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  • 51.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Are health inequalities rooted in the past? Income inequalities in metabolic syndrome decomposed by childhood conditions2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no 2, p. 223-233Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Early life is thought of as a foundation for health inequalities in adulthood. However, research directly examining the contribution of childhood circumstances to the integrated phenomenon of adult social inequalities in health is absent. The present study aimed to examine whether, and to what degree, social conditions during childhood explain income inequalities in metabolic syndrome in mid-adulthood.

    METHODS: The sample (N = 12 481) comprised all 40- and 50-year-old participants in the Västerbotten Intervention Program in Northern Sweden 2008, 2009 and 2010. Measures from health examinations were used to operationalize metabolic syndrome, which was linked to register data including socioeconomic conditions at age 40-50 years, as well as childhood conditions at participant age 10-12 years. Income inequality in metabolic syndrome in middle age was estimated by the concentration index and decomposed by childhood and current socioeconomic conditions using decomposition analysis.

    RESULTS: Childhood conditions jointed explained 7% (men) to 10% (women) of health inequalities in middle age. Adding mid-adulthood sociodemographic factors showed a dominant contribution of chiefly current income and educational level in both gender. In women, the addition of current factors slightly attenuated the contribution of childhood conditions, but with paternal income and education still contributing. In contrast, the corresponding addition in men removed all explanation attributable to childhood conditions.

    CONCLUSIONS: Despite that the influence of early life conditions to adult health inequalities was considerably smaller than that of concurrent conditions, the study suggests that early interventions against social inequalities potentially could reduce health inequalities in the adult population for decades to come.

  • 52.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Income-related inequalities in cardiovascular disease from mid-life to old age in a Northern Swedish cohort: a decomposition analysis2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 149, p. 135-144Article in journal (Refereed)
    Abstract [en]

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

  • 53.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Equitable health services for the young?: A decomposition of income-related inequalities in young adults' utilization of health care in Northern Sweden2017In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, article id 20Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite the goal of the Swedish health system to offer health care according to the principle of horizontal equity, little is known about the equality in access to health care use among young people. To explore this issue, the present study aimed i) to assess horizontal inequity in health care utilization among young people in Northern Sweden; and ii) to explore the contribution of different factors to explain the observed inequalities.

    METHODS: Participants (N = 3016 youths aged 16-25 years) came from the "Health on Equal terms" survey conducted in 2014 in the four northernmost counties in Sweden. Concentration indices (C) and horizontal inequity indices (HI) were calculated to measure inequalities in the utilization of two health care services (general practitioners (GP) and youth clinics). The HI was calculated based on health care utilization and variables representing socioeconomic status (household income), health care needs factors and non-need factors affecting health care use. A decomposition analysis was carried out to explain the income-related inequalities.

    RESULTS: Results showed a significant positive income-related inequality for youth clinic utilization in women (C = 0.166) and total sample (C = 0.097), indicating that services were concentrated among the better-off. In contrast, general practitioner visits showed inequality pointing toward a higher utilization among less affluent individuals; significant in women (C = -0.079), men (C = -0.101) and pooled sample (C = -0.097). After taking health care needs into consideration, the utilization of youth clinics remained significantly pro-rich in women (HI = 0.121) and total sample (HI = 0.099); and consistently pro-poor for the GP visits in the pooled sample (HI = -0.058). The decomposition analyses suggest that socioeconomic inequalities explain a considerable portion of the pro-rich utilization of youth clinics services among young women. The corresponding analyses for GP visits showed that need factors and socioeconomic conditions accounted for the pro-poor concentration of GP visits.

    CONCLUSION: The distribution of GP visits among young people in Northern Sweden slightly favored the low-income group, and thus seems to meet the premises of horizontal equity. In contrast, the findings suggest substantial pro-rich horizontal inequity in the utilization of youth clinics among young women, which are largely rooted in socioeconomic inequalities.

  • 54. Nilsson, D
    et al.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Larsson, JL
    Svedin, CG
    Evaluation of the Linköping youth life experience scale2010In: Journal of Nervous and Mental Disease, ISSN 0022-3018, E-ISSN 1539-736X, Vol. 198, no 10, p. 768-774Article in journal (Refereed)
    Abstract [en]

    The objective of this study was to investigate the psychometric properties of a newly developed instrument for potentially traumatic life events, the Linköping Youth Life Experience Scale (LYLES), and determine the benefits of including adverse childhood circumstances (ACCs) as factors in the evaluation. In addition, we wanted to investigate the difference between interpersonal and noninterpersonal traumatic events, the impact of ACCs, and the cumulative effects of these events on self-reported symptoms of dissociation, depression, and anxiety. Adolescents from the normative population (n = 188) answered the questionnaire LYLES and also the Dissociation-Questionnaire-Sweden and Hospital Anxiety and Depression Scale. The results showed that LYLES was stable, with test-retest r = 0.79 and kappa item per item ranging between k = 0.44 and 1.0. ACCs contributed independently to the explanation of symptoms explaining them better than potentially traumatic events alone, particularly for boys where the impact of ACCs exceeded the impact of events. The conclusions are that LYLES displayed satisfactory psychometric properties and that ACCs seem to be a valuable addition to an instrument to evaluate potentially traumatic events.

