Scandinavian Journal of Public Health

Aim: To define the probability of foetal and neonatal death (PFND) in Lithuania by means of the Medical Birth registry. Methods: The Medical Birth registry for the year 2002 (29,619 pregnancies resulting in delivery) was used, covering social, environmental, health behaviour factors, obstetric history, health status of pregnant women, and delivery. Results: A statistically significant model has been obtained in which 12 out of 45 analysed factors were significant for the risk of perinatal mortality (PM). In the case of previous neonatal pathology, e.g. damage to CNS, the risk of PM (OR 5.2; 95% CI=2.1—13.3) was similar to the reported manual work or harmful working conditions during pregnancy (OR 4.8; 95% CI=1.9—12.1 and OR 4.5; 95% CI=1.3—15.2, respectively). The influence of father's alcohol abuse (OR 2.6; 95% CI=1.4— 4.7) was comparable to that of the stillborns or premature deliveries. The combination of several factors increased PFND significantly: maternal smoking during pregnancy and paternal smoking and alcohol abuse raised PFND to 0.03 (OR 6.8), mother's hard manual work in combination with harmful conditions during pregnancy increased OR more than 10 times (PFND 0.32) as compared with the situation when only one of those factors was present. Conclusions: The influence of social, environmental, and behavioural factors on the risk of PM was comparable to that of some of the complications during a previous pregnancy. The combination of risk factors significantly increased PFND. Using modelling, the individual prognosis may be presented to every pregnant woman at an early stage of pregnancy to potentially decrease the impact of unfavourable risk factors on PM.

Aims: To examine indices of two plausible pathways linking housing conditions in childhood and adult cause-specific mortality: sanitary conditions and economic deprivation. To investigate if the effects of these are explained by education. Methods: Linked register study (housing information from the 1960 Census, the educational register in 1990 and the death register 1990—998). A Sanitary Conditions Index (SCI) and an Economic Deprivation Index (EDI) were constructed from the housing conditions variables. Participants: All men aged 30—54 years (n=55,761) who were residents in Oslo on 1 January 1990 with complete information on housing conditions (80%). Results: Both SCI and EDI were related to all-cause mortality independently of each other. Education explained to a large extent these effects. In a sub-sample, 24% of the effects could be explained by parental education and 31% by own education. The effects found for causes of death failed to give a heterogeneous pattern between the two indices. In the fully adjusted model psychiatric causes of death appeared to be more related to EDI than SCI. Conclusions: The two indices of childhood social circumstances, sanitary conditions and economic deprivation, appeared to be independently associated with all-cause mortality. The effect of both could to a large extent be explained by parental and own education.

Aim: In most countries there are gender differences in sickness absence and in absentees' return to work (RTW). According to different theories sick-listed persons' experiences of encounters with healthcare professionals can influence self-esteem and RTW. The aim was to analyse gender differences in sickness absentees' experiences of negative encounters with healthcare professionals. Methods: A questionnaire, comprising numerous questions on experiences of positive and negative encounters with professionals, was constructed and sent to 10,100 individuals who had been on sick leave for the last 6—8 months. The response rate was 58% (n=5,802). Results: Almost one-third (32%) of the female respondents and one-quarter of the male (24%), respectively, had experienced negative encounters. The most common of such experiences among both women and men were: that they were treated with indifference, with disrespect, that the professional did not take his/her time, did not listen, did not believe in, or doubted complaints. In regression analyses the women had higher significant crude odds ratios, ranging from 1.29 to 1.71, for agreeing to the separate statements on negative encounters. When adjusting for age, ethnicity, and level of education the gender differences were still significant for 14 of the 23 the statements. Conclusion: Women's high rate of sickness absence is considered a problem in most countries. The subjective experiences of women are an important factor to consider in efforts aiming at reducing the sick-leave rates. One important endeavour among professionals in healthcare could be to shift the focus towards a more empowering professional role.

Aims: This study examines the construction of the ``heart disease candidate'' in advertisements for cardiovascular drugs in Scandinavian medical journals. Methods: All advertisements for cardiovascular drugs (n=603) in Scandinavian medical journals (Denmark, Finland, Norway, and Sweden) in 2005 were collected. Only advertisements that portray users (n=289, 48% of the advertisements) were analyzed. Results: The results show that coronary candidacy is constructed as a male condition in half of the advertisements for cardiovascular drugs. The advertisements suggest a gendering of heart disease: men are the major victims of heart failure and cardiac insufficiency, and women are in need of cholesterol-lowering drugs. The cardiovascular drug advertisements portray a restoration of men's hyperactive agency, valorized by means of sporty images, by drawing on masculinity as a fixed trait and behavior. Hypercholesterolemia as a woman's disease reproduces the tyranny of slimness for women: Only women's stoutness is medicalized, and there are no pictures of heavy men. Conclusions: The findings point to the public health implications of gendered images of coronary candidacy in medical advertising.

