Scandinavian Journal of Public Health

Aims: The purpose of this study was to determine the risk for taking early retirement pension (ERP) in cancer survivors who were working at the time of diagnosis. Methods: We conducted a nationwide and population based cohort study including 44,905 persons aged 30—60 years diagnosed with selected cancers in the period 1981—2000 and 211,562 randomly sampled cancer-free controls. Information on socioeconomic status, demography and physical and psychiatric comorbidity was obtained from Danish administrative registries. Results: We analyzed the risk for ERP adjusted for known risk factors and found that cancer patients has an excess risk of ERP compared to cancer-free controls (RR, 1.60; 95% CI, 1.55—1.65 and RR, 1.55; 95% CI, 1.46—1.65 for women and men, respectively). The observed risk factors for taking ERP were late age, dissimilated disease, manual job, sickness leave the year before taking ERP, physical and psychological comorbidity, low education and low income. Three risk categories were identified (high, medium and low) by cancer site and we found that in the high risk category, people diagnosed with leukemia, prostate cancer or ovary cancer had a more than two-fold increased risk for ERP and the risk remained increased with up to 8 years of follow-up. Conclusions: We observed a significantly increased risk for taking early retirement up to 8 years after the cancer diagnosis and that the magnitude of the risk was dependent of cancer sites.

Background: The economic recession in Sweden in the 1990s influenced several aspects of the labour market, including the psychosocial work environment. This study examined psychosocial working conditions in relation to self-reported ill-health in the 1990s by means of the job strain model. Methods: The study was based on two representative cross-sectional samples of Swedish employed men and women in 1991 (n=3,292) and 2000 (n=3,010), together with a panel of employees who were included for both years (n=1,953). The main outcome measures were psychological distress and self-rated poor health. The primary method used was logistic regression. Results: The results suggested that although adverse psychosocial conditions increased during the 1990s, the association with health weakened. However, further analyses showed that poor health increased in most groups with various types of psychosocial conditions, and that reduced relative differences in poor health were discernible. Finally, a longitudinal analysis showed that long-term exposure to and experience of deteriorating psychosocial conditions was most detrimental for health at the end of the 1990s, once health status at baseline had been adjusted for. Conclusions: The increased prevalence of health problems among most groups with various psychosocial conditions during the 1990s, together with reduced relative differences in poor health, might make it more difficult for employers and policy-makers to direct health policies towards specific groups of employees, as the "healthy'' job seems to have disappeared. Another important inference of the results is that psychosocial working conditions seem to be causally related to health.

Objective: To estimate the prevalence of hyperemesis gravidarum (HG) in women living in Norway by their country of birth, and explore whether the variations in the occurrence of HG could be explained by the differences in maternal sociodemographic factors. Design: This was a cross-sectional study. Methods: All primiparous women registered in the Medical Birth Registry of Norway (MBRN) from 1967 through June 2005 (N=900,074) comprised the sample. Data on HG, age, plurality and sex of the fetus were obtained from the MBRN and linked to the data on country of birth and maternal education obtained from Statistics Norway. Independent associations between country of birth and HG were studied by multiple logistic regression with and without adjustment for potential confounders. Results: The overall prevalence of HG in primiparous women in Norway during the study period was 0.89% (95% confidence interval (CI) 0.88—0.92). Women born in Western Europe had the lowest prevalence of HG (0.8%), whereas those born in India and Sri Lanka had the highest (3.2%). Women born in Africa (except North Africa) and India or Sri Lanka were 3.4 (95% CI 2.7— 3.5) and 3.3 (95% CI 2.6—3.4) times more likely to develop HG than women born in Norway, after adjustment for potential confounders. Conclusions: Substantial variations in the prevalence of HG in Norway by country of birth cannot be explained by the differences in maternal sociodemographic factors.

