Ragnar Westerling

Comparing hospital discharge records with death certificates: Can the differences be explained?

Study objective: The quality of mortality statistics is important for epidemiological research. Considerable discrepancies have been reported between death certificates and corresponding hospital discharge records. This study examines whether differences between the death certificates underlying cause of death and the main condition from the final hospital discharge record can be explained by differences in ICD selection procedures. The authors also discuss the implications of unexplained differences for mortality data quality. Design: Using ACME, a standard software for the selection of underlying cause of death, the compatibility between the underlying cause of death and the final main condition was examined. The study also investigates whether data available in the hospital discharge record, but not reported on the death certificate, influence the selection of the underlying cause of death. Setting: Swedish death certificates for 1995 were linked to the national hospital discharge register. The resulting database comprised 69 818 people who had been hospitalised during their final year of life. Main results: The underlying cause of death and the main condition differed at Basic Tabulation List level in 54% of the deaths. One third of the differences could not be explained by ICD selection procedures. Adding hospital discharge data changed the underlying cause in 11% of deaths. For some causes of death, including medical misadventures and accidental falls, the effect was substantial. Conclusion: Most differences between underlying cause of death and final main condition can be explained by differences in ICD selection procedures. Further research is needed to investigate whether unexplained differences indicate lower data quality.

Mortality in relation to employment status during different levels of unemployment

Aims: The aim of this study was to estimate whether the risk for total and cause-specific mortality was related to employment status, and whether mortality in different non-employed groups differed during high and low levels of unemployment. Methods: Structured interviews were used from the Swedish Survey of Living Conditions in 1984—89 and 1992—97, including women and men aged 18 to 64, classified as unemployed (n=2,067), retired or on temporary disability pension (n=2,674), economically inactive for other reasons (n=1,373), and employed (n=38,293). Data were linked to death certificates, as registered in the Cause of Death Register. Cox proportional hazards models were performed for the mortality risk up until eight and a half years following the interview. Results: Being unemployed (OR=1.43), retired, or on temporary disability pension (OR=2.28) or being economically inactive for other reasons (OR=1.63) was related to a risk for total mortality, after considering the level of unemployment, sociodemographic factors and longstanding illness. The risk of death due to external causes was excessive among the unemployed and among those retired or on temporary disability pension, and resulted to a large extent from suicide. The interaction between employment status and level of unemployment was not significant. Conclusions: The level of unemployment seems to have no major influence on the mortality risk. Future interventions for the non-employed groups should focus on preventing avoidable mortality, such as injury and suicide.

Health literacy among refugees in Sweden – a cross-sectional study

BackgroundRefugees have poorer health compared to indigenous populations, which may be explained by lower health literacy, i.e. not being able to access, understand, appraise or apply health information. This study aims to determine levels of functional and comprehensive health literacy, and factors associated with inadequate health literacy, in refugees coming to Sweden.MethodA cross-sectional study was performed among 455 adult refugees speaking Arabic, Dari, Somali or English. Participants in 16 strategically selected language schools for immigrants responded to a questionnaire. Health literacy was measured using the Swedish Functional Health Literacy Scale and the HLS-EU-Q16 questionnaire. Uni- and multivariate statistical methods were used to investigate group differences.ResultsThe majority of the participating refugees had inadequate or limited functional health literacy and comprehensive health literacy. About 60% of them had inadequate functional health literacy and 27% had inadequate comprehensive health literacy. Low education and/or being born in Somalia were factors associated with an increased risk of having inadequate functional health literacy. Having inadequate functional health literacy was associated with an increased risk of having inadequate comprehensive health literacy.ConclusionsThe majority of refugees in the language schools had limited or poor health literacy. Health literacy should be taken into consideration in contexts and in activities addressing migrants. More research is needed to better understand health literacy among refugees and to develop strategies and methods to increase health literacy and make life easier for those with low health literacy.

Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination

To explore why parents refused to allow their 10‐ to 12‐year‐old daughters to receive the human papillomavirus (HPV) vaccination from the Swedish school‐based vaccination programme.

The influence of locus of control on self-rated health in context of chronic disease: a structural equation modeling approach in a cross sectional study

BackgroundSelf-rated health is a robust predictor of several health outcomes, such as functional ability, health care utilization, morbidity and mortality. The purpose of this study is to investigate and explore how health locus of control and disease burden relate to self-rated health among patients at risk for cardiovascular disease.MethodsIn 2009, 414 Swedish patients who were using statins completed a questionnaire about their health, diseases and their views on the three-dimensional health locus of control scale. The scale determines which category of health locus of control – internal, chance or powerful others – a patient most identifies with. The data was analyzed using logistic regression and a structural equation modeling approach.ResultsThe analyses showed positive associations between internal health locus of control and self-rated health, and a negative association between health locus of control in chance and powerful others and self-rated health. High internal health locus of control was negatively associated with the cumulative burden of diseases, while health locus of control in chance and powerful others were positively associated with burden of diseases. In addition, age and education level had indirect associations with self-rated health through health locus of control.ConclusionsThis study suggests that self-rated health is positively correlated with internal locus of control and negatively associated with high locus of control in chance and powerful others in patients at high risk for cardiovascular disease. Furthermore, disease burden seems to be negatively associated with self-rated health.

Health and healthcare utilization among single mothers and single fathers in Sweden.