  • 55.
    Nilsson, Doris
    et al.
    BUP-Elefanten, Department of Child and Adolescent Psychiatry, IMK, Linköping University, Linköping, Sweden.
    Gustafsson, Per E
    Department of Child and Adolescent Psychiatry, IKE, Faculty of Health Sciences, Linköping University, Sweden.
    Svedin, Carl Göran
    Department of Child and Adolescent Psychiatry, IKE, Faculty of Health Sciences, Linköping University, Sweden.
    Self-reported potentially traumatic life events and symptoms of post-traumatic stress and dissociation2010In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 64, no 1, p. 19-26Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate single potentially traumatic events and cumulative effects of these events based on the reported symptoms of post-traumatic stress and dissociation. An additional goal was to evaluate the psychometric properties of Life Incidence of Traumatic Events—Student scale (LITE-S). Methods: 400 adolescents from the normative population answered the questionnaire Life Incidence of Traumatic Experiences (LITE-S) together with Trauma Symptom Checklist for Children (TSCC), Dissociation-Questionnaire-Sweden (Dis-Q-Sweden) and Adolescent-Dissociative Experience Scale (A-DES). The single self-reported traumas, and the cumulative self-reported traumas and their effects on post-traumatic stress disorder and dissociative symptoms scales were examined. The psychometric properties of LITE-S were first investigated through calculating, test–retest reliability by Pearson correlation for the total scale and by Cohen's kappa item per item. Results: Self-reported symptoms were related to both the cumulative traumas and exposure to some single traumas, such as seeing somebody get hurt, having parents destroy things or hurting each other, being whipped or hit, or even being made to carry out some kind of sexual act. Interpersonal events were consistently more strongly related to symptoms across the TSCC clinical scales. Finally, test–retest reliability as found to be for the total scale r=0.76 and kappa item per item ranging between k=0.33 and 0.86. Conclusion: The cumulative effects of potentially traumatic events on adolescents are significant, and interpersonal traumas results in more self-reported symptoms of post-traumatic stress and dissociation than non-interpersonal. LITE has satisfactory psychometric properties concerning reliability. Clinical implications: The results underline the importance in clinical practice of taking into consideration how many potentially traumatic events an adolescent has experienced before, seeking help on specific occasion. This knowledge can help the clinician to understand better the breadth of feelings their client is experiencing and thus can help the clinician better to be able to suggest appropriate treatment.

  • 56. Nilsson, Doris
    et al.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Svedin, Carl-Göran
    The psychometric properties of the Trauma Symptom Checklist for Young Children in a sample of Swedish children2012In: European Journal of Psychotraumatology, ISSN 2000-8066, E-ISSN 2000-8066, Vol. 3, article id 18505Article in journal (Refereed)
    Abstract [en]

    Objective: To evaluate the psychometric properties of the Swedish version of Trauma Symptom Checklist for Young Children (TSCYC).

    Method: The study was composed of a total of 629 children—296 girls and 333 boys—aged 3–11, from a non-clinical population who were rated by their caretakers (26 of whom performed a re-test after 2 weeks) in addition to 59 children from a clinical population with known experience of sexual and/or physical abuse. The caretakers from the normal population completed the TSCYC and Lifetime Incidence of Traumatic Events Scale-parent scale (LITE-P) and the clinical-sample caretakers completed TSCYC. The psychometric properties of the TSCYC were examined, including reliability and validity.

    Results: The reliability (Cronbach's alpha) of the TSCYC, total scale, was α=0.93 (normative group) and α=0.96 (clinical group). For the clinical scales, this ranged between α=0.55–0.88 and 0.77–0.93, respectively. Test-retest for the total scale was r=0.77. Regarding criterion-related validity, the clinical groups scored significantly higher than the normative group, and within the normative group significant relationships were found between exposure to traumatic events and TSCYC scores. Confirmatory factor analysis testing of the construction of the TSCYC indicated significant loadings on the original scales.

    Conclusion: The Swedish version of TSCYC appears to be a screening instrument with satisfactory psychometric qualities for identifying symptoms after trauma in young children. The instrument can also be recommended to clinicians for screening purposes in a European context.

  • 57. Nilsson, Doris Kristina
    et al.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Svedin, Carl Göran
    Lifetime polytraumatization in adolescence and being a victim of bullying2012In: Journal of Nervous and Mental Disease, ISSN 0022-3018, E-ISSN 1539-736X, Vol. 200, no 11, p. 954-961Article in journal (Refereed)
    Abstract [en]

    The purposes of this study were to examine the mental health consequences of having been a victim of bullying and to investigate whether the impact of bullying was dependent on the co-occurrence of other potentially traumatic events, noninterpersonal traumas, interpersonal traumas, as well as adverse childhood circumstances. A community sample of participants (n = 462; 216 males and 246 females) aged 15 to 20 years completed the self-administered Linkoping's Youth Life Experience Scale about lifetime exposure to a range of traumatic and other adverse events and circumstances and the Trauma Symptom Checklist for Children (TSCC). The results showed that those who reported being a victim of bullying reported significantly higher scores on all TSCC clinical scales as well as significantly more other traumatic and adverse family exposures. Multiple linear regression analyses indicated that the impact of bullying on mental health was explained, to a considerable degree, by the accumulation of other adverse and traumatic exposures, particularly in the females.

  • 58. Nilsson, Doris Kristina
    et al.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Svedin, Carl Göran
    Polytraumatization and Trauma Symptoms in Adolescent Boys and Girls: Interpersonal and Noninterpersonal Events and Moderating Effects of Adverse Family Circumstances2012In: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, Vol. 27, no 13, p. 2645-2664Article in journal (Refereed)
    Abstract [en]

    The objective of this study was to investigate the cumulative effect of interpersonal and noninterpersonal traumatic life events (IPEs and nIPEs, respectively) on the mental health of adolescents and to determine if the adverse impacts of trauma were moderated by adverse family circumstances (AFC). Adolescents (mean age 16.7 years) from the normative population (n = 462) completed the questionnaire, the Linkoping Youth Life Experience Scale (LYLES), together with Trauma Symptom Checklist for Children (TSCC). The lifetime accumulation of interpersonal, noninterpersonal, and AFC was independently related to trauma-related symptoms in both boys and girls. The number of AFCs moderated the mental health impact of both IPEs and nIPEs in boys but not in girls. Cumulative exposure to both interpersonal and noninterpersonal traumatic events is important for the mental health of adolescents, and, at least for boys, family circumstances seem to be relevant for the impact of trauma. Our results suggest that broader approaches to the study, prevention, and treatment of trauma, including consideration of cumulative exposure, different types of trauma, and additional social risk factors, could be fruitful.

  • 59.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Virtanen, Pekka
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    How does unemployment affect self-assessed health?: A systematic review focusing on subgroup effects2014In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, no 1, article id 1310Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Almost all studies on the effect on health from unemployment have concluded that unemployment is bad for your health. However, only a few review articles have dealt with this relation in recent years, and none of them have focused on the analysis of subgroups such as age, gender, and marital status. The objective of our article is to review how unemployment relates to self-assessed health with a focus on its effect on subgroups.

