Thor Lithman

Children’s exposure to nitrogen dioxide in Sweden: investigating environmental injustice in an egalitarian country

Study objective: Prior studies have shown that children are particularly sensitive to air pollution. This study examined whether children of low socioeconomic status suffered greater exposure to outdoor nitrogen dioxide than more affluent ones, both at their place of residence and at school, in a country with widespread state intervention for social equity. Design: Local scale data on outdoor nitrogen dioxide obtained from a validated air pollution model were analysed, along with all school children accurately geocoded to their building of residence and school. Participants: All 29 133 children in grades one through nine (aged 7 to 15 years) residing and attending school in Malmö, Sweden, in 2001. Main results: Defining the socioeconomic status of children according to the mean income in their residential building, the spatial scan statistic technique allowed the authors to identify eight statistically significant clusters of low socioeconomic status children, all of which were located in the most polluted areas of Malmö. Four clusters of high socioeconomic status children were found, all of them located in the least polluted areas. The neighbourhood socioeconomic status better predicted the nitrogen dioxide exposure of children than the socioeconomic status of their building of residence. Exposure to nitrogen dioxide at the place of residence and school of attendance regularly increased as the socioeconomic status of a child’s neighbourhood of residence decreased. Conclusions: Evidence of environmental injustice was found, even in a country noted for its egalitarian welfare state. Enforcement of environmental regulations may be necessary to achieve a higher level of environmental equity.

Influence on the Health of the Partner Affected by Tumor Disease in the Wife or Husband Based on a Population-Based Register Study of Cancer in Sweden

PURPOSE To examine health care use and health care costs among partners of persons with cancer. PATIENTS AND METHODS Partners of patients with colon, rectal, lung, breast, and prostate cancer (N = 11,076) were identified via linked data from the Tumor Registry of Southern Sweden and Census Registry of Sweden. Health care use, total costs of health care, and diagnosis of the partner were studied before and after diagnosis of the cancer patient. RESULTS Health care use for partners increased in terms of in-patient care after the cancer diagnosis. A significant increase was seen the second year for partners of patients with colon cancer (risk ratio [RR], 1.55; 95% CI, 1.28 to 1.87) and lung cancer (RR, 1.50; 95% CI, 1.26 to 1.79). Psychiatric diagnoses increased after the cancer diagnosis in the total sample, with a significant increase for partners of colon (RR, 2.66; 95% CI, 1.71 to 4.22), lung (RR, 3.16; 95% CI, 2.23 to 4.57), and prostate cancer patients (RR, 1.68; 95% CI, 1.32 to 2.15). Costs of care increased more than the consumer price index the two years after the cancer diagnosis. Costs of care increased most for male partners and especially for younger male partners (age 25 to 64 years) of patients with colon, rectal, and lung cancers. CONCLUSION The results showed increased health care costs and an increase in psychiatric diagnoses after the cancer diagnosis among partners of cancer patients. Further research is needed to learn more about the situation of the partner and to identify persons at risk of psychiatric morbidity. Knowledge is also needed on how to support the partner in the most efficient way.

The role country of birth plays in receiving disability pensions in relation to patterns of health care utilisation and socioeconomic differences: a multilevel analysis of Malmo, Sweden

BackgroundPeople of low socioeconomic status have worse health and a higher probability of being granted a disability pension than people of high socioeconomic status. It is also known that public and private general physicians and public and private specialists have varying practices for issuing sick leave certificates (which, if longstanding, may become the basis of disability pensions). However, few studies have investigated the influence of a patients country of birth in this context.MethodsWe used multilevel logistic regression analysis with individuals (first level) nested within countries of birth (second level). We analysed the entire population between the ages of 40 and 64 years (n = 80 212) in the city of Malmo, Sweden, in 2003, and identified 73% of that population who had visited a physician at least once during that year. We studied the associations between individuals and country of birth socioeconomic characteristics, as well as individual utilisation of different kinds of physicians in relation to having been granted a disability pension.ResultsLiving alone (ORwomen = 1.72, 95% CI: 1.62–1.82; ORmen = 2.64, 95% CI: 2.46–2.83) and having limited educational achievement (ORwomen = 2.14, 95% CI: 2.00–2.29; ORmen = 2.12, 95% CI: 1.98–2.28) were positively associated with having a disability pension. Utilisation of public specialists was associated with a higher probability (ORwomen = 2.11, 95% CI: 1.98–2.25; ORmen = 2.16, 95% CI: 2.01–2.32) and utilisation of private GPs with a lower probability (ORmen = 0.76, 95% CI: 0.69–0.83) of having a disability pension. However, these associations differed by countries of birth. Over and above individual socioeconomic status, men from middle income countries had a higher probability of having a disability pension (ORmen = 1.61, 95% CI: 1.06–2.44).ConclusionThe country of ones birth appears to play a significant role in understanding how individual socioeconomic differences bear on the likelihood of receiving a disability pension and on associated patterns of health care utilisation.

