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  • 1. Backhans, Mona Christina
    et al.
    Burström, Bo
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Månsdotter, Anna
    Pioneers and laggards: Is the effect of gender equality on health dependent on context?2009Inngår i: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 68, s. 1388-1395Artikkel i tidsskrift (Fagfellevurdert)
    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.

  • 2.
    Brunstrom, Mattias
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Carlberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lindholm, Lars H.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Perspective from Sweden on the global impact of the 2017 american college of cardiology/american heart association hypertension guidelines: a "sprint" beyond evidence in the United States2018Inngår i: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 137, nr 9, s. 886-888Artikkel i tidsskrift (Annet vitenskapelig)
  • 3.
    Brändström, Helge
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård.
    Winsö, Ola
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Haney, Michael
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård.
    Regional intensive care transports: a prospective analysis of distance, time and cost for road, helicopter and fixed-wing ambulances2014Inngår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 22, s. 36-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: There are three different types of ambulance systems, all of which can manage the same secondary intensive care patient transport mission: road ambulance, rotor-wing ambulance, and fixed-wing ambulance. We hypothesized that costs for specific transport distances would differ between systems. We aimed to analyze distances and observed times for ambulance intensive care secondary transport missions together with system costs to assess this. Methods: We prospectively collected data for consecutive urgent intensive care transports into the regional tertiary care hospital in the northern region of Sweden. Distances and transport times were gathered, and a cost model was generated based on these together with fixed and operating costs from the three different ambulance systems. Distance-cost and time-cost estimations were then generated for each transport system. Results: Road ambulance cost relatively less for shorter distances (within 250 kilometers/155 miles) but were relatively time ineffective. The rotor-wing systems were most expensive regardless of distance; but were most time-effective up to 400-500 km (248-310 miles). Fixed-wing systems were more cost-effective for longer distance (300 km/186 miles), and time effective for transports over 500 km (310 miles). Conclusions: In summary, based on an economic model developed from observed regional ICU patient transports, and cost estimations, different ambulance system cost-distances could be compared. Distance-cost and time results show that helicopters can be effective up to moderate ICU transport distances (400-500), though are expensive to operate. For longer ICU patient transports, fixed-wing transport systems are both cost and time effective compared to helicopter-based systems.

  • 4.
    Ellberg, Lotta
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Högberg, Ulf
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Lundman, Berit
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Satisfying parents' preferences with regard to various models of postnatal care is cost-minimizing2006Inngår i: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 85, nr 2, s. 175-181Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: This study describes three options for postnatal care in Sweden and contains a cost analysis of the options in various combinations. The aim of the study was to calculate the cost of a postnatal care model according to new parents' preferences.

    METHODS: Staff costs were calculated for various models of postnatal care, comprising the maternity ward, the family suite, and/or the early discharge program. One of the models was based on answers from 342 parents who specified their preferences with regard to postnatal care in the event of another birth.

    RESULTS: Comparing costs for five different models of postnatal care showed that the proportion of mothers receiving care at the maternity ward crucially influences the total costs. The staff costs differed significantly between the models, ranging from US$448 000 to US$778 000 per 1500 mother-child dyads. MAIN OUTCOME

    MEASURES: Cost calculation of various care models and parents' preferences for postnatal care.

    CONCLUSIONS: Because the parents' preferences with regard to postnatal care created one of the most cost-minimizing care models in the study, it would be possible to better meet parent's desires and, at the same time, reduce costs, without increasing risks in comparison with the early discharge program.

  • 5.
    Eriksson, Kerstin Margareta
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Sjukgymnastik.
    Hagberg, Lars
    Departement of Social medicine and Public Health and centre for Health Care Science Örebro County Council.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Malmgren-Olsson, Eva-Britt
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Sjukgymnastik.
    Österlind, Jonas
    Department of Medicine Sunderby Hospital Luleå.
    Eliasson, Mats
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Quality of life and cost-effectiveness of a 3-year trial of lifestyle intervention in primary health care2010Inngår i: Archives of Internal Medicine, ISSN 0003-9926, E-ISSN 1538-3679, Vol. 170, nr 16, s. 1470-1479Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Lifestyle interventions reduce cardiovascular risk and diabetes but reports on long term effects on quality of life (QOL) and health care utilization are rare. The aim was to investigate the impact of a primary health care based lifestyle intervention program on QOL and cost-effectiveness over 3 years.

    Methods: 151 men and women, age 18-65 yr, at moderate-to-high risk for cardiovascular disease, were randomly assigned to either lifestyle intervention with standard care or standard care alone. Intervention consisted of supervised exercise sessions and diet counseling for 3 months, followed by regular group meetings during 3years. Change in QOL was measured with EuroQol (EQ-5D, EQ VAS), the 36-item Short Form Health Survey (SF-36), and the SF-6D.  The health economic evaluation was performed from a societal view and a treatment perspective. In a cost-utility analysis the costs, gained quality-adjusted life years (QALY) and savings in health care were considered. Cost-effectiveness was also described using the Net Monetary Benefit Method.

    Results: Significant differences between groups over the 3-yr period were shown in EQ VAS, SF-6D and SF-36 physical component summary but not in EQ-5D or SF-36 mental component summary. There was a net saving of 47 USD per participant. Costs per gained QALY, savings not counted, were 1,668 – 4,813 USD. Probabilities of cost-effectiveness were 89 – 100 %, when 50 000 USD was used as stakeholder’s threshold of willingness to pay for a gained QALY.

    Conclusion: Lifestyle intervention in primary care improves QOL and is highly cost-effective in relation to standard care.

  • 6.
    Franzén, Carin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Björnstig, Ulf
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Brulin, Christine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    A cost-utility analysis of nursing intervention via telephone follow-up for injured road users2009Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 9, s. 98-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Traffic injuries can cause physical, psychological, and economical impairment, and affected individuals may also experience shortcomings in their post-accident care and treatment. In an earlier randomised controlled study of nursing intervention via telephone follow-up, self-ratings of health-related quality of life were generally higher in the intervention group than in the control group. OBJECTIVE: To evaluate the cost-effectiveness of nursing intervention via telephone follow-up by examining costs and quality-adjusted life years (QALYs). METHODS: A randomised controlled study was conducted between April 2003 and April 2005. Car occupants, cyclists, and pedestrians aged between 18 and 70 years and attending the Emergency Department of Umeå University Hospital in Sweden after an injury event in the traffic environment were randomly assigned to an intervention (n = 288) or control group (n = 280). The intervention group received routine care supplemented by nursing via telephone follow-up during half a year, while the control group received routine care only. Data were collected from a mail survey using the non-disease-specific health-related quality of life instrument EQ5D, and a cost-effectiveness analysis was performed including the costs of the intervention and the QALYs gained. RESULTS: Overall, the intervention group gained 2.60 QALYs (260 individuals with an average gain of 0.01 QALYs). The car occupants gained 1.54 QALYs (76 individuals, average of 0.02). Thus, the cost per QALY gained was 16 000 Swedish Crown (SEK) overall and 8 500 SEK for car occupants. CONCLUSION: Nursing intervention by telephone follow-up after an injury event, is a cost effective method giving improved QALY to a very low cost, especially for those with minor injuries. 

  • 7.
    Granlund, David
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för nationalekonomi.
    Chuc, NT
    Faculty of Public Health, Hanoi Medical University, Viet Nam.
    Phuc, HD
    Institute of Mathematics, Hanoi, Viet Nam.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Inequality in mortality in Vietnam during a period of rapid transition2010Inngår i: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 70, nr 2, s. 232-239Artikkel i tidsskrift (Fagfellevurdert)
    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.