    METHODS: A search was performed in Web of Science to find articles that measured the effect on health from unemployment. The selection of articles was limited to those written in English, consisting of original data, and published in 2003 or later. Our definition of health was restricted to self-assessed health. Mortality- and morbidity-related measurements were therefore not included in our analysis. For the 41 articles included, information about health measurements, employment status definitions, other factors included in the statistical analysis, study design (including study population), and statistical method were collected with the aim of analysing the results on both the population and factor level.

    RESULTS: Most of the studies in our review showed a negative effect on health from unemployment on a population basis. Results at the factor levels were most common for gender (25 articles), age (11 articles), geographic location (8 articles), and education level (5 articles). The analysis showed that there was a health effect for gender, age, education level, household income, and geographic location. However, this effect differed between studies and no clear pattern on who benefits or suffers more among these groups could be determined. The result instead seemed to depend on the study context. The only clear patterns of association found were for socioeconomic status (manual workers suffer more), reason for unemployment (being unemployed due to health reasons is worse), and social network (a strong network is beneficial).

    CONCLUSIONS: Unemployment affects groups of individuals differently. We believe that a greater effort should be spent on specific groups of individuals, such as men or women, instead of the population as a whole when analysing the effect of unemployment on health.

  • 60. Rajaleid, Kristiina
    et al.
    Nummi, Tapio
    Westerlund, Hugo
    Virtanen, Pekka
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine. Institute for Advanced Social Research, University of Tampere, FI-33014 Tampere, Finland.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Social adversities in adolescence predict unfavourable trajectories of internalized mental health symptoms until middle age: results from the Northern Swedish Cohort.2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no 1, p. 23-29Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Experiencing adversities during upbringing has short-term and long-term effects on mental health. This study aims to explore how social adversities in adolescence predict trajectories of internalized mental health symptoms (IMHS), from adolescence and onward until middle age.

    METHODS: Based on 1040 individuals from the Northern Swedish Cohort Study, a community-based cohort with 27 years of follow-up. We applied latent class growth analysis to extract trajectories of IMHS between ages 16 and 43. Multinomial logistic regression was used to study the association of social adversities (residential mobility, residential crowding, parental loss, unemployment of a parent, physical illness of a parent, mental illness or alcohol problems of a parent) in adolescence with IMHS trajectories.

    RESULTS: Five trajectory classes were identified: 'very low stable' (26% of the sample), 'low stable' (58%), 'moderate stable' (5%), 'increasing' (8%) and 'high decreasing' (3%). Both in men and women, reporting social adversities at the age of 16 increased the risk of belonging to the classes with less favourable development of IMHS. Reporting adversities was positively associated with the initial level of the IMHS trajectories. Thus it seems that the influence of adversities is more pronounced during the early years of follow-up and is attenuated over time.

    CONCLUSION: Experiencing social adversities in adolescence increases the risk of entering unfavourable developmental trajectories of mental health until middle age.

  • 61.
    Ramadani, Royasia Viki
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The moderating effect of income on the relationship between body mass index and health-related quality of life in Northern Sweden2018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: This study aimed to investigate the relationship between body mass index (BMI) and health-related quality of life (HRQoL) and whether this relationship is influenced by the level of income in Northern Sweden. Overweight and obesity are rising major public health problems which also affect HRQoL. While socioeconomic inequalities in health are persisting or increasing in many countries, including Sweden, little attention has been paid to the more complex roles of income in relation to health.

    METHODS: Data were drawn from a 2014 cross-sectional survey from Northern Sweden (Health on Equal Terms), comprising individuals aged 20-84 years ( N = 20,082 individuals included for analysis). BMI and HRQoL were self-reported and individual disposable income in 2012 was retrieved from population registers. Multiple linear regressions were performed with HRQoL scores regressed on BMI and income, their interaction and additional covariates.

    RESULTS: The underweight, overweight and obesity groups reported significantly lower HRQoL compared to the normal weight group. Moreover, the relationship between BMI and HRQoL varied significantly by level of income, with a stronger association among those with the lowest level of income.

    CONCLUSIONS: Income has a role as an effect modifier in the relationship between BMI and HRQoL that can be construed as an indirect income inequality. Efforts to promote HRQoL in populations should consider the different impact of being overweight and obese in different socioeconomic groups.

  • 62.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Socioeconomic inequalities in functional somatic symptoms by social and material conditions at four life course periods in Sweden: a decomposition analysis2015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 8, p. 1-10, article id e006581Article in journal (Refereed)
    Abstract [en]

    Objective: Socioeconomic inequalities in health are deemed a worldwide public health problem, but current research is lacking on key points including determinants of socioeconomic differences in health, and not the least variations of these determinants over the life course. Using a 26-year prospective Swedish community-based cohort, we aim at decomposing socioeconomic inequalities in functional somatic symptoms by social and material life circumstances, at 4 periods of the life course. Design: Repeated cross-sectional study. Setting: Participants came from the Northern Swedish Cohort (n= 1001), who completed questionnaires about occupational class, social and material living conditions, and symptoms at ages 16, 21, 30 and 42. Socioeconomic inequalities were estimated and decomposed using the Blinder-Oaxaca decomposition analysis. Results: Inequalities in symptoms between blue-collar and white-collar socioeconomic groups increased along the life course in the sample. In the decomposition analysis, a high proportion of the gap between socioeconomic groups could be explained by social and material living conditions at ages 16 (84% explained), 30 (45%) and 42 (68%), but not at age 21. Specific social (parental illness at age 16 and violence at ages 30 and 42) and material (parental unemployment at age 16, and own unemployment and financial strain at ages 30 and 42) factors contributed jointly to the health gaps. Conclusions: Socioeconomic inequalities in functional somatic symptoms increased along the life course in this Swedish cohort. A considerable portion of the social gaps in health was explained by concurrent social and material conditions, and the importance of specific adversities was dependent on the life course stage. Our findings suggest that socioeconomic inequalities in functional somatic symptoms may be reduced by addressing both social and material living conditions of disadvantaged families, and also that the life course stage needs to be taken into consideration.

