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Gustafsson, Per E
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Wagenius, C. M., San Sebastian, M., Gustafsson, P. E. & Goicolea, I. (2019). Access for all?: Assessing vertical and horizontal inequities in healthcare utilization among young people in northern Sweden. Scandinavian Journal of Public Health, 47
Open this publication in new window or tab >>Access for all?: Assessing vertical and horizontal inequities in healthcare utilization among young people in northern Sweden
2019 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 47Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Previous studies in Sweden have detected socioeconomic inequities in access to healthcare services. However, there is limited information regarding access in younger populations. The aim of this study was to explore vertical and horizontal inequities in access to healthcare services in young adults in the north of Sweden.

METHODS: The study used data from the Health on Equal Terms survey (age group 16-24 years, n = 2726) for the health and healthcare variables and from national registers for the sociodemographic characteristics. Self-rated healthcare utilization was measured as visits to general practitioners, youth clinics and nurses. Crude and multivariable binomial regression analysis, stratified by sex, was used to assess vertical equity, adjusting for sociodemographic characteristics, and horizontal equity, adjusting for need variables.

RESULTS: Vertical inequity was detected for all three healthcare services (youth clinics, general practitioners and nurses), with variations for men and women. Horizontal inequities were also found for both men and women in relation to all three healthcare services.

CONCLUSIONS: These findings suggest that both vertical and horizontal inequities in access exist for young people in northern Sweden and that the associations between sociodemographic characteristics and healthcare utilization are complex and need further investigation.

Keywords
Inequity, Sweden, access to healthcare, youth
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150573 (URN)10.1177/1403494818774965 (DOI)000458888900001 ()29779450 (PubMedID)
Available from: 2018-08-13 Created: 2018-08-13 Last updated: 2019-04-16Bibliographically approved
San Sebastian, M., Mosquera, P. A. & Gustafsson, P. E. (2019). Do cardiovascular disease prevention programs in northern Sweden impact on population health?: An interrupted time series analysis. BMC Public Health, 19, Article ID 202.
Open this publication in new window or tab >>Do cardiovascular disease prevention programs in northern Sweden impact on population health?: An interrupted time series analysis
2019 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 202Article in journal (Refereed) Published
Abstract [en]

Background: Cardiovascular disease (CVD) is the main cause of morbidity and mortality in Sweden. This study aims to assess the impact of a CVD intervention implemented in 1993 in northern Sweden on the reduction of premature ischemic heart disease (IHD) morbidity and mortality in women and men during the period 1987-2013.

Methods: An ecological controlled interrupted time series design, with pre-intervention period defined as 1987-1993 and post-intervention period 1994-2013 was carried out. For each year, IHD events, stratified by sex, were retrieved from national registers.

Results: Impressive reductions on IHD premature morbidity and mortality were observed to a similar degree in both the intervention county and the other comparison counties across the last 27years. Significant differences in the pre-post intervention trends indicating the intervention group had smaller reductions than expected from its pre-intervention trend and the trend of control counties were found among men for both IHD morbidity and mortality. A similar pattern was observed among women but without significant differences.

Conclusions: Taken together, the data do not support that the intervention has contributed to an additional reduction on IHD morbidity and mortality, above and beyond that which is already seen in neighbouring counties without similar programs.

Place, publisher, year, edition, pages
BioMed Central, 2019
Keywords
Ischemic heart disease, Morbidity, Mortality, Interrupted time series analysis, Intervention, Northern Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-157210 (URN)10.1186/s12889-019-6514-x (DOI)000459132800003 ()30770750 (PubMedID)
Available from: 2019-03-26 Created: 2019-03-26 Last updated: 2019-03-26Bibliographically approved
Szilcz, M., Mosquera, P., San Sebastian, M. & Gustafsson, P. E. (2019). Income inequalities in leisure time physical inactivity in northern Sweden: a decomposition analysis. Scandinavian Journal of Public Health
Open this publication in new window or tab >>Income inequalities in leisure time physical inactivity in northern Sweden: a decomposition analysis
2019 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed) Epub ahead of print
Abstract [en]

AIMS: Increasing income inequalities in leisure time physical inactivity have been reported in the relatively socially equal setting of northern Sweden. The present report seeks to contribute to the literature by exploring the contribution of different factors to the income inequalities in leisure time physical inactivity in northern Sweden.

