. - 2044-6055. ; 11:2 Journal article (peer-reviewed)abstract Objectives Socioeconomic disparities in smoking prevalence remain a challenge to public health. The objective of this study was to present a simple methodology that displays intersectional patterns of smoking and quantify heterogeneities within groups to avoid inappropriate and potentially stigmatising conclusions exclusively based on group averages. Setting This is a cross-sectional observational study based on data from the National Health Surveys for Sweden (2004-2016 and 2018) including 136 301 individuals. We excluded people under 30 years of age, or missing information on education, household composition or smoking habits. The final sample consisted on 110 044 individuals or 80.7% of the original sample. Outcome Applying intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA), we investigated the risk of self-reported smoking across 72 intersectional strata defined by age, gender, educational achievement, migration status and household composition. Results The distribution of smoking habit risk in the population was very heterogeneous. For instance, immigrant men aged 30-44 with low educational achievement that lived alone had a prevalence of smoking of 54% (95% CI 44% to 64%), around nine times higher than native women aged 65-84 with high educational achievement and living with other(s) that had a prevalence of 6% (95% CI 5% to 7%). The discriminatory accuracy of the information was moderate. Conclusion A more detailed, intersectional mapping of the socioeconomic and demographic disparities of smoking can assist in public health management aiming to eliminate this unhealthy habit from the community. Intersectionality theory together with AIHDA provides information that can guide resource allocation according to the concept proportionate universalism.
11.	Beckman, Anders, et al. (author) Country of birth, socioeconomic position, and health care expenditure― a multilevel analysis of the city of Malmö, Sweden 2004 In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 58:2, s. 145-149 Journal article (peer-reviewed)abstract Study objective: The principle of equity aims to guarantee allocation of healthcare resources on the basis of need. Therefore, people with a low income and persons living alone are expected to have higher healthcare expenditures. Besides these individual characteristics healthcare expenditure may be influenced by country of birth. This study therefore aimed to investigate the role of country of birth in explaining individual healthcare expenditure.Design: Multilevel regression model based on individuals (first level) and their country of birth (second level).Setting: The city of Malmö, Sweden.Participants: All the 52 419 men aged 40–80 years from 130 different countries of birth, who were living in Malmö, Sweden, during 1999.Main results: At the individual level, persons with a low income and persons living alone showed a higher healthcare expenditure, with regression coefficients (and 95% confidence intervals) being 0.358 (0.325 to 0.392) and 0.197 (0.165 to 0.230), respectively. Country of birth explained a considerable part (18% and 13%) of the individual differences in the probability of having a low income and living alone, respectively. However, this figure was only 3% for having some health expenditure, and barely 0.7% with regard to costs in the 74% of the population with some health expenditure.Conclusions: Malmö is a socioeconomically segregated city, in which the country of birth seems to play only a minor part in explaining individual differences in total healthcare expenditure. These differences seem instead to be determined by individual low income and living alone.
12.	Beckman, Anders, et al. (author) The role country of birth plays in receiving disability pensions in relation to patterns of health care utilisation and socioeconomic differences: a multilevel analysis of Malmo, Sweden 2006 In: BMC Public Health. - : Springer Science and Business Media LLC. - 1471-2458. ; 6 Journal article (peer-reviewed)abstract Background: People of low socioeconomic status have worse health and a higher probability of being granted a disability pension than people of high socioeconomic status. It is also known that public and private general physicians and public and private specialists have varying practices for issuing sick leave certificates ( which, if longstanding, may become the basis of disability pensions). However, few studies have investigated the influence of a patient's country of birth in this context. Methods: We used multilevel logistic regression analysis with individuals ( first level) nested within countries of birth ( second level). We analysed the entire population between the ages of 40 and 64 years ( n = 80 212) in the city of Malmo, Sweden, in 2003, and identified 73% of that population who had visited a physician at least once during that year. We studied the associations between individuals and country of birth socioeconomic characteristics, as well as individual utilisation of different kinds of physicians in relation to having been granted a disability pension. Results: Living alone ( ORwomen = 1.72, 95% CI: 1.62 - 1.82; ORmen = 2.64, 95% CI: 2.46 - 2.83) and having limited educational achievement (ORwomen = 2.14, 95% CI: 2.00 - 2.29; ORmen = 2.12, 95% CI: 1.98 - 2.28) were positively associated with having a disability pension. Utilisation of public specialists was associated with a higher probability (ORwomen = 2.11, 95% CI: 1.98 - 2.25; ORmen = 2.16, 95% CI: 2.01 - 2.32) and utilisation of private GPs with a lower probability (ORmen = 0.76, 95% CI: 0.69 - 0.83) of having a disability pension. However, these associations differed by countries of birth. Over and above individual socioeconomic status, men from middle income countries had a higher probability of having a disability pension (ORmen = 1.61, 95% CI: 1.06 - 2.44). Conclusion: The country of one's birth appears to play a significant role in understanding how individual socioeconomic differences bear on the likelihood of receiving a disability pension and on associated patterns of health care utilisation.