  • 63.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Do cardiovascular disease prevention programs in northern Sweden impact on population health?: An interrupted time series analysis2019In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 202Article in journal (Refereed)
    Abstract [en]

    Background: Cardiovascular disease (CVD) is the main cause of morbidity and mortality in Sweden. This study aims to assess the impact of a CVD intervention implemented in 1993 in northern Sweden on the reduction of premature ischemic heart disease (IHD) morbidity and mortality in women and men during the period 1987-2013.

    Methods: An ecological controlled interrupted time series design, with pre-intervention period defined as 1987-1993 and post-intervention period 1994-2013 was carried out. For each year, IHD events, stratified by sex, were retrieved from national registers.

    Results: Impressive reductions on IHD premature morbidity and mortality were observed to a similar degree in both the intervention county and the other comparison counties across the last 27years. Significant differences in the pre-post intervention trends indicating the intervention group had smaller reductions than expected from its pre-intervention trend and the trend of control counties were found among men for both IHD morbidity and mortality. A similar pattern was observed among women but without significant differences.

    Conclusions: Taken together, the data do not support that the intervention has contributed to an additional reduction on IHD morbidity and mortality, above and beyond that which is already seen in neighbouring counties without similar programs.

  • 64.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mine, yours or ours?: Income inequality and mental health in Northern Sweden2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, p. 40-41Article in journal (Other academic)
    Abstract [en]

    Background: The relationship between income and population health has received considerable attention in the last decades. Three main explanations of the relationship have been identified: the absolute, the contextual, and the relative income effects hypotheses. The evidence about their relevance, particularly in egalitarian societies like the Scandinavian one, is however inconsistent. The present study aimed to test the three hypotheses in relation to psychological distress in northern Sweden.

    Methods: Data come from the 2014 cross sectional survey “Health on equal terms”, from the four northern-most counties in Sweden, and included people 25-84 years (n = 21,004). Psychological distress was measured by the General Health Questionnaire-12 and information on disposable income came from population registers. Absolute income was operationalized by individual disposable income, contextual income as the municipal-level Gini coefficient and relative income by the Yitzaki index. The research questions were tested by log-binomial regression analysis.

    Results: First, a strong individual income gradient in mental ill health was observed, with the very poor more likely to report poor health (PR = 1.56; 95% CI = 1.19, 2.04) compared to the highest income quintile. Second, municipalities in the quintiles 2-4 of the Gini coefficient had a better mental health than those municipalities in the extremes of the distribution. Third, a clear statistically significant gradient in the association of relative deprivation and ill mental health was also found (PR = 1.37 95% CI = 1.06, 1.76).

    Conclusions: This study suggests a strong, moderate and lack of support for the absolute, relative and contextual income effect hypotheses, respectively. Interventions targeting a reduction in the individual income gap are probably necessary in order to reduce psychosocial distress differences in this population of northern Sweden.

    Key messages:

    • A strong, moderate and lack of support for the absolute, relative and contextual income effect hypotheses, respectively was found in northern Sweden.
    • A reduction in the individual income gap is probably necessary in order to decrease the psychosocial distress differences observed.
  • 65.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Whose income is more important: mine, yours or ours? Income inequality and mental health in northern Sweden2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, no 6, p. 1056-1061Article in journal (Refereed)
    Abstract [en]

    Background: Three main explanations of the relationship between income and population health have been identified: the absolute, the contextual and the relative income hypotheses. The evidence about their relevance particularly in egalitarian societies is, however, inconsistent. This study aimed to test the three hypotheses in relation to psychological distress in northern Sweden.

    Methods: Data come from the 2014 cross-sectional survey from the four northern-most counties in Sweden, and included people aged 25-84 years (n = 21 004). Psychological distress was measured by the General Health Questionnaire-12 and income information came from population registers. Absolute income was operationalized by individual disposable income, contextual income as the municipal-level Gini coefficient and relative income by the Yitzhaki index. Prevalence ratios (PR) were calculated from log-binomial regression analyses.

    Results: A gradient in poor mental health was observed across quintiles of individual income, with the poorest substantially more likely to report poor health compared with the highest quintile (PR = 1.56; 95% CI = 1.19, 2.04). Second, municipalities in the quintiles 2-3 of the Gini coefficient had a better mental health compared with those in the most equal municipalities. Third, a gradient in poor mental health across quintiles of relative deprivation was also found, with the most deprived quintile the most likely to report poor health (PR = 1.37; 95% CI = 1.06, 1.76).

    Conclusion: This study suggests a strong, moderate and lack of support for the absolute, relative and contextual income effect hypotheses, respectively. Interventions targeting a reduction in the individual income gap may be necessary in order to reduce psychosocial distress differences in northern Sweden.

  • 66.
    San Sebastián, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Nursing I, University of Basque Country, Bilbao, Spain.
    Mosquera, Paola A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health care on equal terms?: assessing horizontal equity in health care use in northern Sweden2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no 4, p. 637-643Article in journal (Refereed)
    Abstract [en]

    Background: The Swedish health care system has successively moved toward increased market-orientation, which has raised concerns as to whether Sweden still offers health on equal terms. To explore this issue, this study aimed (i) to assess if the principles of horizontal equity (equal access for equal need regardless of socio-economic factors) are met in Northern Sweden 2006-14; and (ii) to explore the contribution of different factors to the inequalities in access along the same period. Data came from cross sectional surveys known in 2006, 2010 and 2014 targeting 16-84-year-old residents in the four northern-most counties in Sweden. The horizontal inequity index was calculated based on variables representing (i) the individual socioeconomic status, (ii) the health care needs, (iii) non-need factors as well as (iv) health care utilization: general practitioner (GP), specialist doctors, hospitalization. Decomposition analysis of the concentration index for need-standardized health care utilization was applied. Adjusting for needs, there was a higher use of GP services by rich people during the two last surveys, a roughly equal use of specialists, and hospitalization concentrated among the poor but with a clear time trend toward equality. The pro-rich inequalities in GP use were to a large part explained by the income gap. While health care utilization can be considered equitable regarding specialist and hospital use, the increasing pro-rich trend in the use of GP is a concern. Further studies are required to investigate the reasons and a constant monitoring of socioeconomic differences in health care access is recommended.

