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  • 251. Braegger, Christian
    et al.
    Campoy, Cristina
    Colomb, Virginie
    Decsi, Tamas
    Domellof, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Fewtrell, Mary
    Hojsak, Iva
    Mihatsch, Walter
    Molgaard, Christian
    Shamir, Raanan
    Turck, Dominique
    van Goudoever, Johannes
    Vitamin D in the Healthy European Paediatric Population2013Ingår i: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 56, nr 6, s. 692-701Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    In recent years, reports suggesting a resurgence of vitamin D deficiency in the Western world, combined with various proposed health benefits for vitamin D supplementation, have resulted in increased interest from health care professionals, the media, and the public. The aim of this position paper is to summarise the published data on vitamin D intake and prevalence of vitamin D deficiency in the healthy European paediatric population, to discuss the health benefits of vitamin D and to provide recommendations for the prevention of vitamin D deficiency in this population. Vitamin D plays a key role in calcium and phosphate metabolism and is essential for bone health. There is insufficient evidence from interventional studies to support vitamin D supplementation for other health benefits in infants, children, and adolescents. The pragmatic use of a serum concentration >50 nmol/L to indicate sufficiency and a serum concentration <25 nmol/L to indicate severe deficiency is recommended. Vitamin D deficiency occurs commonly among healthy European infants, children, and adolescents, especially in certain risk groups, including breast-fed infants, not adhering to the present recommendation for vitamin D supplementation, children and adolescents with dark skin living in northern countries, children and adolescents without adequate sun exposure, and obese children. Infants should receive an oral supplementation of 400 IU/day of vitamin D. The implementation should be promoted and supervised by paediatricians and other health care professionals. Healthy children and adolescents should be encouraged to follow a healthy lifestyle associated with a normal body mass index, including a varied diet with vitamin D-containing foods (fish, eggs, dairy products) and adequate outdoor activities with associated sun exposure. For children in risk groups identified above, an oral supplementation of vitamin D must be considered beyond 1 year of age. National authorities should adopt policies aimed at improving vitamin D status using measures such as dietary recommendations, food fortification, vitamin D supplementation, and judicious sun exposure, depending on local circumstances.

  • 252.
    Brammås, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Jakobsson, Stina
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Ulvenstam, Anders
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin. Department of Internal Medicine, Section of Cardiology, Östersund Hospital, Sweden.
    Mooe, Thomas
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Mortality After Ischemic Stroke in Patients With Acute Myocardial Infarction Predictors and Trends Over Time in Sweden2013Ingår i: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 44, nr 11, s. 3050-3055Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background and Purpose Acute myocardial infarction (AMI) increases the risk of ischemic stroke, and mortality among these patients is high. Here, we aimed to estimate the 1-year mortality reliably after AMI complicated by ischemic stroke. We also aimed to identify trends over time for mortality during 1998-2008, as well as factors that predicted increased or decreased mortality. Methods Data for 173 233 unselected patients with AMI were collected from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions registry for 1998-2008. Specifically, we analyzed 1-year follow-up and mortality data for patients with AMI with and without ischemic stroke. Kaplan-Meyer analysis was used to analyze mortality trends over time, and Cox regression analysis was used to identify uni- and multivariate predictors of mortality. Results The 1-year mortality was 36.5% for AMI complicated by ischemic stroke and 18.3% for AMI without stroke. Mortality decreased over time in patients with and without ischemic stroke. The absolute decreases in mortality were 9.4% and 7.5%, respectively. Reperfusion and secondary preventive therapies were associated with a decreased mortality rate. Conclusions Mortality after AMI complicated by an ischemic stroke is very high but decreased from 1998 to 2008. The increased use of evidence-based therapies explains the improved prognosis.

  • 253. Bringman, S.
    et al.
    Holmberg, Henrik
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Osterberg, J.
    Location of recurrent groin hernias at TEP after Lichtenstein repair: a study based on the Swedish Hernia Register2016Ingår i: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 20, nr 3, s. 387-391Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    To investigate which type of hernia that has the highest risk of a recurrence after a primary Lichtenstein repair. Male patients operated on with a Lichtenstein repair for a primary direct or indirect inguinal hernia and with a TEP for a later recurrence, with both operations recorded in the Swedish Hernia Register (SHR), were included in the study. The study period was 1994-2014. Under the study period, 130,037 male patients with a primary indirect or direct inguinal hernia were operated on with a Lichtenstein repair. A second operation in the SHR was registered in 2236 of these patients (reoperation rate 1.7 %). TEP was the chosen operation in 737 in this latter cohort. The most likely location for a recurrence was the same as the primary location. If the recurrences change location from the primary place, we recognized that direct hernias had a RR of 1.51 to having a recurrent indirect hernia compared to having a direct recurrence after an indirect primary hernia repair. Recurrent hernias after Lichtenstein are more common on the same location as the primary one, compared to changing the location.

  • 254.
    Briones-Vozmediano, Erica
    et al.
    Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante Public Health Research Group, San Vicente del Raspeig RoadAlicante, Spain.
    Agudelo-Suarez, Andres A
    Faculty of Dentistry, University of Antioquia, Street 67Medellín, Colombia.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Vives-Cases, Carmen
    Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante Public Health Research Group, San Vicente del Raspeig RoadAlicante, Spain; CIBER of Epidemiology and Public Health, Carlos III Institute of Health, Street Melchor Fernández AlmagroMadrid, Spain.
    Economic crisis, immigrant women and changing availability of intimate partner violence services: a qualitative study of professionals' perceptions in Spain2014Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, artikel-id 79Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Since 2008, Spain has been in the throes of an economic crisis. This recession particularly affects the living conditions of vulnerable populations, and has also led to a reversal in social policies and a reduction in resources. In this context, the aim of this study was to explore intimate partner violence (IPV) service providers' perceptions of the impact of the current economic crisis on these resources in Spain and on their capacity to respond to immigrant women's needs experiencing IPV. Methods: A qualitative study was performed based on 43 semi-structured in-depth interviews to social workers, psychologists, intercultural mediators, judges, lawyers, police officers and health professionals from different services dealing with IPV (both, public and NGO's) and cities in Spain (Barcelona, Madrid, Valencia and Alicante) in 2011. Transcripts were imported into qualitative analysis software (Atlas.ti), and analysed using qualitative content analysis. Results: We identified four categories related to the perceived impact of the current economic crisis: a) "Immigrant women have it harder now", b) "IPV and immigration resources are the first in line for cuts", c) " Fewer staff means a less effective service" and d) "Equality and IPV policies are no longer a government priority". A cross-cutting theme emerged from these categories: immigrant women are triply affected; by IPV, by the crisis, and by structural violence. Conclusion: The professionals interviewed felt that present resources in Spain are insufficient to meet the needs of immigrant women, and that the situation might worsen in the future.

  • 255. Briones-Vozmediano, Erica
    et al.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ortiz-Barreda, Gaby
    Gil-González, Diana
    Vives-Cases, Carmen
    Professionals' perceptions of support resources for battered immigrant women: chronicle of an anticipated failure2014Ingår i: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, Vol. 29, nr 6, s. 1006-1027Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The aim of this study was to explore the experience of service providers in Spain regarding their daily professional encounters with battered immigrant women and their perception of this group's help-seeking process and the eventual abandonment of the same. Twenty-nine in-depth interviews and four focus group discussions were conducted with a total of 43 professionals involved in providing support to battered immigrant women. We interviewed social workers, psychologists, intercultural mediators, judges, lawyers, and public health professionals from Spain. Through qualitative content analysis, four categories emerged: (a) frustration with the victim's decision to abandon the help-seeking process, (b) ambivalent positions regarding differences between immigrant and Spanish women, (c) difficulties in the migratory process that may hinder the help-seeking process, and (d) criticisms regarding the inefficiency of existing resources. The four categories were cross-cut by an overarching theme: helping immigrant women not to abandon the help-seeking process as a chronicle of anticipated failure. The main reasons that emerged for abandoning the help-seeking process involved structural factors such as economic dependence, loss of social support after leaving their country of origin, and limited knowledge about available resources. The professionals perceived their encounters with battered immigrant women to be frustrating and unproductive because they felt that they had few resources to back them up. They felt that despite the existence of public policies targeting intimate partner violence (IPV) and immigration in Spain, the resources dedicated to tackling gender-based violence were insufficient to meet battered immigrant women's needs. Professionals should be trained both in the problem of IPV and in providing support to the immigrant population.

