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  • 1.
    Andersson, Elin M
    et al.
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Liv, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nordin, Steven
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lindvall, Kristina
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Does a multi-component intervention including pictorial risk communication about subclinical atherosclerosis improve perceptions of cardiovascular disease risk without deteriorating efficacy beliefs?2024In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 341, article id 116530Article in journal (Refereed)
    Abstract [en]

    Background: Pictorial communication about subclinical atherosclerosis can improve cardiovascular disease (CVD) risk, but whether it leads to long-term shifts in self-rated CVD risk (risk perception) and beliefs about possibility to influence personal risk (efficacy beliefs) is unknown.

    Purpose: To study the impact of personalized color-coded and age-related risk communication about atherosclerosis and motivational conversation, compared to traditional risk factor-based communication, on risk perception and efficacy beliefs. Also, whether risk perception increases with message severity.

    Method: The effect of the pragmatic RCT Visualization of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention (VIPVIZA) was analyzed using a linear mixed effects model with risk perception and efficacy believes at 1-year and 3-year follow up as dependent variables. Participants’ (n = 3532) CVD risk perception and efficacy beliefs were assessed with visual analog scales (0–10). Fixed effects were group (intervention vs control), time point (1 year or 3 years) and interaction between group and time point. Further, the models were adjusted for corresponding baseline measurement of the dependent variable and a baseline × time point interaction. Effect of pictorial color-coded risk in the intervention group was investigated using a corresponding mixed effects model, but with pictorial risk group (message severity) as exposure instead of intervention group.

    Results: After one year, the intervention group rated their CVD risk as higher (m = 0.46, 95% CI 0.32–0.59), with an effect also after 3 years (m = 0.57, 95% CI 0.43–0.70). The effect was consistent in stratified analyses by sex and education. Overall, no effect on efficacy beliefs was observed. In the intervention group, differences in CVD risk perception were found between participants with different color-coded risk messages on atherosclerosis status.

    Conclusion: Personalized, color-coded and age-related risk communication about atherosclerosis had an effect on risk perception with an effect also after 3 years, whereas overall, no effect on efficacy beliefs was observed.

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  • 2. Backhans, Mona Christina
    et al.
    Burström, Bo
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Månsdotter, Anna
    Pioneers and laggards: Is the effect of gender equality on health dependent on context?2009In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 68, p. 1388-1395Article in journal (Refereed)
    Abstract [en]

    This study combines data at individual and area level to examine interactions between equality within couples and gender equality in the municipality in which individuals live. The research question is whether the context impacts on the association between gender equality and health. The material consists of data on 37,423 men and 37,616 women in 279 Swedish municipalities, who had their first child in 1978. The couples were classified according to indicators of their level of gender equality in 1980 in the public sphere (occupation and income) and private sphere (child care leave and parental leave) compared to that of their municipality. The health outcome is compensated days from sickness insurance during 1986-1999 with a cut-off at the 85% percentile. Data were analysed using logistic regression with the overall odds as reference. The results concerning gender equality in the private sphere show that among fathers, those who are equal in an equal municipality have lower levels of sick leave than the average while laggards (less equal than their municipality) and modest laggards have higher levels. In the public sphere, pioneers (more equal t han their municipality) fare better than the average while laggards fare worse. For mothers, those who are traditional in their roles in the public sphere are protected from high levels of sick leave, while the reverse is true for those who are equal. Traditional mothers in a traditional municipality have the lowest level of sick leave and pioneers the highest. These results show that there are distinct benefits as well as disadvantages to being a gender pioneer and/or a laggard in comparison to your municipality. The associations are markedly different for men and women.

  • 3.
    Berglund, Anna Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Eisemann, Martin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Othon
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Social adjustment and spouse relationships among women with stress incontinence before and after surgical treatment1996In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 42, no 11, p. 1537-1544Article in journal (Refereed)
    Abstract [en]

    Forty-five women with stress urinary incontinence (SUI) and their partners have been interviewed three months before and one year after surgical treatment to investigate the social consequences of their impairment. One year after surgery 76% of the women reported that they were cured (group A, n = 34) and 24% that they were improved (group B, n = 11). The cured women were significantly younger than the improved women. The duration of urinary leakage before the operation was significantly shorter in group A than in group B. One year post surgery group A reported a significantly decrease in impediments to exert certain tasks due to urine leakage. As concerns leisure time, group A reported a higher level of overall activities before surgery than group B, whereas postsurgery both groups obtained about the same level of activities. Regarding social support, no differences between the groups occurred as concerns attachment. Furthermore, group A women showed a significantly higher degree of adequacy of social integration compared with group B. The majority of the couples could openly discuss sexual matters with their partners and were satisfied with their sexual life. More than half of the interviewed men reported an increase in sexual desire one year after their partners operation. Whereas about every third woman in both groups reported an increase in sexual desire. However, the frequency of intercourse did not change in any groups. In conclusion, this study underlines the importance of social factors in the assessment of the consequences of stress urinary incontinence and its treatment.

  • 4. Berhane, Y
    et al.
    Gossaye, Y
    Emmelin, M
    Hogberg, U
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Women's health in a rural setting in societal transition in Ethiopia.2001In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 53, no 11, p. 1525-39Article in journal (Refereed)
    Abstract [en]

    There are reports indicating a worsening of women's health in transitional rural societies in sub-Saharan Africa in relation to autonomy, workload, illiteracy, nutrition and disease prevalence. Although these problems are rampant, proper documentation is lacking. The objective of this study was to reflect the health situation of women in rural Ethiopia. Furthermore, the study attempts to address the socio-demographic and cultural factors that have potential influence on the health of women in the context of a low-income setting. A combination of qualitative and quantitative research methods was utilised. In-depth interviews and a cross-sectional survey of randomly selected women were the main methods employed. The Butajira Rural Health Program demographic surveillance database provided the sampling frame. Heavy workload, lack of access to health services, poverty, traditional practices, poor social status and decision-making power, and lack of access to education were among the highly prevalent socio-cultural factors that potentially affect the health of women in Butajira. Though the majority of the women use traditional healers younger women show more tendency to use health services. No improvement of women's status was perceived by the younger generation compared to the older generation. Female genital mutilation is universal with a strong motivation to its maintenance. Nail polish has replaced the rite of nail-extraction before marriage in the younger generation. As the factors influencing the health of women are multiple and complex a holistic approach should be adopted with emphasis on improving access to health care and education, enhancing social status, and mechanisms to alleviate poverty.

  • 5.
    Blaschke, Sarah
    et al.
    Dept of Cancer Experiences Research, Univ of Melbourne.
    O'Callaghan, Clare
    Dept of Cancer Experiences Research, Univ of Melbourne.
    Schofield, Penelope
    Dept of Cancer Experiences Research, Univ of Melbourne.
    Salander, Pär
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Cancer patients' experiences with nature: Normalizing dichotomous realities2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 172, p. 107-114Article in journal (Refereed)
    Abstract [en]

    Aims: To explore cancer patients' subjective experiences with nature in order to examine the relevance of nature-based care opportunities in cancer care contexts. The rationale was to describe the underlying mechanisms of this interaction and produce translatable knowledge. Methods: Qualitative research design informed by grounded theory. Sampling was initially convenience and then theoretical. Competent adults with any cancer diagnosis were eligible to participate in a semi structured interview exploring views about the role of nature in their lives. Audio-recorded and transcribed interviews were analyzed using inductive, cyclic, and constant comparative analysis. Results: Twenty cancer patients (9 female) reported detailed description about their experiences with nature from which a typology of five common nature interactions emerged. A theory model was generated constituting a core category and two inter-related themes explaining a normalization process in which patients negotiate their shifting realities (Core Category). Nature functioned as a support structure and nurtured patients' inner and outer capacities to respond and connect more effectively (Theme A). Once enabled and comforted, patients could engage survival and reconstructive maneuvers and explore the consequences of cancer (Theme B). A dynamic relationship was evident between moving away while, simultaneously, advancing towards the cancer reality in order to accept a shifting normality. From a place of comfort and safety, patients felt supported to deal differently and more creatively with the threat and demands of cancer diagnosis, treatment and outlook. Conclusions: New understanding about nature's role in cancer patients' lives calls attention to recognizing additional forms of psychosocial care that encourage patients' own coping and creative processes to deal with their strain and, in some cases, reconstruct everyday lives. Further research is required to determine how nature opportunities can be feasibly delivered in the cancer care setting.

  • 6.
    Broström, Göran
    et al.
    Umeå University, Faculty of Social Sciences, Department of Statistics.
    Bengtsson, Tommy
    Department of Economic History, Lund University.
    Do conditions in early life affect old-age mortality directly and indirectly?: Evidence from 19th-century rural Sweden2009In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 68, no 9, p. 1583-1590Article in journal (Refereed)
    Abstract [en]

    Previous research has shown that the disease load experienced during the birth year, measured as the infant mortality rate, had a significant influence on old-age mortality in nineteenth-century rural Sweden. We know that children born in years with very high rates of infant mortality, due to outbreaks of smallpox or whooping cough, and who still survived to adulthood and married, faced a life length several years shorter than others. We do not know, however, whether this is a direct effect, caused by permanent physical damage leading to fatal outcomes later in life, or an indirect effect, via its influence on accumulation of wealth and obtained socio-economic status. The Scanian Demographic Database, with information on five rural parishes in southern Sweden between 1813 and 1894, contains the data needed to distinguish between the two mechanisms. First, the effects of conditions in childhood on obtained socio-economic status as an adult are analyzed, then the effects of both early-life conditions and socio-economic status at various stages of life on old-age mortality. By including random effects, we take into account possible dependencies in the data due to kinship and marriage. We find that a high disease load during the first year of life had a strong negative impact on a person's ability to acquire wealth, never before shown for a historical setting. This means that it is indeed possible that the effects of disease load in the first year of life indirectly affect mortality in old age through obtained socio-economic status. We find, however, no effects of obtained socio-economic status on old-age mortality. While the result is interesting per se, constituting a debatable issue, it means that the argument that early-life conditions indirectly affect old-age mortality is not supported. Instead, we find support for the conclusion that the effect of the disease load in early-life is direct or, in other words, that physiological damage from severe infections at the start of life leads to higher mortality at older ages. Taking random effects at family level into account did not alter this conclusion.