13.	Bjerkeli, Pernilla J., et al. (author) Overuse of methylphenidate : an analysis of Swedish pharmacy dispensing data 2018 In: Clinical Epidemiology. - : Dove Press. - 1179-1349. ; 10, s. 1657-1665 Journal article (peer-reviewed)abstract Purpose: To identify overuse of methylphenidate and to investigate patterns of overuse in relation to sociodemographic and clinical characteristics. Patients and methods: Swedish national, pharmacy dispensing data were analyzed for all 56,922 individuals aged 6-79 years, who filled a methylphenidate prescription between 2010 and 2011. Overuse was defined as having above 150% days covered by the dispensed amount during 365 days from the first prescription fill, assuming use at the maximum recommended daily dose. Results: In total, 4,304 individuals (7.6% of the methylphenidate users) were categorized as overusers. The risk of overuse increased with age (OR for 46-65 years vs 6-12 years 17.5, 95% CI 14.3-21.3), and was higher in men (OR 1.4, 95% CI 1.3-1.5) and individuals with low income (OR 1.1, 95% CI 1.0-1.2), as well as in individuals with an attention deficit hyperactivity disorder (ADHD) diagnosis (OR 1.4, 95% CI 1.3-1.6), health care visits (OR 1.3, 95% CI 1.2-1.4), previous ADHD medication use (OR 2.6, 95% CI 2.4-2.8), and previous diagnosis of mental and behavioral disorders due to psychoactive substance use (OR 2.1 95% CI 2.0-2.3). Conclusion: Among individuals using methylphenidate in Sweden, 7.6% receive amounts that are larger than what they should have a medical need for, assuming that they were using the maximum recommended daily dose 365 days per year. Notably, the prevalence of overuse was associated with previous diagnosis of alcohol and drug misuse. The prevalence was also positively associated with higher age and previous use of ADHD medication. These findings may point toward a link between exposure time and overuse. However, future studies with long-term data are needed to investigate this.
14.	Bjerkeli, Pernilla J., et al. (author) Sociodemographic patterns in pharmacy dispensing of medications for erectile dysfunction in Sweden 2018 In: European Journal of Clinical Pharmacology. - : Springer. - 0031-6970 .- 1432-1041. ; 74:2, s. 209-218 Journal article (peer-reviewed)abstract PURPOSE: The purpose of this study is to investigate the relationship between sociodemographic factors and pharmacy dispensing of medications for erectile dysfunction (ED) in the general population of middle-aged and elderly men. By considering a number of medical conditions that could promote or contraindicate use of ED medication, the analysis could help capture prescription patterns that might not be explained by medical needs.METHODS: Individual-level pharmacy dispensing data from 2006 for a population-based cohort of 216,148 men aged 45-79 years in the county Scania, Sweden, were analysed. Multiple logistic regression was applied, and area under the receiver operating characteristic curve (AUC) was calculated to quantify the discriminatory accuracy (DA) of the associations. National trends in pharmacy dispensing of ED medication between 2006 and 2016 were also analysed.RESULTS: Pharmacy dispensing of ED medication increased between 2006 and 2016, particularly among men aged 65-79 years (from 6.8 to 9.2%). Dispensing of ED medication was positively associated with higher socioeconomic position, and divorced and widowed men were more likely to fill a prescription with ED medication than married men. These associations remained after adjusting for medical conditions. The DA of the associations was, however, rather low (AUC = 0.69 among 45-64 year olds and AUC = 0.65 among 65-79 year olds).CONCLUSIONS: Pharmacy dispensing of ED medication seem linked to the individuals socioeconomic position, age and marital status suggesting sociodemographic disparities in the pharmacy dispensing targeting sexual function. However, the low DA of the associations shows the limited capacity of these factors to predict ED medication use at the individual level.
15.	Bjerkeli, Pernilla J., et al. (author) Testosterone prescribing in the population — a short social epidemiological analysis in Sweden 2016 In: Pharmacoepidemiology and Drug Safety. - : Wiley. - 1053-8569 .- 1099-1557. ; 25:1, s. 11-15 Journal article (peer-reviewed)abstract PURPOSE: In recent years, there has been an increased interest for use of pharmaceutical testosterone among elderly men. However, it is still scarcely studied if this use is conditioned by socioeconomic factors in the general population of elderly men.METHODS: Using individual-level data from a population-based cohort of men aged 65-84 years in the County Scania, Sweden, we analysed testosterone use in 2006 in relation to demographic and socioeconomic factors by means of multiple logistic regression. We also analysed national data at the ecological level to investigate trends in prescribing between 2006 and 2014.RESULTS: The prevalence of testosterone use in Sweden among 65- to 84-year-old men increased by 83%, from 3.3 per 1000 men in 2006 to 6.0 in 2014. Testosterone use was more than twice as common in men in the highest income quintile compared with those in the lowest (0.68% versus 0.25%, odds ratio 2.69 and 95% confidence interval 1.80-4.02). Besides in the high-income group, testosterone use was highest in 65- to 69-year-old men, divorced men and, specially, in men with a previous hospital diagnose of hypogonadism.CONCLUSIONS: Our findings show socioeconomic inequities in prescription of testosterone. This is a short analysis based on limited data, but because information on this topic is scarce, our analysis adds a relevant piece of evidence and highlights the need for further research.