  • 8.
    Hagberg, Lars A
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Epidemiologi och folkhälsovetenskap.
    Cost-effectiveness of healthcare-based interventions aimed at improving physical activity.2006Inngår i: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 34, nr 6, s. 641-653Artikkel i tidsskrift (Fagfellevurdert)
  • 9.
    Hagberg, Lars Axel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Epidemiologi och folkhälsovetenskap.
    Is promotion of physical activity a wise use of societal resources? Issues of cost-effectiveness and equity in health.2005Inngår i: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 15, nr 5, s. 304-312Artikkel i tidsskrift (Fagfellevurdert)
  • 10.
    Hagberg, Lars Axel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Centre for Health Care Science, Örebro County Council, Örebro, Sweden.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Measuring the time costs of exercise: a proposed measuring method and a pilot study2010Inngår i: Cost Effectiveness and Resource Allocation, ISSN 1478-7547, E-ISSN 1478-7547, Vol. 8, s. 9-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: The cost of time spent on exercise is an important factor in societal-perspective health economic analyses of interventions aimed at promoting physical activity. However, there are no existing measuring methods for estimating time costs. The aim of this article is to describe a way to measure the costs of time spent on physical activity. We propose a model for measuring these time costs, and present the results of a pilot study applying this model to different groups of exercisers.

    Methods: We began this investigation by developing a model for measuring the time spent on exercise, based on the most important theoretical frameworks for valuing time. In the model, the value of utility in anticipation (expected health benefits) of performing exercise is expressed in terms of health-related quality of life. With this approach, the cost of the time spent on exercise is defined as the value of utility in use of leisure activity forgone minus the value of utility in use of exercise. Utility in use for exercise is valued in comparison with utility in use for leisure activity forgone and utility in use for work.

    To put the model into practice, we developed a questionnaire with the aim of investigating the valuations made by exercisers, and applied this questionnaire among more experienced and less experienced exercisers.

    Results: Less experienced exercisers valued the time spent on exercise as being equal to 26% of net wages, while more experienced exercisers valued this time at 7% of net wages (p < 0.001). The higher time costs seen among the less experienced exercisers correlated to a less positive experience of exercise and a more positive experience of the lost leisure activity. There was a significant inverse correlation between the costs of time spent on exercise, and the frequency and duration of regular exercise.

    Conclusion: The time spent on exercise is an important factor in interventions aimed at promoting physical activity, and should be taken into consideration in cost-effectiveness analyses. The proposed model for measuring the costs of the time spent on exercise seems to be a better method than the previously-used assumptions of time costs.

  • 11.
    Hartini, T Ninuk S
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Padmawati, R Siwi
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Surjono, Achmad
    Winkvist, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    The importance of eating rice: changing food habits among pregnant Indonesian women during the economic crisis2005Inngår i: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 61, nr 1, s. 199-210Artikkel i tidsskrift (Fagfellevurdert)
    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.

  • 12.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Krantz, G.
    Nzayirambaho, M.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Systematic Review of Cost and Cost-effectiveness of Routine Ultrasound during pregnancyManuskript (preprint) (Annet vitenskapelig)
  • 13.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Krantz, G.
    Nzayirambaho, M.
    Semasaka Sengoma, J. P.
    Condo, J.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health related quality of life determinants for Rwandan women after delivery2017Inngår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, nr Suppl_3, s. 436-Artikkel i tidsskrift (Annet vitenskapelig)
    Abstract [en]

    Health related quality of life determinants for Rwandan women after delivery. Does Antenatal care utilization matter? Maternal health conditions are still a major problem in most low-income countries. The postpartum health status and the effect of antenatal care utilization on health are relatively under researched. This study aims at (1) assessing whether receipt of antenatal care according to Rwandan guidelines is associated with mother’s health-related quality of life (HRQoL) and (2) exploring determinants associated with mother’s HRQoL in the first year (1-13 months) after delivery in Rwanda. In 2014 a cross-sectional survey was conducted on 922 women from Kigali City and Northern province of Rwanda, who gave birth in the period of 1–13 months prior to survey. The study population was randomly selected and interviewed using a questionnaire. HRQoL was measured using EQ-5D-3L. Average values of HRQoL were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care on HRQoL was tested in two multivariable linear regression models - with EQ-5D weights and the Visual Analogue Scale score as outcomes respectively - with ANC adequacy and socio-demographic and psychosocial variables as predictors. Mean HRQoL was 0.92 using EQ-5D and 69.58 using EQ-VAS. Fifteen per cent reported moderate pain/discomfort and 1% reported extreme pain/discomfort, 16% reported being moderately anxious/depressed and 3% reported being extremely anxious/depressed. Having more than one child and being cohabitant or single/not married was associated with significantly lower HRQoL, while having good social support and belonging to the highest wealth quintile was associated with higher HRQoL. Antenatal care utilization was not associated with HRQoL among postpartum mothers. Policy makers should address the social determinants of health, and promote social networks among women. There is a need to assess the quality of Antenatal care in Rwanda.

    Key messages:

    • Health related quality of life among postpartum mothers is high. Pain or discomfort and anxiety of depression are most prevalent problems.
    • Antenatal care utilization was not associated with HRQoL among postpartum mothers. Rather social determinants of health are important in determining mother's HRQoL
  • 14.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Condo, Jeanine
    Semasaka Sengoma, Jean Paul
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health-related quality of life determinants among Rwandan women after delivery: does antenatal care utilization matter? A cross-sectional study2018Inngår i: Journal of Health, Population and Nutrition, ISSN 1606-0997, E-ISSN 2072-1315, Vol. 37, artikkel-id 12Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Despite the widespread use of antenatal care (ANC), its effectiveness in low-resource settings remains unclear. In this study, self-reported health-related quality of life (HRQoL) was used as an alternative to other maternal health measures previously used to measure the effectiveness of antenatal care. The main objective of this study was to determine whether adequate antenatal care utilization is positively associated with women's HRQoL. Furthermore, the associations between the HRQoL during the first year (113 months) after delivery and socio-economic and demographic factors were explored in Rwanda.

    Methods: In 2014, we performed a cross-sectional population-based survey involving 922 women who gave birth 1-13 months prior to the data collection. The study population was randomly selected from two provinces in Rwanda, and a structured questionnaire was used. HRQoL was measured using the EQ-5D-3L and a visual analogue scale (VAS). The average HRQoL scores were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care utilization on HRQoL was tested by performing two multivariable linear regression models with the EQ-5D and EQ-VAS scores as the outcomes and ANC utilization and socio-economic and demographic variables as the predictors.

    Results: Adequate ANC utilization affected women's HRQoL when the outcome was measured using the EQ-VAS. Social support and living in a wealthy household were associated with a better HRQoL using both the EQ-VAS and EQ-5D. Cohabitating, and single/unmarried women exhibited significantly lower HRQoL scores than did married women in the EQ-VAS model, and women living in urban areas exhibited lower HRQoL scores than women living in rural areas in the ED-5D model. The effect of education on HRQoL was statistically significant using the EQ-VAS but was inconsistent across the educational categories. The women's age and the age of their last child were not associated with their HRQoL.

    Conclusions: ANC attendance of at least four visits should be further promoted and used in low-income settings. Strategies to improve families' socio-economic conditions and promote social networks among women, particularly women at the reproductive age, are needed.