  • 7. D'Ambruoso, Lucia
    et al.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Qomariyah, Siti Nurul
    Ouédraogo, Moctar
    A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia2010In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 71, no 10, p. 1728-1738Article in journal (Refereed)
    Abstract [en]

    Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach.

  • 8.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Children's perspectives on health promoting living environmens: the significance of social capital2020In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 258, article id 113059Article in journal (Refereed)
    Abstract [en]

    This article discusses the usefulness of social capital as a conceptual tool to design neighbourhoods promoting children’s health. The aim was to explore children’s perspectives of health promoting environments, and we used a combination of photovoice and grounded theory. Children from two neighbourhoods in a Swedish municipality were invited to photograph and discuss places of importance for their well-being. They presented places facilitating togetherness, enjoyable activities and positive emotions, mostly found in their immediate environments: at home, at school and in their neighbourhoods, but the access to these places was unequally distributed between the areas. The results highlight a need for ensuring all children’s access to health promoting places and to include children’s views in policy and planning. Investments in the physical environment need to be combined with efforts to influence norms and collective efficacy to secure local ownership and use of these investments. We found that the concept of social capital is a relevant conceptual tool for understanding what constitutes health-promoting places from children’s perspectives and contributes to a deeper understanding on how physical and social environments are interlinked.

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  • 9.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    Lunds universitet.
    What constitutes a health-enabling neighborhood? A grounded theory situational analysis addressing the significance of social capital and gender.2013In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 97, p. 112-123Article in journal (Refereed)
    Abstract [en]

    Variations in health between neighborhoods are well known and the conceptualization of social capitalhas contributed to an understanding of how contextual factors influence these differences. Studies showpositive health-effects from living in high social capital areas, at least for some population sub-groups.The aim of this qualitative study was to understand what constitutes a ‘health-enabling’ neighborhood.It follows up results from a social capital survey in northern Sweden indicating that the healtheffects of living in a high social capital neighborhood is gendered in favor of women. A grounded theorysituational analysis of eight focus group discussions e four with men and four with women e illustratedsimilar and different positions on how neighborhood characteristics influence health. A neighborhood,where people say hi to each other (“hi-factor”) and where support between neighbors exist, were factorsperceived as positive for health by all, as was a good location, neighborhood greenness and proximity toessential arenas. Women perceived freedom from demands, feeling safe and city life as additional healthenabling factors. For men freedom to do what you want, a sense of belonging, and countryside life wereimportant. To have burdensome neighbors, physical disturbances and a densely living environment wereperceived as negative for health in both groups while demands for a well styled home and feeling unsafewere perceived as negative for health among women. Neighborhood social capital, together with otherelements in the living environment, has fundamental influence on people’s perceived health. Ourfindings do not confirm that social capital is more important for women than for men but that distinctiveform of social capital differ in impact. Investing in physical interventions, such as planning for meetingplaces, constructing attractive green areas, and making neighborhoods walking-friendly, may increasehuman interactions that is instrumental for social capital and is likely to have health promoting effectsfor all.

  • 10.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Changes in access to structural social capital and its influence on self-rated health over time for middle-aged men and women: a longitudinal study from northern Sweden.2015In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 130, p. 250-258Article in journal (Refereed)
    Abstract [en]

    Until recently, most studies on social capital and health have been cross-sectional making it difficult to draw causal conclusions. This longitudinal study used data from 33,621 individuals (15,822 men and 17,799 women) from the Vasterbotten Intervention Program, to analyse how changes in access to individual social capital influence self-rated health (SRH) over time. Two forms of structural social capital, i.e. informal socializing and social participation, were measured. Age, sex, education, marital status, smoking, snuff, physical activity, alcohol consumption, high blood pressure, and body mass index were analysed as potential confounders. The association between changes in access to structural social capital and SRH in the follow-up was adjusted for SRH at baseline, as well as for changes in the socio-demographic and health-risk variables over time. The results support that changes in access to structural social capital over time impact on SRH. Remaining with no/low level of informal socializing over time increased the odds ratio for poor SRH for both men and women (OR of 1.45; 95%CI = 1.22-1.73 among men and OR of 1.56; 95%CI = 1.33-1.84 among women). Remaining with no/low levels of social participation was also detrimental to SRH in men and women (OR 1.14; 95%CI = 1.03-1.26 among men and OR 1.18; 95% Cl = 1.08-1.29 among women). A decrease in informal socializing over time was associated with poor SRH for women and men (OR of 135; 95%CI = 1.16-1.58 among men and OR of 1.57; 95%Cl = 1.36-1.82 among women). A loss of social participation had a negative effect on SRH among men and women (OR of 1.16; 95%Cl = 1.03-130 among men and OR of 1.15; 95%CI = 1.04-1.27 among women). Gaining access to social participation was harmful for SRH for women (OR 1.17; 95%CI = 1.05-131). Structural social capital has complex and gendered effects on SRH and interventions aiming to use social capital for health promotion purposes require an awareness of its gendered nature.

  • 11.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    The importance of gender and conceptualization for understanding the association between collective social capital and health: a multilevel analysis from northern Sweden2011In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 73, no 2, p. 264-273Article in journal (Refereed)
    Abstract [en]

    Growing research on social capital and health has fuelled the debate on whether there is a place effect on health. A central question is whether health inequality between places is due to differences in the composition of people living in these places (compositional effect) or differences in the local social and physical environments (contextual effects). Despite extensive use of multilevel approaches that allows controlling for whether the effects of collective social capital are confounded by access to social capital at the individual level, the picture remains unclear. Recent studies indicate that contextual effects on health may vary for different population subgroups and measuring "average" contextual effects on health for a whole population might therefore be inappropriate. In this study from northern Sweden, we investigated the associations between collective social capital and self-rated health for men and women separately, to understand if health effects of collective social capital are gendered. Two measures of collective social capital were used: one conventional measure (aggregated measures of trust, participation and voting) and one specific place-related (neighbourhood) measure. The results show a positive association between collective social capital and self-rated health for women but not for men. Regardless of the measure used, women who live in very high social capital neighbourhoods are more likely to rate their health as good-fair, compared to women who live in very low social capital neighbourhoods. The health effects of collective social capital might thus be gendered in favour for women. However, a more equal involvement of men and women in the domestic sphere would potentially benefit men in this matter. When controlling for socioeconomic, sociodemographic and social capital attributes at the individual level, the relationship between women's health and collective social capital remained statistically significant when using the neighbourhood-related measure but not when using the conventional measure. Our results support the view that a neighbourhood-related measure provides a clearer picture of the health effects of collective social capital, at least for women.

  • 12.
    Fagrell Trygg, Nadja
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Månsdotter, Anna
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Intersectional inequalities in mental health across multiple dimensions of inequality in the Swedish adult population2021In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 283, article id 114184Article in journal (Refereed)
    Abstract [en]

    Intersectionality has recently gained traction in health inequality research emphasizing multiple intersecting dimensions of inequality as opposed to the traditional unidimensional approaches. In this study inequalities in mental health were estimated across intersections of gender, income, education, occupation, country of birth, and sexual orientation. The outcomes and inequalities of intersectional strata were disentangled analogously to the possibilities described by intersectionality theory; as a result of either of the two inequality dimensions, as a result of the sum the dimensions, or as a unique outcome not equaling the sum. Furthermore the study examined the discriminatory accuracy of the six inequality dimensions as well as the intersectional space comprising 64 strata. 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. Mental health was measured through a self-administered General Health Questionnaire (GHQ)-12, and sociodemographics through survey and linked register data. Intersectional inequalities in mental health were estimated for all pairwise combinations of inequality dimensions by joint inequalities, excess intersectional inequalities and referent inequalities. The findings of the study found that the sum of dimensions contributed to the overall (joint) inequality in mental health rather than a reinforced adverse effect of multiple disadvantages or the contribution by a single dimension. Nevertheless, the dimension of income was found to be the most important in terms of relative contribution. The discriminatory accuracy was low indicating that policy action targeting mental health should be universal rather than focusing on particular groups. The results highlight the unpredictable inequality patterns revealed by an intersectional approach, even for a single health outcome and within one country, and illustrate the need for empirical investigations into the actual population patterns in health that appear in the intersections of multiple disadvantages.