16.	Bøg-Hansen, Erik, et al. (author) Survival in patients with hypertension treated in primary care. A population-based follow-up study in the Skaraborg Hypertension and Diabetes Project. 2004 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 22:4, s. 222-227 Journal article (peer-reviewed)
17.	Cantarero Arevalo, Lourdes, et al. (author) Ethnic differences in asthma treatment among Swedish adolescents: A multilevel analysis of individual heterogeneity. 2016 In: Scandinavian Journal of Public Health. - : SAGE Publications. - 1651-1905 .- 1403-4948. ; 44:2, s. 94-184 Journal article (peer-reviewed)abstract Adolescents with immigrant or ethnic minority background suffering from asthma receive on average less appropriate anti-asthmatic medication (AAM) than the majority population. However, those findings are based on analyses of differences between group averages which prevents our understanding of individual heterogeneity around the averages. Taking into account individual socioeconomic factors and medical needs, we performed multilevel analysis in order to evaluate if maternal country of birth (MCOB) accurately identifies adolescents with inappropriate AAM use.
18.	Carlsson, Frida, et al. (author) Representativity of a postal public health questionnaire survey in Sweden, with special reference to ethnic differences in participation 2006 In: Scandinavian Journal of Public Health. - : SAGE Publications. - 1651-1905 .- 1403-4948. ; 34:2, s. 132-139 Journal article (peer-reviewed)abstract AIM: Non-participation in health surveys is a common phenomenon. When differences between participants and non-participants are considerable, the external validity of the sample survey may decrease and false conclusions might be drawn about the health status of the population. For this reason, the authors aimed to investigate the representativity of a postal questionnaire survey performed in the county of Scania, Sweden, in 1999-2000. The survey, which was based on an 18- to 80-year-old population sample, had a 58% response rate (n = 13 604).METHODS: For some variables, the information obtained using the questionnaire was compared with information obtained from a population register that covers all the population in the county (for the 18- to 80-year-old group, n = 850 476). The population register includes, among other data, information on age, gender, educational level, country of birth, and healthcare expenditure.RESULTS: Men, individuals with a low level of education, and immigrants were under-represented in the survey. However, except for immigrants, the under-representation was not large. Among immigrants, particularly those born in former Yugoslavia, the Arabic-speaking countries, and Poland were very significantly under-represented in the study. By contrast, immigrants born in other Nordic countries had responded to almost the same extent as respondents born in Sweden. The survey sample had about the same healthcare utilization costs as did the general population.CONCLUSIONS: In summary, the "Health Survey for Scania, 2000" seems largely representative of the total Scanian population. A major concern, however, is the under-representation of the immigrant population.
19.	Chaix, Basile, et al. (author) A GPS-Based Methodology to Analyze Environment-Health Associations at the Trip Level : Case-Crossover Analyses of Built Environments and Walking 2016 In: American Journal of Epidemiology. - : Oxford University Press (OUP). - 0002-9262 .- 1476-6256. ; 184:8, s. 570-578 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.
20.	Chaix, Basile, et al. (author) An Interactive Mapping Tool to Assess Individual Mobility Patterns in Neighborhood Studies 2012 In: American Journal of Preventive Medicine. - : Elsevier BV. - 0749-3797. ; 43:4, s. 440-450 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
21.	Chaix, Basile, et al. (author) 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 In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 61:4, s. 349-355 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.
22.	Chaix, Basile, et al. (author) Associations of Supermarket Characteristics with Weight Status and Body Fat: A Multilevel Analysis of Individuals within Supermarkets (RECORD Study) 2012 In: PLoS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 7:4 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.
23.	Chaix, Basile, et al. (author) Children's exposure to nitrogen dioxide in Sweden: investigating environmental injustice in an egalitarian country. 2006 In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 60:3, s. 234-241 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.
24.	Chaix, Basile, et al. (author) Cohort Profile: Residential and non-residential environments, individual activity spaces and cardiovascular risk factors and diseases--The RECORD Cohort Study. 2012 In: International Journal of Epidemiology. - : Oxford University Press (OUP). - 1464-3685 .- 0300-5771. ; 41:5, s. 1283-1292 Journal article (peer-reviewed)
25.	Chaix, Basile, et al. (author) Commentary: Weighing up the Dead and Missing: Reflections on Inverse-probability Weighting and Principal Stratification to Address Truncation by Death. 2012 In: Epidemiology. - 1531-5487. ; 23:1, s. 129-131 Journal article (peer-reviewed)
26.	Chaix, B, et al. (author) Comparison of a spatial approach with the multilevel approach for investigating place effects on health: the example of healthcare utilisation in France 2005 In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 59:6, s. 517-526 Journal article (peer-reviewed)abstract Study objective: Most studies of place effects on health have followed the multilevel analytical approach that investigates geographical variations of health phenomena by fragmenting space into arbitrary areas. This study examined whether analysing geographical variations across continuous space with spatial modelling techniques and contextual indicators that capture space as a continuous dimension surrounding individual residences provided more relevant information on the spatial distribution of outcomes. Healthcare utilisation in France was taken as an illustrative example in comparing the spatial approach with the multilevel approach. Design: Multilevel and spatial analyses of cross sectional data. Participants: 10 955 beneficiaries of the three principal national health insurance funds, surveyed in 1998 and 2000 on continental France. Main results: Multilevel models showed significant geographical variations in healthcare utilisation. However, the Moran's I statistic showed spatial autocorrelation unaccounted for by multilevel models. Modelling the correlation between people as a decreasing function of the spatial distance between them, spatial mixed models gave information not only on the magnitude, but also on the scale of spatial variations, and provided more accurate standard errors for risk factors effects. The socioeconomic level of the residential context and the supply of physicians were independently associated with healthcare utilisation. Place indicators better explained spatial variations in healthcare utilisation when measured across continuous space, rather than within administrative areas. Conclusions: The kind of conceptualisation of space during analysis influences the understanding of place effects on health. In many contextual studies, viewing space as a continuum may yield more relevant information on the spatial distribution of outcomes.
