Bjørn Heine Strand

Measuring the mental health status of the Norwegian population: A comparison of the instruments SCL-25, SCL-10, SCL-5 and MHI-5 (SF-36)

A great number of questionnaires and instruments have been developed in order to measure psychological distress/mental health problems in populations. The Survey of Level of Living in 1998 conducted by Statistics Norway used both Hopkins Symptom Checklist (SCL-25) and the Short Form 36 (SF-36), including the five-item mental health index (MHI-5). Five-item and 10-item versions of the SCL-25 have also been used in Norwegian surveys. The purpose of this study was to investigate the correlation between the various instruments, and to assess and to compare psychometric characteristics. A random sample of 9735 subjects over 15 years of age drawn from the Norwegian population received a questionnaire about their health containing SCL-25 and SF-36. Response rate was 71.9%. Reliability of the SCLs and MHI-5 were assessed by Cronbach alpha. The scores from full and abbreviated instruments were compared regarding possible instrument-specific effects of gender, age and level of education. The correlations between the instruments were calculated. The capacity of the various instruments to identify cases was assessed in terms of sensitivity, specificity, predictive values, receiver operating characteristics (ROC) and area under the curve (AUC). The reliabilities were high (Cronbach alpha>0.8). All instruments showed a significant difference in the mean scores for men and women. The correlation between the various versions of SCL ranged from 0.91 to 0.97. The correlation between the MHI-5 and the SCLs ranged from −0.76 to −0.78. The prevalence rate was 11.1% for SCL-25 scores above 1.75 and 9.7% for scores below 56 in MHI-5. AUC values indicated good screening accordance between the measures (AUC>0.92). The results suggest that the shorter versions of SCL perform almost as well as the full version. The corresponding cut-off points to the conventional 1.75 for SCL-25 are 1.85 for SCL-10 and 2.0 for SCL-5. MHI-5 correlates highly with the SCL and the AUC indicate that the instruments might replace each other in population surveys, at least when considering depression. An operational advantage of the MHI-5 over the SCL instruments is that it has been widely used not only in surveys of mental health, but also in surveys of general health.

Can cardiovascular risk factors and lifestyle explain the educational inequalities in mortality from ischaemic heart disease and from other heart diseases? 26 year follow up of 50 000 Norwegian men and women

Objective: Investigate the degree to which smoking, physical activity, marital status, BMI, blood pressure, and cholesterol explain the association between educational level and ischaemic heart disease (IHD) mortality and other forms of cardiovascular mortality, with main focus on IHD mortality. Design: Prospective health examination survey study conducted in the period 1974–78. Setting: Oppland, Sogn og Fjordane, and Finnmark counties in Norway. Participants: The sample comprised 22 712 men and 21 972 women, aged 35–49 at screening. The subjects were followed up with respect to mortality throughout year 2000. Main results: 4342 men and 2164 women died during the follow up, 1343 men and 258 women of IHD. IHD mortality risk was higher for people with low education compared with people with high education, and people with low education had more adverse risk factors. After adjustment for smoking the IHD mortality relative risk (RR) with 95% confidence limits, in the low educational group decreased from 1.33 (1.18 to 1.50) to 1.16 (1.03 to 1.31) for men, and from 1.72 (1.23 to 2.41) to 1.58 (1.13 to 2.22) for women. Further adjustment for physical activity, marital status, BMI, blood pressure, and cholesterol reduced the RR to 1.03 (0.91 to 1.17) for men and 1.24 (0.88 to 1.75) for women. Conclusions: Unfavourable cardiovascular risk factors and high IHD mortality are more prevalent among less educated than their highly educated peers. After simultaneous adjustment for all recorded risk factors, the excess IHD mortality in the low educational groups was reduced by 91% for men and 67% for women.

Educational inequalities in mortality over four decades in Norway: prospective study of middle aged men and women followed for cause specific mortality, 1960-2000.