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  • 13.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Muraleedharan, V R
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Community Action for Health in India's National Rural Health Mission: One policy, many paths2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 188, p. 82-90Article in journal (Refereed)
    Abstract [en]

    Community participation as a strategy for health system strengthening and accountability is an almost ubiquitous policy prescription. In 2005, with the election of a new Government in India, the National Rural Health Mission was launched. This was aimed at 'architectural correction' of the health care system, and enshrined 'communitization' as one of its pillars. The mission also provided unique policy spaces and opportunity structures that enabled civil society groups to attempt to bring on to the policy agenda as well as implement a more collective action and social justice based approach to community based accountability. Despite receiving a lot of support and funding from the central ministry in the pilot phase, the subsequent roll out of the process, led in the post-pilot phase by the individual state governments, showed very varied outcomes. This paper using both documentary and interview based data is the first study to document the roll out of this ambitious process. Looking critically at what varied and why, the paper attempts to derive lessons for future implementation of such contested concepts.

  • 14.
    Gebel, Michael
    et al.
    Carl von Ossietzky University of Oldenburg, Institute of Social Sciences, Oldenburg, Germany.
    Vossemer, Jonas
    Carl von Ossietzky University of Oldenburg, Institute of Social Sciences, Oldenburg, Germany.
    The impact of employment transitions on health in Germany: A difference-in-differences propensity score matching approach2014In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 108, p. 128-136Article in journal (Refereed)
    Abstract [en]

    This article investigates the effects of transitions between employment and unemployment on health. It also addresses the question of whether or not the widespread use of temporary employment has altered the positive health effects of employment. Drawing on data from the German Socio-Economic Panel for the period 1995–2010, we apply difference-in-differences propensity score matching to identify the direct causal effects of unemployment and reemployment on psychological and physical health. This combination of two approaches towards causal inference controls for both unobserved fixed effects and observable differences in a flexible semi-parametric specification. Our sample includes persons between the ages of 16–54 who have at least experienced one respective employment transition (treatment groups) or are continuously employed or unemployed (control groups). The results show that only psychological but not physical health is causally affected by the respective employment transitions. Specifically, the effects of unemployment and reemployment are of similar size, highlighting the importance of reemployment in compensating unemployment's negative impact on psychological health. In contrast, health selection and confounding seem to be important determinants of the cross-sectional association between unemployment and physical health. Carrying out separate analyses for permanent and temporary workers, we shed new light on the health effects of temporary employment. It has been argued that the rise of temporary employment has introduced a new inequality in the world of work, blurring the line between employment and unemployment. However, contrary to our expectations we find that both employment transitions have effects of a similar size for permanent and temporary workers. In sum, our results highlight two points. First, longitudinal research is needed to properly evaluate the health effects of unemployment, reemployment, and temporary employment. Second, compared to temporary employment, unemployment is still the greater threat to individuals' psychological health.

  • 15. Ginsburg, Carren
    et al.
    Bocquier, Philippe
    Beguy, Donatien
    Afolabi, Sulaimon
    Augusto, Orvalho
    Derra, Karim
    Herbst, Kobus
    Lankoande, Bruno
    Odhiambo, Frank
    Otiende, Mark
    Soura, Abdramane
    Wamukoya, Marylene
    Zabre, Pascal
    White, Michael J.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Healthy or unhealthy migrants?: Identifying internal migration effects on mortality in Africa using health and demographic surveillance systems of the INDEPTH network2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 164, p. 59-73Article in journal (Refereed)
    Abstract [en]

    Migration has been hypothesised to be selective on health but this healthy migrant hypothesis has generally been tested at destinations, and for only one type of flow, from deprived to better-off areas. The circulatory nature of migration is rarely accounted for. This study examines the relationship between different types of internal migration and adult mortality in Health and Demographic Surveillance System (HDSS) populations in West, East, and Southern Africa, and asks how the processes of selection, adaptation and propagation explain the migration-mortality relationship experienced in these contexts. The paper uses longitudinal data representing approximately 900 000 adults living in nine sub-Saharan African HDSS sites of the INDEPTH Network. Event History Analysis techniques are employed to examine the relationship between all-cause mortality and migration status, over periods ranging from 3 to 14 years for a total of nearly 4.5 million person-years. The study confirms the importance of migration in explaining variation in mortality, and the diversity of the migration-mortality relationship over a range of rural and urban local areas in the three African regions. The results confirm that the pattern of migration-mortality relationship is not exclusively explained by selection but also by propagation and adaptation. Consequences for public health policy are drawn. 

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  • 16.
    Granlund, David
    Umeå University, Faculty of Social Sciences, Department of Economics.
    Are private physicians more likely to veto generic substitution of prescribed pharmaceuticals?2009In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 69, no 11, p. 1643-1650Article in journal (Refereed)
    Abstract [en]

    Physicians' decisions whether or not to veto generic substitution were analyzed using a sample of 350,000 pharmaceutical prescriptions from the county of Västerbotten, Sweden. The primary purpose was to test if physicians working at private practices were more likely to oppose substitution than county-employed physicians working on salary. It was found that private physicians were 50-80% more likely to veto substitution. Also, the probability of a veto was found to be increased as patients' copayments decreased. This might indicate moral hazard in insurance, though other explanations are plausible.

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    Are private physicians more likely to veto generic substitution
  • 17.
    Granlund, David
    et al.
    Umeå University, Faculty of Social Sciences, Department of Economics.
    Chuc, NT
    Faculty of Public Health, Hanoi Medical University, Viet Nam.
    Phuc, HD
    Institute of Mathematics, Hanoi, Viet Nam.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Inequality in mortality in Vietnam during a period of rapid transition2010In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 70, no 2, p. 232-239Article in journal (Refereed)
    Abstract [en]

    The associations between socioeconomic variables and mortality for 41,000 adults Vietnamese followed from January 1999 to March 2008 are estimated using Cox's proportionally hazard models. Also, we use decomposition techniques to investigate the relative importance of socioeconomic factors for explaining inequality in age-standardized mortality risk. The results confirm previously found negative association between mortality and income and education, for both men and women. We also found that marital status, at least for men, explain a large and growing part of the inequality. Finally, estimation results for relative education variables suggest that there exist positive spillover of education, meaning that that higher education of one's neighbors or spouse might reduce ones mortality risk.

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    Inequality in mortality in Vietnam during a period of rapid transition
  • 18.
    Gustafsson, Per E
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Fonseca Rodriguez, Osvaldo
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Castel Feced, Sara
    Department of Microbiology, Pediatrics, Radiology, and Public Health, University of Zaragoza, Spain.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Bastos, João Luiz
    Faculty of Health Sciences, Simon Fraser University, Canada.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish population2024In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 343, article id 116589Article in journal (Refereed)
    Abstract [en]

    Primary health care (PHC) systems are a crucial instrument for achieving equitable population health, but there is little evidence of how PHC reforms impact equities in population health. In 2010, Sweden implemented a reform that promoted marketization and privatization of PHC. The present study uses a novel integration of intersectionality-informed and evaluative epidemiological analytical frameworks to disentangle the impact of the 2010 Swedish PHC reform on intersectional inequities in avoidable hospitalizations. The study population comprised the total Swedish population aged 18–85 years across 2001–2017, in total 129 million annual observations, for whom register data on sociodemographics and hospitalizations due to ambulatory care sensitive conditions were retrieved. Multilevel Analysis of Individual Heterogeneity and Discriminatory Analyses (MAIHDA) were run for the pre-reform (2001–2009) and post-reform (2010–2017) periods to provide a mapping of inequities. In addition, random effects estimates reflecting the discriminatory accuracy of intersectional strata were extracted from a series MAIHDAs run per year 2001–2017. The estimates were re-analyzed by Interrupted Time Series Analysis (ITSA), in order to identify the impact of the reform on measures of intersectional inequity in avoidable hospitalizations. The results point to a complex reconfiguration of social inequities following the reform. While the post-reform period showed a reduction in overall rates of avoidable hospitalizations and in age disparities, socioeconomic inequities in avoidable hospitalizations, as well as the importance of interactions between complex social positions, both increased. Socioeconomically disadvantaged groups born in the Nordic countries seem to have benefited the least from the reform. The study supports a greater attention to the potentially complex consequences that health reforms can have on inequities in health and health care, which may not be immediate apparent in conventional evaluations of either population-average outcomes, or by simple evaluations of equity impacts. Methodological approaches for evaluation of complex inequity impacts need further development.

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  • 19.
    Gustafsson, Per E
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Fonseca Rodriguez, Osvaldo
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nilsson, Ingeborg
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Occupational Therapy.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Intersectional inequalities in loneliness among older adults before and during the early phase of the COVID-19 pandemic: A total population survey in the Swedish eldercare setting2022In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, article id 115447Article in journal (Refereed)
    Abstract [en]

    Loneliness among older adults is a public health problem that has received particular attention since the emergence of the COVID-19 pandemic. Studies to date have however found a rather modest psychosocial impact of the pandemic on older adults, and scarce research has analyzed this impact using a comprehensive equity lens. The present study used an intersectional approach to examine social inequalities in loneliness before and during the early phase of the pandemic among older adults receiving eldercare in Sweden. The study population (analytical N = 205,529) came from two waves (2019 and 2020) of a total population survey to all older adult (>65 years of age) home care recipients and nursing home residents in Sweden. Loneliness was self-reported by a single-item measure, and survey data were linked to population register data on age, gender, residential setting, income, and country of birth. Additive binomial regression models were used to estimate prevalence differences and discriminatory accuracy according to an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) approach. Results showed inequalities in loneliness arising particularly in the intersection of country of birth, income, and residential setting. The inequalities widened slightly but ubiquitously following the emergence of the pandemic in 2020, with particularly nursing home residents emerging as a risk group. The discriminatory accuracy of inequalities was consistently low to moderate throughout the analyses but increased marginally during the pandemic in 2020. The study illustrates how social inequalities engenders heterogeneity in the psychosocial risk of older adults before and during the pandemic. These findings should stimulate more nuanced and equity-oriented depictions, research and policies about loneliness among older adults in the peri-pandemic era.