  • 67.
    Szilcz, Máté
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sebastián, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Time trends in absolute and relative socioeconomic inequalities in leisure time physical inactivity in northern Sweden2018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 46, no 1, p. 112-123Article in journal (Refereed)
    Abstract [en]

    AIMS: The aim was to investigate the time trends in educational, occupational, and income-related inequalities in leisure time physical inactivity in 2006, 2010, and 2014 in northern Swedish women and men.

    METHODS: This study was based on data obtained from the repeated cross-sectional Health on Equal Terms survey of 2006, 2010, and 2014. The analytical sample consisted of 20,667 (2006), 31,787 (2010), and 21,613 (2014) individuals, aged 16-84. Logistic regressions were used to model the probability of physical inactivity given a set of explanatory variables. Slope index of inequality (SII) and relative index of inequality (RII) were used as summary measures of the social gradient in physical inactivity. The linear trend in inequalities and difference between gender and years were estimated by interaction analyses.

    RESULTS: The year 2010 displayed the highest physical inactivity inequalities for all socioeconomic position indicators, but educational and occupational inequalities decreased in 2014. However, significant positive linear trends were found in absolute and relative income inequalities. Moreover, women had significantly higher RII of education in physical inactivity in 2014 and significantly higher SII and RII of income in physical inactivity in 2010, than did men in the same years.

    CONCLUSIONS: The recent reduction in educational and occupational inequalities following the high inequalities around the time of the great recession in 2010 suggests that the current policies might be fairly effective. However, to eventually alleviate inequities in physical inactivity, the focus of the researchers and policymakers should be directed toward the widening trends of income inequalities in physical inactivity.

  • 68.
    Szilcz, Máté
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Income inequalities in leisure time physical inactivity in northern Sweden: a decomposition analysis2019In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed)
    Abstract [en]

    AIMS: Increasing income inequalities in leisure time physical inactivity have been reported in the relatively socially equal setting of northern Sweden. The present report seeks to contribute to the literature by exploring the contribution of different factors to the income inequalities in leisure time physical inactivity in northern Sweden.

    METHODS: This study was based on the 2014 Health on Equal Terms survey, distributed in the four northernmost counties of Sweden. The analytical sample consisted of 21,000 respondents aged 16-84. Six thematic groups of explanatory variables were used: demographic variables, socioeconomic factors, material resources, family-, psychosocial conditions and functional limitations. Income inequalities in leisure time physical inactivity were decomposed by Wagstaff-type decomposition analysis.

    RESULTS: Income inequalities in leisure time physical inactivity were found to be explained to a considerable degree by health-related limitations and unfavourable socioeconomic conditions. Material and psychosocial conditions seemed to be of moderate importance, whereas family and demographic characteristics were of minor importance.

    CONCLUSIONS: This study suggests that in order to achieve an economically equal leisure time physical inactivity, policy may need to target the two main barriers of functional limitations and socioeconomic disadvantages.

  • 69. Theorell, Töres
    et al.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Magnusson Hanson, Linda
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Westerlund, Hugo
    Job strain and depressive symptoms in men and women: a prospective study of the working population in Sweden2014In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 68, no 1, p. 78-82Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Several prospective studies have indicated increased risk of developing depressive symptoms in employees who report psychologically demanding and uncontrollable work (job strain). There are diverging findings regarding gender differences in this relationship. The aim was to analyse whether men and women differ with regard to the prospective relationship between adverse psychosocial work environment and depressive symptoms during a 2-year period.

    METHOD: The Swedish Longitudinal Occupational Survey of Health cohort based on representative recruitment of working men and women in Sweden was used. 2731 men and 3446 women had answered questions regarding work environment and mental health in 2008 and 2010. Psychological demands, decision authority, age and income as well as depressive symptoms in 2008 were used as predictors of depressive symptoms in 2010.

    RESULTS: Women reported less decision authority at work and their demand level developed more unfavourably than did men's-resulting in increased job strain gap between men and women from 2008 to 2010. The relationship between demand and decision authority (and job strain) on one hand and depressive symptoms on the other hand was not statistically different in men and women.

    CONCLUSIONS: Overall, women reported higher levels of job strain than men. In Sweden, job strain was as strongly related to depressive symptoms among men as among women.

  • 70.
    Trygg, Nadja
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Månsdotter, A.
    Public Health Agency of Sweden, Stockholm, Sweden.
    Does it add up?: intersectional inequalities in mental health in the Swedish adult population2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 95-95Article in journal (Other academic)
    Abstract [en]

    Background: Social inequalities in mental health is a growing public health concern, but has so far been approached in a disentangled manner. To better capture the complexity of reality with multiple interlocking axes of inequalities, intersectionality theory instead highlights how health is expressed in the interactions between these axes. This may expose important knowledge about particular risk groups and protective factors. In this study, we explore how mental health is distributed across intersections of gender, income, education, class, country of birth and sexual orientation as well as their interaction effects.

    Methods: The study population (N = 52,743) consists of a yearly random sample of the Swedish population 26-84 years between 2010 and 2015, from The Health on Equal Terms survey coordinated by the Public Health Agency of Sweden. Mental health was measured through self-administered General Health Questionnaire (GHQ)-12, and gender, income, education, class, country of birth and sexual orientation through survey and linked register data. Intersectional inequalities in mental health were estimated for all pairwise combination of inequalities by joint disparity, excess intersectional disparity and referent disparities.

    Results: The prevalence of symptoms of poor mental health were highest among non-heterosexuals with low income (40%) followed by non-heterosexual women (38%). However, intersectional inequalities showed unpredictable patterns; among non-heterosexuals, those with long education reported more symptoms (36%) than those with short education (31%). The excess intersectional disparity showed synergistic effects for income in combination with education; country of birth and class, but antagonistic effects for the intersections of gender and income as well as education and class.

    Conclusions: Multiple inequalities in mental health may add up in various and unexpected manners, which needs to be considered in efforts for equity in mental health.

    Key messages:

    • Mental health is distributed in various and unexpected manners across intersections of inequality dimensions.

    • Intersectionality theory may be useful when addressing mental health inequalities.