  • 256. Briones-Vozmediano, Erica
    et al.
    Maquibar, Amaia
    Vives-Cases, Carmen
    Öhman, Ann
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS). Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group of the University of Alicante, Spain.
    Health-Sector Responses to Intimate Partner Violence: fitting the Response Into the Biomedical Health System or Adapting the System to Meet the Response?2018Ingår i: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, Vol. 33, nr 10, s. 1653-1678Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This study aims to analyze how middle-level health systems' managers understand the integration of a health care response to intimate partner violence (IPV) within the Spanish health system. Data were obtained through 26 individual interviews with professionals in charge of coordinating the health care response to IPV within the 17 regional health systems in Spain. The transcripts were analyzed following grounded theory in accordance with the constructivist approach described by Charmaz. Three categories emerged, showing the efforts and challenges to integrate a health care response to IPV within the Spanish health system: "IPV is a complex issue that generates activism and/or resistance," "The mandate to integrate a health sector response to IPV: a priority not always prioritized," and "The Spanish health system: respectful with professionals' autonomy and firmly biomedical." The core category, "Developing diverse responses to IPV integration," crosscut the three categories and encompassed the range of different responses that emerge when a strong mandate to integrate a health care response to IPV is enacted. Such responses ranged from refraining to deal with the issue to offering a women-centered response. Attempting to integrate a response to nonbiomedical health problems as IPV into health systems that remain strongly biomedicalized is challenging and strongly dependent both on the motivation of professionals and on organizational factors. Implementing and sustaining changes in the structure and culture of the health care system are needed if a health care response to IPV that fulfills the World Health Organization guidelines is to be ensured.

  • 257. Briones-Vozmediano, Erica
    et al.
    Vives-Cases, Carmen
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group, University of Alicante, Alicante, Spain.
    "I'm not the woman I was": Women's perceptions of the effects of fibromyalgia on private life2016Ingår i: Health Care for Women International, ISSN 0739-9332, E-ISSN 1096-4665, Vol. 37, nr 8, s. 836-854Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    In this qualitative study, we explored how gender shapes women's experiences of living with fibromyalgia and how it affects their private lives. Through thematic analysis of data from 13 in-depth interviews in Spain, we identified seven themes which reflect that these women feel remorse and frustration for not being able to continue to fulfill the gender expectation of caring for others and for the home. This research contributes to a better understanding of what suffering from fibromyalgia implies for women and provides insights into how families and providers can support women with fibromyalgia in order to achieve a beneficial lifestyle.

  • 258. Briones-Vozmediano, Erica
    et al.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group of Alicante University, Alicante, Spain.
    Vives-Cases, Carmen
    "The complaining women": health professionals' perceptions on patients with fibromyalgia in Spain2018Ingår i: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 40, nr 14, s. 1679-1685Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    PURPOSE: The aim of this study is twofold: (1) to explore health service providers' perceptions regarding fibromyalgia patients in Spain and (2) to analyze possible consequences of these perceptions in terms of how health service providers construct the disease and treat their patients.

    DESIGN: Qualitative study.

    SUBJECTS/PATIENTS: Twelve health service providers (eight men, four women) involved in the care of fibromyalgia patients. Providers were from different disciplines and included general practitioners, rheumatologists, occupational doctors, psychologists, psychiatrists, physiotherapists and behavioral specialists from Spain.

    METHOD: We performed individual semistructured interviews, which were recorded and transcribed to conduct a qualitative content analysis supported by Atlas.ti-7.

    RESULTS: We identified three categories from the interviews: (1) the fibromyalgia patient prototype: the complaining woman, (2) fibromyalgia is considered a women's health issue, but male patients are a privileged minority, and (3) health professionals' attitudes toward fibromyalgia patients: are they really suffering or pretending?

    CONCLUSION: The uncertainty surrounding fibromyalgia together with the fact that those affected are primarily women, seem to influence professional practice in terms of lack of recognition of Fibromyalgia as a severe disease. Increased training of all health professionals is essential to improving the support and attention given to patients suffering from fibromyalgia.

    Implications for rehabilitation: Fibromyalgia

    • In order to improve fibromyalgia patients' attention, health providers should learn how to assist patients without prejudices.

    • Training programs for health providers should include sensitization about the severity of fibromyalgia.

    • Health providers should be aware of the existence of stereotypes about women suffering from fibromyalgia.

    • Fibromyalgia protocols should give skills to health providers to avoid offering a gender-biased attention to patients.

  • 259.
    Brito, Ema C
    Umeå universitet, Medicinsk fakultet, Folkhälsa och klinisk medicin.
    Gene x lifestyle interactions in type 2 diabetes mellitus and related traits2010Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

     

    Background: Type 2 diabetes is thought to result from interactions between genetic and lifestyle factors, but few robust examples exist. The overarching aim of this thesis was to discover such interactions by studying cohorts of white youth and adults from northern Europe in which physical activity, genotypes, and diabetes-related traits or diabetes incidence had been ascertained.

     

    Methods: The thesis includes four papers. In Paper I, we investigated associations and interactions between 35 common PPARGC1A polymorphisms and cardiovascular and metabolic disease traits in 2,101 Danish and Estonian children from the European Youth Heart Study (EYHS). Paper II used the same cohort to test associations and interactions on cardiometabolic traits for the diabetes-predisposing TCF7L2 polymorphism. In Paper III, we assessed associations for 17 type 2 diabetes gene polymorphisms on impaired glucose regulation (IGR) or incident type 2 diabetes, and tested whether these effects are modified by physical activity in a prospective cohort study of ~16,000 initially non-diabetic Swedish adults – the Malmö Preventive Project (MPP). Paper IV aimed to replicate main genetic effects and gene x physical activity interactions for an FTO polymorphism on obesity in 18,435 primarily non-diabetic Swedish (MPP) and Finnish (Prevalence, Prediction and Prevention of Diabetes in Botnia) adults.

    Results: In Paper I, nominally significant associations were observed for BMI (rs10018239, P=0.039), waist circumference (rs7656250, P=0.012; rs8192678 [Gly482Ser], P=0.015; rs3755863, P=0.02; rs10018239, P=0.043), systolic blood pressure (rs2970869, P=0.018) and fasting glucose concentrations (rs11724368, P=0.045). Stronger associations were observed for aerobic fitness (rs7656250, P=0.005; rs13117172, P=0.008) and fasting glucose concentrations (rs7657071, P=0.002). None remained significant after correcting for multiple statistical comparisons. We proceeded by testing for gene × physical activity interactions for the polymorphisms that showed statistical evidence of association (P<0.05) in the main effect models, but none was statistically significant. In Paper II, the minor T allele at the rs7903146 variant was associated with higher glucose levels in older (beta=–0.098 mmol/l per minor allele copy, P=0.029) but not in younger children (beta=–0.001 mmol/l per minor allele copy, P=0.972). A significant inverse association between the minor allele at rs7903146 and height was evident in boys (beta=–1.073 cm per minor allele copy, P=0.001), but not in girls. The test of interaction between the TCF7L2 rs7903146 variant and physical activity on HOMA-B was nominally statistically significant (beta=0.022, Pinteraction=0.015), whereby physical activity reduced the effect of the risk allele on estimated beta-cell function. In Paper III, tests of gene x physical activity interactions on IGR-risk for three polymorphisms were nominally statistically significant: CDKN2A/B rs10811661 (Pinteraction=0.015); HNF1B rs4430796 (Pinteraction=0.026); PPARG rs1801282 (Pinteraction=0.04). Consistent interactions were observed for the CDKN2A/B (Pinteraction=0.013) and HNF1B (Pinteraction=0.0009) variants on 2 hr glucose concentrations. Where type 2 diabetes was the outcome, only one statistically significant interaction effect was observed and this was for the HNF1B rs4430796 variant (Pinteraction=0.0004). The interaction effects for HNF1B on 2 hr glucose and incident diabetes remained significant after correction for multiple testing (Pinteraction=0.015 and 0.0068, respectively). In Paper IV, the minor A allele at rs9939609 was associated with higher BMI (P<0.0001). The tests of gene x physical activity interaction on BMI were not statistically significant in either cohort (Sweden: P=0.71, Finland: P=0.18).

    Conclusions: Variation at PPARGC1A is unlikely to have a major impact on cardiometabolic health in European children, but physical activity may modify the effect of the TFC7L2 variants on beta-cell function in this cohort. In Swedish adults, physical activity modifies the effects of common HNF1B and CDKN2A/B variants on risk of IGR and also modifies the effect of the HNF1B on type 2 diabetes risk. In Swedish and Finnish adults, we were unable to confirm previous reports of an interaction between FTO gene variation and physical activity on obesity predisposition.