Aims: To analyse self-rated health and healthcare utilization with regard to whether the respondents were single or couple parents, mothers or fathers. Methods: A postal questionnaire was distributed nationwide to 4,000 randomly chosen individuals 20—64 years of age, with a response rate of 66%. A total of 1,041 respondents had legal custody of a child (150 were single parents and 891 were couple parents), and thus met the definition of a parent used for this study. Analyses of self-rated health and health care utilization were performed according to sex, age, sociodemographic, and socioeconomic characteristics. Three different statistical methods were applied: Spearman correlation analyses, chi-square analyses and multivariate logistic regression. Results: Both single fathers and single mothers reported worse health than their couple counterparts. However, single fathers had contact with a physician more frequently (OR 1.84) than couple fathers, whereas single mothers did not. Furthermore, single mothers refrained from seeing a physician despite a medical need much more often (OR 2.07) than couple mothers. Conclusions: An uneven distribution of sociodemographic and socioeconomic characteristics might help us to understand why single parents, both mothers and fathers, have worse health than parents who live together. Previously recognized gender differences with regard to healthcare utilization were present in our study as well, and it is possible that these differences are related to the unequal distribution of sociodemographic and socioeconomic assets between single fathers and single mothers found here.

Using ‘amenable mortality’ as indicator of healthcare effectiveness in international comparisons: results of a validation study

Background and study aims There is widespread consensus on the need for better indicators of the effectiveness of healthcare. We carried out an analysis of the validity of amenable mortality as an indicator of the effectiveness of healthcare, focusing on the potential use in routine surveillance systems of between-country variations in rates of mortality. We assessed whether the introduction of specific healthcare innovations coincided with declines in mortality from potentially amenable causes in seven European countries. In this paper, we summarise the main results of this study and illustrate them for four conditions. Data and methods We identified 14 conditions for which considerable declines in mortality have been observed and for which there is reasonable evidence in the literature of the effectiveness of healthcare interventions to lower mortality. We determined the time at which these interventions were introduced and assessed whether the innovations coincided with favourable changes in the mortality trends from these conditions, measured using Poisson linear spline regression. All the evidence was then presented to a Delphi panel. Main results The timing of innovation and favourable change in mortality trends coincided for only a few conditions. Other reasons for mortality decline are likely to include diffusion and improved quality of interventions and in incidence of diseases and their risk factors, but there is insufficient evidence to differentiate these at present. For most conditions, a Delphi panel could not reach consensus on the role of current mortality levels as measures of effectiveness of healthcare. Discussion and conclusions Improvements in healthcare probably lowered mortality from many of the conditions that we studied but occurred in a much more diffuse way than we assumed in the study design. Quantification of the contribution of healthcare to mortality requires adequate data on timing of innovation and trends in diffusion and quality and in incidence of disease, none of which are currently available. Given these gaps in knowledge, between-country differences in levels of mortality from amenable conditions should not be used for routine surveillance of healthcare performance. The timing and pace of mortality decline from amenable conditions may provide better indicators of healthcare performance.

Care or Not Care—that is the Question: Predictors of Healthcare Utilisation in Relation to Employment Status

BackgroundInternational research shows that there is a higher use of care among the unemployed than among the employed, although the findings on the association between unemployment and healthcare use are not conclusive.PurposeTo examine the association between healthcare use and employment status and the factors influencing this relationship.MethodDuring 2002, a questionnaire was sent to 1,000 persons who had recently registered as unemployed (participation rate: n = 570) and to a sample of 1,000 persons representing the Swedish population (participation rate: n = 641). The study design was cross-sectional. Persons still unemployed or otherwise not employed (n = 416) were compared with the employed (n = 414) using logistic regression analyses.ResultsAbout half of those in the unemployed group had contacted a physician. The unemployed were also more likely to have needed but not sought care. Being in the unemployed group was a statistically significant risk factor for reporting unmet care needs, after adjusting for sociodemographic factors (OR = 1.53). The risk of abstaining from seeking care did not persist when considering economy and social network. Among those with unmet care needs, there was still a higher risk in the unemployed group of reporting: a small social network (OR = 2.73), economic hardship (OR = 2.87) and symptoms of depression (OR = 2.04).ConclusionsUnemployment is a risk factor for both contacting a physician and for unmet care needs. A low social network and economic hardship are more present among persons who abstain from seeking healthcare and seem to be more common among the unemployed. The healthcare system should also be aware of the fact that some unemployed people with symptoms of depression abstain from seeking care.

Social capital and inequality in health between single and couple parents in Sweden

Aims: To study whether social capital is associated with health among parents and if so, whether existing inequalities in health between single and couple parents could be better understood by introducing social capital as a possible mechanism for how health is distributed. Material and methods: At total of 2,500 parents with children in the age range of 4—16 years were randomized from existing national registers and asked to participate in a nationally distributed postal questionnaire; 1,589 parents participated (277 single and 1,312 couple), giving a response rate of 64%. The questionnaire contained questions regarding sociodemographic and socioeconomic characteristics, self-rated health, emotional and instrumental social support, civic and social participation, and trust. Social capital was measured by different levels of civic and social participation and trust. A multivariate analysis was used in order to find possible associations between social capital and health, when adjusted for social support, sociodemographic and socioeconomic characteristics. Results: A low level of social capital (both social participation and trust), when adjusted for social support, socioeconomic and sociodemographic variables, was clearly and positively associated with less than good self-rated health. Social capital was unevenly distributed between single and couple mothers. Conclusions: Social capital is positively associated with self-rated health, at an individual level. The uneven distribution of social capital between single and couple mothers may be of some importance when trying to further understand and possibly alter the inequality in health that exists between single and couple parents.

Immigrant women's experiences and views on the prevention of cervical cancer: a qualitative study.

Many Western countries have cervical cancer screening programmes and have implemented nation‐wide human papillomavirus (HPV) vaccination programmes for preventing cervical cancer.