27.	Chaix, Basile, et al. (author) Comparison of a Spatial Perspective with the Multilevel Analytical Approach in Neighborhood Studies: The Case of Mental and Behavioral Disorders due to Psychoactive Substance Use in Malmo, Sweden, 2001. 2005 In: American Journal of Epidemiology. - : Oxford University Press (OUP). - 0002-9262 .- 1476-6256. ; 162:2, s. 171-182 Journal article (peer-reviewed)
28.	Chaix, Basile, et al. (author) Disentangling contextual effects on cause-specific mortality in a longitudinal 23-year follow-up study: impact of population density or socioeconomic environment? 2006 In: International Journal of Epidemiology. - : Oxford University Press (OUP). - 1464-3685 .- 0300-5771. ; 35:3, s. 633-643 Journal article (peer-reviewed)
29.	Chaix, Basile, et al. (author) Income change at retirement, neighbourhood-based social support, and ischaemic heart disease: Results from the prospective cohort study "Men born in 1914" 2007 In: Social Science and Medicine. - : Elsevier BV. - 1873-5347 .- 0277-9536. ; 64:4, s. 818-829 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.
30.	Chaix, Basile, et al. (author) Neighborhood socioeconomic deprivation and residential instability - Effects on incidence of ischemic heart disease and survival after myocardial inforction 2007 In: Epidemiology. - : Ovid Technologies (Wolters Kluwer Health). - 1531-5487 .- 1044-3983. ; 18:1, s. 104-111 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).
31.	Chaix, Basile, et al. (author) Neighbourhood social interactions and risk of acute myocardial infarction. 2008 In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 62:1, s. 62-68 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.
32.	Chaix, Basile, et al. (author) Neighbourhoods in eco-epidemiologic research: Delimiting personal exposure areas. A response to Riva, Gauvin, Apparicio and Brodeur 2009 In: Social Science and Medicine. - : Elsevier BV. - 1873-5347 .- 0277-9536. ; 69:9, s. 1306-1310 Journal article (other academic/artistic)
33.	Chaix, B, et al. (author) Re: "Detecting patterns of occupational illness clustering with alternating logistic regressions applied to longitudinal data" 2004 In: American Journal of Epidemiology. - : Oxford University Press (OUP). - 0002-9262 .- 1476-6256. ; 160:5, s. 505-506 Journal article (other academic/artistic)
34.	Chaix, Basile, et al. (author) Recent Increase of Neighborhood Socioeconomic Effects on Ischemic Heart Disease Mortality: A Multilevel Survival Analysis of Two Large Swedish Cohorts. 2007 In: American Journal of Epidemiology. - : Oxford University Press (OUP). - 0002-9262 .- 1476-6256. ; 165, s. 22-26 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.
35.	Chaix, Basile, et al. (author) Spatial clustering of mental disorders and associated characteristics of the neighbourhood context in Malmo, Sweden, in 2001. 2006 In: Journal of Epidemiology and Community Health. - : BMJ. - 1470-2738 .- 0143-005X. ; 60:5, s. 427-435 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.
36.	Comendeiro-Maaløe, Micaela, et al. (author) Acknowledging the role of patient heterogeneity in hospital outcome reporting : Mortality after acute myocardial infarction in five European countries 2020 In: PLoS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 15:2, s. 0228425-0228425 Journal article (peer-reviewed)abstract BACKGROUND: Hospital performance, presented as the comparison of average measurements, dismisses that hospital outcomes may vary across types of patients. We aim at drawing out the relevance of accounting for patient heterogeneity when reporting on hospital performance.METHODS: An observational study on administrative data from virtually all 2009 hospital admissions for Acute Myocardial Infarction (AMI) discharged in Denmark, Portugal, Slovenia, Spain, and Sweden. Hospital performance was proxied using in-hospital risk-adjusted mortality. Multilevel Regression Modelling (MLRM) was used to assess differences in hospital performance, comparing the estimates of random intercept modelling (capturing hospital general contextual effects (GCE)), and random slope modelling (capturing hospital contextual effects for patients with and without congestive heart failure -CHF). The weighted Kappa Index (KI) was used to assess the agreement between performance estimates.RESULTS: We analysed 46,875 admissions of AMI, 6,314 with coexistent CHF, discharged from 107 hospitals. The overall in-hospital mortality rate was 5.2%, ranging from 4% in Sweden to 6.9% in Portugal. The MLRM with random slope outperformed the model with only random intercept, highlighting a much higher GCE in CHF patients [VPC = 8.34 (CI95% 4.94 to 13.03) and MOR = 1.69 (CI95% 1.62 to 2.21) vs. VPC = 3.9 (CI95% 2.4 to 5.9), MOR of 1.42 (CI95% 1.31 to 1.54) without CHF]. No agreement was observed between estimates [KI = -0,02 (CI95% -0,08 to 0.04].CONCLUSIONS: The different GCE in AMI patients with and without CHF, along with the lack of agreement in estimates, suggests that accounting for patient heterogeneity is required to adequately characterize and report on hospital performance.