Aims: To examine the sexual behaviour of reproductive age women in St Petersburg and its variation according to socio-demographic characteristics. Methods: A cross-sectional survey with a self-administered questionnaire. A random sample of women aged 18—44 in two districts in St Petersburg in 2004 were invited to a woman's clinic to complete a questionnaire. Of those women who were contacted (n=1719), 67% completed the anonymous questionnaire either in a clinic or at home. Results were analyzed according to three age-groups (18—24, 25—34, 35—44 years). Predictive characteristics were studied by use of multivariate models. Results: Younger respondents had on average started sexual life much earlier than the oldest (mean age 17.6 and 19.7 years respectively). The use of contraception at first coitus had become more common for each consecutive generation, though 25% of women aged 18—25 used no contraception, and only 45% used reliable contraception at first intercourse. Around 16% of the women had had two or more sex partners during the previous year, 55% of the youngest and 43% of the oldest had used reliable contraceptive methods. Older women were less likely to use contraceptives in last intercourse. High personal income, having children and low education were related to early age at first intercourse. Being single (women over 24 years) or having high income (women in all ages) was correlated with having had multiple sexual partners. Conclusions: In addition to youth, sexual education should be targeted to older women, many of whom practice risky sexual behaviour.

Aim: To study the current prevalence and trends in overweight and obesity among children and adolescents in Denmark from 1995 to 2000—2002. Methods: Cross-sectional national dietary surveys were conducted in 1995 and 2000—2002. The analysis was based on two random population samples from the Danish civil registration system. Body mass index (BMI) was calculated from self-reported height and weight for 1,026 and 1,152 children and adolescents (4—18 years), who participated in 1995 and 2000—2002, respectively. The prevalence of overweight and obesity was defined according to the international age and gender-specific child BMI cut-off points. In the statistical analysis, overweight and obesity were included in the prevalence of overweight. Results: Mean BMI increased significantly between 1995 and 2000—2002 for all combinations of age groups (4—6, 7—10, 11—14 and 15—18 years) and genders. Prevalence of overweight increased between survey years for boys and girls for all age groups (4—6, 7—10, 11—14 and 15—18 years), although formal statistical significance was not reached (p>0.05). When all children and adolescents (4—18 years) were analysed, the prevalence of overweight rose significantly from 10.9% (95% confidence interval (CI) 9.0—12.8) to 14.4% (95% CI 12.5—16.3) between 1995 and 2000— 2002 (p=0.01), whereas the increase in the prevalence of obesity did not reach significance (1995, 2.3% (95% CI 1.3—3.3) vs. 2000—2002, 2.4% (95% CI 1.6—3.3); p=0.74). Conclusions: The present study revealed a significant increase from 1995 to 2000—2002 in mean BMI for boys and girls for all age groups and a significant increase in the prevalence of overweight when all Danish children and adolescents (4—18 years) were analysed.

Background: Violence against women has long been considered a hidden health burden. Questions about violence have not been included in health surveys; hence, little is known about prevalence and the consequences for health in the general population. No national study has been conducted in Norway. Aims: To estimate the prevalence of partner violence in Norway and the relationship between victimization and somatic health and depression and anxiety and post-traumatic stress symptoms. Methods: Data collection was performed by Statistics Norway. Among a random sample of women aged 20—55 years, 2,407 women returned the questionnaire (63.3%), of whom 2,143 were ever-partnered. Selected demographic characteristics were obtained from registers. Results: In total, 26.8% of 2,143 ever-partnered women had experienced any violence by their partner during their lifetime, and 5.5% in the year before the study. Low educational level, being unmarried, separated or divorced, currently being unemployed, receiving social security benefits and having no children were significantly associated with reporting partner violence. Exposure to partner violence was associated with poor health, depressive and post-traumatic stress symptoms, gynaecological complaints, injuries, and disability, and remained so after controlling for age, education, unemployment, relationship break-up and low economic status. Conclusions: Partner violence is common and was associated with a range of somatic and mental health problems. Thus, violence against women by their partners is an important public health concern.