METHODS: This study was based on the 2014 Health on Equal Terms survey, distributed in the four northernmost counties of Sweden. The analytical sample consisted of 21,000 respondents aged 16-84. Six thematic groups of explanatory variables were used: demographic variables, socioeconomic factors, material resources, family-, psychosocial conditions and functional limitations. Income inequalities in leisure time physical inactivity were decomposed by Wagstaff-type decomposition analysis.

RESULTS: Income inequalities in leisure time physical inactivity were found to be explained to a considerable degree by health-related limitations and unfavourable socioeconomic conditions. Material and psychosocial conditions seemed to be of moderate importance, whereas family and demographic characteristics were of minor importance.

CONCLUSIONS: This study suggests that in order to achieve an economically equal leisure time physical inactivity, policy may need to target the two main barriers of functional limitations and socioeconomic disadvantages.

Place, publisher, year, edition, pages
Sage Publications, 2019
Keywords
Decomposition analysis, income, inequalities, leisure time physical inactivity, northern Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-158197 (URN)10.1177/1403494818812647 (DOI)30632908 (PubMedID)
Available from: 2019-04-16 Created: 2019-04-16 Last updated: 2019-08-15
Trygg, N., Gustafsson, P. E. & Månsdotter, A. (2019). Languishing in the crossroad?: A scoping review of intersectional inequalities in mental health. International Journal for Equity in Health, 18, Article ID 115.
Open this publication in new window or tab >>Languishing in the crossroad?: A scoping review of intersectional inequalities in mental health
2019 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, article id 115Article, review/survey (Refereed) Published
Abstract [en]

The concept of intersectionality has gradually been introduced to health inequality research, adding depth and breadth to the way inequalities in health are approached. We conducted a scoping review with the purpose to systematically map, describe and analyze the literature about intersectional inequalities in mental health. For eligibility, the study had to analyze and report inequality defined by combinations of socioeconomic position, gender, race/ethnicity, sexual orientation or religion. The mental health outcome had to be measured as self-reported symptoms assessed through validated scales, or disorders assessed through diagnostic interviews. The search strategy was applied in two databases and the screening process yielded 20 studies. The interaction of intersectional positions showed no consistent patterns in mental health across studies, but both synergistic and antagonistic effects were observed. In most studies an absolute measure of inequality was used and few studies analyzed factors potentially explaining the intersectional inequalities. Taken together, the findings of this review highlight the value of assessing intersectional inequalities across population groups for priority setting and action on mental health inequalities.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Intersectionality, Methods, Health inequalities, Mental health and disorders
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-161989 (URN)10.1186/s12939-019-1012-4 (DOI)000477013200002 ()31340832 (PubMedID)
Available from: 2019-08-08 Created: 2019-08-08 Last updated: 2019-08-08Bibliographically approved
Amroussia, N., Pearson, J. L. & Gustafsson, P. E. (2019). What drives us apart?: Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults. International Journal for Equity in Health, 18, Article ID 109.
Open this publication in new window or tab >>What drives us apart?: Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults
2019 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, article id 109Article in journal (Refereed) Published
Abstract [en]

Background: Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented; however, there is a lack of research examining the social processes driving these complex inequalities. Using an intersectional framework, the current study examines key processes contributing to inequalities in smoking between four intersectional groups by education and sexual orientation.

Methods: The sample (28,362 adults) was obtained from Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Four intersectional positions were created by education (high- and low-education) and sexual orientation (heterosexual or lesbian, gay, bisexual, or queer/questioning (LGBQ). The joint inequality, the referent socio-economic inequality, and the referent sexual orientation inequality in smoking were decomposed by demographic, material, tobacco marketing-related, and psychosocial factors using non-linear Oaxaca decomposition.