  • 15.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Cost of antenatal care for the health sector and for households in Rwanda2018Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, artikkel-id 262Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Rwanda has made tremendous progress in reduction of maternal mortality in the last twenty years. Antenatal care is believed to have played a role in that progress. In late 2016, the World Health Organization published new antenatal care guidelines recommending an increase from four visits during pregnancy to eight contacts with skilled personnel, among other changes. There is ongoing debate regarding the cost implications and potential outcomes countries can expect, if they make that shift. For Rwanda, a necessary starting point is to understand the cost of current antenatal care practice, which, according to our knowledge, has not been documented so far.

    Methods: Cost information was collected from Kigali City and Northern province of Rwanda through two cross-sectional surveys: a household-based survey among women who had delivered a year before the interview (N = 922) and a health facility survey in three public, two faith-based, and one private health facility. A micro costing approach was used to collect health facility data. Household costs included time and transport. Results are reported in 2015 USD.

    Results: The societal cost (household + health facility) of antenatal care for the four visits according to current Rwandan guidelines was estimated at $160 in the private health facility and $44 in public and faith-based health facilities. The first visit had the highest cost ($75 in private and $21 in public and faith-based health facilities) compared to the three other visits. Drugs and consumables were the main input category accounting for 54% of the total cost in the private health facility and for 73% in the public and faith-based health facilities.

    Conclusions: The unit cost of providing antenatal care services is considerably lower in public than in private health facilities. The household cost represents a small proportion of the total, ranging between 3% and 7%; however, it is meaningful for low-income families. There is a need to do profound equity analysis regarding the accessibility and use of antenatal care services, and to consider ways to reduce households’ time cost as a possible barrier to the use of antenatal care.

  • 16.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Mogren, Ingrid
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Semasaka Sengoma, Jean Paul
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation2019Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, artikkel-id 36Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.

    METHODS: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).

    RESULTS: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.

    DISCUSSION: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

  • 17.
    Hoi, Le Van
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Phuc, Ho D
    Institute of Mathematics, Vietnamese Academy of Science and Technology, Vietnam.
    Dung, Truong V
    Hanoi Medical University, Vietnam.
    Chuc, Nguyen TK
    Hanoi Medical University, Vietnam.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Remaining life expectancy among older people in a rural area of Vietnam: trends and socioeconomic inequalities during a period of multiple transitions2009Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 9, nr 1, s. 471-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Better understanding of the trends and disparities in health at old age in terms of life expectancy will help to provide appropriate responses to the growing needs of health and social care for the older population in the context of limited resources. As a result of rapid economic, demographic and epidemiological changes, the number of people aged 60 and over in Vietnam is increasing rapidly, from 6.7% in 1979 to 9.2% in 2006. Life expectancy at birth has increased but not much are known about changes in old ages. This study assesses the trends and socioeconomic inequalities in RLE at age 60 in a rural area in an effort to highlight this vulnerable group and to anticipate their future health and social needs.

    METHODS: An abridged life table adjusted for small area data was used to estimate cohort life expectancies at old age and the corresponding 95% confidence intervals from longitudinal data collected by FilaBavi DSS during 1999-2006, which covered 7,668 people at age 60+ with 43,272 person-years, out of a total of 64,053 people with 388,278 person-years. Differences in life expectancy were examined according to socioeconomic factors, including socio-demographic characteristics, wealth, poverty and living arrangements.

    RESULTS: Life expectancies at age 60 have increased by approximately one year from the period 1999-2002 to 2003-2006. The increases are observed in both sexes, but are significant among females and relate to improvements among those who belong to the middle and upper household wealth quintiles. However, life expectancy tends to decrease in the most vulnerable groups. There is a wide gap in life expectancy according to poverty status and living arrangements, and the gap by poverty status has widened over the study period. The gender gap in life expectancy is consistent across all socioeconomic groups and tends to be wider amongst the more disadvantaged population.

    CONCLUSIONS: There is a trend of increasing life expectancy among older people in rural areas of Vietnam. Inequalities in life expectancy exist between socioeconomic groups, especially between different poverty levels and also patterns of living arrangements. These inequalities should be addressed by appropriate social and health policies with stronger targeting of the poorest and most disadvantaged groups.

  • 18.
    Hoi, Le Van
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Thang, Pham
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Centrum för befolkningsstudier (CBS).
    Elderly care in daily living in rural Vietnam: Need and its socioeconomic determinants2011Inngår i: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, nr 11, s. 81-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background

    The proportion of older people is increasing rapidly in Vietnam. The majority of the elderly live in rural areas. Their health status is generally improving but this is less pronounced among the most vulnerable groups. The movement of young people for employment and the impact of other socioeconomic changes leave more elderly on their own and with less family support. This study aims to assess the daily care needs and their socioeconomic determinants among older people in a rural setting.

    Methods

    In 2007, people aged 60 years and older, living in 2,240 households, were randomly selected from the FilaBavi Demographic Surveillance System (DSS). They were interviewed using structured questionnaires to assess needed support in activities of daily living (ADLs). Individuals were interviewed about the presence of chronic illnesses that had been diagnosed by a physician. Participant socioeconomic characteristics were extracted from the FilaBavi repeat census. The repeat census used a repeat of the same survey methods and questions as the original FilaBavi DSS. Distributions of study participants by socioeconomic group, supports needed, levels of support received, types of caregivers, and the ADL index were described. Multivariate analyses were performed to identify socioeconomic determinants of the ADL index.

    Results

    The majority of older people do not need of support for each specific ADL item. Dependence in instrumental or intellectual ADLs was more common than for basic ADLs. People who need total help were less common than those who need some help in most ADLs. Over three-fifths of those who need help receive enough support in all ADL dimensions. Children and grandchildren are the main caregivers. Age group, sex, educational level, marital status, household membership, working status, household size, living arrangement, residential area, household wealth, poverty status, and chronic illnesses were determinants of daily care needs in old age.

    Conclusions

    Although majority of older people who needed help received enough support in daily care, the need of care is more demanded in disadvantaged groups. Future community-based, long-term elderly care should focus on instrumental and intellectual ADLs among the general population of older people, and on basic ADLs among those with chronic illnesses. Socioeconomic determinants of care needs should be addressed in future interventions.

  • 19.
    Hoi, Le Van
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Thi Kim Chuc, Nguyen
    Hanoi Medical University, Vietnam.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health-related quality of life, and its determinants, among older people in rural Vietnam2010Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 10, s. 549-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background

    The proportion of people in Vietnam aged 60 and above has increased rapidly in recent decades. However, there is a lack of evidence, particularly in rural settings, on their health-related quality of life (HRQoL) within the context of socioeconomic changes and health-sector reform in the country. This study assesses the level and determinants of HRQoL in a rural district in order to provide evidence for designing and implementing appropriate health policies.

    Methods

    In 2007, 2,873 people aged 60+ living in 2,240 households randomly selected from the FilaBavi demographic surveillance site (DSS) were interviewed using a generic EQ-5D questionnaire to assess their HRQoL. Socioeconomic characteristics of the people and their households were extracted from the DSS's re-census that year, and the EQ-5D index was calculated based on the time trade-off tariff. Multilevel-multivariate linear regression analysis was performed to measure the affect of socioeconomic factors on HRQoL.

    Results

    The EQ-5D index at old age was found to be 0.876 (95%CI: 0.870-0.882). Age between 60-69 or 70-79 years, position as household head, working until old age, literacy, and belonging to better wealth quintiles are determinants of higher HRQoL. Ageing has a primary influence on the deterioration of HRQoL at older ages, mainly due to reduction in physical rather than mental functions. Educational disparity in HRQoL is low, and exists mostly between basic and higher levels of education. Being a household head and working at old age are advantageous for attaining better quality of life in physical rather than psychological terms. Economic conditions affect HRQoL through sensory rather than physical utilities. Long-term living conditions more likely affect HRQoL than short-term economic conditions.