  • 260. Broeders, Mireille
    et al.
    Moss, Sue
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Njor, Sisse
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Poop, Ellen
    Massat, Nathalie
    Duffy, Stephen
    Lynge, Elsebeth
    Paci, Eugenio
    The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies2012Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, s. 14-25Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives To assess the impact of population-based mammographic screening on breast cancer mortality in Europe, considering different methodologies and limitations of the data. Methods We conducted a systematic literature review of European trend studies (n = 17), incidence-based mortality (IBM) studies (n = 20) and case-control (CC) studies (n = 8). Estimates of the reduction in breast cancer mortality for women invited versus not invited and/or for women screened versus not screened were obtained. The results of IBM studies and CC studies were each pooled using a random effects meta-analysis. Results Twelve of the 17 trend studies quantified the impact of population-based screening on breast cancer mortality. The estimated breast cancer mortality reductions ranged from 1% to 9% per year in studies reporting an annual percentage change, and from 28% to 36% in those comparing post- and prescreening periods. In the IBM studies, the pooled mortality reduction was 25% (relative risk [RR] 0.75, 95% confidence interval [CI] 0.69-0.81) among invited women and 38% (RR 0.62, 95% CI 0.56-0.69) among those actually screened. The corresponding pooled estimates from the CC studies were 31% (odds ratio [OR] 0.69, 95% CI 0.57-0.83), and 48% (OR 0.52, 95% CI 0.42-0.65) adjusted for self-selection. Conclusions Valid observational designs are those where sufficient longitudinal individual data are available, directly linking a woman's screening history to her cause of death. From such studies, the best 'European' estimate of breast cancer mortality reduction is 25-31% for women invited for screening, and 38-48% for women actually screened. Much of the current controversy on breast cancer screening is due to the use of inappropriate methodological approaches that are unable to capture the true effect of mammographic screening.

  • 261.
    Brogårdh, Christina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Johansson, Fredrik W
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Nygren, Frida
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Sjölund, Bengt H
    Mode of hand training determines cortical reorganisation: A randomized controlled study in healthy adults2010Ingår i: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 42, nr 8, s. 789-794Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To evaluate two commonly used forms of hand training with respect to influence on dexterity and cortical reorganization.

    Subjects: Thirty healthy volunteers (mean age 24.2 years).

    Methods: The subjects were randomized to 25 min of shaping exercises or general activity training of the non-dominant hand. The dexterity and the cortical motor maps (number of excitable positions) of the abductor pollicis brevis muscle were evaluated pre- and post-training by the Purdue Peg Board test and transcranial magnetic stimulation, respectively.

    Results: After shaping exercises the dexterity increased significantly (p ≤ 0.005) for both hands, mostly so in the non-dominant hand. The cortical motor map of the abductor pollicis brevis muscle shifted forwardly into the pre-motor area without expanding. After general activity training, no significant improvements in dexterity were found for the non-dominant hand. The cortical motor map of the non-dominant abductor pollicis brevis muscle expanded significantly (p = 0.03) in the posterior (sensory) direction.

    Conclusion: These results indicate that shaping exercises, but not general activity training, increase dexterity of the trained non-dominant hand in parallel with a shift of location of active transcranial magnetic stimulation positions. Shifts of active cortical areas might be important for the interpretation of brain plasticity in common behavioural tasks.

  • 262.
    Brogårdh, Christina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Vestling, Monika
    Sjölund, Bengt H
    Forced use therapy in patients with subacute stroke: The mitt can be thrown!: A randomised controlled study with blinded observersManuskript (preprint) (Övrigt vetenskapligt)
  • 263. Brooks, Chloe
    et al.
    D'Ambruoso, Lucia
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kazimierczak, Karolina
    Ngobeni, Sizzy
    Twine, Rhian
    Tollman, Stephen
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana.
    Kahn, Kathleen
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Introducing visual participatory methods to develop local knowledge on HIV in rural South Africa2017Ingår i: BMJ Global Health, E-ISSN 2059-7908, Vol. 2, nr 3, artikel-id e000231Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: South Africa is a country faced with complex health and social inequalities, in which HIV/AIDS has had devastating impacts. The study aimed to gain insights into the perspectives of rural communities on HIV-related mortality.

    METHODS: A participatory action research (PAR) process, inclusive of a visual participatory method (Photovoice), was initiated to elicit and organise local knowledge and to identify priorities for action in a rural subdistrict underpinned by the Agincourt Health and Socio-Demographic Surveillance System (HDSS). We convened three village-based discussion groups, presented HDSS data on HIV-related mortality, elicited subjective perspectives on HIV/AIDS, systematised these into collective accounts and identified priorities for action. Framework analysis was performed on narrative and visual data, and practice theory was used to interpret the findings.

    FINDINGS: A range of social and health systems factors were identified as causes and contributors of HIV mortality. These included alcohol use/abuse, gender inequalities, stigma around disclosure of HIV status, problems with informal care, poor sanitation, harmful traditional practices, delays in treatment, problems with medications and problematic staff-patient relationships. To address these issues, developing youth facilities in communities, improving employment opportunities, timely treatment and extending community outreach for health education and health promotion were identified.

    DISCUSSION: Addressing social practices of blame, stigma and mistrust around HIV-related mortality may be a useful focus for policy and planning. Research that engages communities and authorities to coproduce evidence can capture these practices, improve communication and build trust.

    CONCLUSION: Actions to reduce HIV should go beyond individual agency and structural forces to focus on how social practices embody these elements. Initiating PAR inclusive of visual methods can build shared understandings of disease burdens in social and health systems contexts. This can develop shared accountability and improve staff-patient relationships, which, over time, may address the issues identified, here related to stigma and blame.

  • 264.
    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 States2018Ingår i: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 137, nr 9, s. 886-888Artikel i tidskrift (Övrigt vetenskapligt)
  • 265.
    Brunström, Mattias
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Ng, Nawi
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden.
    Dahlström, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lindholm, Lars H.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lönnberg, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Carlberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Association of Physician Education and Feedback on Hypertension Management With Patient Blood Pressure and Hypertension Control2020Ingår i: JAMA Network Open, ISSN 2574-3805, Vol. 3, nr 1, artikel-id e1918625Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Importance: Elevated systolic blood pressure (SBP) is the most important risk factor for premature death worldwide. However, hypertension detection and control rates continue to be suboptimal.

    Objective: To assess the association of education and feedback to primary care physicians with population-level SBP and hypertension control rates.

    Design, Setting, and Participants: This pooled series of 108 population-based cohort studies involving 283 079 patients used data from primary care centers in 2 counties (Västerbotten and Södermanland) in Sweden from 2001 to 2009. Participants were individuals aged 18 years or older who had their blood pressure (BP) measured and recorded in either county during the intervention period. All analyses were performed in February 2019.

    Exposures: An intervention comprising education and feedback for primary care physicians in Västerbotten County (intervention group) compared with usual care in Södermanland County (control group).

    Main Outcomes and Measures: Difference in mean SBP levels between counties and likelihood of hypertension control in the intervention county compared with the control county during 24 months of follow-up.

    Results: A total of 136 541 unique individuals (mean [SD] age at inclusion, 64.6 [16.1] years; 57.0% female; mean inclusion BP, 142/82 mm Hg) in the intervention county were compared with 146 538 individuals (mean [SD] age at inclusion, 65.7 [15.9] years; 58.3% female; mean inclusion BP, 144/80 mm Hg) in the control county. Mean SBP difference between counties during follow-up, adjusted for inclusion BP and other covariates, was 1.1 mm Hg (95% CI, 1.0-1.1 mm Hg). Hypertension control improved by 8.4 percentage points, and control was achieved in 37.8% of participants in the intervention county compared with 29.4% in the control county (adjusted odds ratio, 1.30; 95% CI, 1.29-1.31). Differences between counties increased during the intervention period and were more pronounced in participants with higher SBP at inclusion. Results were consistent across all subgroups.

    Conclusions and Relevance: This study suggests that SBP levels and hypertension control rates in a county population may be improved by educational approaches directed at physicians and other health care workers. Similar strategies may be adopted to reinforce the implementation of clinical practice guidelines for hypertension management.

  • 266.
    Brydsten, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Yesterday once more? Unemployment and health inequalities across the life course in northern Sweden2017Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    Abstract

    Background. It is relatively well established in previous research that unemployment has direct health consequences in terms of mental and physical ill health. Recently, knowledge has emerged indicating that unemployment can lead to economic consequences that remain long after re-establishment in the labour market. However, few empirical studies have been able to apply a life course perspective asking whether there are also long-term health consequences of unemployment, and, when and in which context unemployment may affect the individual health status across the life course. The aim of this thesis was to analyse the relationship between unemployment and illness across the life course, and how it relates to individual and structural factors in the geographical setting of northern Sweden. In particular, three main areas have been explored: youth unemployment and illness in adulthood (Paper I and Paper II), contextual unemployment of national unemployment rate and neighbourhood unemployment (Paper II and Paper III) and lastly, social determinants of health inequality between employment statuses (Paper IV).