Objectives To determine the extent to which educational inequalities in relation to mortality widened in Norway during 1960-2000 and which causes of death were the main drivers of this disparity. Design Nationally representative prospective study. Setting Four cohorts of the Norwegian population aged 45-64 years in 1960, 1970, 1980, and 1990 and followed up for mortality over 10 years. Participants 359 547 deaths and 32 904 589 person years. Main outcome measures All cause mortality and deaths due to cancer of lung, trachea, or bronchus; other cancer; cardiovascular diseases; suicide; external causes; chronic lower respiratory tract diseases; or other causes. Absolute and relative indices of inequality were used to present differences in mortality by educational level (basic, secondary, and tertiary). Results Mortality fell from the 1960s to the 1990s in all educational groups. At the same time the proportion of adults in the basic education group, with the highest mortality, decreased substantially. As mortality dropped more among those with the highest level of education, inequalities widened. Absolute inequalities in mortality denoting deaths among the basic education groups minus deaths among the high education groups doubled in men and increased by a third in women. This is equivalent to an increase in the slope index of inequality of 105% in men and 32% in women. Inequalities on a relative scale widened more, from 1.33 to 2.24 among men (P=0.01) and from 1.52 to 2.19 among women (P=0.05). Among men, absolute inequalities mainly increased as a result of cardiovascular diseases, lung cancer, and chronic lower respiratory tract diseases. Among women this was mainly due to lung cancer and chronic lower respiratory tract diseases. Unlike the situation in men, absolute inequalities in deaths due to cardiovascular causes narrowed among women. Chronic lower respiratory tract diseases contributed more to the disparities in inequalities among women than among men. Conclusion All educational groups showed a decline in mortality. Nevertheless, and despite the fact that the Norwegian welfare model is based on an egalitarian ideology, educational inequalities in mortality among middle aged people in Norway are substantial and increased during 1960-2000.

Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries

Background Over the last decades of the 20th century, a widening of the gap in death rates between upper and lower socioeconomic groups has been reported for many European countries. For most countries, it is unknown whether this widening has continued into the first decade of the 21st century. Methods We collected and harmonised data on mortality by educational level among men and women aged 30–74 years in all countries with available data: Finland, Sweden, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Spain, Italy, Hungary, Lithuania and Estonia. Results Relative inequalities in premature mortality increased in most populations in the North, West and East of Europe, but not in the South. This was mostly due to smaller proportional reductions in mortality among the lower than the higher educated, but in the case of Lithuania and Estonia, mortality rose among the lower and declined among the higher educated. Mortality among the lower educated rose in many countries for conditions linked to smoking (lung cancer, women only) and excessive alcohol consumption (liver cirrhosis and external causes). In absolute terms, however, reductions in premature mortality were larger among the lower educated in many countries, mainly due to larger absolute reductions in mortality from cardiovascular disease and cancer (men only). Despite rising levels of education, population-attributable fractions of lower education for mortality rose in many countries. Conclusions Relative inequalities in premature mortality have continued to rise in most European countries, and since the 1990s, the contrast between the South (with smaller inequalities) and the East (with larger inequalities) has become stronger. While the population impact of these inequalities has further increased, there are also some encouraging signs of larger absolute reductions in mortality among the lower educated in many countries. Reducing inequalities in mortality critically depends upon speeding up mortality declines among the lower educated, and countering mortality increases from conditions linked to smoking and excessive alcohol consumption such as lung cancer, liver cirrhosis and external causes.

Type 2 Diabetes as a Risk Factor for Dementia in Women Compared With Men: A Pooled Analysis of 2.3 Million People Comprising More Than 100,000 Cases of Dementia