  • 71.
    Trygg, Nadja
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Månsdotter, Anna
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Languishing in the crossroad?: A scoping review of intersectional inequalities in mental health2019In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, article id 115Article, review/survey (Refereed)
    Abstract [en]

    The concept of intersectionality has gradually been introduced to health inequality research, adding depth and breadth to the way inequalities in health are approached. We conducted a scoping review with the purpose to systematically map, describe and analyze the literature about intersectional inequalities in mental health. For eligibility, the study had to analyze and report inequality defined by combinations of socioeconomic position, gender, race/ethnicity, sexual orientation or religion. The mental health outcome had to be measured as self-reported symptoms assessed through validated scales, or disorders assessed through diagnostic interviews. The search strategy was applied in two databases and the screening process yielded 20 studies. The interaction of intersectional positions showed no consistent patterns in mental health across studies, but both synergistic and antagonistic effects were observed. In most studies an absolute measure of inequality was used and few studies analyzed factors potentially explaining the intersectional inequalities. Taken together, the findings of this review highlight the value of assessing intersectional inequalities across population groups for priority setting and action on mental health inequalities.

  • 72.
    Waenerlund, Anna-Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Virtanen, Pekka
    School of Health Sciences, University of Tampere, Finland.
    Are changes in labour market attachment over 12 years related to health status?: An analysis of the Northern Swedish Cohort.Manuscript (preprint) (Other academic)
  • 73.
    Waenerlund, Anna-Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Virtanen, Pekka
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Is the core-periphery labour market structure related to perceived health? Findings of the Northern Swedish Cohort.2011In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 11, p. 956-Article in journal (Refereed)
    Abstract [en]

    Background: There is controversy as to whether peripheral employment is related to poor health status or not. This study aims at examining whether 1) the accumulation of time in peripheral labour market positions is associated with psychological distress and poor or average self-rated health; 2) the proposed association is different among women than among men.

    Method: Participants in the 1995 and 2007 follow-up surveys of the Northern Swedish Cohort (n = 985) completed self-administered questionnaires about psychological and general health and about employment positions during the follow-up years. Associations between 12 year peripheral labour market positions (no, low, medium and high exposure) and health were examined using logistic regression.

    Results: Exposure to peripheral employment was positively related to psychological distress in both women and men (p-values for trend < 0.001). Adjustment for sociodemographics and psychological distress at baseline, as well as for unemployment and being out of the labour market at the follow-up, resulted in attenuation of the odds ratios, particularly in the group with high exposure to peripheral employment, although results remained significant in men in the fully adjusted model. Women and men with high exposure to peripheral employment had high odds of poor or average self-rated health, but the association was rendered non-significant after adjustment for the covariates.

    Conclusions: Our findings suggest that exposure to peripheral employment positions has an impact particularly on mental health, partly due to the over-representation of other unfavourable social and employment conditions among those with substantial exposure to peripheral employment.

  • 74.
    Waenerlund, Anna-Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Virtanen, Pekka
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    History of labour market attachment as a determinant of health status: a 12-year follow-up of the Northern Swedish Cohort2014In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 4, no 2, p. e004053-Article in journal (Refereed)
    Abstract [en]

    Objective The present study aims at using trajectory analysis to measure labour market attachment (LMA) over 12years and at examining whether labour market tracks relate to perceived health status.

    Design Data were retrieved from a 26-year prospective cohort study, the Northern Swedish Cohort.

    Setting and participants All ninth grade students (n=1083) within the municipality of Lulea in northern Sweden were included in the baseline investigation in 1981. The vast majority (94%) of the original cohort participated at the fourth follow-up. In this study, 969 participants were included.

    Measures Perceived health status (psychological distress and non-optimal self-rated health) at age 42 and the data obtained from questionnaires.

    Results We have identified four tracks in relation to LMA across the 12-year period: permanent', high level', strengthening' and poor level' of attachment. LMA history relates to psychological distress. High level (OR 1.55 (95% CI 1.06 to 2.27)), strengthening (OR 1.95 (95% CI 1.29 to 2.93)) and poor attachment (OR 3.14 (95% CI 2.10 to 4.70) involve higher OR for psychological distress compared with permanent attachment. The overall p value remained significant in the final model (p=0.001). Analyses regarding non-optimal self-rated health displayed a similar pattern but this was not significant in the final model.

    Conclusions Our results suggest that health status in mid-life, particularly psychological distress, is related to patterns of LMA history, to a large part independently of other social risk factors and previous health. Consideration of heterogeneity and time in LMA might be important when analysing associations with perceived health.

  • 75.
    Waenerlund, Anna-Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Trends in educational and income inequalities in cardiovascular morbidity in middle age in Northern Sweden 1993–20102018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, article id 1403494818790406Article in journal (Refereed)
    Abstract [en]

    AIMS: Research is scarce regarding studies on income and educational inequality trends in cardiovascular disease in Sweden. The aim of this study was to assess trends in educational and income inequalities in first hospitalizations due to cardiovascular disease (CVD) from 1993 to 2010 among middle-aged women and men in Northern Sweden.

    METHODS: The study comprised repeated cross-sectional register data from year 1993-2010 of all individuals aged 38-62 years enrolled in the Västerbotten Intervention Programme (VIP). Data included highest educational level, total earned income and first-time hospitalization for CVD from national registers. The relative and slope indices of inequality (RII and SII, respectively) were used to estimate educational and income inequalities in CVD for six subsamples for women and men, and interaction analyses were used to estimate trends across time periods.

    RESULTS: Educational RII and SII were stable in women, while they decreased in men. Income inequalities in CVD developed differently compared with educational inequalities, with RII and SII for both men and women increasing during the study period, the most marked for RII in women rising from 1.52 in the 1990s to 2.62 in the late 2000s.

    CONCLUSIONS: The trend of widening income inequalities over 18 years in the middle-aged in Northern Sweden, in the face of stable or even decreasing educational inequalities, is worrisome from a public health perspective, especially as Swedish authorities monitor socioeconomical inequalities exclusively by education. The results show that certain social inequalities in CVD rise and persist even within a traditionally egalitarian welfare regime.