Low adherence with antihypertensives in actual practice: the association with social participation - a multilevel analysis

BackgroundLow adherence is a key factor in explaining impaired effectiveness and efficiency in the pharmacological treatment of hypertension. However, little is known about which factors determine low adherence in actual practice.The purpose of this study is to examine whether low social participation is associated with low adherence with antihypertensive medication, and if this association is modified by the municipality of residence.Methods1288 users of antihypertensive medication were identified from The Health Survey in Scania 2000, Sweden. The outcome was low adherence with antihypertensives during the last two weeks. Multilevel logistic regression with participants at the first level and municipalities at the second level was used for analyses of the data.ResultsLow social participation was associated with low adherence with antihypertensives during the last two weeks (OR = 2.05, 95% CI: 1.05–3.99), independently of low educational level. However, after additional adjustment for poor self-rated health and poor psychological health, the association between low social participation and low adherence with antihypertensives during the last two weeks remained but was not conclusive (OR = 1.80, 95% CI: 0.90–3.61). Furthermore, the association between low social participation and low adherence with antihypertensives during the last two weeks varied among municipalities in Scania (i.e., cross-level interaction).ConclusionLow social participation seems to be associated with low adherence with antihypertensives during the last two weeks, and this association may be modified by the municipality of residence. Future studies aimed at investigating health-related behaviours in general and low adherence with medication in particular might benefit if they consider area of residence.

Benzodiazepine prescribing patterns in a high-prescribing Scandinavian community

SummarySales statistics indicate large variations in benzodiazepine consumption between the Scandinavian countries; the current difference between Denmark (highest) and Sweden (lowest) is almost two-fold. There are also large within-country variations; e.g. benzodiazepine sales in the Swedish city of Helsingborg, which is close to Denmark, were at the average Danish level and were the highest in Sweden.Repeated prescription analyses were carried out in Helsingborg, and register data were used to compare the extent of psychiatric morbidity and psychosocial problems in this city with those in neighbouring cities.Benzodiazepine consumption was higher than the national average in all age groups. However, neither the choice of the predominant benzodiazepine agents nor the dose size or number of doses per prescription showed any major deviation. Hence, Helsingborg may have a larger proportion of benzodiazepine users or longer exposure periods among users. The latter is supported by the fact that about 40% of all benzodiazepine prescriptions were repeated. Psychiatric morbidity, suicide rate, alcohol-related diseases, unemployment and the proportion of socially isolated subjects were higher than the county average. On the other hand, within the county, there were cities that despite lower benzodiazepine sales had an equal or higher rate of suicide, unemployment and alcohol-related diseases. Of all benzodiazepine prescriptions processed in Helsingborg, >30% were issued by <5% of the prescribers (≥15 prescriptions per prescriber and per week).Thus, the higher usage of benzodiazepines in Helsingborg may partly be related to higher psychiatric morbidity and more psychosocial problems, but deviant prescribing habits among a minority of physicians are also important.

Social inequalities in health- do they diminish with age? Revisiting the question in Sweden 1999

BackgroundIndividuals with low income have poorer health and should, therefore, have higher health expenditure than people with high income particularly in countries with a universal health care system. However, it has been discussed if social inequities in health diminish with age and we, hence, aimed to analyse this question.MethodsWe performed an age stratified cross-sectional analysis using averages, logistic and linear regression modelling of health care contacts, health care expenditures and mortality in relation to individual income in five groups by quintiles. The population consisted of all the 249,855 men aged 40 to 80 years living in the county of Skåne, Sweden during 1999.ResultsFor working-age people (40-59 year old) we find a clear socioeconomic gradient with increasing probability of health care contact, relative expenditure and mortality as income decreased. The point estimations for 1st (highest)-2nd-3rd-4th and 5th (lowest) income groups were: (1.00-1.13-1.21-1.42 and 1.15), (1.00-1.16-1.29-1.69 and 1.89) and (1.00-1.35-1.44-2.82 and 4.12) for health care contact, relative expenditure and mortality respectively. However, in the elderly (75-80 year old) these point estimates were (1.00-0.83-0.59-0.61 and 0.39), (1.00-1.04-1.05-1.02 and 0.96) and (1.00-1.06-1.30-1.33 and 1.49).ConclusionsAs expected among working-age individuals, lower income was associated with higher health care contact, relative expenditure and mortality. However, the existence of opposite socioeconomic gradients in health care utilisation and mortality in the elderly suggests that factors related to a high income might condition allocation of resources, or that current medical care is ineffective to treat determinants of income differences in mortality occurring earlier in the lifecourse.

Low Cancer Rates among Patients with Dementia in a Population-Based Register Study in Sweden.

Background: Some studies have suggested a lower incidence of cancer in patients with dementia. We studied this further for 18 cancer types in population-based registers. Methods: In 19,756 cases and in 147,324 age- and sex-matched controls a diagnosis of dementia was studied 9–45 months prior to the diagnosis of cancer. Results: Overall a diagnosis of dementia was significantly less common among the cancer cases (risk ratio, RR = 0.60; 95% CI = 0.52–0.69). Conclusion: The study confirms previous findings that patients with dementia have a lower risk of cancer. Because the effect was seen for all tumour types and especially for patients older than 70 years and since the deficit was more pronounced for patients with tumours situated within the body, the data suggest that malignancies are underdiagnosed for persons with dementia.