37.	Dahlin, Lars B., et al. (author) Carpal Tunnel Syndrome and Ulnar Nerve Entrapment Are Associated with Impaired Psychological Health in Adults as Appraised by Their Increased Use of Psychotropic Medication 2022 In: Journal of Clinical Medicine. - : MDPI AG. - 2077-0383. ; 11:13 Journal article (peer-reviewed)abstract We aimed to study psychological health, as approximated by the use of psychotropic drugs, in a population diagnosed and surgically treated for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, also considering the demographic and socioeconomic factors of the individuals. Linking data from five large national registers, use of psychotropics (at least one dispensation during the first year after the surgery or the baseline date) was examined in around 5.8 million people 25–80 years old residing in Sweden 2010. Among these individuals, 9728 (0.17%), 890 (0.02%) and 149 (0.00%) were identified as diagnosed and surgically treated for CTS, UNE, or both, respectively. As much as 28%, 34% and 36% in each group, respectively, used psychotropic drugs, compared with 19% in the general population. Regression analyses showed a general higher risk for use of psychotropics related to these nerve compression disorders, to higher age, being a woman, and having low income or low occupational qualification level. Individuals born outside of Sweden had a lower risk. We conclude that surgically treated individuals with a nerve compression disorder have an increased risk of impaired psychological health. Caregivers should be aware of the risk and provide necessary attention.
38.	Dahlin, Lars, et al. (author) Overuse of the psychoactive analgesics opioids and gabapentinoid drugs in patients having surgery for nerve entrapment disorders 2023 In: Scientific Reports. - : NATURE PORTFOLIO. - 2045-2322. ; 13:1 Journal article (peer-reviewed)abstract Knowledge about risks for overuse of psychoactive analgesics in patients having primary surgery for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, is limited. We investigated if patients with those nerve entrapment disorders have a higher risk of overuse of psychoactive analgesics (i.e., opioids and gabapentinoid drugs) before, after, and both before and after surgery than observed in the general population after accounting for demographical and socioeconomic factors. Using a large record linkage database, we analysed 5,966,444 individuals (25-80 years), residing in Sweden December 31st, 2010-2014, of which 31,380 underwent surgery 2011-2013 for CTS, UNE, or both, applying logistic regression to estimate relative risk (RR) and 95% confidence interval (CI). Overall, overuse of the psychoactive analgesics was low in the general population. Compared to those individuals, unadjusted RR (95% CI) of overuse ranged in patients between 2.77 (2.57-3.00) with CTS after surgery and 6.21 (4.27-9.02) with both UNE and CTS after surgery. These risks were only slightly reduced after adjustment for demographical and socioeconomic factors. Patients undergoing surgery for CTS, UNE, or both, have a high risk of overuse of psychoactive analgesics before, after, and both before and after surgery.
39.	Dalemo, Sofia, et al. (author) Variation in plasma calcium analysis in primary care in Sweden--a multilevel analysis. 2010 In: BMC family practice. - : Springer Science and Business Media LLC. - 1471-2296. ; 11 Journal article (peer-reviewed)abstract Primary hyperparathyroidism (pHPT) is a common disease that often remains undetected and causes severe disturbance especially in postmenopausal women. Therefore, national recommendations promoting early pHPT detection by plasma calcium (P-Ca) have been issued in Sweden. In this study we aimed to investigate variation of P-Ca analysis between physicians and health care centres (HCCs) in primary care in county of Skaraborg, Sweden.
40.	de Jong, Kim, et al. (author) Area-aggregated assessments of perceived environmental attributes may overcome single-source bias in studies of green environments and health: results from a cross-sectional survey in southern Sweden 2011 In: Environmental Health. - 1476-069X. ; 10 Journal article (peer-reviewed)abstract Background: Most studies assessing health effects of neighborhood characteristics either use self-reports or objective assessments of the environment, the latter often based on Geographical Information Systems (GIS). While objective measures require detailed landscape data, self-assessments may yield confounded results. In this study we demonstrate how self-assessments of green neighborhood environments aggregated to narrow area units may serve as an appealing compromise between objective measures and individual self-assessments. Methods: The study uses cross-sectional data (N = 24,847) from a public health survey conducted in the county of Scania, southern Sweden, in 2008 and validates the Scania Green Score (SGS), a new index comprising five self-reported green neighborhood qualities (Culture, Lush, Serene, Spacious and Wild). The same qualities were also assessed objectively using landscape data and GIS. A multilevel (ecometric) model was used to aggregate individual self-reports to assessments of perceived green environmental attributes for areas of 1,000 square meters. We assessed convergent and concurrent validity for self-assessments of the five items separately and for the sum score, individually and area-aggregated. Results: Correlations between the index scores based on self-assessments and the corresponding objective assessments were clearly present, indicating convergent validity, but the agreement was low. The correlation was even more evident for the area-aggregated SGS. All three scores (individual SGS, area-aggregated SGS and GIS index score) were associated with neighborhood satisfaction, indicating concurrent validity. However, while individual SGS was associated with vitality, this association was not present for aggregated SGS and the GIS-index score, suggesting confounding (single-source bias) when individual SGS was used. Conclusions: Perceived and objectively assessed qualities of the green neighborhood environment correlate but do not agree. An index score based on self-reports but aggregated to narrow area units can be a valid approach to assess perceived green neighborhood qualities in settings where objective assessments are not possible or feasible.