    Methods. This thesis is positioned in Sweden between the early 1980s and the mid-2010s, following two comparable cohorts sampled from northern Sweden (26 and 19 years follow-up time respectively from youth to midlife) and a cross-sectional sample from 2014 of the four northernmost counties in Sweden. The two longitudinal cohorts comprised the Northern Swedish Cohort and the Younger Northern Swedish Cohort, consisting of all pupils in the 9th grade of compulsory school in Luleå municipality in 1981 and 1989. The participants responded to an extensive questionnaire on socioeconomic factors, work and health, in 5 and 2 waves respectively of data collections. Neighbourhood register data from Statistics Sweden was also collected for all participants in the Northern Sweden Cohort. At the latest data collection, 94.3% (n=1010) participated in the Northern Sweden Cohort and 85.6% (n=686) in the Younger Northern Sweden Cohort. The cross-sectional study Health on Equal Terms is a national study, administered by the Public Health Agency together with Statistics Sweden and county councils with the aim of mapping public health and living conditions in the country over time. In this thesis, material from 2014 has been used for northern Sweden with a response rate of around 50% (effective sample n=12769). The statistical analyses used were linear regression, multilevel analysis and difference-in-difference analysis to estimate the concurrent and long-term health consequences of unemployment, and a decomposition analysis to disentangle the inequality in health between different labour market positions. The health outcomes in focus were functional somatic symptoms (the occurrence of relatively common physical illnesses such as head, muscle and stomach ache, insomnia and palpitation) and psychological distress.

    Results. Among men only, as little as one month of youth unemployment was related to increased levels of functional somatic symptoms in midlife, regardless of previous ill health or unemployment later in life, although only during relatively low national unemployment (pre-recession) when comparing with youth unemployment during high national unemployment (recession). This was explained by the health promoting effect of more time spent in higher education during the recession period. Furthermore, the health impact of neighbourhood unemployment highlights the importance of the contextual setting for individuals’ health both across the life course and at specific periods of life. Lastly, employment-related mental health inequalities exist for both men and women in all life phases (youth, adulthood and midlife). Economic and social deprivation related to unemployment and illness varied across different phases in life and across genders.

    Conclusion. The key findings of this thesis paint a rather pessimistic vision of the future: one’s own and others’ unemployment may cause not only ill health today but also ill health later in life. Importantly, the responsibility of unemployment and the associated ill health should not be placed on the already marginalised individuals and communities. Instead, the responsibility should be directed towards the structural aspects of society and the political choices that shape these. In other words, health inequality manifested by the position in the labour market is socially produced, unfair and changeable through political decisions. The results of this study therefore cannot contribute to any simple or concrete solutions to the concurrent or long-term health consequences of individual or contextual unemployment, as the solution is beyond the areas of responsibility and abilities of research. However, if there are long-term health consequences of one’s own and other people’s unemployment, labour market and public health policies should be initiated from a young age and continue throughout the life course to reduce individual suffering and future costs of social insurance, sick-leave and unemployment benefits.

  • 267.
    Brydsten, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Does contextual unemployment matter for health status across the life course? A longitudinal multilevel study exploring the link between neighbourhood unemployment and functional somatic symptoms2017Ingår i: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 43, s. 113-120Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This study examines whether neighbourhood unemployment is related to functional somatic symptoms, independently of the individual employment, across the life course and at four specific life course periods (age 16, 21, 30 and 42). Self-reported questioner data was used from a 26-year prospective Swedish cohort (n=1010) with complementary neighbourhood register data. A longitudinal and a set of age-specific cross-sectional hierarchal linear regressions was carried out. The results suggest that living in a neighbourhood with high unemployment has implications for residents' level of functional somatic symptoms, regardless of their own unemployment across time, particularly at age 30.

  • 268.
    Brydsten, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Does contextual unemployment matter for health status across the life course?2016Konferensbidrag (Refereegranskat)
  • 269.
    Brydsten, Anna
    et al.
    Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.
    Hammarström, Anne
    Department of Public Health and Caring Sciences, Public Health Unit, Uppsala University, Uppsala, Sweden.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health inequalities between employed and unemployed in northern Sweden: a decomposition analysis of social determinants for mental health2018Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, nr 59, artikel-id 59Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Even though population health is strongly influenced by employment and working conditions, public health research has to a lesser extent explored the social determinants of health inequalities between people in different positions on the labour market, and whether these social determinants vary across the life course. This study analyses mental health inequalities between unemployed and employed in three age groups (youth, adulthood and mid-life), and identifies the extent to which social determinants explain the mental health gap between employed and unemployed in northern Sweden.

    Methods: The Health on Equal Terms survey of 2014 was used, with self-reported employment (unemployed or employed) as exposure and the General Health Questionnaire (GHQ-12) as mental health outcome. The social determinants of health inequalities were grouped into four dimensions: socioeconomic status, economic resources, social network and trust in institutional systems. The non-linear Oaxaca decomposition analysis was applied, stratified by gender and age groups.

    Results: Mental health inequality was found in all age groups among women and men (difference in GHQ varying between 0.12 and 0.20). The decomposition analysis showed 43–51% of the total inequality among youths, 42–98% among adults and 60–65% among middle-aged. The main contributing factors were shown to vary between age groups: cash margin (among youths and middle-aged men), financial strain (among adults and middle-aged women), income (among men in adulthood), along with trust in others (all age groups), practical support (young women) and social support (middle-aged men); stressing how the social determinants of health inequalities vary across the life course.

    Conclusions: The health gap between employments was explained by the difference in access to economic and social resources, and to a smaller extent in the trust in the institutional systems. Findings from this study corroborate that much of the mental health inequality in the Swedish labour market is socially and politically produced and potentially avoidable. Greater attention from researchers, policy makers on unemployment and public health should be devoted to the social and economic deprivation of unemployment from a life course perspective to prevent mental health inequality.

  • 270.
    Brydsten, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The impact of economic recession on the association between youth unemployment and functional somatic symptoms in adulthood: a difference-in-difference analysis from Sweden2016Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, artikel-id 230Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The impact of macroeconomic conditions on health has been extensively explored, as well as the relationship between individual unemployment and health. There are, however, few studies taking both aspects into account and even fewer studies looking at the relationship in a life course perspective. In this study the aim was to assess the role of macroeconomic conditions, such as national unemployment level, for the long-term relationship between individual unemployment and functional somatic symptoms (FSS), by analysing data from two longitudinal cohorts representing different periods of unemployment level in Sweden.

    Methods: A difference-in-difference (DiD) analysis was applied, looking at the difference over time between recession and pre-recession periods for unemployed youths (age 21 to 25) on FSS in adulthood. FSS was constructed as an index of ten self-reported items of somatic ill-health. Covariates for socioeconomics, previous health status and social environment were included.

    Results: An association was found in the difference of adult FSS between unemployed and employed youths in the pre-recession and recession periods, remaining in the adjusted model for the pre-recession period. The DiD analysis between unemployed youths showed that men had significantly lower adult FSS during the recession compared to men in the pre-recession time.

    Conclusions: Adulthood FSS showed to be significantly lower among unemployed youths, in particular among men, during recession compared to pre-recession times. Since this is a fairly unexplored research field, more research is needed to explore the role of macroeconomic conditions for various health outcomes, long-term implications and gender differences.

  • 271.
    Brydsten, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Socialmedicin.
    Strandh, Mattias
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Johansson, Klara
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Youth unemployment and functional somatic symptoms in adulthood: results from the Northern Swedish cohort2015Ingår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 25, nr 5, s. 796-800Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Little is known about the possible long-term health consequences of youth unemployment. Research indicates that unemployment may lead to socioeconomic downward mobility and mental health problems, but we still lack knowledge of the long-term health consequences of youth unemployment. This article examines the potential long-term association between youth unemployment and functional somatic symptoms in adulthood. 

    Methods: The ‘Northern Swedish cohort’ was used with data from five data collections, from 1981 (age 16) until 2007 (age 42). Youth unemployment was measured as months in unemployment between age 16 and 21, and health outcome as functional somatic symptoms (an index of 10 items of self-reported symptoms). Linear regression was used to analyse the relationship between months in youth unemployment and functional somatic symptoms at age 21 and age 42, stratified for women and men and adjusted for potential confounders, such as time spent in education at age 21 and later unemployment between age 21 and 42. 

    Results: Youth unemployment was significantly related to functional somatic symptoms at age 21 for men after controlling for confounders, but not for women. Among men, the association remained for functional somatic symptoms at age 42, after controlling for confounders. 

    Conclusions: Adolescence seems to be a sensitive period during which unemployment could have remaining health effects in adulthood, at least for men, though assumptions of causality are tentative and more research is needed.

