Juan Merlo

Social capital and health: does egalitarianism matter? A literature review

The aim of the paper is to critically review the notion of social capital and review empirical literature on the association between social capital and health across countries. The methodology used for the review includes a systematic search on electronic databases for peer-reviewed published literature. We categorize studies according to level of analysis (single and multilevel) and examine whether studies reveal a significant health impact of individual and area level social capital. We compare the study conclusions according to the countrys degrees of economic egalitarianism. Regardless of study design, our findings indicate that a positive association (fixed effect) exists between social capital and better health irrespective of countries degree of egalitarianism. However, we find that the between-area variance (random effect) in health tends to be lower in more egalitarian countries than in less egalitarian countries. Our tentative conclusion is that an association between social capital and health at the individual level is robust with respect to the degree of egalitarianism within a country. Area level or contextual social capital may be less salient in egalitarian countries in explaining health differences across places.

Comparison of different procedures to identify probable cases of myocardial infarction and stroke in two Swedish prospective cohort studies using local and national routine registers

In prospective cohort studies, person-time time is calculated from baseline until the first definite event occurs or until censoring. A way to correctly identify and date definite events when only routine registers are available is to retrieve all hospital discharge notes and death certificates with a diagnosis of probable event and perform a consecutive revision. It is important to detect all possible hospital stays as they may contain useful information for the revision study. Furthermore, loss to follow-up can be avoided by extending the retrieval outside the specific geographical area where the cohort was defined. The aims of this study were (i) to describe a comprehensive retrieval of probable myocardial infarctions (diagnosis with International Classification of Diseases 8th and 9th revisions codes 410–414) or stroke (codes 430–438), (ii) to quantify the relative efficiency of different local and national routine registers or their combination compared with the use of all available registers together, and (iii) to audit local and national registers by comparing their outcome at the county level. The study was performed in two prospective cohorts studies i.e., `Men-born-1914 (n = 500) from Skåne (period 1982–1993), and Skara-1 (n = 683) from Skaraborg (period 1988–1994.). All available routine registers were linked to the cohorts. The use of all available routine registers improved retrieval of both individual and hospital stays with a discharge diagnosis of probable event and gave an enhanced basis for a future validation study. Local registers were not completely covered by the national register, but the accessible combination of national in-patient and mortality registers was an efficient alternative.

Atrial fibrillation and its association with type 2 diabetes and hypertension in a Swedish community.

Aim:u2002 To explore the prevalence of atrial fibrillation in patients with hypertension and type 2 diabetes and to identify possible mechanisms for the development of atrial fibrillation.

Comparison of dose standard units for drug utilisation studies.

Abstract.Objective. As employment of different dose standards would be impractical and confusing, the aim of this article is to compare the defined daily dose (DDD) with some more recently proposed standards, namely, the minimum marketed dose (MMD), the equipotential dose (ED), the average daily dose (ADD), and the non-standard prescribed daily dose (PDD).Methods.Literature review, critical comparative analysis.Results.The DDD, defined by an independent scientific committee assisting the WHO Collaborating Centre for Drugs Statistics Methodology, has been employed in a large number of national and international comparative studies at the population level, usually as number of DDDs per 1000 inhabitants per day. However, the DDD can also be used at the individual level. The PDD, not being a standard unit, can be appropriately used in a second step to explain differences detected by the DDD methodology.Conclusions.1A globally accepted dose standard unit is important in drug utilisation studies, particularly if different investigations are to be compared. None of the alternatives seemed to offer any advantage over the DDD. Hence there is reason to advocate use of the DDD as the sole standard dose unit in all pharmacoepidemiologic studies.A globally accepted dose standard unit is important in drug utilisation studies, particularly if different studies are to be compared [1]. As units of costs, packages or prescriptions are inadequate for obvious reasons, the defined daily dose (DDD) concept was introduced many years ago [2]. A DDD of a drug is defined by an independent scientific committee assisting the WHO Collaborating Centre for Drug Statistics Methodology, following an extensive review of the literature, as the assumed average daily dose of a drug for its main indication in adults [1,u20053]. For comparative use the number of DDDs sold or prescribed is generally given as per 1000 inhabitants per day [1]. As such it has been used in a large number of studies and statistics on drug utilisation at the population level. However, the DDD may also be used at the individual level (see below).Recently, some alternative standard dose concepts have appeared, such as the minimum marketed dose (MMD) [4], the equipotential dose (ED) [5] and the average daily dose (ADD) [6]. As employment of different dose standards would be impractical and confusing, the present report assessed the possible advantages and disadvantages of MMD, ED and ADD relative to those of the DDD. The non-standard prescribed daily dose (PDD) is also discussed.