41.	Due, Pernille, et al. (author) Is victimization from bullying associated with medicine use among adolescents? A nationally representative cross-sectional survey in Denmark 2007 In: Pediatrics. - : American Academy of Pediatrics (AAP). - 1098-4275 .- 0031-4005. ; 120:1, s. 110-117 Journal article (peer-reviewed)abstract OBJECTIVE. The goal was to examine whether being a victim of bullying was associated with medicine use, taking into account the increased prevalence of physical and psychological symptoms. METHODS. The study population included all students in grades 5, 7, and 9 (mean ages: 11.6, 13.6, and 15.6 years, respectively) in a random sample of schools in Denmark (participation rate: 88.5%; N = 5205). The students reported health problems, medicine use, bullying, and a range of psychosocial conditions in an anonymous standardized questionnaire. The outcome measure was self-reported medicine use for headache, stomachache, difficulties in getting to sleep, and nervousness. The determinant was frequency of exposure to bullying, measured with 1 item. RESULTS. In multivariate models adjusted for age and social class, we found that adolescent victims of bullying used medicine for pains and psychological problems more often than did adolescents who were not bullied. The increased odds of using medicine were not explained by the higher prevalence of symptoms among the bullied children. CONCLUSIONS. We found victimization from bullying to be associated with medicine use, even when we controlled for the higher prevalence of symptoms among bullied victims. The medications that adolescents use can have adverse effects, in addition to the potentially health-damaging effects of bullying. Policy makers, health care professionals, and school staff should be aware that the adolescent victims of bullying are prone to excess use of medicine, and preventive actions should be taken to decrease the level of bullying as well as the use of medicine among adolescents.
42.	Due, Pernille, et al. (author) Relevance of motor skill problems in victims of bullying - In reply 2007 In: Pediatrics. - : American Academy of Pediatrics (AAP). - 1098-4275 .- 0031-4005. ; 120:5, s. 1227-1228 Journal article (other academic/artistic)
43.	Due, Pernille, et al. (author) Socioeconomic Inequality in Exposure to Bullying During Adolescence: A Comparative, Cross-Sectional, Multilevel Study in 35 Countries 2009 In: American Journal of Public Health. - 1541-0048. ; 99:5, s. 907-914 Journal article (peer-reviewed)abstract Objectives. We examined the socioeconomic distribution of adolescent exposure to bullying internationally and documented the contribution of the macroeconomic environment. Methods. We used an international survey of 162305 students aged 11, 13, and 15 years from nationally representative samples of 5998 schools in 35 countries in Europe and North America for the 2001-2002 school year. The survey used standardized measures of exposure to bullying and socioeconomic affluence. Results. Adolescents from families of low affluence reported higher prevalence of being victims of bullying (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.10, 1.16). International differences in prevalence of exposure to bullying were not associated with the economic level of the country (as measured by gross national income) or the school, but wide disparities in affluence at a school and large economic inequality (as measured by the Gini coefficient) at the national level were associated with an increased prevalence of exposure to bullying. Conclusions. There is socioeconomic inequality in exposure to bullying among adolescents, leaving children of greater socioeconomic disadvantage at higher risk of victimization. Adolescents who attend schools and live in countries where socioeconomic differences are larger are at higher risk of being bullied. (Am J Public Health. 2009;99:907-914. doi:10.2105/AJPH.2008.139303)
44.	Due, P., et al. (author) Socioeconomic position, macroeconomic environment and overweight among adolescents in 35 countries 2009 In: International Journal of Obesity. - : Springer Science and Business Media LLC. - 1476-5497 .- 0307-0565. ; 33:10, s. 1084-1093 Journal article (peer-reviewed)abstract Objective: It is important to understand levels and social inequalities in childhood overweight within and between countries. This study examined prevalence and social inequality in adolescent overweight in 35 countries, and associations with macroeconomic factors. Design: International cross-sectional survey in national samples of schools. Subjects: A total of 11-, 13- and 15-year-olds from 35 countries in Europe and North America in 2001-2002 (N = 162 305). Measurements: The main outcome measure was overweight based on self-reported height and weight ( body mass index cut-points corresponding to body mass index of 25 kg/m(2) at the age of 18 years). Measures included family and school affluence (within countries), and average country income and economic inequality (between countries). Results: There were large variations in adolescent overweight, from 3.5% in Lithuanian girls to 31.7% in boys from Malta. Prevalence of overweight was higher among children from less affluent families in 21 of 24 Western and 5 of 10 Central European countries. However, children from more affluent families were at higher risk of overweight in Croatia, Estonia and Latvia. In Poland, Lithuania, Macedonia and Finland, girls from less affluent families were more overweight whereas the opposite was found for boys. Average country income was associated with prevalence and inequality in overweight when considering all countries together. However, economic inequality as measured by the Gini coefficient was differentially associated with prevalence and socioeconomic inequality in overweight among the 23-high income and 10-middle income countries, with a positive relationship among the high income countries and a negative association among the middle income countries. Conclusion: The direction and magnitude of social inequality in adolescent overweight shows large international variation, with negative social gradients in most countries, but positive social gradients, especially for boys, in some Central European countries. Macroeconomic factors are associated with the heterogeneity in prevalence and social inequality of adolescent overweight. International Journal of Obesity (2009) 33, 1084-1093; doi:10.1038/ijo.2009.128; published online 21 July 2009
45.	Eek, Frida, et al. (author) Health Care Utilisation and Attitudes towards Health Care in Subjects Reporting Environmental Annoyance from Electricity and Chemicals. 2009 In: Journal of Environmental and Public Health. - : Hindawi Limited. - 1687-9813 .- 1687-9805. ; 2009:Apr 14 Journal article (peer-reviewed)abstract Environmentally intolerant persons report decreased self-rated health and daily functioning. However, it remains unclear whether this condition also results in increased health care costs. The aim of this study was to describe the health care consumption and attitudes towards health care in subjects presenting subjective environmental annoyance in relation to the general population, as well as to a group with a well-known disorder as treated hypertension (HT). Methods. Postal questionnaire (n = 13 604) and record linkage with population-based register on health care costs. Results. Despite significantly lower subjective well being and health than both the general population and HT group, the environmentally annoyed subjects had lower health care costs than the hypertension group. In contrast to the hypertension group, the environmentally annoyed subjects expressed more negative attitudes toward the health care than the general population. Conclusions. Despite their impaired subjective health and functional capacity, health care utilisation costs were not much increased for the environmentally annoyed group. This may partly depend on negative attitudes towards the health care in this group.