  • 272.
    Brändström, Anders
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Demografiska databasen.
    Edvinsson, Sören
    Umeå universitet, Samhällsvetenskapliga fakulteten, Demografiska databasen.
    Rogers, John
    Historiska institutionen, Uppsala universitet.
    Illegitimacy, infant feeding practices and infant survival in Sweden, 1750-1950: A regional analysis2002Ingår i: Hygiea Internationalis, ISSN 1403-8668, E-ISSN 1404-4013, Vol. 3, nr 1, s. 13-52Artikel i tidskrift (Refereegranskat)
  • 273.
    Brännlund, Annica
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Higher education and psychological distress: a 27-year prospective cohort study in Sweden2014Ingår i: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 42, nr 2, s. 155-162Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aims: Research identifies a positive link between education and a reduction of psychological distress, but few studies have analysed the long-term impact of education on psychological distress. This study followed the same cohort for 27 years, investigating the association between education and adult psychological distress. Further, it discuss whether the link can be understood through the mediating mechanisms of social and labour-market resources, furthermore, if the mechanisms operate differently for men and women. Method: A 27-year prospective cohort study was performed at ages 16, 18, 21, 30 and 43. The cohort consisted of all students (n = 1083, of which 1001 are included in this study) in their final year of compulsory school in Sweden. Data were collected through comprehensive questionnaires (response rate 96.4%), and analysed with OLS regression, with psychological distress at age 21, 30 and 43 as dependent variable. Baseline psychological distress, measures of social and labour-market resources, and possible educational selection factors were used as independent variables. To compare the overall magnitude of educational differences, a kappa index was calculated. Results: A positive relation between higher education and less psychological distress was found. When becoming older this relation weakens and a link between social and labour-market resources and psychological distress is observed, indicating that education in a long-term perspective operates through the suggested mechanisms. Additionally, the mechanisms work somewhat differently for men than for women: labour-market resources were significant for men and social resources were important for women. Conclusions: Main findings: higher education is positively linked to less psychological distress, and the link can somewhat be understood through the mechanisms of social and labour-market resources.

  • 274.
    Brännström, Inger
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Community participation and social patterning in cardiovascular disease intervention1993Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    This study addresses health policy and public health in the field of cardiovascular disease (CVD) on the local level in Sweden. The overall aim is to contribute to the assessment of structural and social conditions within public health by analysing participation processes and outcome patterns in a local health programme. The northern Swedish MONICA study served as a reference area. The research strategy has been to integrate quantitative and  qualitative methodologies and, thereby, focus on different aspects of the health programme under study.

    The mortality rate was excessive in the study area of Norsjö relative to both provincial and national figures over a period of more than 10 years. This finding formed the basis for a tenyear comprehensive and community-based health programme towards the prevention of CVD and diabetes.

    Even in this seemingly homogeneous area it was found that socio-economic circumstances were associated with the public health. Almost half of the study population had hypercholesterolaemia (;>6.5 mmol/1), 19% of men and 25% of women were smokers and 30% and 29%, respectively, had high blood pressure. Age had a strong impact on all outcome measures. After adjustments for age and social factors it was found that the relative risk of having hypercholesterolaemia dropped significantly in both sexes during the six years of intervention. The probability of being a smoker was significantly reduced only in highly educated groups. No statistically significant change over time could be found for the risk of suffering high blood pressure. In the reference area of northern Sweden there were no changes over time for any of the selected risk factors. The likelihood of self-assessed good health decreased with increasing risk factor load, with the exception of hypercholesterolaemia , in all social strata.

    The authorities, including the health and medical staff, were the main actors on the mediastage. Men in manual occupations were least affected by the media coverage. The actors and the public as well as the media viewed the health programme as orientated towards individual lifestyles. Community participation was mainly defined by the actors based on the medical and health planning approach. Differences in interpretations, social interests, personal conflicts and ideological constraints among the actors at local level were observed. Some critical attitudes towards the organization and management of the health programme were also noted among the citizens. However, a majority of the public wanted the health programme to continue. The present study underlines the importance of considering age, gender and social differences in the planning and evaluation of CVD preventive programmes.

  • 275.
    Brännström, Inger
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Does it matter how epilepsy is considered and classified?2002Ingår i: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 359, nr 9315, s. 1439-Artikel i tidskrift (Refereegranskat)
  • 276.
    Brännström, Inger
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Lindblad, Inga-Britt
    Umeå universitet, Humanistiska fakulteten, Litteraturvetenskap och nordiska språk.
    Mass communication and health promotion: The power of the media and public opinion1994Ingår i: Health Communication, ISSN 1041-0236, E-ISSN 1532-7027, Vol. 6, nr 1, s. 21-36Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    By means of content analysis, this study evaluated the ways in which a community-based preventive program in Sweden in the field of cardiovascular diseases and diabetes was reported in the news by the Swedish mass media We were also interested in determining whether, and to what extent, 5 years of exposure to the media had affected the health habits of the residents in the intervention area. Thus, the views of the public were obtained via a cross-sectional posttest survey of all adults 16 to 80 years of age. Responses were obtained from 65% of the population. Data were interpreted within a framework of a three-dimensional power approach: control of issue resolution, control of information content, and emphasis and control of ideology. The health program has attracted much attention, and some of the contents have been commented on in depth (e.g., dietary habits, health examinations, and organizational issues). The authorities, including the health and medical staff, were the main actors on the media stage. The media coverage was largely restricted to middle-aged men, whereas women, children, young people, and pensioners were less salient in the news. The mass media were found to emphasize an individual standpoint concerning health habits, and when the "ordinary people" appeared it was as exemplary models in the spirit of the health program. The results indicated sex and social class differences among people recalling the media news. Men in manual occupations were the least affected by the media coverage of the health program.

  • 277.
    Brännström, Inger
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Persson, Lars Åke M.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Wall, Stig
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Towards a framework for outcome assessment of health intervention: Conceptual and methodological considerations1994Ingår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 4, nr 2, s. 125-130Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    We provide a framework for assessing the outcome of community-based intervention programmes for the promotion of cardiovascular health at local level. Particular attention is therefore given to conceptual components connected with community participation in health programmes and to methodological approaches in the evaluation of cardiovascular disease (CVD)-prevention programmes. In a search of the literature covering more than 20 years (1966–1988) in 2 databases (MEDLINE and SOCA), we found that the concepts of ‘community participation’ and ‘community involvement’ have mainly been used during the latter half of the study period. The concepts were often used interchangeably and with no statement as to their precise meanings. The methodological examination of 2 well-known community-based CVO-preventive programmes revealed that most of the scientific papers from these programmes dealt with health behavioural and/or medical effects. The suggested framework presented in this study is designed as a longitudinal process analysis focusing on critical key steps along the path from input to output. The suggested research strategy is problem-orientated, inter-disciplinary and based on a multi-method approach.

  • 278.
    Brännström, Inger
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Persson, Lars Åke
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Wall, Stig
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Gender and social patterning of health: the Norsjö cardiovascular preventive programme in northern Sweden 1985-19901994Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 12, nr 3, s. 155-161Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To assess the extent to which the impact of social stratification on cardiovascular disease (CVD) risk factors was different among men and women.

    DESIGN: Pooled data from six (1985-90) cross-sectional health surveys.

    SETTING: The intervention area is an inland municipality, Norsjö, in northern Sweden with a population of 5,300 inhabitants.

    MAIN OUTCOME MEASURES: Smoking, high blood pressure, hypercholesterolaemia, and perceived health status.

    RESULTS: Almost half of the study population had hypercholesterolaemia (> or = 6.5 mmol/l), 19% of men and 25% of women were smokers, and 30% and 29%, respectively, had hypertension. Age had a strong impact on all outcome measures. Social factors were associated with smoking in women and with hypercholesterolaemia in men. There were no sex differences in perceived good health. The likelihood of self-assessed good health decreased with increasing risk factor load, with the exception of hypercholesterolaemia, in all social strata.

    CONCLUSION: The present study implies the importance of considering age, gender, and social differences in intervention and evaluation of CVD preventive programmes. The study also demonstrate that self-defined health contains important information on cardiovascular risk profile.

  • 279.
    Brännström, Inger
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Rosén, M
    SPRI, Stockholm, Sweden.
    Wall, Stig
    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 global hälsa.
    Local health planning and intervention: the case of a Swedish municipality1988Ingår i: Scandinavian journal of primary health care. Supplement, ISSN 0284-6020, Vol. 1, s. 57-64Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This article attempts to illustrate the process from community diagnosis to community involvement by a case study from the north of Sweden. The case of Norsjö is one of few documented Swedish examples of a preventive program with a broad participation from the community. The results up to now are promising and further illustrate the importance of decentralized health planning and local data.