OBJECTIVE Type 2 diabetes confers a greater excess risk of cardiovascular disease in women than in men. Diabetes is also a risk factor for dementia, but whether the association is similar in women and men remains unknown. We performed a meta-analysis of unpublished data to estimate the sex-specific relationship between women and men with diabetes with incident dementia. RESEARCH DESIGN AND METHODS A systematic search identified studies published prior to November 2014 that had reported on the prospective association between diabetes and dementia. Study authors contributed unpublished sex-specific relative risks (RRs) and 95% CIs on the association between diabetes and all dementia and its subtypes. Sex-specific RRs and the women-to-men ratio of RRs (RRRs) were pooled using random-effects meta-analyses. RESULTS Study-level data from 14 studies, 2,310,330 individuals, and 102,174 dementia case patients were included. In multiple-adjusted analyses, diabetes was associated with a 60% increased risk of any dementia in both sexes (women: pooled RR 1.62 [95% CI 1.45–1.80]; men: pooled RR 1.58 [95% CI 1.38–1.81]). The diabetes-associated RRs for vascular dementia were 2.34 (95% CI 1.86–2.94) in women and 1.73 (95% CI 1.61–1.85) in men, and for nonvascular dementia, the RRs were 1.53 (95% CI 1.35–1.73) in women and 1.49 (95% CI 1.31–1.69) in men. Overall, women with diabetes had a 19% greater risk for the development of vascular dementia than men (multiple-adjusted RRR 1.19 [95% CI 1.08–1.30]; P < 0.001). CONCLUSIONS Individuals with type 2 diabetes are at ∼60% greater risk for the development of dementia compared with those without diabetes. For vascular dementia, but not for nonvascular dementia, the additional risk is greater in women.

Physical capability in mid-life and survival over 13 years of follow-up: British birth cohort study

Objectives To examine associations between three commonly used objective measures of physical capability assessed at age 53 and a composite score of these measures and all cause mortality; to investigate whether being unable to perform these tests is associated with mortality. Design Cohort study. Setting MRC National Survey of Health and Development in England, Scotland, and Wales. Participants 1355 men and 1411 women with data on physical capability at age 53 who were linked to the National Health Service (NHS) central register for death notification. Main outcome measure All cause mortality between ages 53 (1999) and 66 (2012). Results For each of the three measures of physical capability (grip strength, chair rise speed, and standing balance time) those participants unable to perform the test and those in the lowest performing fifth were found to have higher mortality rates than those in the highest fifth. Adjustment for baseline covariates partially attenuated associations but in fully adjusted models the main associations remained. For example, the fully adjusted hazard ratio of all cause mortality for the lowest compared with the highest fifth of a composite score of physical capability was 3.68 (95% confidence interval 2.03 to 6.68). Those people who could not perform any of the tests had considerably higher rates of death compared with those people able to perform all three tests (8.40, 4.35 to 16.23). When a series of models including different combinations of the measures were compared by using likelihood ratio tests, all three measures of physical capability were found to improve model fit, and a model including all three measures produced the highest estimate of predictive ability (Harrell’s C index 0.71, 95% confidence interval 0.65 to 0.77). There was some evidence that standing balance time was more strongly associated with mortality than the other two measures. Conclusions Lower levels of physical capability at age 53 and inability to perform capability tests are associated with higher rates of mortality. Even at this relatively young age these measures identify groups of people who are less likely than others to achieve a long and healthy life.

Educational differences in cancer mortality among women and men: a gender pattern that differs across Europe

We used longitudinal mortality data sets for the 1990s to compare socioeconomic inequalities in total cancer mortality between women and men aged 30–74 in 12 different European populations (Madrid, Basque region, Barcelona, Slovenia, Turin, Switzerland, France, Belgium, Denmark, Norway, Sweden, Finland) and to investigate which cancer sites explain the differences found. We measured socioeconomic status using educational level and computed relative indices of inequality (RII). We observed large variations within Europe for educational differences in total cancer mortality among men and women. Three patterns were observed: Denmark, Norway and Sweden (significant RII around 1.3–1.4 among both men and women); France, Switzerland, Belgium and Finland (significant RII around 1.7–1.8 among men and around 1.2 among women); Spanish populations, Slovenia and Turin (significant RII from 1.29 to 1.88 among men; no differences among women except in the Basque region, where RII is significantly lower than 1). Lung, upper aerodigestive tract and breast cancers explained most of the variations between gender and populations in the magnitude of inequalities in total cancer mortality. Given time trends in cancer mortality, the gap in the magnitude of socioeconomic inequalities in cancer mortality between gender and between European populations will probably decrease in the future.