46.	Engström, Gunnar, et al. (author) Distribution and determinants of ischaemic heart disease in an urban population. A study from the myocardial infarction register in Malmo, Sweden 2000 In: Journal of Internal Medicine. - : Wiley. - 1365-2796 .- 0954-6820. ; 247:5, s. 588-596 Journal article (peer-reviewed)abstract OBJECTIVE: Age adjusted incidence of myocardial infarction has been found to vary substantially between the residential areas of the city of Malmo. The objective of this study was to assess the extent to which major biological risk factors and socio-economic circumstances account for the differences in incidence of and mortality from myocardial infarction. DESIGN: Ecological study of risk factor prevalence and incidence and mortality from myocardial infarction. SETTING: Seventeen administrative areas in Malmo, Sweden. SUBJECTS: Assessment of risk factor prevalence was based on 28 466 men and women, ranging from 45 to 73 years old, who were recruited as participants in the Malmo Diet and Cancer study. Information on serum lipids was available in a random subsample of 5362 subjects. Information about socio-economic level of the residential area was based on statistics from the Malmo City Council and Statistics Sweden. MAIN OUTCOME MEASURES: Weighted least square regressions between prevalence of risk factors (i.e. smoking, hypertension, obesity, diabetes, hypercholesterolemia and hypertriglyceridemia), a myocardial infarction risk score, a socio-economic score and incidence and mortality from myocardial infarction. RESULTS: The risk factor prevalence and myocardial infarction incidence was highest in areas with low socio-economic level. Prevalence of smoking, obesity and hypertension was significantly associated with myocardial infarction incidence and mortality rates amongst men (all r > 0.60). Prevalence of smoking was significantly associated with incidence and mortality from myocardial infarction amongst women (r = 0.66 and r = 0.61, respectively). A myocardial infarction risk score based on four biological risk factors explained 40-60% of the intra-urban geographical variation in myocardial infarction incidence and mortality. The socio-economic score added a further 2-16% to the explained variance. CONCLUSION: In an urban population with similar access to medical care, well-known biological cardiovascular risk factors account for a substantial proportion of the intra-urban geographical variation of incidence of and mortality from myocardial infarction. The socio-economic circumstances further contribute to the intra-urban variation in disease.
47.	Ericsson, Lovisa, et al. (author) Revisiting socio-economic inequalities in sedentary leisure time in Sweden : An intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA) 2023 In: Scandinavian Journal of Public Health. - : Sage Publications. - 1403-4948 .- 1651-1905. ; 51:4, s. 570-578 Journal article (peer-reviewed)abstract Aims: Swedish public health reports have repeatedly provided information about socio-economic inequalities in sedentary leisure time, despite that, in the interest of health equity, physical activity should be equally distributed in the population. Such public health reports, however, neither consider the intersection of multiple socio-demographic factors nor the individual heterogeneity around group averages. Drawing on intersectionality theory, this study aimed to revisit previous findings on sedentary leisure time from Swedish public health surveys and demonstrate how the analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can be used for analysing complex health inequalities.Methods: Using data from Swedish national public health surveys (2004–2015), we applied the AIHDA to define 72 intersectional groups by categories of age, gender, educational achievement, migration status and household composition. We then calculated (a) the absolute and relative risk of sedentary leisure time and (b) the discriminatory accuracy (DA) of the intersectional grouping.Results: The average risk of sedentary leisure time ranged from 5.8% among native-born, highly educated, young women living alone to 41.0% among immigrated young men, living alone, with low education. The risk was higher in strata comprising immigrated people with low education and lower in strata including native-born, highly educated people. However, the DA of the grouping was poor, indicating a substantial overlap of individual risk between groups.Conclusions: Using the AIHDA and drawing on intersectionality, this study provides an improved mapping of the socio-economic distribution of sedentary leisure time in Sweden, with the poor DA suggesting universal rather than targeted physical activity interventions.