    Conclusions

    HRQoL at old age is at a high level, and varies substantially according to socioeconomic factors. Its determinants should be addressed in social and health policies designed to improve health of older people, especially among the most vulnerable groups.

  • 20.
    Hoi, Le Van
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Tien, Nguyen Thi Kim
    Tien, Nguyen Van
    Dung, Dao Van
    Chuc, Nguyen Thi Kim
    Sahlen, Klas-Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sahlen, Klas Göran
    Umeå universitet, Samhällsvetenskapliga fakulteten, Centrum för befolkningsstudier (CBS). Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Centrum för befolkningsstudier (CBS).
    Willingness to use and pay for options of care for community dwelling older people in rural Vietnam2012Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 12, s. 36-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: The proportion of people in Vietnam who are 60 years and over has increased rapidly. The emigration of young people and impact of other socioeconomic changes leave more elderly on their own and with less family support. This study assesses the willingness to use and pay for different models of care for community-dwelling elderly in rural Vietnam.

    Methods: In 2007, people aged 60 and older and their family representatives, living in 2,240 households, were randomly selected from the FilaBavi Demographic Surveillance Site. They were interviewed using structured questionnaires to assess dependence in activities of daily living (ADLs), willingness to use and to pay for day care centres, mobile care teams, and nursing centres. Respondent socioeconomic characteristics were extracted from the FilaBavi repeated census. Percentages of those willing to use models and the average amount (with 95% confidence intervals) they are willing to pay were estimated. Multivariate analyses were performed to measure the relationship of willingness to use services with ADL index and socioeconomic factors. Four focus group discussions were conducted to explore people's perspectives on the use of services. The first discussion group was with the elderly. The second discussion group was with their household members. Two other discussion groups included community association representatives, one at the communal level and another at the village level.

    Results: Use of mobile team care is the most requested service. The fewest respondents intend to use a nursing centre. Households expect to use services for their elderly to a greater extent than do the elderly themselves. Willingness to use services decreases when potential fees increase. The proportion of respondents who require that services be free-of-charge is two to three times higher than the proportion willing to pay full cost. Households are willing to pay more than the elderly for day care and nursing centres. The elderly are more willing to pay for mobile teams than are their households. Age group, sex, literacy, marital status, living arrangement, living area, working status, poverty, household wealth and dependence in ADLs are factors related to willingness to use services.

    Conclusions: Community-centric elderly care will be used and partly paid for by individuals if it is provided by the government or associations. Capacity building for health professional networks and informal caregivers is essential for developing formal care models. Additional support is needed for the most vulnerable elderly to access services.

  • 21.
    Jerdén, Lars
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Cost-effectiveness of a personal health document in different distribution settings2008Inngår i: Health promotion journal of Australia, ISSN 1036-1073, Vol. 19, nr 2, s. 125-131Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The aim was to compare the cost-effectiveness of different ways to distribute a personal health document that was primarily aimed at supporting behaviour change. Personal health documents have been widely used in health-promoting efforts but their effective use is rather sparsely studied. METHODS: Four types of distribution were tested in Sweden: primary health care centres (n=418); work site meetings (n=164); at an occupational health examination (n=279); by mail (n=445). Participant behaviour changes were measured by a questionnaire. Cost calculations were made based on the results of the study. RESULTS: Between 10% and 26% of participants reported behaviour changes as a result of reading the booklet. A change in health situation was less likely using postal distribution. There were no significant differences between the other types of distribution. Cost-effective distribution at work sites and in occupational health was superior to distribution in primary health care when direct costs were used. Distribution at work sites was the least cost-effective when indirect costs, i.e. productivity losses of participants, were included. CONCLUSIONS: Cost-effectiveness analyses support distribution of personal health documents in occupational health. In primary health care, high training costs in combination with low distribution rates might be problematic. Providing information during distribution at work sites is time-consuming and might therefore be a problem if productivity losses are taken into account.

  • 22. Johansson, Pia M
    et al.
    Tillgren, Per E
    Guldbrandsson, Karin A
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    A model for cost-effectiveness analyses of smoking cessation interventions applied to a Quit-and-Win contest for mothers of small children.2005Inngår i: Scand J Public Health, ISSN 1403-4948, Vol. 33, nr 5, s. 343-52Artikkel i tidsskrift (Fagfellevurdert)
  • 23.
    Kriit, Hedi Katre
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för hållbar hälsa.
    Stewart Williams, Jennifer
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Forsberg, Bertil
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för hållbar hälsa.
    Sommar, Johan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för hållbar hälsa.
    Health economic assessment of a scenario to promote bicycling as active transport in Stockholm, Sweden2019Inngår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 9, artikkel-id e030466Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: To conduct a health economic evaluation of a proposed investment in urban bicycle infrastructure in Stockholm County, Sweden.

    DESIGN: A cost-effectiveness analysis is undertaken from a healthcare perspective. Investment costs over a 50-year life cycle are offset by averted healthcare costs and compared with estimated long-term impacts on morbidity, quantified in disability-adjusted life years (DALYs). The results are re-calculated under different assumptions to model the effects of uncertainty.

    SETTING: The Municipality of Stockholm (population 2.27 million) committed funds for bicycle path infrastructure with the aim of achieving a 15% increase in the number of bicycle commuters by 2030. This work is based on a previously constructed scenario, in which individual registry data on home and work address and a transport model allocation to different modes of transport identified 111 487 individuals with the physical capacity to bicycle to work within 30 min but that currently drive a car to work.

    RESULTS: Morbidity impacts and healthcare costs attributed to increased physical activity, change in air pollution exposure and accident risk are quantified under the scenario. The largest reduction in healthcare costs is attributed to increased physical activity and the second largest to reduced air pollution exposure among the population of Greater Stockholm. The expected net benefit from the investment is 8.7% of the 2017 Stockholm County healthcare budget, and 3.7% after discounting. The economic evaluation estimates that the intervention is cost-effective and each DALY averted gives a surplus of €9933. The results remained robust under varied assumptions pertaining to reduced numbers of additional bicycle commuters.

    CONCLUSION: Investing in urban infrastructure to increase bicycling as active transport is cost-effective from a healthcare sector perspective.

  • 24.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Cost and Outcomes of Actions Aimed At Increased Equity 1211072012Inngår i: INTERNATIONAL CONFERENCE ON GLOBAL PUBLIC HEALTH 2012, Colombo, 2012, s. 157-173Konferansepaper (Fagfellevurdert)
    Abstract [en]

    BACKGROUND Equity in health is one important goal in public health and health care. Thus is the health of the nation a function of both level and distribution of health. One sign of the importance of the equity goal is studies that try to estimate the cost of inequity. However, this kind of study has no clear policy implications. More useful are studies that estimate the cost of interventions aimed at increased equity in combination with estimated of the consequences of the intervention. Objectives Elaborate a model for estimating and valuing costs and consequences of interventions aimed at increased equity. Design A Markov model was used to estimate the remaining expected QALYs during the period 16 to 100 years for different educational levels and sexes. An intervention with the purpose to prevent drop outs from high school was analyzed. The level and distribution of health were estimated before and after the intervention, as well as the cost for the intervention and the QALYs gained by the intervention. Results The gaps between the different educational levels were significant before intervention (about 6-7 QALYs). The intervention under study reduced the gaps, and the cost-effectiveness ratios were far below accepted threshold levels for cost-effectiveness. Conclusion This example proves that a systematic analysis of interventions aimed at increase equity is possible, and give useful information to those responsible for policy-making. In general, the main problem in the context of public health and social policies is to present convincing evidence regarding causality.