Results: Material conditions made the largest contribution to the joint inequality (9.8 percentage points (p.p.), 140.9%), referent socio-economic inequality (10.01 p.p., 128.4%), and referent sexual orientation inequality (4.91 p.p., 59.8%), driven by annual household income. Psychosocial factors made the second largest contributions to the joint inequality (2.12 p.p., 30.3%), referent socio-economic inequality (2.23 p.p., 28.9%), and referent sexual orientation inequality (1.68 p.p., 20.5%). Referent sexual orientation inequality was also explained by marital status (20.3%) and targeted tobacco marketing (11.3%).

Conclusion: The study highlights the pervasive role of material conditions in inequalities in cigarette smoking across multiple dimensions of advantage and disadvantage. This points to the importance of addressing material disadvantage to reduce combined socioeconomic and sexual orientation inequalities in cigarette smoking.

Place, publisher, year, edition, pages
BioMed Central, 2019
Keywords
Sexual and Gender minorities, Education, Cigarette smoking, Intersectionality, Health inequality, Blinder-Oaxaca decomposition
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-161895 (URN)10.1186/s12939-019-1015-1 (DOI)000475907200001 ()31315627 (PubMedID)
Available from: 2019-08-08 Created: 2019-08-08 Last updated: 2019-08-08Bibliographically approved
Jonsson, F., San Sebastian, M., Hammarström, A. & Gustafsson, P. E. (2018). Are neighbourhood inequalities in adult health explained by socio-economic and psychosocial determinants in adolescence and the subsequent life course in northern Sweden?: A decomposition analysis. Health and Place, 52, 127-134
Open this publication in new window or tab >>Are neighbourhood inequalities in adult health explained by socio-economic and psychosocial determinants in adolescence and the subsequent life course in northern Sweden?: A decomposition analysis
2018 (English)In: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 52, p. 127-134Article in journal (Refereed) Published
Abstract [en]

This study explains neighbourhood deprivation inequalities in adult health for a northern Swedish cohort by examining the contribution of socio-economic and psychosocial determinants from adolescence (age 16), young adulthood (age 21) and midlife (age 42) to the disparity. Self-reported information from 873 participants was drawn from questionnaires, with complementary neighbourhood register data. The concentration index was used to estimate the inequality while decomposition analyses were run to attribute the disparity to its underlying determinants. The results suggest that socio-economic and psychosocial factors in midlife explain a substantial part, but also that the inequality can originate from conditions in adolescence and young adulthood.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Decomposition analysis, Life course, Neighbourhood inequality, Northern Sweden, Social determinants
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150249 (URN)10.1016/j.healthplace.2018.05.010 (DOI)000439053800014 ()29886129 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-0451Swedish Research Council Formas, 259-2012-37Västerbotten County Council, 355661Västerbotten County Council, 402131
Available from: 2018-07-25 Created: 2018-07-25 Last updated: 2018-11-12Bibliographically approved
Mosquera, P. A., San Sebastian, M., Ivarsson, A. & Gustafsson, P. E. (2018). Decomposition of gendered income-related inequalities in multiple biological cardiovascular risk factors in a middle-aged population. International Journal for Equity in Health, 17, Article ID 102.
Open this publication in new window or tab >>Decomposition of gendered income-related inequalities in multiple biological cardiovascular risk factors in a middle-aged population
2018 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, article id 102Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Socioeconomic inequalities in cardiovascular disease seem to widen or endure in Sweden. However, research on inequalities in antecedent cardiovascular risk factors (CVRFs), and particularly what underpins them, is scarce. The present study aimed 1) to estimate income-related inequalities in eight biological cardiovascular risk factors in Swedish middle-aged women and men; and 2) to examine the contribution of demographic, socioeconomic, behavioural and psychosocial determinants to the observed inequalities.

METHODS: Participants (N = 12,481) comprised all 40- and 50-years old women and men who participated in the regional Västerbotten Intervention Programme in Northern Sweden during 2008, 2009 and 2010. All participants completed a questionnaire on behavioural and psychosocial conditions, and underwent measurements with respect to eight CVRFs (body mass index; waist circumference; total cholesterol; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol; triglycerides; systolic/diastolic blood pressure; glucose tolerance). Data on cardiovascular risk, psychosocial and health behaviours were linked to national register data on income and other socioeconomic and demographic factors. To estimate income inequalities in each CVRF concentration indexes were calculated, and to examine the contribution of the underlying determinants to the observed inequalities a Wagstaff-type decomposition analysis was performed separately for women and men.