Changes in mortality inequalities over two decades: register based study of European countries

Objective To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group. Design Register based study. Data source Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively). Setting All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania. Results Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations. Conclusions Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

Trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors: repeated cross-sectional surveys from the Nord-Trøndelag Health Study (HUNT) 1984–2008

BackgroundThere has been an overall decrease in incident ischaemic heart disease (IHD), but the reduction in IHD risk factors has been greater among those with higher social position. Increased social inequalities in IHD mortality in Scandinavian countries is often referred to as the Scandinavian “public health puzzle”. The objective of this study was to examine trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors (smoking, diabetes, hypertension and high total cholesterol) over the last three decades among Norwegian middle-aged women and men.MethodsPopulation-based, cross-sectional data from The Nord-Trøndelag Health Study (HUNT): HUNT 1 (1984–1986), HUNT 2 (1995–1997) and HUNT 3 (2006–2008), women and men 40–59 years old. Educational inequalities were assessed using the Slope Index of Inequality (SII) and The Relative Index of Inequality (RII).ResultsSmoking prevalence increased for all education groups among women and decreased in men. Relative and absolute educational inequalities in smoking widened in both genders, with significantly higher absolute inequalities among women than men in the two last surveys. Diabetes prevalence increased in all groups. Relative inequalities in diabetes were stable, while absolute inequalities increased both among women (p = 0.05) and among men (p = 0.01). Hypertension prevalence decreased in all groups. Relative inequalities in hypertension widened over time in both genders. However, absolute inequalities in hypertension decreased among women (p = 0.05) and were stable among men (p = 0.33). For high total cholesterol relative and absolute inequalities remained stable in both genders.ConclusionWidening absolute educational inequalities in smoking and diabetes over the last three decades gives rise to concern. The mechanisms behind these results are less clear, and future studies are needed to assess if educational inequalities in secondary prevention of IHD are larger compared to educational inequalities in primary prevention of IHD. Continued monitoring of IHD risk factors at the population level is therefore warranted. The results emphasise the need for public health efforts to prevent future burdens of life-style-related diseases and to avoid further widening in socioeconomic inequalities in IHD mortality in Norway, especially among women.

Socioeconomic inequalities in alcohol related cancer mortality among men: To what extent do they differ between Western European populations?

We aim to study socioeconomic inequalities in alcohol related cancers mortality [upper aerodigestive tract (UADT) (oral cavity, pharynx, larynx, oesophagus and liver)] in men and to investigate whether the contribution of these cancers to socioeconomic inequalities in cancer mortality differs within Western Europe. We used longitudinal mortality datasets, including causes of death. Data were collected during the 1990s among men aged 30–74 years in 13 European populations [Madrid, the Basque region, Barcelona, Turin, Switzerland (German and Latin part), France, Belgium (Walloon and Flemish part, Brussels), Norway, Sweden, Finland]. Socioeconomic status was measured using the educational level declared at the census at the beginning of the follow‐up period. We conducted Poisson regression analyses and used both relative [Relative index of inequality (RII)] and absolute (mortality rates difference) measures of inequality. For UADT cancers, the RIIs were above 3.5 in France, Switzerland (both parts) and Turin whereas for liver cancer they were the highest (around 2.5) in Madrid, France and Turin. The contribution of alcohol related cancer to socioeconomic inequalities in cancer mortality was 29–36% in France and the Spanish populations, 17–23% in Switzerland and Turin, and 5–15% in Belgium and the Nordic countries. We did not observe any correlation between mortality rates differences for lung and UADT cancers, confirming that the pattern found for UADT cancers is not only due to smoking. This study suggests that alcohol use substantially influences socioeconomic inequalities in male cancer mortality in France, Spain and Switzerland but not in the Nordic countries and nor in Belgium.