  • 25.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Health economic evaluation of community-based cardiovascular disease prevention: some theoretical aspects and empirical results1996Doktoravhandling, med artikler (Annet vitenskapelig)
    Abstract [en]

    This thesis addresses the health economic evaluation of community-based interventions against cardiovascular disease (CVD), with special emphasis on the Västerbotten Intervention Project (VIP), run since 1985.

    The framework is a simple evaluation model consisting of two parts; the selection and measurement of empirical consequences caused by the project under evaluation (e.g. changes in mortality, well-being, use of resources) and a set of values (e.g. efficiency, equity) aimed at assessing the goodness of these consequences.

    The project’s effects on CVD were predicted by means of risk factors measured in Norsjö between 1985-1990, applied to an epidemiological model based on a logistic risk equation derived from the Framingham population. Cost per life-years saved ranged from £14 900 to net savings, depending on the assumptions. The favourable cost-effectiveness in this kind of intervention has earlier been predicted from theoretical models, but this is the first study based on real experiences from contemporary community-based interventions against CVD. Furthermore, all social classes have benefited from the intervention. Also potential adverse effects in the form of excess mortality due to low cholesterol levels were investigated, and they were negligible in comparison with the health gains.

    The value of an intervention from a citizen’s perspective was investigated through an interview study (n≈100) in accordance with the contingent valuation method. Great expectations concerning mortality effects on the community level and future savings in health care were good predictors for assigning the intervention a high value. On the contrary, personal benefits in the form of a decreasing risk for CVD had no positive association with the value of the intervention. Hence, the consequences that the cost-effectiveness analysis accounts for - mortality and savings - coincide with the most valuable consequences from the citizen's perspective.

    In a democracy, the set of values used to determine the success or failure of a programme like a prevention project must agree with values held by the majority of the citizens. Therefore, the attitudes to ethical values among Swedish politicians (n≈450) responsible for health care have been mapped. The support for the health maximization principle was weak, and a trade-off between efficiency and equity was preferred. About 70% of the respondents were prepared to sacrifice health gains to achieve increased equity.

  • 26.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health economic evaluation of the Västerbotten Intervention Programme2017Inngår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, nr suppl_3, s. 205-Artikkel i tidsskrift (Annet vitenskapelig)
    Abstract [en]

    Results from a study that calculated the cost-effectiveness ofthe VIP intervention based on prevented deaths, transformedto QALYs gained, will be shown. The intervention isexceptionally cost-effective both in health care and societalperspectives.

  • 27.
    Lindholm, Lars
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Löfgren, Curt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Meili, Kaspar
    Nygren, Lennart
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sahlen, Klas-Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Nytt sätt att mäta livskvalitet öppnar för effektivare insatser2018Inngår i: Dagens samhälle, ISSN 1652-6511, nr 31, s. 26-26Artikkel i tidsskrift (Annet (populærvitenskap, debatt, mm))
  • 28.
    Lindholm, Lars
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Löfroth, Emil
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Rosén, Måns
    Does productivity influence priority setting? A case study from the field of CVD prevention.2008Inngår i: Cost Effectiveness and Resource Allocation, ISSN 1478-7547, E-ISSN 1478-7547, Vol. 6, s. 6-Artikkel i tidsskrift (Fagfellevurdert)
  • 29.
    Lindholm, Lars
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Stenling, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Stenlund, Hans
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    A cost-effectiveness analysis of a community based CVD program in Sweden based on a retrospective register cohort2018Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 18, artikkel-id 452Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Several large scale community-based cardiovascular disease prevention programs were initiated in the 80s, and one was the Västerbotten Intervention Programme, Sweden. As an initial step in 1985, a pilot study was introduced in the Norsjö municipality that combined individual disease prevention efforts among the middle-aged population with community-oriented health promotion activities. All citizens at 30, 40, 50, and 60 years of age were invited to a physical examination combined with a healthy dialogue at the local primary health care centre. Västerbotten Intervention Program is still running following the same lines and is now a part of the ordinary public health in the county. The purpose of this study is to estimate the costs of running Västerbotten Intervention Programme from 1990 to 2006, versus the health gains and savings reasonably attributable to the program during the same time period. Methods: A previous study estimated the number of prevented deaths during the period 1990-2006 which can be attributed to the programme. We used this estimate and calculated the number of QALYs gained, as well as savings in resources due to prevented non-fatal cases during the time period 1990 to 2006. Costs for the programmes were based on previously published scientific articles as well as current cost data from the county council, who is responsible for the programme. Result: The cost per QALY gained from a societal perspective is SEK 650 (Euro 68). From a health care sector perspective, the savings attributable to the VIP exceeded its costs. Conclusion: Our analysis shows that Västerbotten Intervention Programme is extremely cost-effective in relation to the Swedish threshold value (SEK 500000 per QALY gained or Euro 53,000 per QALY gained). Other research has also shown a favorable effect of Västerbotten Intervention Programme on population health and the health gap. We therefore argue that all health care organizations, acting in settings reasonably similar to Sweden, have good incentive to implement programs like Västerbotten Intervention Programme.

  • 30.
    Lämås, Kristina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Jacobsson, Catrine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Engström, Birgitta
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hinder och möjligheter att använda hälsoekonomiska analyser inom omvårdnad: en litteraturstudie2004Rapport (Annet vitenskapelig)
  • 31.
    Lämås, Kristina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Engström, Birgitta
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Jacobsson, Catrine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Abdominal massage for people with constipation: a cost utility analysis2010Inngår i: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 66, nr 8, s. 1719-1729Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    AIM: This paper is a report of a study conducted to evaluate change in health-related quality of life for people with constipation receiving abdominal massage and to estimate the cost-effectiveness of two alternative scenarios developed from the original trial.

    BACKGROUND: Constipation is a common problem and is associated with decrease in quality of life. Abdominal massage appears to decrease the severity of gastrointestinal symptoms, but its impact on health-related quality of life has not been assessed.

    METHODS: A randomized controlled trial including 60 participants was conducted in Sweden between 2005 and 2007. The control group continued using laxatives as before and the intervention group received additional abdominal massage. Health-related quality of life was assessed using the EQ-5D and analyzed with linear regression. Two scenarios were outlined to conduct a cost utility analysis. In the self-massage scenario patients learned to give self-massage, and in the professional massage scenario patients in hospital received abdominal massage from an Enrolled Nurse.

    RESULTS: Linear regression analysis showed that health-related quality of life was statistically significantly increased after 8 weeks of abdominal massage. About 40% were estimated to receive good effect. For 'self-massage', the cost per quality adjusted life year was euro75,000 for the first 16 weeks. For every additional week of abdominal massage, the average dropped and eventually approached euro8300. For 'professional massage', the cost per quality adjusted life year was euro60,000 and eventually dropped to euro28,000.

    CONCLUSION: Abdominal massage may be cost-effective in the long-term and it is relevant to consider it when managing constipation. A crucial aspect will be to identify those who will benefit.

  • 32.
    Lämås, Kristina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Stenlund, Hans
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Engström, Birgitta
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Jacobsson, Catrine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Effects of abdominal massage in management of constipation: a randomized controlled trial2009Inngår i: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 46, nr 6, s. 759-767Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background. Associated with decreases in quality of life, constipation is a relatively common problem. Abdominal massage appears to increase bowel function, but unlike laxatives with no negative side effects. Because earlier studies have methodological flaws and cannot provide recommendations, more research is needed.

    Objective. This study investigates the effects of abdominal massage on gastrointestinal functions and laxative intake in people who have constipation.

    Design. Randomized controlled trial.