  • 280.
    Brännström, Inger
    et al.
    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, Allmänmedicin.
    Persson, Lars Åke
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Wester, P O
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Wall, Stig
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Changing social patterns of risk factors for cardiovascular disease in a Swedish community intervention programme1993Ingår i: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 22, nr 6, s. 1026-1037Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Since 1985 a small-scale community-based cardiovascular disease (CVD) preventive programme has been in operation in an inland municipality, Norsjö, in Northern Sweden. The aim of this study was to assess the development of the relationship between social position and CVD risk factors in repeated cross-sectional surveys (1985-1990) among all men and women aged 30, 40, 50 and 60 years in the study area, using an age-stratified random sample from the Northern Sweden MONICA Study of 1986 and 1990 as reference population. These multiple cross-sectional surveys comprised a self-administered questionnaire and a health examination. Of the study population 95% (n = 1499) and 80% of those in the reference area (n = 3208) participated. Subjects were classified with regard to demographic, structural and social characteristics in relation to CVD risk factors and self-reported health status. Time trends in classical risk factor occurrence were assessed in terms of age- and sex- adjusted odds ratios using Mantel-Haenszel procedures. When simultaneously adjusting for several potential confounders we used a logistic regression analysis. Initially, more than half of the study population, both males and females, had and elevated (> or = 6.5 mmol/l) serum cholesterol level. After adjustments had been made for age and social factors it was found that the relative risk of hypercholesterolaemia dropped substantially and significantly among both sexes during the 6 years of CVD intervention in the study area. However, the probability of being a smoker was significantly reduced only in highly educated groups. Among other risk factors no single statistically significant change over time could be found. In the reference area there were no changes over time for the selected CVD risk factors. People in the study area had a less favourable perception of their health than those in the reference area. Social differences were found when perceived good health was measured, especially in variables indicating emotional and social support. When sex, age and social factors had been accounted for there was not clear change over the years in perceived good health.

  • 281. Buckland, G
    et al.
    Ros, M M
    Roswall, N
    Bueno-de-Mesquita, H B
    Travier, N
    Tjonneland, A
    Kiemeney, L A
    Sacerdote, C
    Tumino, R
    Ljungberg, Börje
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Urologi och andrologi.
    Gram, I T
    Weiderpass, E
    Skeie, G
    Malm, J
    Ehrnström, R
    Chang-Claude, J
    Mattiello, A
    Agnoli, C
    Peeters, P H
    Boutron-Ruault, M C
    Fagherazzi, G
    Clavel-Chapelon, F
    Nilsson, Lena Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Näringsforskning.
    Amiano, P
    Trichopoulou, A
    Oikonomou, E
    Tsiotas, K
    Sánchez, M J
    Overvad, K
    Quirós, J R
    Chirlaque, M D
    Barricarte, A
    Key, T J
    Allen, N E
    Khaw, K T
    Wareham, N
    Riboli, E
    Kaaks, R
    Boeing, H
    Palli, D
    Romieu, I
    Romaguera, D
    Gonzalez, C A
    Adherence to the Mediterranean diet and risk of bladder cancer in the EPIC cohort study2014Ingår i: International Journal of Cancer, ISSN 0020-7136, E-ISSN 1097-0215, Vol. 134, nr 10, s. 2504-2511Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    There is growing evidence of the protective role of the Mediterranean diet (MD) on cancer. However, to date no epidemiological study has investigated the influence of the MD on bladder cancer. We evaluated the association between adherence to the MD and risk of urothelial cell bladder cancer (UCC), according to tumor aggressiveness, in the European Prospective Investigation into Cancer and Nutrition (EPIC). The analysis included 477,312 participants, recruited from ten European countries between 1991 and 2000. Information from validated dietary questionnaires was used to develop a relative Mediterranean diet score (rMED), including nine dietary components. Cox regression models were used to assess the effect of the rMED on UCC risk, while adjusting for dietary energy and tobacco smoking of any kind. Stratified analyses were performed by sex, BMI, smoking status, European region and age at diagnosis. During an average follow-up of 11 years, 1,425 participants (70.9% male) were diagnosed with a first primary UCC. There was a negative but non-significant association between a high versus low rMED score and risk of UCC overall (HR: 0.84 [95% CI 0.69, 1.03]) and risk of aggressive (HR: 0.88 [95% CI 0.61, 1.28]) and non-aggressive tumors (HR: 0.78 [95% CI 0.54, 1.14]). Although there was no effect modification in the stratified analyses, there was a significant 34% (p = 0.043) decreased risk of UCC in current smokers with a high rMED score. In EPIC, the MD was not significantly associated with risk of UCC, although we cannot exclude that a MD may reduce risk in current smokers.

  • 282. Bukachi, Salome A
    et al.
    Onyango-Ouma, Washington
    Siso, Jared Maaka
    Nyamongo, Isaac K
    Mutai, Joseph K
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Olsen, Øystein Evjen
    Byskov, Jens
    Healthcare priority setting in Kenya: a gap analysis applying the accountability for reasonableness framework2014Ingår i: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 29, nr 4, s. 342-361Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    In resource-poor settings, the accountability for reasonableness (A4R) has been identified as an important advance in priority setting that helps to operationalize fair priority setting in specific contexts. The four conditions of A4R are backed by theory, not evidence, that conformance with them improves the priority setting decisions. This paper describes the healthcare priority setting processes in Malindi district, Kenya, prior to the implementation of A4R in 2008 and evaluates the process for its conformance with the conditions for A4R. In-depth interviews and focus group discussions with key players in the Malindi district health system and a review of key policy documents and national guidelines show that the priority setting process in the district relies heavily on guidelines from the national level, making it more of a vertical, top-down orientation. Multilateral and donor agencies, national government, budgetary requirements, traditions and local culture influence the process. The four conditions of A4R are present within the priority setting process, albeit to varying degrees and referred to by different terms. There exists an opportunity for A4R to provide a guiding approach within which its four conditions can be strengthened and assessed to establish whether conformance helps improve on the priority setting process.

  • 283. Bunker, Aditi
    et al.
    Sewe, Maquins Odhiambo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sié, Ali
    Rocklöv, Joacim
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sauerborn, Rainer
    Excess burden of non-communicable disease years of life lost from heat in rural Burkina Faso: a time series analysis of the years 2000-20102017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 11, artikel-id e018068Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: Investigate the association of heat exposure on years of life lost (YLL) from non-communicable diseases (NCD) in Nouna, Burkina Faso, between 2000 and 2010.

    Design: Daily time series regression analysis using distributed lag non-linear models, assuming a quasi-Poisson distribution of YLL.

    Setting: Nouna Health and Demographic Surveillance System, Kossi Province, Rural Burkina Faso.

    Participants: 18 367 NCD-YLL corresponding to 790 NCD deaths recorded in the Nouna Health and Demographic Surveillance Site register over 11 years.

    Main outcome measure: Excess mean daily NCD-YLL were generated from the relative risk of maximum daily temperature on NCD-YLL, including effects delayed up to 14 days.

    Results: Daily average NCD-YLL were 4.6, 2.4 and 2.1 person-years for all ages, men and women, respectively. Moderate 4-day cumulative rise in maximum temperature from 36.4 degrees C (50th percentile) to 41.4 degrees C (90th percentile) resulted in 4.44 (95% CI 0.24 to 12.28) excess daily NCDYLL for all ages, rising to 7.39 (95% CI 0.32 to 24.62) at extreme temperature (42.8 degrees C; 99th percentile). The strongest health effects manifested on the day of heat exposure (lag 0), where 0.81 (95% CI 0.13 to 1.59) excess mean NCD-YLL occurred daily at 41.7 degrees C compared with 36.4 degrees C, diminishing in statistical significance after 4 days. At lag 0, daily excess mean NCD-YLL were higher for men, 0.58 (95% CI 0.11 to 1.15) compared with women, 0.15 (95% CI -0.25 to 9.63) at 41.7 degrees C vs 36.4 degrees C.

    Conclusion: Premature death from NCD was elevated significantly with moderate and extreme heat exposure. These findings have important implications for developing adaptation and mitigation strategies to reduce ambient heat exposure and preventive measures for limiting NCD in Africa.

  • 284. Bunker, Aditi
    et al.
    Wildenhain, Jan
    Vandenbergh, Alina
    Henschke, Nicholas
    Rocklöv, Joacim
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hajat, Shakoor
    Sauerborn, Rainer
    Effects of Air Temperature on Climate-Sensitive Mortality and Morbidity Outcomes in the Elderly; a Systematic Review and Meta-analysis of Epidemiological Evidence2016Ingår i: EBioMedicine, ISSN 0360-0637, E-ISSN 2352-3964, Vol. 6, s. 258-268Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Introduction: Climate change and rapid population ageing are significant public health challenges. Understanding which health problems are affected by temperature is important for preventing heat and cold-related deaths and illnesses, particularly in the elderly. Here we present a systematic review and meta-analysis on the effects of ambient hot and cold temperature (excluding heat/cold wave only studies) on elderly (65+ years) mortality and morbidity.

    Methods: Time-series or case-crossover studies comprising cause-specific cases of elderly mortality (n = 3,933,398) or morbidity (n = 12,157,782) were pooled to obtain a percent change (%) in risk for temperature exposure on cause-specific disease outcomes using a random-effects meta-analysis. Results: A 1 degrees C temperature rise increased cardiovascular (3.44%, 95% CI 3.10-3.78), respiratory (3.60%, 3.18-4.02), and cerebrovascular (1.40%, 0.06-2.75) mortality. A 1 degrees C temperature reduction increased respiratory (2.90%, 1.84-3.97) and cardiovascular (1.66%, 1.19-2.14) mortality. The greatest risk was associated with cold-induced pneumonia (6.89%, 20-12.99) and respiratory morbidity (4.93% 1.54-8.44). A 1 degrees C temperature rise increased cardiovascular, respiratory, diabetes mellitus, genitourinary, infectious disease and heat-related morbidity.