48.	Evans, Clare R., et al. (author) Multilevel versus single-level regression for the analysis of multilevel information : The case of quantitative intersectional analysis 2020 In: Social Science and Medicine. - : Elsevier BV. - 0277-9536. ; 245 Journal article (peer-reviewed)abstract Intersectional MAIHDA involves applying multilevel models in order to estimate intercategorical inequalities. The approach has been validated thus far using both simulations and empirical applications, and has numerous methodological and theoretical advantages over single-level approaches, including parsimony and reliability for analyzing high-dimensional interactions. In this issue of SSM, Lizotte, Mahendran, Churchill and Bauer (hereafter “LMCB”) assert that there has been insufficient clarity on the interpretation of fixed effects regression coefficients in intersectional MAIHDA, and that stratum-level residuals in intersectional MAIHDA are not interpretable as interaction effects. We disagree with their second assertion; however, the authors are right to call for greater clarity. For this purpose, in this response we have three main objectives. (1) In their commentary, LMCB incorrectly describe model predictions based on MAIHDA fixed effects as estimates of “grand means” (or the mean of means), when they are actually “precision-weighted grand means.” We clarify the differences between average predicted values obtained by different models, and argue that predictions obtained by MAIHDA are more suitable to serve as reference points for residual/interaction effects. This further enables us to clarify the interpretation of residual/interaction effects in MAIHDA and conventional models. Using simple simulations, we demonstrate conditions under which the precision-weighted grand mean resembles a grand mean, and when it resembles a population mean (or the mean of all individual observations) obtained using single-level regression, explaining the results obtained by LMCB and informing future research. (2) We construct a modification to MAIHDA that constrains the fixed effects so that the resulting model predictions provide estimates of population means, which we use to demonstrate the robustness of results reported by Evans et al. (2018). We find that stratum-specific residuals obtained using the two approaches are highly correlated (Pearson corr = 0.98, p < 0.0001) and no substantive conclusions would have been affected if the preference had been for estimating population means. However, we advise researchers to use the original, unconstrained MAIHDA. (3) Finally, we outline the extent to which single-level and MAIHDA approaches address the fundamental goals of quantitative intersectional analyses and conclude that intersectional MAIHDA remains a promising new approach for the examination of inequalities.
49.	Galán, Iñaki, et al. (author) Individual and Contextual Factors Associated With Hazardous Drinking in Spain : Evidence From a National Population-Based Study 2020 In: Alcoholism: Clinical and Experimental Research. - : Wiley. - 0145-6008 .- 1530-0277. ; 44:11, s. 2247-2256 Journal article (peer-reviewed)abstract BACKGROUND: Heavy drinking (HD) and binge drinking (BD) exhibit marked differences in their relationships with contextual-level factors imbedded in geographical areas of residence. The objective is to identify sociodemographic factors, both at the individual and at the contextual level, associated with these 2 main hazardous consumption patterns.METHODS: Cross-sectional study using data from the 2011 to 2012 National Health Survey in Spain. The sample included 21,007 individuals ≥15 years of age. HD was defined as an alcohol intake of ≥40 g/d in men and ≥24 g/d in women. BD was defined as the consumption in the previous month of ≥6 alcoholic drinks (men) or ≥5 drinks (women) within 4 to 6 hours. Individual-level variables included sociodemographic factors, urban/rural residence, smoking, and perceived social support. Contextual-level variables covered percentage of population with no schooling, unemployment rate, and hospitality industry-related economic activity, all at the census tract level. We analyzed data using multilevel logistic regression and calculated areas under the curve (AUC).RESULTS: Being male, smoking, high-income, and low perceived social support were associated with both hazardous drinking patterns. Younger individuals were at higher risk for BD but at lower risk for HD. BD was more common among rural than urban dwellers (odds ratios [OR] = 1.35; 95% CI: 1.05 to 1.72), whereas HD was less likely in participants residing in areas with high unemployment rates (OR = 0.62; 95% CI: 0.41 to 0.93). HD was more likely in census tracts with higher levels of hospitality industry activity (OR = 1.74; 95% CI: 1.20 to 2.54). The AUC increased substantially for both HD and BD when the census tract variable was entered in the respective models (reaching 89.5 and 93.3%, respectively).CONCLUSIONS: Except for age, both drinking patterns have similar associations with individual-level variables but disparate links to contextual-level indicators. In both cases, accounting for area of residence substantially increased the ability to discriminate between high-risk drinkers from nonhazardous alcohol consumers.
50.	Galán, Iñaki, et al. (author) Small area influences on the individual unhealthy lifestyle behaviors : A multilevel analysis of discriminatory accuracy 2021 In: Health and Place. - : Elsevier BV. - 1353-8292. ; 67 Journal article (peer-reviewed)abstract We estimated the discriminatory power of area of residence (census tract) on the prevalence of main risk factors for chronic diseases. Results, based on a sample of 21,007 participants from the 2011–2012 National Health Survey of Spain, show a differential influence of the geosocial environment on the four health risk factors. Accounting for census tracts substantially increases the discriminatory power regarding at-risk alcohol consumption, unbalanced diet, and leisure-time sedentarism but not tobacco consumption. However, the socioeconomic characteristics of the tracts played a minor role. Further research on the specific geosocial contextual variables explaining variability in these risk factors is necessary.

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