RESULTS: Health inequalities ranged from small to substantial with generally greater magnitude in women. The highest inequalities among women were seen in BMI, triglycerides and HDL-cholesterol (Concentration index = - 0.1850; - 0.1683 and - 0.1479 respectively). Among men the largest inequalities were seen in glucose regulation, BMI and abdominal obesity (Concentration index = - 0.1661; - 0.1259 and - 0.1172). The main explanatory factors were, for both women and men socioeconomic conditions (contributions ranging from 54.8 to 76.7% in women and 34.0-72.6% in men) and health behaviours (contributions ranging from 6.9 to 20.5% in women and 9.2 to 26.9% in men). However, the patterns of specific dominant explanatory factors differed between CVRFs and genders.

CONCLUSION: Taken together, the results suggest that the magnitude of income-related inequalities in CVRFs and their determinants differ importantly between the risk factors and genders, a variation that should be taken into consideration in population interventions aiming to prevent inequalities in manifest cardiovascular disease.

Keywords
Cardiovascular risk factors, Decomposition analysis, Income inequality, Middle age, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150576 (URN)10.1186/s12939-018-0804-2 (DOI)000438822600001 ()30005665 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-2725Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-0451Swedish Research Council, 2008-7491
Available from: 2018-08-13 Created: 2018-08-13 Last updated: 2019-01-31Bibliographically approved
Trygg, N., Gustafsson, P. E. & Månsdotter, A. (2018). Does it add up?: intersectional inequalities in mental health in the Swedish adult population. Paper presented at 11th European Public Health Conference Winds of change: towards new ways of improving public health in Europe Ljubljana, Slovenia, 28 November–1 December, 2018.. European Journal of Public Health, 28, 95-95
Open this publication in new window or tab >>Does it add up?: intersectional inequalities in mental health in the Swedish adult population
2018 (English)In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 95-95Article in journal, Meeting abstract (Other academic) Published
Abstract [en]

Background: Social inequalities in mental health is a growing public health concern, but has so far been approached in a disentangled manner. To better capture the complexity of reality with multiple interlocking axes of inequalities, intersectionality theory instead highlights how health is expressed in the interactions between these axes. This may expose important knowledge about particular risk groups and protective factors. In this study, we explore how mental health is distributed across intersections of gender, income, education, class, country of birth and sexual orientation as well as their interaction effects.

Methods: The study population (N = 52,743) consists of a yearly random sample of the Swedish population 26-84 years between 2010 and 2015, from The Health on Equal Terms survey coordinated by the Public Health Agency of Sweden. Mental health was measured through self-administered General Health Questionnaire (GHQ)-12, and gender, income, education, class, country of birth and sexual orientation through survey and linked register data. Intersectional inequalities in mental health were estimated for all pairwise combination of inequalities by joint disparity, excess intersectional disparity and referent disparities.

Results: The prevalence of symptoms of poor mental health were highest among non-heterosexuals with low income (40%) followed by non-heterosexual women (38%). However, intersectional inequalities showed unpredictable patterns; among non-heterosexuals, those with long education reported more symptoms (36%) than those with short education (31%). The excess intersectional disparity showed synergistic effects for income in combination with education; country of birth and class, but antagonistic effects for the intersections of gender and income as well as education and class.

Conclusions: Multiple inequalities in mental health may add up in various and unexpected manners, which needs to be considered in efforts for equity in mental health.

Key messages:

  • Mental health is distributed in various and unexpected manners across intersections of inequality dimensions.

  • Intersectionality theory may be useful when addressing mental health inequalities.