Similar support for three different life course socioeconomic models on predicting premature cardiovascular mortality and all-cause mortality

BackgroundThere are at least three broad conceptual models for the impact of the social environment on adult disease: the critical period, social mobility, and cumulative life course models. Several studies have shown an association between each of these models and mortality. However, few studies have investigated the importance of the different models within the same setting and none has been performed in samples of the whole population. The purpose of the present study was to study the relation between socioeconomic position (SEP) and mortality using different conceptual models in the whole population of Scania.MethodsIn the present investigation we use socioeconomic information on all men (N = 48,909) and women (N = 47,688) born between 1945 and 1950, alive on January, 1st,1990, and living in the Region of Scania, in Sweden. Focusing on three specific life periods (i.e., ages 10–15, 30–35 and 40–45), we examined the association between SEP and the 12-year risk of premature cardiovascular mortality and all-cause mortality.ResultsThere was a strong relation between SEP and mortality among those inside the workforce, irrespective of the conceptual model used. There was a clear upward trend in the mortality hazard rate ratios (HRR) with accumulated exposure to manual SEP in both men (p for trend < 0.001 for both cardiovascular and all-cause mortality) and women (p for trend = 0.01 for cardiovascular mortality) and (p for trend = 0.003 for all-cause mortality). Inter- and intragenerational downward social mobility was associated with an increased mortality risk. When applying similar conceptual models based on workforce participation, it was shown that mortality was affected by the accumulated exposure to being outside the workforce.ConclusionThere was a strong relation between SEP and cardiovascular and all-cause mortality, irrespective of the conceptual model used. The critical period, social mobility, and cumulative life course models, showed the same fit to the data. That is, one model could not be pointed out as the best model and even in this large unselected sample it was not possible to adjudicate which theories best describe the links between life course SEP and mortality risk.

The relation between self-rated health, socioeconomic status, body mass index and disability pension among middle-aged men

The aim of this study was to assess the relations between self-rated health (SRH), socioeconomic status (SES), body mass index (BMI) and disability pension. Five birth-year cohorts of middle-aged male residents in Malmö, Sweden, were invited and 5313 with complete data constituted the cohort in this study. Each subject was followed for approximately 11 years. Of all subjects, 73% perceived their health as perfect and among obese men and blue collar workers, the corresponding figures were 67 and 68% respectively. The adjusted odds ratios for SRH less than perfect was 1.3 (CI: 1.1–1.7) for obese subjects and 1.7 (CI: 1.5–1.9) for blue collar workers. The interaction between low SES and obesity was estimated to 11% which was not statistically significant. The adjusted relative risks (RR) of disability pension was 3.3 for subjects with SRH less than perfect, 2.2 for blue collar workers and 2.0 for obese subjects, all statistically significant and only marginally less than the crude RR. Thus, SRH among middle-aged men was associated with obesity as well as low SES, but no evidence of synergism between obesity and low SES in relation to SRH was found. Furthermore, poor SRH in particular, but also low SES and obesity, independently predicted disability pension.

The association between socioeconomic position, use of revascularization procedures and five-year survival after recovery from acute myocardial infarction

BackgroundPatients living under better socioeconomic circumstances often receive more active treatments after an acute myocardial infarction (AMI) compared to less affluent patients. However, most previous studies were performed in countries with less comprehensive coverage for medical services. In this Swedish nation-wide longitudinal study we wanted to evaluate long-term survival after AMI in relation to socioeconomic position (SEP) and use of revascularization.MethodsFrom the Swedish Myocardial Infarction Register we identified all 45 to 84-year-old patients (16,041 women and 30,366 men) alive 28 days after their first AMI during the period 1993 to 1996. We obtained detailed information on the use of revascularization, cumulative household income from the 1975 and 1990 censuses and 5-year survival after the AMI.ResultsPatients with the highest cumulative income (adding the values of the quartile categories of income in 1975 and 1990) underwent a revascularization procedure within one month after their first AMI two to three times as often as patients with the lowest cumulative income and had half the risk of death within five years. The socioeconomic differences in the use of revascularization procedures could not be explained by differences in co-morbidity or type of hospital at first admission. Patients who underwent revascularization showed a similar lowered mortality risk in the different income groups, while there were strong socioeconomic differences in long-term mortality among patients who did not undergo revascularization.ConclusionThis nationwide Swedish study showed that patients with high income had a better long-term survival after recovery from their AMI compared to patients with low income. Furthermore, even though the use of revascularization procedures is beneficial, low SEP groups receive it less often than high SEP groups.