    Discussion: Elevated risks for the elderly were prominent for temperature-induced cerebrovascular, cardiovascular, diabetes, genitourinary, infectious disease, heat-related, and respiratory outcomes. These risks will likely increase with climate change and global ageing.

  • 285. Burattini, M N
    et al.
    Coutinho, F A B
    Lopez, L F
    Ximenes, R
    Quam, Mikkel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wilder-Smith, Annelies
    Massad, E
    Potential exposure to Zika virus for foreign tourists during the 2016 Carnival and Olympic Games in Rio de Janeiro, Brazil2016Ingår i: Epidemiology and Infection, ISSN 0950-2688, E-ISSN 1469-4409, Vol. 144, nr 9, s. 1904-1906Artikel i tidskrift (Refereegranskat)
  • 286. Bureau, Christophe
    et al.
    Adebayo, Danielle
    Chalret de Rieu, Mael
    Elkrief, Laure
    Valla, Dominique
    Peck-Radosavljevic, Markus
    McCune, Anne
    Vargas, Victor
    Simon-Talero, Macarena
    Cordoba, Juan
    Angeli, Paolo
    Rosi, Silvia
    MacDonald, Stewart
    Malago, Massimo
    Stepanova, Maria
    Younossi, Zobair M
    Trepte, Claudia
    Watson, Randall
    Borisenko, Oleg
    Sun, Sun
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Synergus AB, Danderyd, Sweden; Health Outcomes and Economic Evaluation Research Group, Department of Learning, Information, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Inhaber, Neil
    Jalan, Rajiv
    Alfapump® system vs. large volume paracentesis for refractory ascites: a multicenter randomized controlled study2017Ingår i: Journal of Hepatology, ISSN 0168-8278, E-ISSN 1600-0641, Vol. 67, nr 5, s. 940-949Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background and aims: Patients with refractory ascites (RA) require repeated large volume paracenteses (LVP), which involves frequent hospital visits and is associated with a poor quality-of-life. This study assessed safety and efficacy of an automated, low-flow pump (alfapump® [AP]) compared with LVP standard of care [SoC].

    Methods: A randomized controlled trial, in seven centers, with six month patient observation was conducted. Primary outcome was time to first LVP. Secondary outcomes included paracentesis requirement, safety, health-related quality-of-life (HRQoL), and survival. Nutrition, hemodynamics, and renal injury biomarkers were assessed in a sub-study at three months.

    Results: Sixty patients were randomized and 58 were analyzed (27 AP, 31 SoC, mean age 61.9years, mean MELD 11.7). Eighteen patients were included in the sub-study. Compared with SoC, median time to first LVP was not reached after six months in the AP group, meaning a significant reduction in LVP requirement for the AP patients (AP, median not reached; SoC, 15.0days (HR 0.13; 95%CI 13.0-22.0; p<0.001), and AP patients also showed significantly improved Chronic Liver Disease Questionnaire (CLDQ) scores compared with SoC patients (p<0.05 between treatment arms). Improvements in nutritional parameters were observed for hand-grip strength (p=0.044) and body mass index (p<0.001) in the sub-study. Compared with SoC, more AP patients reported adverse events (AEs; 96.3% vs. 77.4%, p=0.057) and serious AEs (85.2 vs. 45.2%, p=0.002). AEs consisted predominantly of acute kidney injury in the immediate post-operative period, and re-intervention for pump related issues, and were treatable in most cases. Survival was similar in AP and SoC.

    Conclusions: The AP system is effective for reducing the need for paracentesis and improving quality of life in cirrhotic patients with RA. Although the frequency of SAEs (and by inference hospitalizations) was significantly higher in the AP group, they were generally limited and did not impact survival.

    Lay summary: The alfapump® moves abdominal fluid into the bladder from where it is then removed by urination. Compared with standard treatment, the alfapump reduces the need for large volume paracentesis (manual fluid removal by needle) in patients with medically untreatable ascites. This can improve life quality for these patients.

  • 287.
    Burlac, Mihaela
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Health economic evaluation: Cost-Effectiveness Analysis of Antenatal Obesity Prevention Program among Children in Sweden. A Markov model.2019Självständigt arbete på avancerad nivå (masterexamen), 10 poäng / 15 hpStudentuppsats (Examensarbete)
    Abstract [en]

    Background: A hypothetical antenatal obesity prevention program was developed, consisting of a 5-day workshop led by a licensed psychologist, nutritionist and a trained nurse. The goals of the program were to train volunteer midwives on how properly provide the future mothers with reliable information needed in order to promote healthy behaviors, such as the importance of physical activities during pregnancy and after, breastfeeding, and healthy eating. Hence, it will bring a positive effect on the lifestyle of children.

    Objectives: To perform a cost-effectiveness analysis of implementing antenatal obesity prevention program among children in Sweden against no-intervention using a health care perspective with a time horizon of 15 years.

    Methodology: A Markov model based cost-effectiveness analysis method was used for the study’s purpose. Data was obtained from various sources previously published from Sweden, US, UK, Australia and Germany. A hypothetical cohort of 1000 children were used to stimulate moving between four health states, such as normal weight, overweight, obese and death state in order to estimate the possible health outcomes of the intervention. Incremental cost-effectiveness ratios (ICERs) were calculated revealing the intervention cost per cases of obesity averted, and cost per quality adjusted life years gained (QALYs).

    Results: The antenatal obesity prevention program provides additional 0.02 cases of obesity averted, and 0.05 QALYs gained at an additional cost of 3,741.92 $ when compared with no-intervention. According to the analysis, the ICER calculated as the cost per cases of obesity averted is 187,096.00 $, and the ICER calculated as cost per QALYs gained is 74,838.40$.

    Conclusion: The cost-effective analysis of the antenatal obesity prevention program shows no significant health benefits compared with no-intervention, so that we can state that the program is not cost-effective.

  • 288.
    Burlac, Mihaela
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health professionals’ perspectives and working experiences with adolescent pregnancies in the Republic of Moldova: a qualitative study2018Självständigt arbete på avancerad nivå (magisterexamen), 10 poäng / 15 hpStudentuppsats (Examensarbete)
    Abstract [en]

    Background: Adolescent pregnancies have both positive and negative consequences that have an impact on the health and well-being of girls. High incidence rate of adolescent pregnancies occur mostly in disadvantaged areas and in families with low socioeconomic status. Factors associated with early childbearing are sexual violence and abuse, improper or no use of contraceptive methods due to no access to information and sexual health services, insufficient communication and counseling with families and health professionals. Health professionals can play a key role in supporting girls to fulfill their sexual and reproductive rights, including their right to a safe and pleasurable sexual life and to decide when (if at all) to get pregnant. In this study protocol we will apply the Right approach to Sexual and Reproductive Health framework, to explore and analyze health professionals’ perspectives about adolescent pregnancies, and their work experiences with the purpose of providing suggestions that can contribute to improve the quality of sexual and reproductive health services for pregnant adolescents at the Public Institution of Mother and Child.

    Objectives: The objective of the thesis is to describe a protocol for a qualitative study, analyzing health professionals’ perspectives and working experiences with adolescent pregnancies in the Republic of Moldova. By using Rights approach to Sexual and Reproductive Health, the researchers will gain in-depth understanding about how health workers perceive girls’ sexual and reproductive health and rights, and how this influences the services they provide to pregnant adolescents.

    Methodology: The study will be conducted in the capital of the Republic of Moldova, Chisinau, at the Public Medico-Sanitary Institution for Scientific Research in the field of Mother and Child Health Care. A qualitative methodology with in-depth face-to-face interviews with health professionals, will be applied. An inductive thematic analysis approach will be used during data analysis. The findings will be arranged into themes that will reflect the Right approach to Sexual and Reproductive Health concepts, while remaining open to new emerging fields. Actions will be taken in order to enhance the trustworthiness of the study. To increase dependability, the study will use an emergent design, and triangulation of researchers in order to increase credibility. To increase transferability, the researchers will provide a detailed description about study setting, data collection and analysis, and reflexivity will strengthen confirmability of the findings.

  • 289.
    Burén, Jonas
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Glucose and lipid metabolism in insulin resistance: an experimental study in fat cells2003Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    Type 2 diabetes is usually caused by a combination of pancreatic β-cell failure and insulin resistance in target tissues like liver, muscle and fat. Insulin resistance is characterised by an impaired effect of insulin to reduce hepatic glucose production and to promote glucose uptake in peripheral tissues. The focus of this study was to further elucidate cellular mechanisms for insulin resistance that may be of relevance for type 2 diabetes in humans. We used rat and human adipocytes as an established model of insulin’s target cells.

