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Self-rated health in public health evaluation
Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
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.

Place, publisher, year, edition, pages
2004. , 100 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 884
Keyword [en]
Public health, process evaluation, community intervention, self-rated health, public health
Keyword [sv]
Folkhälsomedicin
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-226ISBN: 91-7305-624-3 (print)OAI: oai:DiVA.org:umu-226DiVA: diva2:142737
Public defence
2004-04-23, 135, 9A, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2004-04-06 Created: 2004-04-06 Last updated: 2010-01-22Bibliographically approved
List of papers
1. Co-operation, participation and conflicts faced in public health: lessons learned from a long-term prevention programme in Sweden
Open this publication in new window or tab >>Co-operation, participation and conflicts faced in public health: lessons learned from a long-term prevention programme in Sweden
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1994 (English)In: Health Education Research, ISSN 0268-1153, E-ISSN 1465-3648, Vol. 9, no 3, 317-329 p.Article in journal (Refereed) Published
Abstract [en]

A comprehensive community-based programme for prevention of cardiovascular diseases (CVD) and diabetes was established in 1985 in a small municipality in northern Sweden. A cross-sectional survey to the general public was performed and semi-structured open-ended interviews were taken of actors at different levels. Notes from official records were also included in the study. The aim was to describe and discuss some factors that promote or constrain community participation in health programmes. The results generally confirmed that the right of definition concerning the health programme mainly remained with the health professionals. Community participation was mainly defined by the actors based on the medical and health planning approach and, thereby, as a means to transform health policy plans into reality by transmitting health knowledge and increasing consciousness among the citizens of the need for changing lifestyles. However, participation as a means of identifying problems and demonstrating power relationships and as elements in promoting local democracy was hardly represented among the actors at all. Overall, the CVD health programme was characterized by consensus between the actors. Despite this, debates and arguments about interpretations, social interests, personal conflicts and ideological constraints were observed. However, a majority of the public wanted the CVD preventive programme to continue.

Place, publisher, year, edition, pages
Oxford University Press, 1994
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-3848 (URN)10.1093/her/9.3.317 (DOI)10150452 (PubMedID)
Available from: 2004-04-06 Created: 2004-04-06 Last updated: 2017-12-14Bibliographically approved
2. Pol-ethical considerations in public health.: The views of Swedish health care politicians
Open this publication in new window or tab >>Pol-ethical considerations in public health.: The views of Swedish health care politicians
1999 (English)In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 9, no 2, 124-130 p.Article in journal (Refereed) Published
Abstract [en]

Background: Public health policy is often concerned with the conflicting values emanating from the individually formulated ethics for curative care and more collectively oriented ethics. In this study we have focused on the pol-ethical considerations involved in Swedish health care politicians' assessment of public health measures. Methods: We described a hypothetical situation in a questionnaire, where a community has a 50% excess mortality for disease X, compared to the national average. Scientific disagreements were identified and discussed. The respondents gave their preference for a specific intervention strategy and considered, on a graded scale, 17 different value statements related to ethical principles and intervention strategies. Results: Only one out of 451 politicians preferred the alternative ‘no intervention’. The majority preferred an intervention including active involvement of primary health care. There was overall strong support for equity and beneficence. A factor analysis gave a model for the association between ethical values, political affiliation and choice of intervention strategies. The relative weights of autonomy and equity were strongly related to political affiliation. Conclusions: Among Swedish health care politicians there is consensus about the value of performing interventions in public health when the problem is large, even if there is some uncertainty about the consequences. Their overall strong support for equity and beneficence implies that these principles are crucial when formulating policies for interventions. Politicians need to state their ethical standpoint explicitly so that we as citizens can judge their decisions and actions based on our own political ideology and support for basic ethical principles.