  • 76.
    Wagenius, Cecilia M.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Norrbotten County Council, Public Health Centre, Sweden.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Access for all?: Assessing vertical and horizontal inequities in healthcare utilization among young people in northern Sweden2019In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 47Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies in Sweden have detected socioeconomic inequities in access to healthcare services. However, there is limited information regarding access in younger populations. The aim of this study was to explore vertical and horizontal inequities in access to healthcare services in young adults in the north of Sweden.

    METHODS: The study used data from the Health on Equal Terms survey (age group 16-24 years, n = 2726) for the health and healthcare variables and from national registers for the sociodemographic characteristics. Self-rated healthcare utilization was measured as visits to general practitioners, youth clinics and nurses. Crude and multivariable binomial regression analysis, stratified by sex, was used to assess vertical equity, adjusting for sociodemographic characteristics, and horizontal equity, adjusting for need variables.

    RESULTS: Vertical inequity was detected for all three healthcare services (youth clinics, general practitioners and nurses), with variations for men and women. Horizontal inequities were also found for both men and women in relation to all three healthcare services.

    CONCLUSIONS: These findings suggest that both vertical and horizontal inequities in access exist for young people in northern Sweden and that the associations between sociodemographic characteristics and healthcare utilization are complex and need further investigation.

  • 77.
    Wennberg, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Poor breakfast habits in adolescence predict the metabolic syndrome in adulthood2015In: Public Health Nutrition, ISSN 1368-9800, E-ISSN 1475-2727, Vol. 18, no 1, p. 122-129Article in journal (Refereed)
    Abstract [en]

    Objective: To analyse whether poor breakfast habits in adolescence predict the metabolic syndrome and its components in adulthood. Previous studies suggest that regular breakfast consumption improves metabolic parameters. Design: Prospective. Breakfast habits and other lifestyle variables at age 16 years were assessed from questionnaires. Poor breakfast habits were defined as skipping breakfast or only drinking or eating something sweet. At age 43 years, the effective sample consisted of 889 participants defined as having the metabolic syndrome or not, using the International Diabetes Federation criteria. Logistic regression was used to calculate odds ratios and confidence intervals. Setting: The Northern Swedish Cohort, a longitudinal population-based cohort with 27-year follow-up. Subjects: Adolescents (age 16 years). Results: Prevalence of the metabolic syndrome at age 43 years was 27.0%. Of the participants, 9.9% were classified with poor breakfast habits at age 16 years. Adjusted odds for the metabolic syndrome at age 43 years was OR = 1.68 (95% CI 1.01, 2.78) for those with poor breakfast habits at age 16 years compared with breakfast eaters. Looking at the metabolic syndrome components, poor breakfast habits at age 16 years were associated with central obesity (OR = 1.71; 95% CI 1.00, 2.92) and high fasting glucose (OR = 1.75; 95% CI 1.01, 3.02) at age 43 years, even after multivariate adjustments. Conclusions: Poor breakfast habits in adolescence predicted the metabolic syndrome in adulthood. Of the metabolic syndrome components, poor breakfast habits in adolescence predicted central obesity and high fasting glucose in adulthood. Further research is needed to fully understand the relationship between early breakfast habits and adult metabolic syndrome.

  • 78.
    Wennberg, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Gustafsson, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Irregular eating of meals in adolescence and the metabolic syndrome in adulthood: results from a 27-year prospective cohort2016In: Public Health Nutrition, ISSN 1368-9800, E-ISSN 1475-2727, Vol. 19, no 3, p. 667-673Article in journal (Refereed)
    Abstract [en]

    Objective: The objective was to investigate whether irregular eating of meals in adolescence predicts the metabolic syndrome and its components in adulthood, and if any specific meal is of particular importance. Design: Prospective cohort study with 27 years of follow-up. Information on meals (breakfast, school lunch and dinner with family), lifestyle (alcohol consumption, smoking habits, physical activity, consumption of sweets and pastries) at age 16 years was assessed from questionnaires, and presence or not of the metabolic syndrome and its components were defined at age 43 years in 889 participants (82.1 % of total cohort). Logistic regression was used to calculate odds ratios and confidence intervals. Setting: The Northern Swedish Cohort; all school-leavers of the 9th grade in the town Lulea in 1981. Subjects: Adolescents (age 16 years). Results: Irregular eating of meals at age 16 years was associated with higher prevalence of the metabolic syndrome at age 43 years (OR=1.74; 95 % CI 1.12, 2.71), but this was explained by concurrent unhealthy lifestyle at age 16 years. Poor breakfast at age 16 years was the only meal associated with the metabolic syndrome at age 43 years, independent of other meals, BMI (kg/m2) and lifestyle at age 16 years (OR = 1.67; 95 % CI 1.00, 2.80). Conclusions: Irregular eating of meals in adolescence predicted the metabolic syndrome in adulthood, but not independently of BMI and lifestyle in adolescence. Poor breakfast in adolescence was the only specific meal associated with future metabolic syndrome, even after adjustments. Breakfast eating should be encouraged in adolescence.

  • 79.
    Wennberg, Patrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Dunstan, David W
    Wennberg, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Television viewing and low leisure-time physical activity in adolescence independently predict the metabolic syndrome in mid-adulthood2013In: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, Vol. 36, no 7, p. 2090-2097Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE We investigated whether television (TV) viewing and low leisure-time physical activity in adolescence predict the metabolic syndrome in mid-adulthood.

    RESEARCH DESIGN AND METHODS TV viewing habits and participation in leisure-time physical activity at age 16 years were assessed by self-administered questionnaires in a population-based cohort in Northern Sweden. The presence of the metabolic syndrome at age 43 years was ascertained in 888 participants (82% of the baseline sample) using the International Diabetes Federation criteria. Odds ratios (ORs) and CIs were calculated using logistic regression.

    RESULTS The overall prevalence of the metabolic syndrome at age 43 years was 26.9%. Adjusted OR for the metabolic syndrome at age 43 years was 2.14 (95% CI 1.24-3.71) for those who reported "watching several shows a day" versus "one show/week" or less and 2.31 (1.13-4.69) for leisure-time physical activity "several times/month" or less compared with "daily" leisure-time physical activity at age 16 years. TV viewing at age 16 years was associated with central obesity, low HDL cholesterol, and hypertension at age 43 years, whereas low leisure-time physical activity at age 16 years was associated with central obesity and triglycerides at age 43 years.