Aims: First, to examine whether autonomy-supportive and self-efficacy-enhancing individual lifestyle counselling was associated with improved maintenance of heart-protective diets and smoking cessation compared with group-based counselling. Second, to investigate to what extent reported motivation was associated with maintenance of dietary changes. Methods: A randomized controlled trial and longitudinal study of predictor variables in a four-week heart rehabilitation setting with two years follow-up. A total of 176 (38 female) patients were included, mainly with coronary heart disease. The main outcome measures were dietary changes and smoking cessation. Motivational factors were tested for predictive power in the three dietary outcomes: daily intake of fruit and vegetables, a low saturated fat diet, and weekly intake of fish dinners. Results: No clinically significant difference in improvement of dietary maintenance was found between the two groups. The between-group difference in smoking status change was statistically insignificant (p=0.12). Both groups showed an improvement in their dietary measures. Self-efficacy predicted an increased frequency of eating fish dinners (p=0.001) and more daily units of fruit and vegetables (p<0.001). Autonomous motivation had a marginal association with increased intake of fruits and vegetables (p=0.08) and was significantly associated with a lower saturated fat diet (p=0.001). Conclusions: Among this highly motivated group of rehabilitation patients, no effect was found of adding autonomy-supportive, individual counselling to group-based interventions. Based on longitudinal documentation, this cardiac rehabilitation programme improves long-term maintenance of dietary changes, and this maintenance is related to autonomous motivation and self-efficacy.

Background: Despite effective treatments and preventive measures for the major causes of child illness and death in less wealthy nations, child mortality remains high in resource-poor settings due in part to ineffective health service delivery models. Methods: The Navrongo Community Health and Family Planning Project is a longitudinal community trial of alternative organizational strategies for health service delivery in a rural, impoverished area of Ghana. In one area, nurses are placed in communities with doorstep visitation and service responsibilities. A second area includes training of a local health volunteer and community involvement in health delivery. A third area combines both strategies. Under-five mortality rates were calculated and Poisson regression was used to adjust for potential confounding characteristics. Results: In areas with village-based community nurse services, under-five child mortality fell by 14% during five years of program implementation compared with before the intervention, with reductions in infant (5%), early child (18%), and late child (39%) mortality. The volunteer intervention was associated with a 14% increase in mortality, primarily driven by a 135% increase in early child mortality. Areas with both nurses and volunteers saw an 8% increase, with small increases in all age groups. Mortality in a comparison area with standard Ministry of Health services fell by 4% during the same time period. Conclusions: These results suggest that convenient, accessible professional nursing care can reduce child mortality in impoverished African settings. However, they do not demonstrate a beneficial effect of community volunteers and suggest a possible negative impact on children's survival.

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.

Background: The potential risks of Swedish moist snuff (snus) are debated and studies have shown diverging results. Aims: The aim of this study is to investigate whether there is any excess risk of ischaemic heart disease (IHD) and stroke from snuff use. Methods: The Swedish Survey of Living Conditions from 1988—89 was record-linked to the Swedish Cause of Death Register and the Swedish Hospital Discharge Register to investigate excess mortality and hospitalization from IHD and stroke. A Poisson regression model was used and incidence rate ratios (IRRs) for snuff and smoking were calculated controlling for age, physical activity, self-reported health, number of longstanding illnesses, residential area, and socioeconomic position. Results: Among snuff users there were no excess risks of mortality or hospitalization from IHD (IRR 0.8; 0.5—1.2,) or stroke (IRR 1.1; 0.7—1.8), but, as expected, clear excess risks were found for smokers (IRR 1.7; 1.4—2.1 for IHD, and IRR 1.4; 1.0—1.9 for stroke). Conclusions: This study has not shown any excess risk among users of snuff for IHD or stroke. If there is a risk associated with snuff it is evidently much lower than those associated with smoking.

Aim: Sweden's child injury fatality rates are among the lowest in the world. The country has engaged in a number of community injury-prevention programmes. The purpose of this study was to compare child injury hospitalization rates from the Skaraborg District with the rest of Sweden. Our study hypothesis was that municipalities that offered comprehensive child injury-prevention programmes would see significant decreases in their child injury hospitalization rates, compared with other areas. Methods: The study areas comprised three groups, consisting of municipalities in Skaraborg that had adapted the Safe Communities approach to injury prevention programmes, other municipalities in the District, and the rest of Sweden. The aim of the analysis was twofold: (1) to fit time trends for children's injuries in various areas in an integrated manner; and (2) to compare time trends across locations between community safety-promotion programmes as well as with the control areas. Panel data models and parametric splines were used. Results: There were differences between incidence rates in the study areas and with regard to gender. There was a steep decrease in injury rates in one of the Safe Communities study areas for both genders. Conclusions: The methods applied in this analysis reveal more detailed and sophisticated time trends than the usual simple linear regression approach. The model provided a clearer view of the interactions of gender, area, and time as they impacted on children's injuries, and allowed for better insight into the impact of safety programmes.