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  • 20.
    Gustafsson, Per E.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Socioeconomic disadvantage in adolescent women and metabolic syndrome in mid-adulthood: an examination of pathways of embodiment in the Northern Swedish Cohort2012In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 74, no 10, p. 1630-1638Article in journal (Refereed)
    Abstract [en]

    Research indicates that disadvantaged socioeconomic status in childhood or adolescence increases specifically women's risk for developing metabolic syndrome in adulthood. Construing this observation as an expression of embodiment, the present study aims at examining the 'social chain of risk' and the 'reproduction' hypotheses as pathways of this embodiment. Participants were all women in the Northern Swedish Cohort, a 27-year prospective Swedish cohort, with data collection in 1981 at age 16 years (n = 1083, 506 women), and follow-up at age 21, 30 and 43 (n = 482 women) years. The analytical sample was n = 399 women (79% of the original cohort). Socioeconomic disadvantage was defined as parental manual occupation at age 16, and metabolic syndrome according to standardized criteria at age 43. The social chain of risk was operationalized as accumulated social and material adversities at age 16, 21, 30 and 43 years, and reproductive factors by age at menarche, early childbearing (before age 22), and number of children at age 43. In logistic regression with metabolic syndrome as the outcome, the OR for adolescent socioeconomic status was rendered non-significant and reduced by 21.6% after adjustment for cumulative adversity over the life course. Of the reproductive factors, only age at menarche lead to an OR reduction at all (by 43%). Our study suggests that women's embodiment of socioeconomic disadvantage during upbringing is partly explained by adversity over the subsequent life course. Future studies should incorporate the living conditions of women over the life course as a possible pathway whereby early life socioeconomic conditions are embodied. (C) 2012 Elsevier Ltd. All rights reserved.

  • 21.
    Hanlon, Charlotte
    et al.
    King's College London, Institute of Psychiatry, Health Services and Population Research Department, London, UK.
    Whitley, Rob
    Dartmouth Psychiatric Research Center, Dartmouth Medical School, Lebanon, NH, USA.
    Wondimagegn, Dawit
    Department of Psychiatry, Faculty of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.
    Alem, Atalay
    Department of Psychiatry, Faculty of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.
    Prince, Martin
    King's College London, Institute of Psychiatry, Health Services and Population Research Department, London, UK.
    Postnatal mental distress in relation to the sociocultural practices of childbirth: an exploratory qualitative study from Ethiopia2009In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 69, no 8, p. 1211-1219Article in journal (Refereed)
    Abstract [en]

    Sociocultural patterning of the postnatal period in non-Western settings has been hypothesised to protect against postnatal depression. In 2004, in a predominantly rural area of Ethiopia, we conducted 25 in-depth interviews and five focus group discussions with purposively selected participants including perinatal women, fathers, grandmothers, traditional and religious leaders, birth attendants and community leaders. Our main objectives were (1) to examine societal recognition of problematic distress states in the postnatal period and relate this to Western conceptualisations of postnatal depression and (2) to relate the occurrence of distress states to sociocultural patterning of the postnatal period. Inductive analysis was employed to identify salient themes. Participants spontaneously described culturally problematic distress states occurring in the postnatal period, although did not consider them to be illness. Vulnerability and danger of the postnatal period was emphasised, with risk of supernatural attack and physical harm leading to distress states. Participants also spoke of how gender disadvantage and economic strain intersect with cultural patterning of the postnatal period, threatening mental health due to the resulting disappointed expectations and exclusion, as well as exacerbation of pre-existing problems. Cultural dissonance, where a person's beliefs or actions are out of kilter with strong prevailing cultural norms, may be an important risk factor for postnatal distress in rural Ethiopia, where the postnatal period is extensively culturally elaborated.

  • 22. Harling, Guy
    et al.
    Kobayashi, Lindsay C.
    Farrell, Meagan T.
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Tollman, Stephen
    Berkman, Lisa
    Social contact, social support, and cognitive health in a population-based study of middle-aged and older men and women in rural South Africa2020In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 260, article id 113167Article in journal (Refereed)
    Abstract [en]

    Background: Several theories seek to explain how social connections and cognitive function are interconnected in older age. These include that social interaction protects against cognitive decline, that cognitive decline leads to shedding of social connections and that cognitive decline leads to increased instrumental support. We investigated how patterns of social contact, social support and cognitive health in rural South Africa fit with these three theories.

    Method: We used data from the baseline of "Health and Aging in Africa: a Longitudinal Study of an INDEPTH community in South Africa" (HAALSI), a population-based study of 5059 individuals aged >= 40 years. We evaluated how a range of egocentric social connectedness measures varied by respondents' cognitive function.

    Results: We found that respondents with lower cognitive function had smaller, denser social networks that were more local and more kin-based than their peers. Lower cognitive function was associated with receipt of less social support generally, but this difference was stronger for emotional and informational support than for financial and physical support. Impairment was associated with greater differences among those aged 40-59 and those with any (versus no) educational attainment.

    Conclusions: The patterns we found suggest that cognitively impaired older adults in this setting rely on their core social networks for support, and that theories relating to social connectedness and cognitive function developed in higher-income and higher-education settings may also apply in lower-resource settings elsewhere.

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  • 23.
    Hartini, T Ninuk S
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Padmawati, R Siwi
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Surjono, Achmad
    Winkvist, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    The importance of eating rice: changing food habits among pregnant Indonesian women during the economic crisis2005In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 61, no 1, p. 199-210Article in journal (Refereed)
    Abstract [en]

    This article presents qualitative and quantitative research findings on food habits of pregnant Indonesian women in relation to the economic crisis that arose in 1997. Between 1996 and 1998, dietary intakes were estimated for 450 pregnant women in Central Java. Between January and June 1999, four focus group discussions, 16 in-depth interviews and four non-participant observations were held with women, two in-depth interviews were held with traditional birth attendants, and four with midwives. Women were categorized as urban or rural, rich or poor, and according to rice field ownership. The women reported that before the crisis they bought more foods and cooked more meals and snacks. During the crisis, cooking methods became simpler and cooking tasty foods was more important than cooking nutritious foods. This involved using plenty of spices and cooking oil, but reducing the use of expensive nutritious foods. The herbal drink jamu was drunk by 15% of pregnant women; its consumption was lower during than before the economic crisis. Twenty-six percent of the women avoided certain foods due to food taboos, and most of these women avoided beneficial foods; this phenomenon decreased during the crisis among the rich and the rural, poor, landless women. In spite of increased prices for rice, women did not decrease their rice consumption during the crisis because rice was believed to have the highest value for survival, to provide strength during pregnancy and delivery, and to be easier to store and cook. Finally, children and husbands had highest priority in being served food, and women were the last to eat.

  • 24.
    Herrera Rodríguez, Andrés
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Dahlgren, Lars
    Umeå University, Faculty of Social Sciences, Department of Sociology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Pathways to suicidal behaviour among adolescent girls in Nicaragua2006In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 62, no 4, p. 805-814Article in journal (Refereed)
    Abstract [en]

    Adolescent girls are the most frequent suicide attempters worldwide. However, there is little knowledge about pathways leading to suicidal behaviour among young people, in particular in low-income countries. This study explores the motives and processes related to suicidal behaviour among young girls in Nicaragua. Individual in-depth interviews were conducted with eight girls aged between 12 and 19 admitted to hospital after attempting suicide. The audio-taped interviews lasted 2–4 h and were transcribed, translated into English and coded for content. Grounded theory and content analysis were used to construct a theory of the mechanisms behind their suicidal behaviour.

    A tentative model exploring pathways to suicidal behaviour is described with four main categories: structuring conditions, triggering events, emotions and actions taken. The model illustrates the dialectic interplay between structure and actions taken. Actions taken were categorized as problem solving or various forms of escape where failure with either of these strategies resulted in a suicide attempt.

    Dysfunctional families, absent fathers and lack of integration into society were some of the structuring conditions that lead to emotional distress. Abuse, deaths in the family, break-up with boyfriends or suicide among friends acted as triggering events. A striking finding was the obvious narrative competence of the girls.

    Our findings indicate that suicide prevention programmes for young people must offer support from professionals, independent of their family and social networks. Institutions in the community in contact with young people with suicidal behaviour must develop communicative skills to offer a trusting environment mobilising the resources that young people have.

  • 25.
    Hult, Carl
    et al.
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Stattin, Mikael
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Järvholm, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Comparing mortality rates and recognizing health selection bias: A response to Wallman and Svärdsudd2010In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 70, no 10, p. 1489-1491Article in journal (Other academic)
  • 26.
    Hult, Carl
    et al.
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Stattin, Mikael
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Järvholm, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Timing of retirement and mortality: A cohort study of Swedish construction workers2010In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 70, no 10, p. 1480-1486Article in journal (Refereed)
    Abstract [en]

    Recent studies indicate that early retirement per se may have a negative effect on health to such an extent that it increases mortality risk. One type of early retirement often referred to in these studies is retirement with disability pension/benefit. Given the overall objective of disability benefit programmes - to help the disabled live socially and economically satisfactory lives, freed from exposure to employment health hazards and thus avoid further declines in health - the finding is challenging. This paper examined the relationship between timing of retirement and mortality using a cohort of Swedish construction workers. The mortality risk of disability pensioners - excluding those with diagnoses normally connected to increased mortality - was compared with the risk of those continuing to work. Although initial indications were in line with earlier results, it became obvious that the increased mortality risk of disability pensioners did not depend on early retirement per se but on poor health before early retirement not explicitly recognized in the diagnosis on which the disability pension rested. The results indicate that there are no general differences in mortality depending on timing of retirement. Future studies of mortality differences arising from working or not working must sufficiently control for health selection effects into the studied retirement paths.