    Participants and method. A sample of 60 people with constipation was included and randomised in two groups. The intervention group received abdominal massage in addition to an earlier prescribed laxative and the control group received only laxatives according to earlier prescriptions. Gastrointestinal function was assessed with Gastrointestinal Symptoms Rating Scale (GSRS) on three occasions; at baseline, week 4 and week 8. The statistical methods included linear regression, Wilcoxon sign rank test, and Mann-Whitney U-test.

    Result. Abdominal massage significantly decreased severity of gastrointestinal symptoms assessed with GSRS according to total score (p=.003), constipation syndrome (p=.013), and abdominal pain syndrome (p=.019). The intervention group also had significant increase of bowel movements compared to the control group (p=.016). There was no significant difference in the change of the amount of laxative intake after 8 weeks.

    Conclusions. Abdominal massage decreased severity of gastrointestinal symptoms, especially constipation and abdominal pain syndrome, and increased bowel movements. The massage did not lead to decrease in laxative intake, a result that indicates that abdominal massage could be a complement to laxatives rather than a substitute.

  • 33.
    Lämås, Kristina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Willman, Ania
    Sektionen för hälsa, Blekinge Tekniska Högskola.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Jacobsson, Catrine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Economic evaluation of nursing practices: a review of literature2009Inngår i: International Nursing Review, ISSN 0020-8132, E-ISSN 1466-7657, Vol. 56, nr 1, s. 13-20Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: The importance of cost-effectiveness of nursing practices and its influence on prioritizations has been discussed in literature. It is, however, unclear to what extent health economic analysis has been used in the area of nursing.

    Aim: The aim of this paper was to investigate how studies of nursing practices apply economic evaluations.

    Methods: A literature review was conducted that included studies through August 2007. The search was performed using Medline, CINAHL, PsycINFO, Econlit, DARE, HTA, NHS EED, Cochrane reviews, and clinical trials with a search term connected to nursing and health economics. Protocols were used in the screening procedure and the result is reported in a descriptive form.

    Results: The search identified 115 studies published between1984 and august 2007. Studies were found in the following nursing practices: provision of support and treatment (n=17); assessing suffering/wellbeing (n=1); preventing or treating ill health (n=53); and organization of individual care (n=44). In 22% of all studies, the authors explicitly presented the health economic method used. In 25% of all studies, the perspective of the economic analysis was explicitly stated and there were a large variability in cost considered in the analysis. In 82 studies, the authors reported cost-effective intervention.

    Conclusions: Although economic evaluation of nursing practice has increased, it is still a rather small area. According to the items elucidated in this study, further methodological improvement is needed to evaluate the economics of nursing.

  • 34.
    Löfgren, Curt
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Boman, Kurt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Olofsson, Mona
    Department of Medicine, Skellefteå County Hospital, Skellefteå, Sweden.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Is cardiac consultation with remote-controlled real-time echocardiography a wise use of resources?2009Inngår i: Telemedicine journal and e-health, ISSN 1530-5627, E-ISSN 1556-3669, Vol. 15, nr 5, s. 431-438Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Northern Sweden is a sparsely populated area with six hospitals and about 50 healthcare centers. The elderly population is a large proportion of the total of population, and the incidence of cardiovascular disease is high. The objective of this research was to analyze the costs and benefits of cardiac consultation in healthcare centers involving long-distance, remote-controlled, real-time echocardiography. The distance diagnostics were developed and tested in two healthcare centers. Experiences of the feasibility of this approach were used as a basis for an economic analysis with regard to heart failure. The societal costs for two different systems were calculated, namely, traditional hospital diagnosis versus distance diagnosis using the new system. The potential prime gainers were the patients. Their traveling time, and thereby their time costs, were significantly reduced. The quality of care may also have been improved. From the health authorities' perspective, the costs of the two systems were approximately equal. Since county council costs are not greatly affected, the large reduction in patient travel time and the improved quality of care ought to be a sufficient incentive for large-scale tests.

  • 35.
    Löfgren, Curt
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ming, HV
    Thanh, NX
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sahlén, Klas-Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Catastrophic Health Expenditure and Impoverishment among the Elderly Households in Vietnam.Inngår i: Artikkel i tidsskrift (Fagfellevurdert)
  • 36.
    Löfgren, Curt
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Thanh, Nguyen
    Institute of Health Economics, Edmonton, Canada.
    Chuc, Nguyen
    Dept. of Health Economics, Faculty of Public Health, Hanoi Medical University, Vietnam.
    Emmelin, Anders
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    People's willingness to pay for health insurance in rural Vietnam2008Inngår i: Cost Effectiveness and Resource Allocation, ISSN 1478-7547, E-ISSN 1478-7547, Vol. 6, s. 16-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: The inequity caused by health financing in Vietnam, which mainly relies on out-of-pocket payments, has put pre-payment reform high on the political agenda. This paper reports on a study of the willingness to pay for health insurance among a rural population in northern Vietnam, exploring whether the Vietnamese are willing to pay enough to sufficiently finance a health insurance system.

    METHODS: Using the Epidemiological Field Laboratory for Health Systems Research in the Bavi district (FilaBavi), 2070 households were randomly selected for the study. Existing FilaBavi interviewers were trained especially for this study. The interview questionnaire was developed through a pilot study followed by focus group discussions among interviewers. Determinants of households' willingness to pay were studied through interval regression by which problems such as zero answers, skewness, outliers and the heaping effect may be solved.

    RESULTS: Households' average willingness to pay (WTP) is higher than their costs for public health care and self-treatment. For 70-80% of the respondents, average WTP is also sufficient to pay the lower range of premiums in existing health insurance programmes. However, the average WTP would only be sufficient to finance about half of total household public, as well as private, health care costs. Variables that reflect income, health care need, age and educational level were significant determinants of households' willingness to pay. Contrary to expectations, age was negatively related to willingness to pay.

    CONCLUSION: Since WTP is sufficient to cover household costs for public health care, it depends to what extent households would substitute private for public care and increase utilization as to whether WTP would also be sufficient enough to finance health insurance. This study highlights potential for public information schemes that may change the negative attitude towards health insurance, which this study has uncovered. A key task for policy makers is to win the trust of the population in relation to a health insurance system, particularly among the old and those with relatively low education.

  • 37.
    Löfroth, Emil
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Centre for Epidemiology, National Board of Health and Welfare, SE-106 30, Stockholm, Sweden.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Wilhelmsen, Lars
    Rosén, Måns
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Centre for Epidemiology, National Board of Health and Welfare, SE-106 30, Stockholm, Sweden.
    Optimising health care within given budgets: primary prevention of cardiovascular disease in different regions of Sweden2006Inngår i: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 75, nr 2, s. 214-229Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This study investigated the consequences of applying strict health maximisation to the choice between three different interventions with a defined budget. We analysed three interventions or preventing cardiovascular diseases, through doctor's advice on smoking cessation, through blood-pressure-lowering drugs. and through lipid-lowering drugs. A state transition model has been used to estimate the cost-utility ratios for entire population in three different county Councils in Sweden, where the populations were stratified into mutually excluding risk groups. The incremental cost-utility ratios are being presented in a league table and combined with the local resources and the local epidemiological data as a proxy for need for treatment, All interventions with an incremental cost-utility ratio exceeding the threshold ratios are excluded from being funded, The threshold varied between 1687 EURO and 6192 EURO. The general reallocation of resources between the three interventions Was a 60% reduction of blood-pressure-lowering drugs with redistribution of resources to advice on smoking cessation and to lipid-lowering drugs. One advantage of this method is that the results are very concrete. Recommendations can thereby he more precise which hopefully will create a public debate between decision-makers, practising phsicians and patient groups.