Aims: The prevalence of overweight and obesity is increasing in many countries. We aimed to investigate differences in mortality and severe morbidity between underweight people (body mass index (BMI)<18.5), overweight people (BMI 25 to <30), obese people (BMI≥30), and those with normal weights (BMI 18.5 to <25). Methods: Random samples of the Swedish population aged 16—74 years in 1980—81 and 1988—89 were followed for 12 years with regard to all-cause mortality and mortality from circulatory diseases, all inpatient care, and inpatient care for circulatory and musculoskeletal diseases. Relative risks (RRs) for different levels of BMI were adjusted for age, longstanding illness, smoking, and educational level at baseline. In addition, analyses were made with delayed entry until the fourth-year after interview. Results: Obesity and underweight, but not overweight, was associated with higher all-cause mortality. Among underweight men, the adjusted RR for all-cause mortality was 2.4 (95% confidence interval 1.6—3.6), and among underweight women it was 2.0 (1.5—2.7), but population attributable risks (PARs) were small, at 1.2% and 2.7%, respectively. Overweight was associated with increased risks for inpatient care for circulatory diseases, with PARs being 13.4% among men and 8.1% among women, and musculoskeletal diseases (PARs were 12.7% and 12.9%, respectively). Obese men and women had about 50% higher risks of all-cause mortality than normal-weight people, PARs being 3.2% and 3.8% respectively. Conclusions: This study supports the findings of other studies, in that overweight seems to be an exaggerated risk factor for all-cause mortality, but is related to other chronic disease. Underweight and obesity generally implies greater increases of RRs, but avoidance of overweight may have greater effect on the population level with regard to reduced cardiovascular and locomotor disease.

Aims: To improve the understanding of specific clinical problems at the end of life, including the role of advancing age, physical function and cognitive function. Methods: The study is part of an explorative survey of data relevant to end-of-life healthcare services during the last 3 months of life of a randomly selected sample of the population of a Swedish county. Data were selected through retrospective reviews of death certificates and medical records, and comprise information from 12 municipalities and 229 individuals. Results: A range of prevalent concerns was found. Overall deterioration, urinary incontinence, constipation, impaired skin integrity, anxiety and sleep disturbances were significantly associated with dependency on others for activities of daily living; pulmonary rattles and swallowing disturbances were associated with cognitive disorientation; excepting cough, advancing age did not have significant impacts on these prevalent clinical concerns. Conclusions: A range of distressing conditions constitute a common pathway for many individuals at or near the end of life. The incorporation of health promotion as a principle of palliative care will probably benefit individuals at the end of life, and includes a proactive focus and emphasis on enhanced well-being at the time of diagnosis of a life-threatening illness. For individuals with physical and cognitive limitations imparting a state of dependency, it is reasonable to provide assurance of care for individuals' specific needs by professionals with both training for and competence in this special and sometimes unique clinical environment.

Aims: To assess changes in access to highly active antiretroviral therapy (HAART) between the end of 2002 and the end of 2005, and to review the capacity for further HAART scale-up in the then 52 Member States of the WHO European Region. Methods: Analysis of data from four surveys evaluating access to HAART, supplemented by regional estimates of the number of people receiving HAART. Changes in access to HAART are evaluated in terms of changes in the number of people receiving HAART over time and changes in country-level HAART coverage. Results: During 2003—2005, the total number of individuals receiving HAART increased by an estimated 101,000, from 242,000 to 343,000 (a 42% increase); 85,000 were in the west region (a 36% increase) and 16,000 in the centre and east regions (a 229% increase). The number of countries providing "high'' coverage with HAART (>75% of those in need receiving it) increased from 29 to 38, and the number of countries providing no HAART declined from eight to four. Conclusions: Despite high and increasing coverage in many European countries, access to HAART remained inequitable in terms of geographical location. By the end of 2005, all countries in the west provided "high'' HAART coverage as compared with half of countries in the centre and east. Six east countries still provided poor or no HAART coverage. Countries must address how to further equitably increase the number of people receiving HAART.

Aims: To analyse whether there is an association between sex and poor self-reported health (SRH) and psychological distress in Kurdish immigrants. Methods: This cross-sectional study is based on a sample consisting of immigrants, aged 27— 60 years, with self-reported Kurdish ethnicity (n=111, men; n=86, women) in Sweden originating from Iran and Turkey. It is based on data collected in 1996 from the first Swedish National Survey on the living conditions of immigrant groups conducted by Statistics Sweden. The prevalences of reporting poor health, sleeping difficulties, general fatigue and anxiety were estimated by sex. The association between sex and SRH and psychological distress was analysed by an unconditional logistic regression model estimating odds ratios (OR) with 95% confidence intervals. The final model was adjusted for age, marital status, education, housing and employment. Immigrant-specific migration-related variables were used to explore possible reasons for the sex differences. Results: Kurdish men and women had a high prevalence of poor SRH and psychological distress. Age-adjusted odds ratios for anxiety were higher in Kurdish women. Sex differences in anxiety remained even when marital status, education, housing and employment were taken into account. Conclusions: Kurdish men and women report a high prevalence of poor SRH and indicators of psychological distress. Women had a higher risk for anxiety than men. Negative experiences of pre-migration as well as post-migration experiences, such as economic difficulties, preoccupation with the political situation in the home country, perceived discrimination, and feelings of poor control over one's life, were associated with the outcomes.