Aims: To describe the accumulated prevalence of HIV testing in the Danish population until and including the year 2000. Methods: The study was based on nationally representative data from the Danish Health Interview Survey 2000. Multiple logistic regression analysis investigated the association between HIV testing and background variables, such as gender, age, marital status, educational level, and sexual orientation. Results: Overall 28.5% of the Danish population aged over 16 years have ``ever been tested for HIV''. More females (29.4%) than males (27.6%) were tested; 12.6% might not be aware of their blood being HIV tested when donating blood. More males (17.1%) than females (13.8%) had donated blood after 1985. Although males 30—39 years old were the most tested, males 50—59 years old had the highest odds of having donated blood after 1985. Concerning education, the less education one had, the less likely one was to have been HIV tested. Of men having sex with men, only 44% were ``ever HIV tested''. Conclusions: Positive association between extent of HIV testing and some sociodemographic factors was seen. Heterosexuals are HIV tested at lower rates than men having sex with men. Yet, stronger promotion of HIV testing among men having sex with men is recommended. Targeting prevention efforts towards other known risk groups is also recommended.

Aim: This study explored professionals' and trusted community inhabitants' explanations of the violence between intimate partners and their suggestions for preventive activities. It was performed in a rural district in northern Vietnam. Methods: A total of 20 men and 20 women were strategically selected for focus-group discussions and the analyses followed the procedure for qualitative thematic content analysis. Results: It was pointed out that violence against women was not discussed openly in the community and women subjected to violence kept silent and avoided seeking help in order not to reveal what was happening in the family. The informants perceived the violence as an interplay between individual and family-related factors and sociocultural norms and practices where Confucian ideology exerted a strong influence. When it came to prevention, there was a strong belief in educating the people and in enforcing policy and law. Conclusions: As described by the informants, traditional attitudes to gender roles and women's power disadvantage are found to be behind most of the explanations for intimate partner violence. Collaboration between sectors at local level, between the health sector and other bodies, and with community leaders as spokesmen would help to improve openness and reduce society's tolerance of violence against women. The mass media also have an important role to play.

The increasing use of the risk concept in healthcare has caused concern among medical doctors, especially general practitioners (GPs). Critics have claimed that risk identification and intervention create unfounded anxiety, that the concept of risk is not useful at the individual patient level, that patients' risk concept is different from an epidemiological one, that resources are better spent elsewhere, or that commercial interests take advantage of risk information to promote sales. In this paper the authors discuss the concept of risk and address the critique. There is evidence that commercial interests promote risk interventions, that patients may misunderstand risk information, and that risk information can cause unnecessary anxiety. The authors have found no empirical data on the amount of time primary healthcare providers spend on risk interventions, and have not identified any valid arguments that risk information is not useful for the individual patient. Decision-making under uncertainty is a core element of medical practice, and GPs need to be suitably trained to inform patients such that they make good decisions when they are faced with uncertainty. The concept of risk is therefore useful for GPs, and in fact a key issue. It is concluded that risk critique should be based on sound theory and empirical data. Critics may do well in making clear distinctions between facts and value judgements.

Aims: The aim of this paper is to review the literature concerning the existence of prestige hierarchies for medical specialities and diseases. Moreover, the implications of prestige for priority setting in healthcare systems are discussed. Methods: The study is based on a review of the literature. Papers were obtained through the National Library of Medicine, PubMed. The search was conducted on 14 July 2005, and included articles from 1950 until that date. The medical subject headings ``disease'', ``illness'', and ``medical specialities'' were combined with the search word ``prestige''. A total of 183 papers were found. Only studies focusing on prestige hierarchies for medical specialities and diseases were included. The final search identified 20 articles, six of which specifically established hierarchies for medical specialities and diseases. Results: The review documented prestige hierarchies for medical specialities and diseases. Explanatory characteristics behind the distribution of prestige were identified. It was demonstrated that active, specialized, biomedical, and high-technological types of medicine practised on organs in the upper part of the bodies of young or middle-aged people were accorded high levels of prestige. Medicine with the opposite characteristics had low levels of prestige. Conclusions: Medical specialities and diseases differ with regard to prestige. Characteristics related to specialties and diseases determine their prestige. The authors suggest that differences in prestige bear consequences for actual priority setting in healthcare systems, and contend that this should be further investigated.

Aims: To examine the feasibility of a school intervention using a personal health document adapted for adolescents. Methods: The health document was developed in close cooperation with groups of adolescents and tested among seventh-grade students at two junior high schools (n=339). The document was presented to the students by their regular teachers. For evaluation, an adolescent questionnaire was used at baseline and after one year. Results: After one year, 87% of adolescents reported having written in the health document, and 77% reported having had classes with discussions on subjects in the document. The health document was perceived as useful by 35% of the adolescents. Factors significantly related to personal usefulness were being born outside Sweden, experiencing fair treatment by teachers, being a non-smoker, and having a positive school experience. Conclusions: Implementation of a personal health document in junior high-school health education was feasible and well accepted.