  • 38. Mahendradhata, Yodi
    et al.
    Probandari, Ari
    Ahmad, Riris A
    Utarini, Adi
    Trisnantoro, Laksono
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    van der Werf, Marieke J
    Kimerling, Michael
    Boelaert, Marleen
    Johns, Benjamin
    Van der Stuyft, Patrick
    The incremental cost-effectiveness of engaging private practitioners to refer tuberculosis suspects to DOTS services in Jogjakarta, Indonesia2010Inngår i: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 82, nr 6, s. 1131-1139Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    We aimed to evaluate the incremental cost-effectiveness of engaging private practitioners (PPs) to refer tuberculosis (TB) suspects to public health centers in Jogjakarta, Indonesia. Effectiveness was assessed for TB suspects notified between May 2004 and April 2005. Private practitioners referred 1,064 TB suspects, of which 57.5% failed to reach a health center. The smear-positive rate among patients reaching a health center was 61.8%. Two hundred eighty (280) out of a total of 1,306 (21.4%) new smear-positive cases were enrolled through the PPs strategy. The incremental cost-effectiveness ratio per smear-positive case successfully treated for the PPs strategy was US$351.66 (95% CI 322.84-601.33). On the basis of an acceptability curve using the National TB control program's willingness-to-pay threshold (US$448.61), we estimate the probability that the PPs strategy is cost-effective at 66.8%. The strategy of engaging PPs was incrementally cost-effective, although under specific conditions, most importantly a well-functioning public directly observed treatment, short-course (DOTS) program.

  • 39. Mendis, Shanthi
    et al.
    Lindholm, Lars H.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Anderson, Simon G.
    Alwan, Ala
    Koju, Rajendra
    Onwubere, Basden J. C.
    Kayani, Azhar Mahmood
    Abeysinghe, Nihal
    Duneas, Alfredo
    Tabagari, Sergo
    Fan, Wu
    Sarraf-Zadegan, Nizal
    Nordet, Porfirio
    Whitworth, Judith
    Heagerty, Anthony
    Total cardiovascular risk approach to improve efficiency of cardiovascular prevention in resource constrain settings2011Inngår i: Journal of Clinical Epidemiology, ISSN 0895-4356, E-ISSN 1878-5921, Vol. 64, nr 12, s. 1451-1462Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objectives: To determine the population distribution of cardiovascular risk in eight low- and middle-income countries and compare the cost of drug treatment based on cardiovascular risk (cardiovascular risk thresholds >= 30%/>= 40%) with single risk factor cutoff levels.

    Study Design and Setting: Using World Health Organization (WHO) and the International Society of Hypertension risk prediction charts, cardiovascular risk was categorized in a cross-sectional study of 8,625 randomly selected people aged 40-80 years (mean age, 54.6 years) from defined geographic regions of Nigeria, Iran, China, Pakistan, Georgia, Nepal, Cuba, and Sri Lanka. Cost estimates for drug therapy were calculated for three countries.

    Results: A large fraction (90.0-98.9%) of the study population has a 10-year cardiovascular risk <20%. Only 0.2-4.8% are in the high-risk categories (>= 30%). Adopting a total risk approach and WHO guidelines recommendations would restrict unnecessary drug treatment and reduce the drug costs significantly.

    Conclusion: Adopting a total cardiovascular risk approach instead of a single risk factor approach reduces health care expenditure by reducing drug costs. Therefore, limited resources can be more efficiently used to target high-risk people who will benefit the most. This strategy needs to be complemented with population-wide measures to shift the cardiovascular risk distribution of the whole population. (C) 2011 Elsevier Inc. All rights reserved.

  • 40. Månsdotter, Anna
    et al.
    Ekman, Björn
    Feldman, Inna
    Hagberg, Lars
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    We Propose a Novel Measure for Social Welfare and Public Health: Capability-Adjusted Life-Years, CALYs2017Inngår i: Applied Health Economics and Health Policy, ISSN 1175-5652, E-ISSN 1179-1896, Vol. 15, nr 4, s. 437-440Artikkel i tidsskrift (Fagfellevurdert)
  • 41. Månsdotter, Anna
    et al.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Lundberg, Michael
    Health, wealth and fairness based on gender: the support for ethical principles.2006Inngår i: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, ISSN 0277-9536, Vol. 62, nr 9, s. 2327-2335Artikkel i tidsskrift (Fagfellevurdert)
  • 42. Månsdotter, Anna
    et al.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Lundberg, Michael
    Winkvist, Anna
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Parental share in public and domestic spheres: a population study on gender equality, death, and sickness.2006Inngår i: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 60, nr 7, s. 616-620Artikkel i tidsskrift (Fagfellevurdert)
  • 43.
    Månsdotter, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Winkvist, Anna
    Paternity leave in Sweden: costs, savings and health gains.2007Inngår i: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 82, nr 1, s. 102-115Artikkel i tidsskrift (Fagfellevurdert)
  • 44.
    Månsdotter, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Women, men and public health - how the choice of normative theory affects resource allocation.2004Inngår i: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 69, nr 3, s. 351-364Artikkel i tidsskrift (Fagfellevurdert)
  • 45. Månsdotter, Anna
    et al.
    Lundberg, Michael
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    How does gender equality progress link to alcohol care and death?: A registry study of the Swedish parental cohort of 1988/19892012Inngår i: Journal of Public Health Policy, ISSN 0197-5897, E-ISSN 1745-655X, Vol. 33, nr 1, s. 105-118Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This article examines how gender equality during early parenthood (1988-1991) associates with alcohol-related inpatient care or mortality (1992-2006). We categorised all Swedish couples having had a first child together in 1988-1989 (N = 118 595) as traditional, or gender equal, or untraditional based on income and occupational position (bread-winning indicators), parental leave and temporary child care (child-care indicators). Overall, traditional women run lower risk, whereas traditional men and untraditional women (those opposing the traditional division of parenthood responsibilities) run higher risks of alcohol harm than their gender-equal counterparts. Journal of Public Health Policy (2012) 33, 105-118. doi:10.1057/jphp.2011.48; published online 15 September 2011

  • 46. Månsdotter, Anna M
    et al.
    Rydberg, Malin K
    Wallin, Eva
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Andréasson, Sven
    A cost-effectiveness analysis of alcohol prevention targeting licensed premises.2007Inngår i: Eur J Public Health, ISSN 1101-1262Artikkel i tidsskrift (Fagfellevurdert)
  • 47.
    Neumann, Anne
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Center of Evidence-Based Healthcare, University Hospital, Technische Universität Dresden, Germany.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Schoffer, Olaf
    Klug, Stefanie J.
    Norström, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The cost-effectiveness of interventions targeting lifestyle change for the prevention of diabetes in a Swedish primary care and community based prevention program2017Inngår i: European Journal of Health Economics, ISSN 1618-7598, E-ISSN 1618-7601, Vol. 18, nr 7, s. 905-919Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Policymakers need to know the cost-effec-tiveness of interventions to prevent type 2 diabetes (T2D). The objective of this study was to estimate the cost-effectiveness of a T2D prevention initiative targeting weight reduction, increased physical activity and healthier diet in persons in pre-diabetic states by comparing a hypothetical intervention versus no intervention in a Swedish setting. Methods: A Markov model was used to study the cost-effectiveness of a T2D prevention program based on lifestyle change versus a control group where no prevention was applied. Analyses were done deterministically and probabilistically based on Monte Carlo simulation for six different scenarios defined by sex and age groups (30, 50, 70 years). Cost and quality adjusted life year (QALY) differences between no intervention and intervention and incremental cost-effectiveness ratios (ICERs) were estimated and visualized in cost-effectiveness planes (CE planes) and cost-effectiveness acceptability curves (CEA curves). Results: All ICERs were cost-effective and ranged from 3833 € /QALY gained (women, 30 years) to 9215 € /QALY gained (men, 70 years). The CEA curves showed that the probability of the intervention being cost-effective at the threshold value of 50,000 € per QALY gained was very high for all scenarios ranging from 85.0 to 91.1%. Discussion/conclusion: The prevention or the delay of the onset of T2D is feasible and cost-effective. A small investment in healthy lifestyle with change in physical activity and diet together with weight loss are very likely to be cost-effective.

