Kristiina Manderbacka

Assessing reliability of a measure of self-rated health

The test-retest reliability of self-rated health is analysed and compared with the reliability of health questions phrased more as well as less precisely. Differences in reliability between men and women and between age groups are also assessed. The study is based on 204 and 409 re-interviews from the 1991 Swedish Level of Living Survey and the 1989 Survey of Living Conditions respectively. The results show that the reliability of self-rated health is as good as or even better than that of most of the more specific questions. Only an indicator of high blood pressure showed significantly higher reliability. The reliability of self-rated health is good in all subgroups studied, and is even excellent among older men. It is concluded that the good overall reliability of self-rated health found in this study is in line with previous results concerning the validity of peoples assessments of their general health as well as results concerning the basis upon which they make these judgements.

Do risk factors and health behaviours contribute to self-ratings of health?

This study examined the relative importance of five risk factors and health behaviours (namely dietary habits, leisure time exercise, smoking, alcohol consumption and body mass index) on self-ratings of health among the Swedish adult population. The data come from the 1991 Swedish Level of Living Survey, a face-to-face survey interview based on a sample representative of the Swedish population aged between 18 and 75 years (n = 5306). The analyses were carried out using logistic regression analysis. With the exception of the consumption of dietary fat, all the risk factors and health behaviours studied were associated with self-rated health. When they were adjusted for health problems and functional limitations most of the associations weakened or disappeared altogether, but smoking and use of vegetables in the diet were still associated with self-rated health. Self-ratings of young adults (18-34 years) were found to be related to body mass index even when health problems were adjusted for, with both obesity and underweight contributing to less than good self-rated health. The results indicate that risk factors and health behaviours do not, in general, directly contribute to self-ratings of health. Instead, their effect is mediated by more specific health problems and their functional consequences. However, smoking and not consuming vegetables, as well as obesity and underweight among young respondents, were found to have an independent association with self-rated health. This may reflect the effects of health problems not captured by our indicators of ill health, but may also indicate that risk factors and risky behaviours are considered to have an effect on ones perceived health even in the absence of health consequences.

The effect of point of reference on the association between self-rated health and mortality

This study examines the effect of point of reference on the predictive validity of self-rated health for mortality in a 5-year follow-up period. Two self-rated health measures are examined: an age group comparative question and a global question with no explicit point of reference. The baseline data (SweOld) is a nationally representative interview survey among Swedish people aged 77+ in 1992. Mortality for the 1992-1996 period was analysed using Cox proportional hazards regression models. Age-referential self-rated health was found to be a better predictor of elderly mens mortality both in non-adjusted models and in models adjusting for age and both self-rated health measures. In separate analyses, both measures were found to be equally strong predictors of womens mortality. When adding both measures into the model simultaneously, the age-referential question lost much of its predictive power. The findings suggest that self-rated health measures are not insensitive to differences in question wording.

How did the recent increase in the supply of coronary operations in Finland affect socioeconomic and gender equity in their use

Study objective: To explore how the increased supply of coronary bypass operations and angioplasties from 1988 to 1996 influenced socioeconomic and gender equity in their use. Design: Register based linkage study; information on coronary procedures from the Finnish Hospital Discharge Register in 1988 and 1996 was individually linked to national population censuses in 1970–1995 to obtain patients’ socioeconomic data. Data on both hospitalisations and mortality attributable to coronary heart disease obtained from similar linkage schemes were used to approximate the relative need of procedures in socioeconomic groups. Setting: Finland, 2 094 846 inhabitants in 1988 and 2 401 027 in 1996 aged 40 years and older, and Discharge Register data from all Finnish hospitals offering coronary procedures in 1988 and 1996. Main results: The overall rate of coronary revascularisations in Finland increased by about 140% for men and 250% for women from 1988 to 1996. Over the same period, socioeconomic and gender disparities in operation rates diminished, as did the influence of regional supply of procedures on the extent of these differences. However, men, and better off groups in terms of occupation, education, and family income, continued to receive more operations than women and the worse off with the same level of need. Conclusions: Although revascularisations in Finland increased 2.5-fold overall, some socioeconomic and gender inequities persisted in the use of cardiac operations relative to need. To improve equity, a further increase of resources may be needed, and practices taking socioeconomic and gender equity into account should be developed for the referral of coronary heart disease patients to hospital investigations.

Examining points of reference of self-rated health among Swedish oldest old

The aim of the study is to assess the relative importance of comparisons with people of the same age and comparisons with the respondents own health 1 year before the survey as two likely points of reference for ratings of health status among the elderly. Data was derived from the Swedish Panel Study of Living Conditions of the Oldest Old (n=438) comprising those aged 77-98. On the basis of multiple regression analyses we first map the relationships between three measures of self-rated health (SRH) on the one hand and measures of ill-health and physical functioning on the other. In our main analyses it is shown that both men and women use other persons of the same age as an important point of reference when rating their own health. Our results also tend to suggest that men, in contrast to women, also refer to recent changes in their own health when giving a general health rating.