  • 27.
    Högberg, Björn
    Umeå University, Faculty of Social Sciences, Department of Social Work. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Educational stressors and secular trends in school stress and mental health problems in adolescents2021In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 270, article id 113616Article in journal (Refereed)
    Abstract [en]

    Increasing mental health problems among adolescents have been have reported in several countries over the last decades. Yet, little is known regarding the societal changes underlying secular trends in adolescent mental health. The educational stressors hypothesis states that educational expansion and a shift to knowledge economies makes life chances of adolescents more dependent on their educational performance, thus generating more school stress and, in turn, mental health problems. The present study tests this hypothesis using multilevel analyses and panel data techniques to analyse data from the Health Behavior in School-aged Children (HBSC) survey, including more than 150,000 adolescents in 33 European countries over 12 years.

    Results show that economic change, as measured by changes in national gross domestic product, but not educational expansion, contributes to more school stress in adolescents. Both economic change and educational expansion makes school stress more consequential for mental health problems, such that the effect of stress on mental health problems becomes stronger as countries grow richer and more educated. I conclude that, consistent with the educational stressors hypothesis, economic change and educational expansion has likely contributed to increasing mental health problems in adolescents.

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  • 28.
    Högberg, Björn
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Strandh, Mattias
    Umeå University, Faculty of Social Sciences, Department of Social Work. Centre for Research on Child and Adolescent Mental Health, Karlstad University, Sweden.
    Hagquist, Curt
    Gender and secular trends in adolescent mental health over 24 years – The role of school-related stress2020In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 250, article id 112890Article in journal (Refereed)
    Abstract [en]

    Increasing levels of psychosomatic symptoms, and other mental health problems, among adolescents, and especially among girls, have been reported across various countries. The “educational stressors hypothesis” states that this trend can be explained by an increasing amount of stressors in the school environment. This study tests this hypothesis, using repeated cross-sectional data, between the years 1993–2017, from the Health Behaviours of School-aged Children (HBSC) survey. Regression and decomposition techniques are used to investigate the role of school stress for trends in psychosomatic symptoms, and for gender differences in symptoms.

    Results show that the effects of school stress on psychosomatic symptoms have become stronger over time, but that they can only account for a small share of the overall increase in symptoms since 1993. However, school stress has increased more among girls than among boys, and it explains about half of the growth of the gender gap in symptoms. Thus, school stress accounts for a substantial portion of the increase in symptoms for girls, but only a minor share of the increase for boys. In sum, we found weak evidence for the educational stressors hypothesis in regard to the overall trend in symptoms, but strong evidence for it in explaining the growing gender gap.

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  • 29.
    Högberg, Björn
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Strandh, Mattias
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Petersen, Solveig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Johansson, Klara
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Education system stratification and health complaints among school-aged children2019In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 220, p. 159-166Article in journal (Refereed)
    Abstract [en]

    Research shows that the school environment is an important social determinant of health among children and adolescents. However, we know virtually nothing of the health consequences of national education systems and policies, for example the stratification of pupils by academic ability. This study aimed to investigate if education system stratification is related to self-reported psychological and somatic health complaints of pupils aged 11 to 15, and social inequalities in such health complaints.

    Survey data from the Health Behaviors of School-aged Children (HBSC) survey, covering 33 countries and more than 180 000 pupils in primary and lower secondary school, were used. Multilevel models showed that education system stratification was not associated with the average levels of health complaints of pupils, but cross-level interaction effects showed that stratification moderated the relationship between social background and health complaints, such that inequalities in health complaints were smaller in countries with more stratified systems. Moreover, this moderating effect was mediated by the school learning environmentand social relations in school. Specifically, social inequalities in school pressure, academic self-concept, school climate, and school satisfaction were smaller in more stratified education systems, which in turn accounted for smaller inequalities in health complaints in these countries.

  • 30.
    Isaksson, Joakim
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Salander, Pär
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Lilliehorn, Sara
    Umeå University, Faculty of Social Sciences, Department of Social Work. Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Laurell, Göran
    Institutionen för kirurgiska vetenskaper, Öron-, näs- och halssjukdomar, Uppsala universitet.
    Living an everyday life with head and neck cancer 2-2.5 years post-diagnosis: a qualitative prospective study of 56 patients2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 154, p. 54-61Article in journal (Refereed)
    Abstract [en]

    Rationale: There are many studies available describing how patients are affected by head and neck cancer (HNC) and its treatment. Usually these studies are quantitative and focus on assessing patients' quality of life or distress post-treatment. These studies are important, but they are of limited value if we are interested in understanding more about HNC in an everyday life context.

    Objective: The purpose was to determine how life was lived and valued during and after treatment for HNC and to detect different transitions in returning to everyday life.

    Methods: During 2009-2012, 56 patients with HNC were consecutively included, and interviewed at 6, 12, and 24 months post-treatment about how they lived their lives. All patients received primary treatment at a tertiary referral university hospital in Sweden.

    Results: Four different trajectories and transitions emerged. The first group (n=15) evalutated their illness experience as a past parenthesis in their life suggesting that they had psychologically left the illness behind. In the second group (n=9), the impact of the disease seemed to be diluted by other strains in their life, and although these patients to some extent were still hampered by side effects, they regarded them as 'no big deal'. The cancer really made a difference in the third group (n=12) in both positive and negative ways and seemed to reflect a balance between such effects. In the fourth group (n=20), the physical and/or psychological problems predominated and the patients' lives had changed for the worse.

    Conclusion: The narratives showed that being afflicted by HNC has different impacts depending on how the patients live their lives – it is a matter of individual transition in an everyday life context. This idiosyncracy challenges the meaningfulness of screening efforts to identify vulnerable groups for psychosocial intervention.

  • 31.
    Kero, Anneli
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Jacobsson, Lars
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Legal abortion: a painful necessity2001In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 53, no 11, p. 1481-1490Article in journal (Refereed)
    Abstract [en]

    This study was conducted to increase knowledge about the psychosocial background and current living conditions of Swedish women seeking abortion, along with their motives for abortion and their feelings towards pregnancy and abortion. Two hundred and eleven women answered a questionnaire when they consulted the gynaecologist for the first time. The study indicates that legal abortion may be sought by women in many circumstances and is not confined to those in special risk groups. For example, most women in the sample were living in stable relationships with adequate finances. The motives behind a decision to postpone or limit the number of children revealed a wish to have children with the right partner and at the right time in order to combine good parenting with professional career. The study shows that prevailing expectations about lifestyle render abortion a necessity in family planning. One-third of the women had had a previous abortion(s) and 12% had become pregnant in a situation where they had felt pressured or threatened by the man. Two-thirds of the women characterised their initial feelings towards the pregnancy solely in painful words while nearly all the others reported contradictory feelings. Concerning feelings towards the coming abortion, more than half expressed both positive and painful feelings such as anxiety, relief, grief, guilt, anguish, emptiness and responsibility, while one-third expressed only painful feelings. However, almost 70% stated that nothing could change their decision to have an abortion. Thus, this study highlights that contradictory feelings in relation to both pregnancy and the coming abortion are common but are very seldom associated with doubts about the decision to have an abortion.

  • 32.
    Kero, Anneli
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Wellbeing and mental growth: long-term effects of legal abortion2004In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 58, no 12, p. 2559-2569Article in journal (Refereed)
    Abstract [en]

    The present study aims to increase knowledge about coping with legal abortion by studying women's reasoning, reactions and emotions over a period of 1 year. The study comprises interviews focusing on the experiences and effects of abortion in 58 women, 4 and 12 months after the abortion. The women also answered a questionnaire before the abortion concerning their living conditions, decision-making process and feelings about the pregnancy and the abortion. Majority of the women did not experience any emotional distress post-abortion and almost all the woman reported that they had coped well at the 1-year follow-up, although 12 had had severe emotional distress directly post-abortion. Furthermore, almost all described the abortion as a relief or a form of taking responsibility and more than half reported only positive experiences such as mental growth and maturity of the abortion process. Those without any emotional distress post-abortion stated clearly before the abortion that they did not want to give birth since they prioritised work, studies and/or existing children. The study shows that women generally are able to make the complex decision to have an abortion without suffering any subsequent regret or negative effects, as ascertained at the 1-year follow-up.

  • 33. Kobayashi, Lindsay C.
    et al.
    Glymour, M. Maria
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of t he Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Payne, Collin F.
    Wagner, Ryan G.
    Montana, Livia
    Mateen, Farrah J.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of t he Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Berkman, Lisa F.
    Childhood deprivation and later-life cognitive function in a population-based study of older rural South Africans2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 190, p. 20-28Article in journal (Refereed)
    Abstract [en]

    Rationale: Little research has evaluated the life course drivers of cognitive aging in South Africa.

    Objectives: We investigated the relationships of self-rated childhood health and father's occupation during childhood with later-life cognitive function score and whether educational attainment mediated these relationships among older South Africans living in a former region of Apartheid-era racial segregation.