    Glucocorticoids, e.g. cortisol, can induce insulin resistance in vivo. In the present study, pretreatment of rat adipocytes in vitro for 24 h with the cortisol analogue dexamethasone produced a downregulation of glucose uptake capacity as well as a marked depletion of cellular insulin receptor substrate 1 (IRS-1) and protein kinase B (PKB), two proteins suggested to play a critical role in the intracellular signal transduction pathway of insulin. The amount of phosphorylated PKB in response to acute insulin treatment was decreased in parallel to total PKB content. The basal rate of lipolysis was enhanced, but insulin’s antilipolytic effect was not consistently altered following dexamethasone pretreatment.

    Alterations in blood glucose as well as insulin levels may be of great importance for cellular as well as whole-body insulin resistance. High glucose (≥15 mM) for 24 h induced a decrease in glucose uptake capacity in rat adipocytes and IRS-1 content was reduced whereas IRS-2 was increased. Long-term pretreatment with a high insulin concentration downregulated insulin binding capacity and when combined with high glucose, it produced a pronounced

    reduction of cellular IRS-1 and 2 content together with insensitivity to insulin’s effect to activate PKB and a decrease in glucose uptake capacity. A common denominator for a decrease in glucose uptake capacity in our rat adipocyte studies seems to be a decrease in IRS-1 content.

    Adipocytes from type 2 diabetes patients are insulin-resistant, but in our work the insulin resistance could be reversed by incubation of the cells at a physiological glucose level for 24 h. Insulin resistance in fresh adipocytes from type 2 diabetes patients was associated with in vivo insulin resistance and glycemic level and with adipocyte cell size and waist-hip ratio

    (WHR).

    As a potential mechanism for postprandial dyslipidemia in type 2 diabetes, we examined the nutritional regulation of subcutaneous adipose tissue lipoprotein lipase (LPL) activity. It was upregulated by ~40-50 % after a standardised lipid-enriched meal and this was very similar in type 2 diabetes patients and control subjects, suggesting that the postprandial

    hypertriglyceridemia found in type 2 diabetes is not explained by an altered nutritional regulation of LPL in subcutaneous fat.

    In conclusion, the present work provides evidence for novel interactions between glucocorticoids and insulin in the regulation of glucose metabolism that may potentially contribute to the development of insulin resistance. High levels of glucose and insulin produce perturbations in the insulin signalling pathway that may be of relevance for human type 2 diabetes. Cellular insulin resistance may be secondary to the diabetic state in vivo, e.g. via glucotoxicity. This is supported by our finding that insulin resistance in adipocytes from type 2 diabetes patients can be reversed after incubation at a physiological glucose level.

    Key words: adipocyte, insulin resistance, type 2 diabetes, insulin signalling, glucose uptake,

    insulin, glucose, dexamethasone, insulin receptor substrate, protein kinase B, GLUT4,

    lipoprotein lipase.

  • 290.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    A transition towards a healthier global population?2015Ingår i: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 386, nr 10009, s. 2121-2122Artikel i tidskrift (Refereegranskat)
  • 291.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Achieving better global health policy, even when health metrics data are scanty2014Ingår i: The Handbook of Global Health Policy / [ed] Brown GW, Yamey G, Wamala S, Wiley-Blackwell, 2014, s. 119-132Kapitel i bok, del av antologi (Refereegranskat)
  • 292.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Causes of child death estimates: making use of the InterVA model2015Ingår i: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 386, nr 9997, s. 953-953Artikel i tidskrift (Refereegranskat)
  • 293.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. edical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
    Cause-specific mortality findings from the Global Burden of Disease project and the INDEPTH Network2016Ingår i: The Lancet Global Health, E-ISSN 2214-109X, Vol. 4, nr 11, s. e785-e786Artikel i tidskrift (Refereegranskat)
  • 294.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa.
    Child mortality is (estimated to be) falling2016Ingår i: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 388, nr 10063, s. 2965-2967Artikel i tidskrift (Refereegranskat)
  • 295.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Climate change and population health in Africa: where are the scientists?2009Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, s. 173-176Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Despite a growing awareness of Africans' vulnerability to climate change, there is relatively little empirical evidence published about the effects of climate on population health in Africa. This review brings together some of the generalised predictions about the potential continent-wide effects of climate change with examples of the relatively few locally documented population studies in which climate change and health interact. Although ecologically determined diseases such as malaria are obvious candidates for susceptibility to climate change, wider health effects also need to be considered, particularly among populations where adequacy of food and water supplies may already be marginal.

  • 296.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Correlation between noncommunicable disease mortality in people aged 30-69 years and those aged 70-89 years2019Ingår i: Bulletin of the World Health Organization, ISSN 0042-9686, E-ISSN 1564-0604, Vol. 97, nr 9, s. 589-596Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To investigate whether the key metric for monitoring progress towards sustainable development goal target 3.4 that is measuring premature noncommunicable disease mortality (deaths among people aged 30-69 years), is ageist.

    Methods: To examine the relationship between premature noncommunicable disease mortality and noncommunicable disease mortality in older people, a database of mortality rates for cardiovascular disease, cancer, chronic obstructive pulmonary disease and diabetes in people aged 30 to 69 years and 70 to 89 years was compiled using estimates from the Global Burden of Disease Study 2017. The data covered 195 countries, six time-points and both sexes, giving 2340 instances. The World Health Organization's (WHO's) life-table method for the premature noncommunicable disease mortality metric was applied to the data.

    Findings: There was a strong correlation between noncommunicable disease mortality patterns in the premature and older age groups, which suggests that measuring premature noncommunicable disease mortality is informative about such mortality in later life. Neither time nor geographical location had a substantial effect on this correlation. However, there were female-to-male differences in age-specific probabilities of death due to noncommunicable disease, implying that noncommunicable disease mortality should be assessed using a sex-disaggregated approach.

    Conclusion: As the established WHO metric for premature noncommunicable disease mortality was predictive of noncommunicable disease mortality in older people, the metric should not be construed as ageist Focusing resources on measuring premature noncommunicable disease mortality will be appropriate, particularly in settings without universal civil death registration. This approach should not prejudice the provision of health services throughout the life-course.

  • 297.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Epidemiology without borders: an anational view of global health2009Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Most analyses of global health use country as a unit of observation, not least because countries are intrinsic to health services and to many international organisations. However, this can mask geographical influences on population health, which do not respect political boundaries.

    METHODS: A global anational database was constructed with one degree cells of latitude and longitude, and used to calculate densities for population and key health indicators. These data were aggregated into 240 15 degrees ansectors, 171 of which were populated. Differences in ansector rank orders between population density and health outcomes (infant, maternal and HIV-related deaths and income) were calculated and mapped as quintiles.

    FINDINGS: Individual ansectors contained parts of 1-21 countries. Mapping by ansector showed that the four outcomes analysed were strongly geographically correlated. Sub-Saharan Africa was consistently disadvantaged in terms of health outcomes, while the Indian sub-continent was at an advantage in terms of HIV mortality, despite poverty.

    INTERPRETATION: Although in most cases it makes sense to analyse health on a national basis, these findings highlight the often unquestioned assumptions involved in doing so. Even if global patterns of health do not turn out so differently when analysed anationally, some major effects on health, such as climate change, are not nationally based, and should not necessarily be nationally analysed. Progress towards Millennium Development Goals must be evaluated on a population basis, rather than by counting countries achieving targets. Data files are available in Excel format and attached as separate files to this paper (see Supplementary files under Reading Tools online).

  • 298.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Global health estimated over two decades2017Ingår i: Nature, ISSN 0028-0836, E-ISSN 1476-4687, Vol. 545, nr 7655, s. 421-422Artikel i tidskrift (Refereegranskat)
  • 299.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Integrated multisource estimates of mortality for Thailand in 20052010Ingår i: Population Health Metrics, ISSN 1478-7954, E-ISSN 1478-7954, Vol. 8, s. Article nr 10-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Estimates of mortality in Thailand during 2005 have been published, integrating multiple data sources including national vital registration and a national follow-up cluster sample, covering both deaths in health facilities (approximately one-third) and elsewhere. The methodological challenge is to make the best use of the existing data, supplemented by additional data that are feasible to obtain, in order to arrive at the best possible overall estimates of mortality. In this case, information from the national vital registration database was supplemented by a verbal autopsy survey of approximately 2.5% of deaths, the latter being used to validate routine cause-of-death data and information from medical records. This led to a revised national cause-specific mortality envelope for Thailand in 2005, amounting to 447,104 deaths. However, difficulties over standardizing verbal autopsy interpretation may mean that there are still some uncertainties in these revised estimates.

  • 300.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Is global health really global?2013Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, s. 1-3Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This editorial is based on a keynote address given at the International Conference on Global Public Health, Colombo, Sri Lanka, in December 2012. It accompanies a set of papers which were also presented at the conference. So far, these papers describe a range of global health issues, from the health status of the United Arab Emirates through to social determinants of health in India. Two papers from Rwanda and India consider specific aspects of oral public health, which was a major sub-theme of the conference.

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