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Self-rated ill-health strengthens the effect of biomedical risk factors in predicting stroke especially for men: An incident case referent study
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.ORCID iD: 0000-0003-3025-2690
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
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2003 (English)In: Journal of Hypertension, ISSN 0263-6352, Vol. 21, no 5, 887-896 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To examine how self-rated ill-health interacts with biomedical stroke risk factors in predicting stroke and to explore differences between men and women and educational groups. DESIGN: An incident case-referent study where the study subjects had participated in a prior health survey. SETTING: Nested within the Västerbotten Intervention Program (VIP) and the Northern Sweden MONICA cohorts. SUBJECTS: The 473 stroke cases had two referents per case, matched for age, sex and residence, from the same study cohorts. RESULTS: Self-rated ill-health independently increased the risk of stroke, specifically for men. The interaction effect between self-rated health and biomedical risk factor load was greater for men than for women. The attributable proportion due to interaction between having a risk factor load of 2+ and self-rated ill-health was 42% for men and 15% for women. Better-educated individuals with self-rated ill-health and two or more of the biomedical risk factors had a higher risk of stroke than the less educated. Calculations of the respective contribution to the stroke cases of self-rated health, hypertension and smoking showed that self-rated ill-health had a role in 20% of the cases and could alone explain more than one-third of the cases among those who rated their health as bad, more so for men than for women. CONCLUSIONS: The results underscore the importance of including both a gender and a social perspective in discussing the role of self-rated health as a predictor of disease outcome. Physicians must be more gender sensitive when discussing their patient's own evaluation of health in relation to biomedical risk factors.

Place, publisher, year, edition, pages
2003. Vol. 21, no 5, 887-896 p.
Keyword [en]
stroke, self-rated health, cardiovascular risk factors, social factors, interaction, effect modification, incident case-referent study
National Category
Medical and Health Sciences
URN: urn:nbn:se:umu:diva-3851PubMedID: 12714862OAI: diva2:142735
Available from: 2004-04-06 Created: 2004-04-06 Last updated: 2015-04-29Bibliographically approved
In thesis
1. Self-rated health in public health evaluation
Open this publication in new window or tab >>Self-rated health in public health evaluation
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

There is still a debate concerning the evidence base for community interventions. The randomised clinical trial design (RCT) is increasingly challenged as a gold standard for their evaluation. This thesis takes the Norsjö health programme in Västerbotten as the starting point for a discussion about the ethical platform of community interventions and for exploring the role of self-rated health. The specific objectives are: 1) to better understand barriers to community participation and to assess the role of ethical premises among decision-makers, 2) to explore how health related norms and attitudes interact with self-rated health and the risk factor outcome of an intervention and 3) to analyse the gender and socio-cultural interplay of self-rated health with biomedical risk factors for cardiovascular disease.

The participation and views of different actors in the planning and implementation phases of the intervention were studied by contrasting information between official documents, interviews with decision makers and professionals and questionnaires to community members. The role of basic values in setting priorities and choosing intervention strategies utilised a questionnaire design with hypothetical scenarios sent to a representative sample of Swedish health care politicians. Qualitative research interviews were used to explore health related norms and attitudes. Health examination measurements and questionnaire data formed the basis for analysis of the development of self-rated health and risk factor load during a 10-year follow-up of the intervention. Access to a stroke registry enabled a case-referent approach for studying the interaction between bio-medical risk factors, socio-demographic factors and self-rated health. Data from the Västerbotten Intervention Programme (VIP) could be utilised for a cross-country comparison with a “sister project” in Otsego, U.S.A.

The results point to both strengths and limitations of the efforts made to involve people in the intervention. The problem definition mainly remained with the professionals and participation as a goal in itself, strengthening local democracy was felt to be an exaggerated ambition. However, there was an overall agreement about the seriousness of the health problem, the need to intervene and about the implementation mode. Self-rated health and reported behavioural change were important indicators of participation and young men with bad health seemed to have been least involved. Among Swedish health care politicians there was an overall agreement to allocate resources for prevention directed towards communities when there are serious health problems. The majority preferred an intervention strategy that involved primary health care. The risk of harm by creating some degree of anxiety or stigma was for many considered an acceptable drawback of a successful intervention. The follow-up study revealed a positive risk factor reduction accompanied by a positive development of self-rated health, especially for men. Additional support for an intervention effect was given through a comparison with a reference area. The interaction pattern between risk reduction and self-rated health was more polarised for men than for women, with a corresponding pattern for the lower compared to the higher educated. These results could be linked to a transition in the health related norm system and to “ideal types” representing attitudinal sets towards the intervention. The case-referent analysis suggested an interaction effect between self-rated health and bio-medical risk factor load in predicting stroke that was greater for men than for women. The cross-country comparison revealed a stronger influence of education in the U.S.A. The lower educated, with a high risk load, had a greater risk of self-rated poor health than their Swedish counterparts.

The thesis suggests that self-rated health is an unexplored indicator, potentially important for understanding the complexity of community interventions. Self-rated health may predict disease development as well as modify the impact of established risk factors.

100 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 884
Public health, process evaluation, community intervention, self-rated health, public health, Folkhälsomedicin
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
urn:nbn:se:umu:diva-226 (URN)91-7305-624-3 (ISBN)
Public defence
2004-04-23, 135, 9A, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Available from: 2004-04-06 Created: 2004-04-06 Last updated: 2010-01-22Bibliographically approved

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Emmelin, MariaWeinehall, LarsStegmayr, BirgittaDahlgren, LarsStenlund, HansWall, Stig
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