Place, publisher, year, edition, pages
Oxford University Press, 2018
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-157988 (URN)10.1093/eurpub/cky213.272 (DOI)000461384200222 ()
Conference
11th European Public Health Conference Winds of change: towards new ways of improving public health in Europe Ljubljana, Slovenia, 28 November–1 December, 2018.
Note

Supplement 4

Available from: 2019-04-09 Created: 2019-04-09 Last updated: 2019-04-09Bibliographically approved
Ramadani, R. V., Mosquera, P. A., San Sebastián, M. & Gustafsson, P. E. (2018). The moderating effect of income on the relationship between body mass index and health-related quality of life in Northern Sweden. Scandinavian Journal of Public Health
Open this publication in new window or tab >>The moderating effect of income on the relationship between body mass index and health-related quality of life in Northern Sweden
2018 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVES: This study aimed to investigate the relationship between body mass index (BMI) and health-related quality of life (HRQoL) and whether this relationship is influenced by the level of income in Northern Sweden. Overweight and obesity are rising major public health problems which also affect HRQoL. While socioeconomic inequalities in health are persisting or increasing in many countries, including Sweden, little attention has been paid to the more complex roles of income in relation to health.

METHODS: Data were drawn from a 2014 cross-sectional survey from Northern Sweden (Health on Equal Terms), comprising individuals aged 20-84 years ( N = 20,082 individuals included for analysis). BMI and HRQoL were self-reported and individual disposable income in 2012 was retrieved from population registers. Multiple linear regressions were performed with HRQoL scores regressed on BMI and income, their interaction and additional covariates.

RESULTS: The underweight, overweight and obesity groups reported significantly lower HRQoL compared to the normal weight group. Moreover, the relationship between BMI and HRQoL varied significantly by level of income, with a stronger association among those with the lowest level of income.

CONCLUSIONS: Income has a role as an effect modifier in the relationship between BMI and HRQoL that can be construed as an indirect income inequality. Efforts to promote HRQoL in populations should consider the different impact of being overweight and obese in different socioeconomic groups.

Place, publisher, year, edition, pages
Sage Publications, 2018
Keywords
obesity, Sweden, health-related quality of life, income, inequality
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150608 (URN)10.1177/1403494818761418 (DOI)29516787 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2014- 2725Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-0451
Available from: 2018-08-14 Created: 2018-08-14 Last updated: 2019-04-04
Szilcz, M., Mosquera, P. A., Sebastián, M. S. & Gustafsson, P. E. (2018). Time trends in absolute and relative socioeconomic inequalities in leisure time physical inactivity in northern Sweden. Scandinavian Journal of Public Health, 46(1), 112-123
Open this publication in new window or tab >>Time trends in absolute and relative socioeconomic inequalities in leisure time physical inactivity in northern Sweden
2018 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 46, no 1, p. 112-123Article in journal (Refereed) Published
Abstract [en]

AIMS: The aim was to investigate the time trends in educational, occupational, and income-related inequalities in leisure time physical inactivity in 2006, 2010, and 2014 in northern Swedish women and men.

METHODS: This study was based on data obtained from the repeated cross-sectional Health on Equal Terms survey of 2006, 2010, and 2014. The analytical sample consisted of 20,667 (2006), 31,787 (2010), and 21,613 (2014) individuals, aged 16-84. Logistic regressions were used to model the probability of physical inactivity given a set of explanatory variables. Slope index of inequality (SII) and relative index of inequality (RII) were used as summary measures of the social gradient in physical inactivity. The linear trend in inequalities and difference between gender and years were estimated by interaction analyses.

RESULTS: The year 2010 displayed the highest physical inactivity inequalities for all socioeconomic position indicators, but educational and occupational inequalities decreased in 2014. However, significant positive linear trends were found in absolute and relative income inequalities. Moreover, women had significantly higher RII of education in physical inactivity in 2014 and significantly higher SII and RII of income in physical inactivity in 2010, than did men in the same years.

CONCLUSIONS: The recent reduction in educational and occupational inequalities following the high inequalities around the time of the great recession in 2010 suggests that the current policies might be fairly effective. However, to eventually alleviate inequities in physical inactivity, the focus of the researchers and policymakers should be directed toward the widening trends of income inequalities in physical inactivity.

Place, publisher, year, edition, pages
Sage Publications, 2018
Keywords
Physical inactivity, relative index of inequality, slope index of inequality, socioeconomic inequality, time trend
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-143318 (URN)10.1177/1403494817713123 (DOI)000428758000016 ()28707564 (PubMedID)
Note

Special Issue

Available from: 2017-12-20 Created: 2017-12-20 Last updated: 2018-06-09Bibliographically approved
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