    Methods: Data were from baseline assessments of "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community" (HAALSI), a population-based study of 5059 men and women aged >= 40 years in 2015 in rural Agincourt sub-district, South Africa. Childhood health, father's occupation during childhood, and years of education were self-reported in study interviews. Cognitive measures assessed time orientation, numeracy, and word recall, which were included in a z-standardized latent cognitive function score variable. Linear regression models adjusted for age, sex, and country of birth were used to estimate the total and direct effects of each childhood risk factor, and the indirect effects mediated by years of education.

    Results: Poor childhood health predicted lower cognitive scores (total effect = -0.28; 95% CI = -035, -0.21, versus good); this effect was not mediated by educational attainment. Having a father in a professional job during childhood, while rare (3% of sample), predicted better cognitive scores (total effect = 0.25; 95% CI = 0.10, 0.40, versus unskilled manual labor, 29% of sample). Half of this effect was mediated by educational attainment. Education was linearly associated with later-life cognitive function score (0.09; 95% CI = 0.09, 0.10 per year achieved).

    Conclusion: In this post-Apartheid, rural South African context, older adults with poor self-reported childhood health or whose father worked in unskilled manual labor had relatively poor cognitive outcomes. Educational attainment strongly predicted cognitive outcomes, and appeared to be, in part, a mechanism of social stratification in later-life cognitive health in this context.

  • 34.
    Kristoffersson, Emelie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Rönnqvist, Hanna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Andersson, Jenny
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Bengs, Carita
    Umeå University, Faculty of Social Sciences, Department of Food, Nutrition and Culinary Science.
    Hamberg, Katarina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    "It was as if I wasn't there": experiences of everyday racism in a Swedish medical school2021In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 270, article id 113678Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to explore and analyze how cultural/ethnic minority students at a Swedish medical school perceive and make sense of educational experiences they viewed as related to their minority position. We interviewed 18 medical students (10 women, and 8 men), who self-identified as coming from minority backgrounds. Data were collected and analyzed simultaneously, inspired by constructivist grounded theory methodology. The concepts 'everyday racism' and 'racial microaggressions' served as a theoretical framework for understanding how inequities were experienced and understood. Participants described regularly encountering subtle adverse treatment from supervisors, peers, staff, and patients. Lack of support from bystanders was a common dimension of their stories. These experiences marked interviewees' status as 'Other' and made them feel less worthy as medical students. Interviewees struggled to make sense of being downgraded, excluded, and discerned as different, but seldom used terms like being a victim of discrimination or racism. Instead, they found other explanations by individualizing, renaming, and relativizing their experiences. Our results indicate that racialized minority medical students encounter repeated practices that, either intentionally or inadvertently, convey disregard and sometimes contempt based on ideas about racial and/or cultural 'Otherness'. However, most hesitated to name the behaviors and comments experienced as "discriminatory" or "racist", likely because of prevailing ideas about Sweden and, in particular, medical school as exempt from racism, and beliefs that racial discrimination can only be intentional. To counteract this educational climate of exclusion medical school leadership should provide supervisors, students, and staff with theoretical concepts for understanding discrimination and racism, encourage them to engage in critical self-reflection on their roles in racist power relations, and offer training for bystanders to become allies to victims of racism.

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  • 35.
    Landstedt, Evelina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Almquist, Ylva B.
    Eriksson, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Disentangling the directions of associations between structural social capital and mental health: Longitudinal analyses of gender, civic engagement and depressive symptoms2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 163, p. 135-143Article in journal (Refereed)
    Abstract [en]

    The present paper analysed the directions of associations between individual-level structural social capital, in the form of civic engagement, and depressive symptoms across time from age 16-42 years in Swedish men and women. More specifically, we asked whether civic engagement was related to changes in depressive symptoms, if it was the other way around, or whether the association was bi-directional. This longitudinal study used data from a 26-year prospective cohort material of 1001 individuals in Northern Sweden (482 women and 519 men). Civic engagement was measured by a single-item question reflecting the level of engagement in clubs/organisations. Depressive symptoms were assessed by a composite index. Directions of associations were analysed by means of gender-separate cross-lagged structural equation models. Models were adjusted for parental social class, parental unemployment, parental health, and family type at baseline (age 16). Levels of both civic engagement and depressive symptoms were relatively stable across time. The model with the best fit to data showed that, in men, youth civic engagement was negatively associated with depressive symptoms in adulthood, thus supporting the hypothesis that involvement in social networks promotes health, most likely through provision of social and psychological support, perceived influence, and sense of belonging. Accordingly, interventions to promote civic engagement in young men could be a way to prevent poor mental health for men later on in life. No cross-lagged effects were found among women. We discuss this gender difference in terms of gendered experiences of civic engagement which in turn generate different meanings and consequences for men and women, such as civic engagement not being as positive for women's mental health as for that of men. We conclude that theories on structural social capital and interventions to facilitate civic engagement for health promoting purposes need to acknowledge gendered life circumstances. (C) 2016 Elsevier Ltd. All rights reserved.

  • 36.
    Linander, Ida
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Alm, Erika
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Harryson, Lisa
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Negotiating the (bio)medical gaze: Experiences of trans-specific healthcare in Sweden2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 174, p. 9-16Article in journal (Refereed)
    Abstract [en]

    In Sweden as well as in other western countries persons with trans experiences have to go through a clinical evaluation in order to get access to gender-confirming medical procedures. The aim of this study is to analyse care-users' experiences of navigating and negotiating access to gender-confirming medical procedures in Sweden. Biomedicalisation is used as a theoretical framework in order to analyse how technoscientific and neoliberal developments are parts of constructing specific experiences within trans-specific care. Constructivist grounded theory was used to analyse 14 interviews with persons having experiences of, or considering seeking, trans-specific healthcare. The participants experienced trans-specific healthcare as difficult to navigate because of waiting times, lack of support, provider ignorance and relationships of dependency between healthcare-users and providers. These barriers pushed the users to take responsibility for the care process themselves, through ordering hormones from abroad, acquiring medical knowledge and finding alternative support. Based on the participants' experiences, it can be argued that the shift of responsibility from care-providers to users is connected to a lack of resources within trans-specific care, to neoliberal developments within the Swedish healthcare system, but also to discourses that frame taking charge of the care process as an indicator that a person is in need of or ready for care. Thus, access to gender-confirming medical procedures is stratified, based on the ability and opportunity to adopt a charge-taking role and on economic and geographic conditions. Based on the results and discussion, we conclude that trans-specific care ought to focus on supporting the care-seekers throughout the medical process, instead of the current focus on verifying the need for care. There is also a need for increased knowledge and financial resources. A separation between legal and medical gender reassignment could contribute to a better relationship between care-providers and care-users and increase the quality of care.

  • 37.
    Linander, Ida
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Lundberg, Tove
    Department of Psychology, Lund University, Lund, Sweden.
    Alm, Erika
    Department of Cultural Sciences, Gothenburg University, Gothenburg, Sweden.
    The gender minority stress model and/or cisnormativity?: The need for pluralistic theoretical perspectives in improving trans health and medicine2024In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 351, article id 116957Article in journal (Refereed)
    Abstract [en]

    The minority stress model has become a well-used framework to explain and analyse health among LGBTQ people, and specifically among transgender and gender-diverse people (TGD), when it is sometimes called ‘the gender minority stress model’. Scholars have argued the need for critical discussions about some of the assumptions underlying the gender minority stress model and how it has been used and discussed. Drawing on a pluralistic understanding of theories and employing a Foucauldian understanding of critique, we discuss implicit assumptions and epistemological standpoints of the gender minority stress model and the connected limitations. We also ask what the concept of cisnormativity can give rise to in comparison with the minority stress framework. We make four arguments: 1) the calls for extensions to the model could be seen as a desire to understand and analyse TGD people's health from an all-encompassing perspective, resulting in theoretical vagueness and the silencing of excluded aspects; 2) in the gender minority stress literature, identity is largely taken for granted and there is no consideration of how power is constitutive for all subjects; 3) the model risks individualising the effects of social norms, and internalisation could be further theoretically developed in relation to the repression hypothesis; 4) in the translation process from LGB minorities to TGD, as well as in thinking about cisnormativity, the issue of gender-affirming care has largely been neglected. By initiating a critical discussion around these issues and illustrating how different theories and frameworks can illuminate different possibilities for thinking and knowing, we aim to open up new routes for thinking about TGD health and medicine.

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  • 38.
    Lindgren, Simon
    et al.
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Richardson, Lorna
    School of Art, Media and American Studies, University of East Anglia, Norwich Research Park, Norwich, United Kingdom.
    Endometriosis pain and epistemic community: mapping discourses in online discussions among sufferers2023In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 326, article id 115889Article in journal (Refereed)
    Abstract [en]

    We focused in this study on how the private experience of pain is made public through online discourse by sufferers of endometriosis. Empirically, we analyse two highly active endometriosis communities on the online social platform Reddit. Drawing on a mixed-methods design, we leverage large-scale social data, and a combination of computational and interpretive approaches for text analysis to study the role and shape of interactions relating to ‘pain’ for the formation of epistemic community online around endometriosis. The dataset, consisting of 70,817 forum posts and comments, was collected in May of 2021. Our study shows how pain becomes meaningful for endometriosis sufferers in relation to a multidimensional discursive space of words and concepts that are used to express it. Pain was frequently disguised, underplayed or hidden altogether, from fears of misunderstanding, medical dismissal, and embarrassment. Clearly, peer validation can be found in the relative anonymity of Reddit discussions. While the experience of pain is individual and subjective, when communities share similar experiences this reinforces patient ownership of the pain, which in turn supports the epistemic authority of the patient collective. A detailed understanding of how and why pain is discussed in online spaces has much to contribute more broadly to discussions of experiential collective knowledge production among individuals with endometriosis and other chronic illnesses.