    CONCLUSIONS Both TV viewing and low leisure-time physical activity in adolescence independently predicted the metabolic syndrome and several of the metabolic syndrome components in mid-adulthood. These findings suggest that reduced TV viewing in adolescence, in addition to regular physical activity, may contribute to cardiometabolic health later in life.

  • 80.
    Wennberg, Patrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Howard, Bethany
    Wennberg, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Television viewing over the life course and the metabolic syndrome in mid-adulthood: a longitudinal population-based study2014In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 68, no 10, p. 928-933Article in journal (Refereed)
  • 81. Westerlund, Hugo
    et al.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Theorell, Tores
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Social Adversity in Adolescence Increases the Physiological Vulnerability to Job Strain in Adulthood: A Prospective Population-Based Study2012In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 7, no 4, p. e35967-Article in journal (Refereed)
    Abstract [en]

    Background: It has been argued that the association between job strain and health could be confounded by early life exposures, and studies have shown early adversity to increase individual vulnerability to later stress. We therefore investigated if early life exposure to adversity increases the individual's physiological vulnerability job strain in adulthood. Methodology/Principal Findings: In a population-based cohort (343 women and 330 men, 83% of the eligible participants), we examined the association between on the one hand exposure to adversity in adolescence, measured at age 16, and job strain measured at age 43, and on the other hand allostatic load at age 43. Adversity was operationalised as an index comprising residential mobility and crowding, parental loss, parental unemployment, and parental physical and mental illness (including substance abuse). Allostatic load summarised body fat, blood pressure, inflammatory markers, glucose, blood lipids, and cortisol regulation. There was an interaction between adversity in adolescence and job strain (B = 0.09, 95% CI 0.02 to 0.16 after adjustment for socioeconomic status), particularly psychological demands, indicating that job strain was associated with increased allostatic load only among participants with adversity in adolescence. Job strain was associated with lower allostatic load in men (beta = -0.20, 95% CI -0.35 to -0.06). Conclusions/Significance: Exposure to adversity in adolescence was associated with increased levels of biological stress among those reporting job strain in mid-life, indicating increased vulnerability to environmental stressors.

  • 82. Westerlund, Hugo
    et al.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Theorell, Töres
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Parental academic involvement in adolescence, academic achievement over the life course and allostatic load in middle age: a prospective population-based cohort study2013In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 67, no 6, p. 508-513Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Parental involvement in their children's studies, particularly in terms of academic socialisation, has been shown to predict academic achievement, and is thus a candidate modifiable factor influencing life course socioeconomic circumstances. Socioeconomic disadvantage is thought to impact on health over the life course partly by allostatic load, that is, cumulative biological risk. We sought to elucidate the role of parental involvement at age 16 on the life course development of allostatic load.

    METHODS: In a population-based cohort (365 women and 352 men, 67% of the eligible participants), we examined the association between parental involvement in their offspring's studies, measured by teacher and pupil ratings at age 16 and an allostatic load index summarising 12 physiological risk markers at age 43. Mediation through life course academic and occupational achievement was assessed by entering school grades, adult educational achievement and socioeconomic position at age 43 in a linear regression analysis in a stepwise manner and testing for mediation.

    RESULTS: Parental interest in their offspring's studies during the last year of compulsory school-rather than the parent's social class or availability of practical academic support-was found to predict adult allostatic load (β=-0.12, 95% CI -0.20 to -0.05). Further adjustments indicated that academic achievement over the life course mediated a large part of the effect of parental interest on allostatic load.

    CONCLUSIONS: Parental interest in their offspring's studies may have protective effects by decreasing the likelihood of a chain of risk involving low academic achievement, low socioeconomic position and high accumulated physiological stress.

  • 83.
    Westerlund, Hugo
    et al.
    Stockholm, Sweden .
    Rajaleid, Kristiina
    Stockholm, Sweden .
    Virtanen, Pekka
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Socialmedicin. Tampere, Finland .
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Socialmedicin.
    Nummi, Tapio
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Socialmedicin. Tampere, Finland .
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Socialmedicin.
    Parental academic involvement in adolescence as predictor of mental health trajectories over the life course: a prospective population-based cohort study.2015In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, p. 653-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Mental health problems are rising, especially among younger people, indicating a need to identify determinants of the development of mental health over the life course. Parental involvement in their children's studies, particularly in terms of academic socialisation, has been shown to predict better mental health in adulthood, as well as other more favourable health outcomes, but no study published so far has examined its impact on trajectories of mental health. We therefore sought to elucidate the role of parental involvement at age 16 on the life course development of internalised mental health symptoms.

    METHODS: In a population-based cohort (452 women and 488 men, 87 % of the eligible participants), we examined the association between parental involvement in their offspring's studies, measured by teacher and pupil ratings at age 16, and an index of internalised mental health symptoms at the ages of 16, 18, 21, 30, and 43. Using latent class trajectory analysis, 5 different trajectories were derived from these indices: Very low stable (least symptoms), Low stable, Increasing, Moderate stable, and High decreasing (most symptoms). Multinomial logistic regression was used to regress trajectory membership on the parental involvement variables.

    RESULTS: Teacher-rated parental interest in their offspring's studies during the last year of compulsory school was associated with a lower risk of entering the Moderate stable (OR = 0.54; 95 % CI 0.30 to 0.98) and High decreasing (OR = 0.41; 0.18 to 0.91) trajectories, compared with the Low stable, also after adjustment for sex, parental social class and mental health, family unemployment and own school grades. Both these associations were present only in children with grades above the national average. Student-rated availability of assistance with homework was associated with a higher chance of entering the Very low stable trajectory in the whole sample (OR = 1.24; 1.07 to 1.43), in men (OR = 1.25; 1.05 to 1.48) and in those with above average grades (OR = 1.39; 1.13 to 1.72), and with a lower risk of entering the Moderate stable in women (OR = 0.74; 0.55 to 0.99), also after the same adjustments.

    CONCLUSIONS: Parental involvement in their offspring's studies may buffer against poor mental health in adolescence which may track into adulthood.

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