Drinking and unemployment : contrasting patterns among men and women

Research on unemployment has paid only little attention to drinking and drinking problems. From the 1970s onwards the association of drinking and unemployment has come under systematic study. Contrasting tendencies emerge from this research. This paper distinguishes three instances of drinking and drinking problems and examines their association with employment status, i.e., (i) frequency of drinking, (ii) frequency of intoxication, and (iii) frequency of health problems due to drinking. A panel survey was conducted in 1983-1984, consisting of a sample of Finnish men and women, originally jobseekers in industry. Prevalence data and results of logistic regression analyses on the association of the three instances of drinking and drinking problems with employment status are presented. The frequency of drinking was unassociated with employment status for men and women at either of the two measurement points. Neither did the frequency of intoxication show any clear association with employment status. In contrast, the frequency of health problems due to drinking was associated in a statistically significant way with unemployment among men. Among women the association was rather the opposite, but it was not statistically significant. The paper concludes that it is important to distinguish between overall drinking and drinking problems, and between the determinants of male and female drinking problems. It is likely that selective processes at the labour market as well as social causation during unemployment lie behind the observed association of male unemployment and drinking problems.

Socioeconomic inequities in invasive cardiac procedures among patients with incident angina pectoris or myocardial infarction

Aims: In many countries, systematic socioeconomic disparities have emerged in the use of invasive cardiac procedures among myocardial infarction patients and hospitalized coronary patients. This study prospectively examined socioeconomic differences in the use of cardiac procedures in a national cohort of incident coronary patients. Methods: The data were based on individual register linkages among 49,846 patients with incident angina pectoris (AP) or myocardial infarction (MI) during one-year follow-up in 1995—98 in Finland. Socioeconomic differences in invasive coronary procedures were examined using proportional hazard models. Results: The analyses showed that women, AP patients, and persons with lower socioeconomic status received fewer procedures during the one-year follow-up than men, MI patients, and those with higher socioeconomic status. Socioeconomic differences in the utilization of cardiac procedures were similar in both AP and MI groups, among both men and women, and by all socioeconomic indicators: social class, education, and income. Disparities were already emerging after the 28-day follow-up among men and women in both patient groups, and they persisted throughout the study period. Controlling for disease severity, comorbidity, and hospital district did not modify the results. Conclusions: Socioeconomic disparities in receiving invasive coronary procedures among AP patients without MI were similar to those in MI patients.

Diabetes and depression? Secular trends in the use of antidepressants among persons with diabetes in Finland in 1997-2007.

The association between diabetes and depression is well demonstrated. Less is known about the trends in use of antidepressants in the rapidly growing population of diabetics. We examined trends in antidepressant medication use during 1997–2007 in Finland among persons with or without diabetes using register‐based data on both diabetes and antidepressant use.

Persisting Health Inequalities: Social Class Differentials in Illness in the Scandinavian Countries

Finland, Norway and Sweden are highly developed welfare states with a long tradition of egalitarian health and welfare policies. This article analyzes social class differentials in self-reported limiting long-standing illness among men and women in these countries. The data consisted of nation-wide Level of Living Surveys made in 1986–87 in Finland (N=11,783), Norway (N=4,211) and Sweden (N=4,699). Women reported both long-standing illness and limiting long-standing illness slightly more often than men. The prevalence of limiting long-standing illness was lower in Sweden than in Finland and Norway. In all countries blue-collar workers reported ill-health more often than white-collar employees. The prevalence of self-reported limiting long-standing illness among Swedish upper white-collar workers was very low and that among Finnish farmers very high. Skilled female workers showed the worst health whereas Swedish upper class men showed the best health. The reasons for these social inequalities, and their implications for social policy, are discussed.

Amputations and socioeconomic position among persons with diabetes mellitus, a population-based register study

Objective Low socioeconomic position is a known health risk. Our study aims to evaluate the association between socioeconomic position (SEP) and lower limb amputations among persons with diabetes mellitus. Design Population-based register study. Setting Finland, nationwide individual-level data. Participants All persons in Finland with any record of diabetes in the national health and population registers from 1991 to 2007 (FinDM II database). Methods Three outcome indicators were measured: the incidence of first major amputation, the ratio of first minor/major amputations and the 2-year survival with preserved leg after the first minor amputation. SEP was measured using income fifths. The data were analysed using Poisson and Cox regression as well as age-standardised ratios. Results The risk ratio of the first major amputation in the lowest SEP group was 2.16 (95% CI 1.95 to 2.38) times higher than the risk in the highest SEP group (p<0.001). The incidence of first major amputation decreased by more than 50% in all SEP groups from 1993 to 2007, but there was a stronger relative decrease in the highest compared with the lowest SEP group (p=0.0053). Likewise, a clear gradient was detected in the ratio of first minor/major amputations: the higher the SEP group, the higher the ratio. After the first minor amputation, the 2-year and 10-year amputation-free survival rates were 55.8% and 9.3% in the lowest and 78.9% and 32.3% in the highest SEP group, respectively. Conclusions According to all indicators used, lower SEP was associated with worse outcomes in the population with diabetes. Greater attention should be paid to prevention of diabetes complications, adherence to treatment guidelines and access to the established pathways for early expert assessment when diabetic complications arise, with a special attention to patients from lower SEP groups.