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  • 39.
    Lindqvist, Olav
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Tishelman, Carol
    Room for Death - International museum-visitors' preferences regarding the end of their life2015In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 139, p. 1-8Article in journal (Refereed)
    Abstract [en]

    Just as pain medications aim to relieve physical suffering, supportive surrounding for death and dying may facilitate well-being and comfort. However, little has been written of the experience of or preferences for the surroundings in which death and dying take place. In this study, we aim to complement our research from perspectives of patients, family members and staff, with perspectives from an international sample of the general public. Data derives from a project teaming artists and craftspeople together to create prototypes of space for difficult conversations in end-of-life (EoL) settings. These prototypes were presented in a museum exhibition, "Room for Death", in Stockholm in 2012. As project consultants, palliative care researchers contributed a question to the public viewing the exhibition, to explore their reflections: "How would you like it to be around you when you are dying?" Five-hundred and twelve responses were obtained from visitors from 46 countries. While preliminary analysis pointed to many similarities in responses across countries, continued analysis with a phenomenographic approach allowed us to distinguish different foci related to how preferences for surroundings for EoL were conceptualized. Responses were categorized in the following inductively-derived categories: The familiar death, The 'larger-than life' death, The lone death, The mediated death, The calm and peaceful death, The sensuous death, The 'green' death, and The distanced death. The responses could relate to a single category or be composites uniting different categories in individual combinations, and provide insight into different facets of contemporary reflections about death and dying. Despite the selective sample, these data give reason to consider how underlying assumptions and care provision in established forms for end-of-life care may differ from people's preferences. This project can be seen as an example of innovative endeavors to promote public awareness of issues related to death and dying, within the framework of health-promoting palliative care. (C) 2015 Elsevier Ltd. All rights reserved.

  • 40. Lippman, Sheri A.
    et al.
    Neilands, Torsten B.
    Leslie, Hannah H.
    Maman, Suzanne
    MacPhail, Catherine
    Twine, Rhian
    Peacock, Dean
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pettifor, Audrey
    Development, validation, and performance of a scale to measure community mobilization2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 157, p. 127-137Article in journal (Refereed)
    Abstract [en]

    Rationale: Community mobilization approaches (CMAs) are increasingly becoming key components of health programming. However, CMAs have been ill defined and poorly evaluated, largely due to the lack of measurement tools to assess mobilization processes and impact. Objective: We developed the Community Mobilization Measure (CMM), composed of a set of scales to measure mobilization domains hypothesized to operate at the community-level. The six domains include: shared concerns, critical consciousness, leadership, collective action, social cohesion, and organizations and networks. We also included the domain of social control to explore synergies with the related construct of collective efficacy. Method: A survey instrument was developed and pilot tested, then revised and administered to 1181 young people, aged 18-35, in a community-based survey in rural South Africa. Item response modeling and exploratory factor analyses were conducted to assess model fit, dimensionality, reliability, and validity. Results: Results indicate the seven-dimensional model, with linked domains but no higher order construct, fit the data best. Internal consistency reliability of the factors was strong, with rho values ranging from 0.81 to 0.93. Six of seven scales were sufficiently correlated to represent linked concepts that comprise community mobilization; social control was less related to the other components. At the village level, CMM sub-scales were correlated with other metrics of village social capital and integrity, providing initial evidence of higher-level validity, however additional evaluation of the measure at the community level is needed. Conclusion: This is the first effort to develop and validate a comprehensive measure for community mobilization. The CMM was designed as an evaluation tool for health programming and should facilitate a more nuanced understanding of mechanisms of change associated with CM, ultimately making mobilizing approaches more effective.

  • 41.
    Lo Iacono, Sergio
    et al.
    Utrecht University, Department of Sociology/ICS, Utrecht, Netherlands.
    Przepiorka, Wojtek
    Utrecht University, Department of Sociology/ICS, Utrecht, Netherlands.
    Buskens, Vincent
    Utrecht University, Department of Sociology/ICS, Utrecht, Netherlands.
    Corten, Rense
    Utrecht University, Department of Sociology/ICS, Utrecht, Netherlands.
    van de Rijt, Arnout
    Utrecht University, Department of Sociology/ICS, Utrecht, Netherlands.
    COVID-19 vulnerability and perceived norm violations predict loss of social trust: A pre-post study2021In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 291, article id 114513Article in journal (Refereed)
    Abstract [en]

    While pandemic containment measures benefit public health, they may jeopardize the social structure of society. We hypothesize that lockdowns and prolonged social distancing measures hinder social support and invite norm violations, eroding social trust. We conducted a pre-registered pre-post study on a representative sample of the Dutch population (n = 2377; participation rate = 88.8%), measuring social trust reported by the same individuals before and after the first wave of the COVID-19 pandemic. Results show that social trust in the Netherlands suddenly dropped from its historically stable level, reaching one of its lowest points on record. The decline was stronger among residents belonging to official high-risk categories, especially if they perceived themselves as likely to become infected. Individuals who more strongly agreed with self-isolation norms or did not perceive a widespread compliance or agreement with such norms also reported a greater loss of trust.

  • 42. Lynöe, N
    et al.
    Mattsson, B
    Sandlund, Mikael
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    The attitudes of patients and physicians towards placebo treatment--a comparative study.1993In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 36, no 6, p. 767-74Article in journal (Refereed)
    Abstract [en]

    Placebo treatment in clinical practice can be given either in order to comply with the wishes of the patient, or with the purpose of doing good and not causing harm. In the former instance, the procedure may be in accordance with the interests of the patient, yet be in conflict with the interests of the medical profession. In the latter instance, the procedure presupposes that in most cases the patient has not been informed of the nature of the treatment; this type of procedure may jeopardize a trusting patient-doctor relationship. Therefore, it is of interest to investigate both the extent to which patients and physicians feel they can accept placebo treatment and a paternalistic attitude, and in which particular situations. In order to shed some light on this matter, we compiled a questionnaire built around three case histories which problematize placebo treatment and paternalistic acts. The questionnaire was distributed to 100 patients and 100 physicians. 83 patients and 94 physicians responded. The results show that patients and physicians do not automatically follow specific group interests. Physicians are more inclined to respect the patient's option to refuse medical treatment than the patients are inclined to respect a physician's professional autonomy. Patients appear more to be paternalistic in their judgements than physicians, but one cannot rule out the possibility that the answers of the physicians reflect the fact that placebo treatment represent a socially undesirable behaviour. We conclude that theoretical and normative analyses of the perspective of the actors ought to be supplemented by empirical research.(ABSTRACT TRUNCATED AT 250 WORDS)

  • 43.
    Malmström, Nina
    et al.
    Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Öhlén, Joakim
    Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Centre for Person-Centred Care, University of Gothenburg, Gothenburg, Sweden; Palliative Centre at the Sahlgrenska University Hospital Region Västra Götaland, Gothenburg, Sweden.
    Jakobsson Larsson, Birgitta
    Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Department of Neurology, Uppsala University Hospital, Uppsala, Sweden.
    Nilsson, Stefan
    Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Centre for Person-Centred Care, University of Gothenburg, Gothenburg, Sweden; Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Nygren, Ingela
    Department of Neurology, Uppsala University Hospital, Uppsala, Sweden; Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden.
    Andersen, Peter M.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Ozanne, Anneli
    Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Adolescents' challenging and grief-filled transitions when living with a parent with ALS: a qualitative interpretive study2024In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 354, article id 117063Article in journal (Refereed)
    Abstract [en]

    Objective: The study aimed to explore the meaning for adolescents of living with a parent with amyotrophic lateral sclerosis (ALS).

    Methods: The design is qualitative. Interviews were conducted between December 2020 and April 2022 with 11 adolescents (8-25 y), living in households with a parent with ALS in Sweden. The analysis was phenomenologically hermeneutical.

    Results: The adolescents were in a difficult and exposed situation, especially if the parent had a severe disability and assistant care providers were in the home. Witnessing the gradual loss of the parent in an indefinite battle against time, while still needing them, elicited grief-filled and hard-to-manage emotions. Everyday life was turned upside down, resulting in greater responsibility for the adolescents, not only in helping with household chores and assisting the ill parent, but also in emotionally protecting both parents. It forced the adolescents to mature faster and put their own life on hold, triggering experiences of being limited. This, together with changing family roles yet being more attached to home, reinforced the imbalance in the adolescents' lives. The interpreted whole of the adolescents' narratives revealed that living with a parent with ALS meant a challenging and grieving transition during an already transition-filled adolescence, which left the adolescents struggling to keep a foothold on a life torn apart.

    Conclusion: The unbalanced life situation may hinder the adolescents' identity formation and emancipation, which are developmentally important for managing a healthy and independent adulthood. The results emphasize the importance of early targeted support to reach this vulnerable group in order to secure their health.