Keyword
ethics, policy, public health
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-3849 (URN)10.1093/eurpub/9.2.124 (DOI)
Available from: 2004-04-06 Created: 2004-04-06 Last updated: 2017-12-14Bibliographically approved
3. To be seen, confirmed and involved - a ten year follow-up of perceived health and cardiovascular risk factors in a Swedish community intervention programme
Open this publication in new window or tab >>To be seen, confirmed and involved - a ten year follow-up of perceived health and cardiovascular risk factors in a Swedish community intervention programme
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2007 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 7, 190- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Public health interventions are directed towards social systems and it is difficult to foresee all consequences. While targeted outcomes may be positively influenced, interventions may at worst be counterproductive. To include self-reported health in an evaluation is one way of addressing possible side-effects. This study is based on a 10 year follow-up of a cardiovascular community intervention programme in northern Sweden. METHODS: Both quantitative and qualitative approaches were used to address the interaction between changes in self-rated health and risk factor load. Qualitative interviews contributed to an analysis of how the outcome was influenced by health related norms and attitudes. RESULTS: Most people maintained a low risk factor load and a positive perception of health. However, more people improved than deteriorated their situation regarding both perceived health and risk factor load. "Ideal types" of attitude sets towards the programme, generated from the interviews, helped to interpret an observed polarisation for men and the lower educated. CONCLUSION: Our observation of a socially and gender differentiated intervention effect suggests a need to test new intervention strategies. Future community interventions may benefit from targeting more directly those who in combination with high risk factor load perceive their health as bad and to make all participants feel seen, confirmed and involved.

Place, publisher, year, edition, pages
BioMed Central, 2007
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-16220 (URN)10.1186/1471-2458-7-190 (DOI)000249033200001 ()17672911 (PubMedID)
Available from: 2008-09-05 Created: 2008-09-05 Last updated: 2017-12-14Bibliographically approved
4. Self-rated ill-health strengthens the effect of biomedical risk factors in predicting stroke especially for men: An incident case referent study
Open this publication in new window or tab >>Self-rated ill-health strengthens the effect of biomedical risk factors in predicting stroke especially for men: An incident case referent study
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2003 (English)In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, 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.

Keyword
stroke, self-rated health, cardiovascular risk factors, social factors, interaction, effect modification, incident case-referent study
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-3851 (URN)12714862 (PubMedID)
Available from: 2004-04-06 Created: 2004-04-06 Last updated: 2017-12-14Bibliographically approved
5. Cardiovascular risk factor burden has a stronger association with self-rated poor health in adults in the US than in Sweden, especially for the lower educated.
Open this publication in new window or tab >>Cardiovascular risk factor burden has a stronger association with self-rated poor health in adults in the US than in Sweden, especially for the lower educated.
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2006 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 34, no 2, 140-149 p.Article in journal (Refereed) Published
Abstract [en]

Background: There is an ongoing debate about the importance of biomedical and sociodemographic risk factors in the prediction of self-rated health. Objectives: To compare the association of sociodemographic and cardiovascular risk factors and self-rated health in Sweden and the US. Design: Data from two population-based cross-sectional health surveys, one in Sweden and one in the US. Subjects: The surveys included questionnaire and measured data from 5,461 adults in Sweden and 7,643 in the US. Participants were between 35 and 65 years of age. Results: The odds ratios for poor self-rated health for the included cardiovascular risk factors were greater in the US. Low education was significantly more prevalent among those with self-rated poor health in the US, but not in Sweden. Using Swedes with high education as reference group (OR51), adults in the US with low education and 2+ risk factors had a greater than threefold risk (OR56.3) of self-rated poor health compared with Swedish low-educated adults with the same risk factor burden (OR51.9). The better-educated US adults with 2+ risk factors were significantly more likely to report poor health (OR53.4) compared with their Swedish counterparts (OR52.4). Conclusions: The interaction between risk factors, education, and self-rated health suggests a frightening picture, especially for the US. Public health interventions for reducing cardiovascular risk factors need to include both population and individual measures. Taking people’s overall evaluation of their health into account when assessing total health risk is important.

Keyword
Adult, Aged, Cardiovascular Diseases/epidemiology/*etiology, Cross-Sectional Studies, Educational Status, Female, Health Surveys, Humans, Life Style, Male, Middle Aged, Questionnaires, Risk Assessment/methods, Risk Factors, Self Concept, Socioeconomic Factors, Sweden/epidemiology, United States/epidemiology
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-14127 (URN)10.1080/14034940510032365 (DOI)16581706 (PubMedID)
Available from: 2007-05-23 Created: 2007-05-23 Last updated: 2017-12-14Bibliographically approved

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