Background: Developing a better understanding of if, and when, patients need care at a general hospital is an urgent challenge, as the proportion of general hospital beds being occupied by older patients is continuously increasing. Methods: In a randomized controlled trial, of 142 patients aged 60 years or more admitted to a city general hospital due to acute illness or exacerbation of a chronic disease, 72 (intervention group) were randomized to intermediate care at a community hospital, and 70 (general hospital group) to further general hospital care. The patients were followed up for 12 months. The need for long-term home care and nursing homes, mortality and the number of admissions and days in general hospital for all diseases were monitored. Results: Thirty-five patients, 13 (18.1%) of the patients included in the intervention group and 22 (31.4%) in the general hospital group, died within 12 months (p=0.03). Patients in the intervention group were observed for a longer period of time than those in the general hospital group; 335.7 (95% confidence interval (CI) 312.0—359.4) vs. 292.8 (95% CI 264.1—321.5) days (p=0.01). There were statistically no differences in the need for long-term primary-level care or in the number of admissions or days spent in general hospital beds. Conclusions: Intermediate care at the community hospital in Trondheim is an equal alternative to ordinary prolonged care at the city general hospital, as fewer patients were in need of community care services, and significantly fewer patients died during the 12-month follow-up time.

Aims: To compare belief in own effort to stay healthy, health behaviour and body mass index (BMI) among non-Western immigrants with Danish citizenship and citizens with Danish background. Methods: Based on the National Health Interview Survey 2005, logistic regression analyses were used to examine differences in belief in own effort to stay healthy, in health behaviour and in BMI between 136 non-Western immigrants with Danish citizenship and 9,901 citizens with Danish background in the age group 25—64 years. Results: Non-Western immigrants had lower odds for reporting that own effort is very important to maintain good health (odds ratio (OR) 0.45; 95% confidence interval (CI) 0.32—0.62) and for reporting consuming more alcohol on a weekly basis than recommended by the Danish National Board of Health (OR 0.21, 95% CI 0.09—0.51). The odds were higher for non-Western immigrants for than citizens with Danish background for reporting sedentary spare-time activities (OR 2.96, 95% CI 1.96—4.17), daily consumption of boiled vegetables (OR 2.50, 95% CI 1.77—3.53), and daily consumption of salad/raw vegetables (OR 2.84, 95% CI 2.02—3.99). We found no differences in daily smoking, daily fruit consumption, BMI≥25 or BMI≥30. Conclusions: The non-Western immigrants are healthier in terms of alcohol and vegetable consumption and unhealthier with regard to leisure-time physical activity. The non-Western immigrants are less likely to report that their own effort is important in maintaining good health.

Aims: To assess the Edinburgh Postnatal Depression Scale (EPDS), a self-administered questionnaire created to screen for symptoms of postpartum depression in the community, from an epidemiological and ethical perspective. Screening, as the practice of investigating apparently healthy individuals to detect unrecognised disease or its precursors, has interpretation problems and is complicated by deliberations on probabilities for something to occur, on which the scientific community is unanimous. Methods: Our ethical analysis is made using a framework with two different dimensions, the ethical principles autonomy and beneficence and the affected persons. To balance the ethical costs and the ethical benefits of EPDS an analogy with the assessment of pharmaceutics is used. Results: In this article we argue that routine EPDS screening of Swedish postpartum women would lead to considerable ethical problems due to the weak scientific foundation of the screening instrument. Despite a multitude of published studies, the side-effects in terms of misclassifications have not been considered carefully. The EPDS does not function very well as a routine screening instrument. The dualism created is too reductive and fails to recognize the plurality of difference that exists in the social word. Conclusions: Public health authorities should not advocate screening of unproved value. Screening is not just a medical issue but also an ethical one.