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  • 44.
    Maluka, Stephen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania.
    San Sebastiån, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byskov, Jens
    DBL-Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark.
    Olsen, Øystein E
    DBL-Centre for Health Research and Development and Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania.
    Shayo, Elizabeth
    National Institute for Medical Research (NIMR), P.O. Box 9653, Dar Es Salaam, Tanzania.
    Ndawi, Benedict
    Primary Health Care Institute (PHCI), P.O. Box 235, Iringa, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Decentralized health care priority-setting in Tanzania: evaluating against the accountability for reasonableness framework2010In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 71, no 4, p. 751-759Article in journal (Refereed)
    Abstract [en]

    Priority-setting has become one of the biggest challenges faced by health decision-makers worldwide. Fairness is a key goal of priority-setting and Accountability for Reasonableness has emerged as a guiding framework for fair priority-setting. This paper describes the processes of setting health care priorities in Mbarali district, Tanzania, and evaluates the descriptions against Accountability for Reasonableness. Key informant interviews were conducted with district health managers, local government officials and other stakeholders using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting in the district was observed. The results indicate that, while Tanzania has a decentralized public health care system, the reality of the district level priority-setting process was that it was not nearly as participatory as the official guidelines suggest it should have been. Priority-setting usually occurred in the context of budget cycles and the process was driven by historical allocation. Stakeholders' involvement in the process was minimal. Decisions (but not the reasoning behind them) were publicized through circulars and notice boards, but there were no formal mechanisms in place to ensure that this information reached the public. There were neither formal mechanisms for challenging decisions nor an adequate enforcement mechanism to ensure that decisions were made in a fair and equitable manner. Therefore, priority-setting in Mbarali district did not satisfy all four conditions of Accountability for Reasonableness; namely relevance, publicity, appeals and revision, and enforcement. This paper aims to make two important contributions to this problematic situation. First, it provides empirical analysis of priority-setting at the district level in the contexts of low-income countries. Second, it provides guidance to decision-makers on how to improve fairness, legitimacy, and sustainability of the priority-setting process.

  • 45. Marklund, Staffan
    et al.
    Bolin, Malin
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    von Essen, Jan
    Can individual health differences be explained by workplace characteristics?—A multilevel analysis2008In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 66, no 3, p. 650-662Article in journal (Refereed)
    Abstract [en]

    Research on work-related health has mainly focused on individual factors. The present study expands the focus by exploring the role of organizational characteristics of workplaces for different individual health outcomes. The aim of the study was to look at differences in relative effect of workplace variations on five health outcomes, and to explain those differences in health outcomes by organizational characteristics. The sample encompassed 90 workplaces in Sweden and about 4300 individuals employed within these workplaces. Measurement of the workplace characteristics was carried out independently of the measurement of the individual's working conditions and health. Organizational data were collected by interviews with local managers at participating workplaces, and individual data were obtained by means of a survey of the employees. The results showed that a significant proportion of the variance in sickness absence, work ability, general health, and musculoskeletal disorders was attributed to the workplace. Of eight tested organizational characteristics, customer adaptation, lean production, and performance control could explain some of this workplace variance. The results also showed that only one organizational effect remained significant when controlled for the individual confounder of age and gender. High customer adaptation is associated with higher sickness absence. This association is not mediated via differences in mental and physical job strain.

  • 46.
    Mewes, Jan
    et al.
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Giordano, Giuseppe Nicola
    Self-rated health, generalized trust, and the Affordable Care Act: a US panel study, 2006–20142017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 190, p. 48-56Article in journal (Refereed)
    Abstract [en]

    Previous research shows that generalized trust, the belief that most people can be trusted, is conducive to people's health. However, only recently have longitudinal studies suggested an additional reciprocal pathway from health back to trust. Drawing on a diverse body of literature that shows how egalitarian social policy contributes to the promotion of generalized trust, we hypothesize that this other ‘reverse’ pathway could be sensitive to health insurance context. Drawing on nationally representative US panel data from the General Social Survey, we examine whether the Affordable Care Act of 2010 could have had influence on the deteriorating impact of worsening self-rated health (SRH) on generalized trust. Firstly, using two-wave panel data (2008–2010, N = 1403) and employing random effects regression models, we show that a lack of health insurance coverage negatively determines generalized trust in the United States. However, this association is attenuated when additionally controlling for (perceived) income inequality. Secondly, utilizing data from two separate three-wave panel studies from the US General Social Survey (2006–10; N = 1652; 2010–2014; N = 1187), we employ fixed-effects linear regression analyses to control for unobserved heterogeneity from time-invariant factors. We demonstrate that worsening SRH was a stronger predictor for a decrease in generalized trust prior (2006–2010) to the implementation of the Affordable Care Act. Further, the negative effect of fair/poor SRH seen in the 2006–2010 data becomes attenuated in the 2010–2014 panel data. We thus find evidence for a substantial weakening of the previously established negative impact of decreasing SRH on generalized trust, coinciding with the most significant US healthcare reforms in decades. Social policy and healthcare policy implications are discussed.

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  • 47.
    Mitchell, Jeffrey
    et al.
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Chihaya Da Silva, Guilherme Kenjy
    Umeå University, Faculty of Social Sciences, Department of Geography. Institute for Analytical Sociology, Linköping University, Linköping, Sweden.
    Tract level associations between historical residential redlining and contemporary fatal encounters with police2022In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 302, article id 114989Article in journal (Refereed)
    Abstract [en]

    How does structural racism influence where people are killed during encounters with police? We analyzed geo-located incidents of fatal encounters with police that occurred between 2000 and 2020 in Census tracts that received a classification by the Home Owners Loan Corporation (HOLC) during the 1930's. Statistical models show that incidents of fatal encounters with police in formerly redlined areas are 66% more likely than in zones that received the most favorable “A” rating. These differences remain even when tract historical and contemporary racial compositions, along with contemporary economic conditions, are taken into account. The effects of contemporary racial composition and economic conditions overshadow the effect of zone classifications only in areas with high proportions of Black residents or residents in poverty (>60% or >30% respectively). These findings provide evidence of structural biases in policing rooted in historical segregation policies.

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  • 48.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Income-related inequalities in cardiovascular disease from mid-life to old age in a Northern Swedish cohort: a decomposition analysis2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 149, p. 135-144Article in journal (Refereed)
    Abstract [en]

    While the social determinants of cardiovascular disease (CVD) are fairly well-known, the determinants of socioeconomic inequalities in CVD are scarcely studied and almost completely based on cross-sectional designs in which the changing circumstances across the life course are not taken into account. The present study seeks to incorporate a life course approach to the social determinants of socioeconomic inequalities in CVD. The specific aims were to 1) examine how income-related inequalities in CVD change over two decades of the mid-late life course, and 2) identify the key social determinants of the inequalities at each time period. The cohort (N = 44,039) comprised all individuals aged 40-60 years in 1990 who during 1990-2010 were enrolled in the county-wide preventive effort :"Västerbotten Intervention Program" (VIP). The cohort was followed over these two decades by Swedish population register data linked within the Umeå SIMSAM Lab micro data infrastructure. First-time hospitalization for CVD and mean earned income were used to calculate the concentration index (C) during four periods of 5-6 years. The C for each period was decomposed by sociodemographic factors, using Wagstaff-type decomposition analysis. Results suggest that inequalities in CVD increase gradually from mid-life to old age; from initially non-significant to particularly marked among the elderly. The decomposition showed that, from middle to old age, educational and employment inequalities underwent a transition from initially dominant to a moderate role in explaining the health inequalities, coupled with an increasing importance of age and a stable role of income. In conclusion, the study illustrates the need for incorporating a dynamic life course perspective into research, policy and practice concerned with equity in health.

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    fulltext
  • 49. Månsdotter, Anna
    et al.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lundberg, Michael
    Health, wealth and fairness based on gender: the support for ethical principles.2006In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, ISSN 0277-9536, Vol. 62, no 9, p. 2327-2335Article in journal (Refereed)
  • 50. Nichter, Mark
    et al.
    Padmawati, Siwi
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Introducing smoking cessation to Indonesian males treated for tuberculosis: The challenges of low-moderate level smoking2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 152, p. 70-79Article in journal (Refereed)
    Abstract [en]

    There is a dearth of information about the smoking habits of people currently and formerly treated for tuberculosis (TB) in low- and middle-income countries (LMICs). In this paper we describe research carried out in Indonesia between 2007 and 2011 designed to investigate both the impact of TB-specific quit smoking messages in the TB clinic and at home, and shifts in patterns of smoking among those formerly treated for TB who continue to smoke. The results of a modest two-arm smoking cessation trial involving 87 patients undergoing Directly Observed Therapy Short course treatment (DOTS) for TB are presented. In one arm patients received a TB-specific quit smoking message delivered by doctors and a TB and smoking educational booklet and quit smoking guide. In the second, family support arm, patients also received on-going cessation messages delivered by family members trained to be DOTS supporters. The study followed patients twice during their six months of DOTS treatment and twice six months post treatment. Both arms of the study reduced rates of smoking during and following TB treatment significantly with 73% of patients in the doctor arm and 71% in the family support arm remaining quit at the end of the treatment (month 6). When complete abstinence at six months after treatment was taken as a primary outcome measure, no statistical difference was found in the effectiveness of the two arms of the intervention. Notably, 67% of higher-level smokers at baseline and 33% of low-moderate level smokers at baseline quit entirely. Many of those who resumed smoking did so at low-moderate levels (<6 cigarettes a day). Eighty-four percent of patients who quit during treatment maintained their abstinence six months after treatment, 13% resumed smoking at a low-moderate level (<6 cigarettes), and only 3% resumed smoking at a higher level. A purposeful sample of 15 patients who shifted from heavy smoking (20-40 cigarettes per day) to low-moderate levels of smoking post treatment were followed for an additional 12 months. We report on their ability to sustain lower levels of smoking and self-perceived smoking status given their dramatic reduction in cigarette consumption. This is the first study of low-moderate level smoking among patients formerly treated for TB conducted anywhere in South-East Asia.

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