Contribution of main causes of death to social inequalities in mortality in the whole population of Scania, Sweden

BackgroundTo more efficiently reduce social inequalities in mortality, it is important to establish which causes of death contribute the most to socioeconomic mortality differentials. Few studies have investigated which diseases contribute to existing socioeconomic mortality differences in specific age groups and none were in samples of the whole population, where selection bias is minimized. The aim of the present study was to determine which causes of death contribute the most to social inequalities in mortality in each age group in the whole population of Scania, Sweden.MethodsData from LOMAS (Longitudinal Multilevel Analysis in Skåne) were used to estimate 12-year follow-up mortality rates across levels of socioeconomic position (SEP) and workforce participation in 975,938 men and women aged 0 to 80 years, during 1991–2002.ResultsThe results generally showed increasing absolute mortality differences between those holding manual and non-manual occupations with increasing age, while there were inverted u-shaped associations when using relative inequality measures. Cardiovascular diseases (CVD) contributed to 52% of the male socioeconomic difference in overall mortality, cancer to 18%, external causes to 4% and psychiatric disorders to 3%. The corresponding contributions in women were 55%, 21%, 2% and 3%. Additionally, those outside the workforce (i.e., students, housewives, disability pensioners, and the unemployed) showed a strongly increased risk of future mortality in all age groups compared to those inside the workforce. Even though coronary heart disease (CHD) played a major contributing role to the mortality differences seen, stroke and other types of cardiovascular diseases also made substantial contributions. Furthermore, while the most common types of cancers made substantial contributions to the socioeconomic mortality differences, in some age groups more than half of the differences in cancer mortality could be attributed to rarer cancers.ConclusionCHD made a major contribution to the socioeconomic differences in overall mortality. However, there were also important contributions from diseases with less well understood mechanistic links with SEP such as stroke and less-common cancers. Thus, an increased understanding of the mechanisms connecting SEP with more rare causes of disease might be important to be able to more successfully intervene on socioeconomic differences in health.

Association of outpatient utilisation of non-steroidal anti-inflammatory drugs and hospitalised heart failure in the entire Swedish population

Abstract. Objective: Individual-based studies on restricted geographical settings have suggested that non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate congestive heart failure. As NSAID use is very extensive, it might increase the occurrence of symptomatic heart failure in the general population. Therefore, in order to study the impact of NSAID utilisation (prescribed and over the counter) on hospitalised heart failure in an entire country (Sweden), we performed an ecological analysis, a design appropriate for studying large geographical areas. Methods: We employed weighted (population size) ecological linear regression to study the association between outpatient utilisation of NSAIDs during 1989–1993 and hospitalised heart failure in 1993 in 283 of Swedens 288 municipalities. Data were adjusted for age and gender proportions, socio-economic factors, latitude and utilisation of cardiovascular drugs, aspirin, low-dose aspirin and paracetamol. Results: The unadjusted relative risk of hospitalised heart failure for each increase of one standard deviation of NSAID utilisation (5.8 defined daily doses/1000 inhabitants/day) was 1.23 [95% confidence interval (CI) 1.18, 1.27]. After adjustments, the relative risk was 1.08 (95% CI 1.04, 1.12); the corresponding values if aspirin (non-low-dose) was included as an NSAID were 1.26 (95% CI 1.23, 1.28) and 1.07 (95% CI 1.04, 1.10). There was no such adjusted association with the utilisation of paracetamol – 0.95 (95% CI 0.92, 0.98). Conclusion: The NSAID–heart failure association already established by individual-based studies on restricted geographical settings was corroborated in the present ecological study based on the whole population of an entire country (Sweden). Efforts should be made to promote a rational use of NSAIDs in the general population.

Gender differences in daily smoking prevalence in different age strata: A population-based study in southern Sweden

Objectives: To investigate gender differences in daily smoking prevalence in different age groups in southern Sweden. Methods: The 2004 public-health survey in Skane is a cross-sectional study. A total of 27,757 persons aged 18—80 years answered a postal questionnaire, which represents 59% of the random sample. A logistic regression model was used to investigate the associations between gender and daily smoking according to age. The multivariate analysis was performed to investigate the importance of possible confounders (country of origin, education, snus use, alcohol consumption, leisure-time physical activity, and BMI) on the gender differences in daily smoking in different age groups. Results: 14.9% of the men and 18.1% of the women were daily smokers. Middle-aged respondents were daily smokers to a significantly higher extent than young and old respondents. The prevalence of daily smoking also varied according to other demographic, socioeconomic, health related behaviour, and BMI characteristics. The crude odds ratios of daily smoking were 1.79 (1.42—2.26) among women compared to men in the 18—24 years age group, and 0.95 (0.80—1.12) in the 65—80 years age group. These odds ratios changed to 2.00 (1.49—2.67) and 0.95 (0.76—1.18), respectively, when all confounders were included. Conclusions: For the first time in Sweden women have a higher prevalence of daily smoking than men. The odds ratios of daily smoking are highest among women compared to men in the youngest age group of 18—24 years and the odds ratios decrease with increasing age. The findings point to a serious public health problem. Strategic interventions targeting young womens tobacco smoking are needed.