The Danish effect on Swedish alcohol costs An analysis based on hospitalization data from southern Sweden.

This study investigated: (a) the cost and change in hospitalizations related to alcohol misuse for the healthcare sector and (b) the effect of distance to the border on alcohol-related hospitalization costs. The first objective was analyzed using descriptive statistics and the second using ordinary least squares regression on aggregated municipality data. The total cost decreased marginally during the study period while the number of patient-cases decreased substantially, presenting evidence of a substitution towards outpatient care. The increase in average treatment cost and the almost constant total cost provide evidence for a societal increase in the burden of alcohol-related diseases. We found a negative effect for distance to Denmark on alcohol-related hospitalization cost for the year 2003. The effect was smaller for 1998, suggesting that the increase in private import quotas during the study period has affected individuals’ consumption level and/or consumption pattern. We also found indications that the increase in import quotas lead to a higher cost increase for heavy consumers than for low consumers.

Prostate cancer - Prevalence-based healthcare costs

Objective: To calculate the total costs of in‐ and outpatient healthcare for patients with prostate cancer based on an episode‐of‐care approach. The cost analysis includes costs incurred during the first year of diagnosis, a longitudinal 3‐year analysis and the incremental cost of prostate cancer during the first year of diagnosis. Material and Methods: Patients registered with prostate cancer between 1998 and 2000, according to the data files of the Southern Swedish Regional Tumour Registry, were given encrypted identifiers that could also be used in the Patient Administrative System of the Region Skåne County Council, making it possible to identify consumption of healthcare on an episode‐of‐care basis. Itemized costs for resources used by each individual patient were calculated from the complete accounting system of the County Council. Results: Healthcare costs for prostate cancer during the first year varied between 45 000 and 51 000 SEK per patient. The second‐ and third‐year costs were progressively lower, with an estimated total cost of 114 000 SEK over a period of 3 years. The age‐standardized incremental cost of prostate cancer corresponded to 33 000 SEK during the first year, compared to the average cost per inhabitant. Conclusions: The episode‐of‐care approach, based on encrypted identifiers for the identification of the diagnoses of individual patients and their utilization of healthcare, gives a unique opportunity to estimate the healthcare costs of specific diseases. The incremental healthcare cost per patient with prostate cancer corresponded to 33 000 SEK during the first year.

Prostate Cancer in the Pre and Post Diagnosis Phase – A Population Based Study on Health Care Costs

Prostate cancer is associated with significant health care costs and is a major public health concern. The aim of this study was to examine and analyse all direct health care costs among prostate cancer in the pre- and post diagnostic phase of the disease. The aim was also to examine if outcomes of ill health in terms of health care use and health care costs increased among partners of prostate cancer patients. We used population-based data for monitoring health care costs, including in- and outpatient care and pharmaceuticals. Health care costs were monitored in relation to time periods before and after the prostate cancer diagnosis for both patients and their partners. The major part of health care costs for prostate cancer patients occurred during the first year following the diagnosis. A clear difference was seen between costs for survivors and costs for deceased; the first year following the diagnosis costs was about 50% higher for deceased and 2-3 times higher the following years. Health care costs increased with higher Gleason score in the year following the diagnosis. Higher health care costs were seen for patients treated with primary radiotherapy. Lowest costs were seen for patients with expectancy. Health care costs were higher for patients with curative treatments compared to those with palliative treatments. Partners had an increase in health care use both the first and second year following the diagnosis of the prostate cancer patient leading to an increase in health care costs. The cost burden of prostate cancer varies along the different phases of the disease. When planning for care and allocation of resources for care the impact on the partner should also be considered.Background: This study examines health problems among military recruits in Saudi Arabia as part of work in the Medical Service Department of the Ministry of Defense to improve health care services and to raise health awareness among the people of the Kingdom. This study is part of wider work to investigate the health status of the Saudi Arabian population, and identifies areas where further development should be channelled. Methods: We adopted a cross-sectional design involving 2,518 men who were new military recruits and were screened over 4 months from July to September 2014 in the Al-Morooj health centre in Riyadh, Saudi Arabia. The results of the screening process were analysed using descriptive statistics and the Chi-squared test of association. Results: Of the screened recruits, 4.7% were carriers or affected by sickle cell disease, 3.2% suffered from colour blindness, and 0.6% tested positive for hepatitis B. 2.8% tested positive for illegal substances, with 90% of those testing positive for cannabis, and 10% for amphetamines. Conclusions: Hereditary health problems are still a major issue in Saudi Arabia, because of the culture of marriage within families. There are several programs operated by the government to reduce the burden of hereditary health problems and to raise awareness among the population, but these will take several years to show results. Other health programs to educate the public and increase awareness are needed. Funding for the health sector needs to be increased in line with other high income countries, with medical research taking a priority. Substance abuse is an increasing problem that needs to be tackled efficiently. Support and counselling programs for young people might improve the situation.