  • 48.
    Neumann, Anne
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Cancer Epidemiology, University Cancer Center, University Hospital, Technische Universität Dresden, Germany.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Schoffer, Olaf
    Cancer Epidemiology, University Cancer Center, University Hospital, Technische Universität Dresden, Germany.
    Norström, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Johansson, Ingegerd
    Umeå universitet, Medicinska fakulteten, Institutionen för odontologi.
    Klug, Stefanie J.
    Cancer Epidemiology, University Cancer Center, University Hospital, Technische Universität Dresden, Germany.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Risk equations for the development of worsened glucose status and type 2 diabetes mellitus in a Swedish intervention program2013Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, artikkel-id 1014Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Several studies investigated transitions and risk factors from impaired glucose tolerance (IGT) to type 2 diabetes mellitus (T2D). However, there is a lack of information on the probabilities to transit from normal glucose tolerance (NGT) to different pre-diabetic states and from these states to T2D. The objective of our study is to estimate these risk equations and to quantify the influence of single or combined risk factors on these transition probabilities. Methods: Individuals who participated in the VIP program twice, having the first examination at ages 30, 40 or 50 years of age between 1990 and 1999 and the second examination 10 years later were included in the analysis. Participants were grouped into five groups: NGT, impaired fasting glucose (IFG), IGT, IFG&IGT or T2D. Fourteen potential risk factors for the development of a worse glucose state (pre-diabetes or T2D) were investigated: sex, age, education, perceived health, triglyceride, blood pressure, BMI, smoking, physical activity, snus, alcohol, nutrition and family history. Analysis was conducted in two steps. Firstly, factor analysis was used to find candidate variables; and secondly, logistic regression was employed to quantify the influence of the candidate variables. Bootstrap estimations validated the models. Results: In total, 29 937 individuals were included in the analysis. Alcohol and perceived health were excluded due to the results of the factor analysis and the logistic regression respectively. Six risk equations indicating different impacts of different risk factors on the transition to a worse glucose state were estimated and validated. The impact of each risk factor depended on the starting or ending pre-diabetes state. High levels of triglyceride, hypertension and high BMI were the strongest risk factors to transit to a worsened glucose state. Conclusions: The equations could be used to identify individuals with increased risk to develop any of the three pre-diabetic states or T2D and to adapt prevention strategies.

  • 49.
    Neumann, Anne
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Cancer Epidemiology, University Cancer Center, University Hospital.
    Schoffer, Olaf
    Cancer Epidemiology, University Cancer Center, University Hospital.
    Norström, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Klug, Stefanie J
    Cancer Epidemiology, University Cancer Center, University Hospital.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health-related quality of life for pre-diabetic states and type 2 diabetes mellitus: a cross-sectional study in Västerbotten Sweden2014Inngår i: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 12, nr 1, artikkel-id 150Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Type 2 diabetes (T2D) decreases health-related quality of life, but there is a lack of information about the health status of people in pre-diabetic states. However, information on health utility weights (HUWs) for pre-diabetic states and T2D are essential to estimate the effect of prevention initiatives. We estimated and compared HUWs for healthy individuals, those with pre-diabetes and those with T2D in a Swedish population and evaluated the influence of age, sex, education and body mass index on HUWs.

    Methods: Participants of the Västerbotten Intervention Program, Sweden, between 2002 and 2012, who underwent an oral glucose tolerance test or indicated they had T2D and who filled in the Short Form-36 questionnaire (SF-36) were included. Individuals were categorized as healthy, being in any of three different pre-diabetic states, or as T2D. The pre-diabetic states are impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or a combination of both (IFG&IGT). The SF-6D index was used to convert SF-36 responses to HUWs. HUWswere stratified by age, sex, education and body mass index. Beta regression analyses were conducted to estimate the effect of multiple risk factors on the HUWs.

    Results: In total, 55 882 individuals were included in the analysis. The overall mean HUW was 0.764. The mean HUW of healthy individuals was 0.768, 0.759 for those with IFG, 0.746 for those with IGT, 0.745 for those with IFG&IGT, and 0.738 for those with T2D. In the overall model, all variables except underweight vs. normal weight were significantly associated with HUW. Younger age, male sex, and higher education were associated with increased HUW. Normal weight, or being overweight was associated with elevated HUW, while obesity was associated with lower HUW.

    Conclusions: Healthy individuals had higher HUWs than participants with T2D, while individuals with IFG, IGT or IFG&IGT had HUWs that ranged between those for NGT and T2D. Therefore, preventing the development of pre-diabetic states would improve health-related quality of life in addition to lowering the risk of developing T2D.

  • 50.
    Neumann, Anne
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Schwarz, Peter
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Estimating the cost-effectiveness of lifestyle intervention programmes to prevent diabetes based on an example from Germany: Markov modelling2011Inngår i: Cost Effectiveness and Resource Allocation, ISSN 1478-7547, E-ISSN 1478-7547, Vol. 9, nr 1, artikkel-id 17Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Type 2 diabetes mellitus (T2D) poses a large worldwide burden for health care systems. One possible tool to decrease this burden is primary prevention. As it is unethical to wait until perfect data are available to conclude whether T2D primary prevention intervention programmes are cost-effective, we need a model that simulates the effect of prevention initiatives. Thus, the aim of this study is to investigate the long-term cost-effectiveness of lifestyle intervention programmes for the prevention of T2D using a Markov model. As decision makers often face difficulties in applying health economic results, we visualise our results with health economic tools.

    METHODS: We use four-state Markov modelling with a probabilistic cohort analysis to calculate the cost per quality-adjusted life year (QALY) gained. A one-year cycle length and a lifetime time horizon are applied. Best available evidence supplies the model with data on transition probabilities between glycaemic states, mortality risks, utility weights, and disease costs. The costs are calculated from a societal perspective. A 3% discount rate is used for costs and QALYs. Cost-effectiveness acceptability curves are presented to assist decision makers.

    RESULTS: The model indicates that diabetes prevention interventions have the potential to be cost-effective, but the outcome reveals a high level of uncertainty. Incremental cost-effectiveness ratios (ICERs) were negative for the intervention, ie, the intervention leads to a cost reduction for men and women aged 30 or 50 years at initiation of the intervention. For men and women aged 70 at initiation of the intervention, the ICER was EUR27,546/QALY gained and EUR19,433/QALY gained, respectively. In all cases, the QALYs gained were low. Cost-effectiveness acceptability curves show that the higher the willingness-to-pay threshold value, the higher the probability that the intervention is cost-effective. Nonetheless, all curves are flat. The threshold value of EUR50,000/QALY gained has a 30-55% probability that the intervention is cost-effective.

    CONCLUSIONS: Lifestyle interventions for primary prevention of type 2 diabetes are cost-saving for men and women aged 30 or 50 years at the start of the intervention, and cost-effective for men and women aged 70 years. However, there is a high degree of uncertainty around the ICERs. With the conservative approach adopted for this model, the long-term effectiveness of the intervention could be underestimated.

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