Impact of an oral care subsidization reform on intersectional inequities in self-rated oral health in Sweden.

BACKGROUND: Oral health in Sweden is good at the population level, but seemingly with persisting or increasing inequities over the last decades. In 2008, a major Swedish reform introduced universal partial subsidies to promote preventive care and reduce the treatment cost for patients with extensive care needs. This study aimed to apply an intersectional approach to assess the impact of the 2008 subsidization reform on inequities in self-rated oral health among adults in Sweden over the period 2004-2018. METHODS: Data from 14 national surveys conducted over 2004-2018 were divided into three study periods: pre-reform (2004-2007), early post-reform (2008-2012) and late post-reform (2013-2018). The final study population was 118,650 individuals aged 24-84 years. Inequities in self-rated oral health were examined by intersectional analysis of individual heterogeneity and discriminatory accuracy across 48 intersectional strata defined by gender, age, educational level, income, and immigrant status. RESULTS: Overall, the prevalence of poor self-rated oral health decreased gradually after the reform. Gender-, education- and income-related inequities increased after the reform, but no discernible change was seen for age- or immigration-related inequities. The majority of intersectional strata experienced patterns of persistently or delayed increased inequities following the reform. CONCLUSIONS: Increased inequities in self-rated oral health were found in most intersectional strata following the reform, despite the seemingly positive oral health trends at the population level. Applying an intersectional approach might be particularly relevant for welfare states with overall good oral health outcomes but unsuccessful efforts to reduce inequities.

Prevalence and change in social inequalities in physical activity before and during the COVID-19 pandemic in Sweden.

BACKGROUND: Physical activity is crucial for our wellbeing. Since the COVID-19 pandemic emerged, physical activity behaviour has changed globally, and social inequalities that already exist in physical activity have increased. However, there is limited knowledge of how these inequalities have evolved in Sweden. Thus, the aim of this study was to assess the prevalence of physical activity, and the socioeconomic inequalities in physical activity before and during the COVID-19 pandemic. METHODS: This study analysed data from the national 'Health on Equal Terms' survey which was conducted on participants between 16 and 84, through a repeated cross-sectional design in 2018 (pre-pandemic) and 2021 (during the pandemic). The socioeconomic variables included gender, age, education, occupation, income, and place of birth. For both years, the prevalence of low physical activity, the absolute risk differences, the slope index of inequality, and the slope index difference for each of the variables were calculated. RESULTS: The level of physical activity increased for the total population studied. However, the social inequalities that existed in 2018 increased over time and across age, education, occupation, income, and place of birth, but not with regard to gender. CONCLUSIONS: Even though the Swedish population increased their levels of physical activity during the COVID-19 pandemic, the social inequalities that already existed in physical activity increased. Interventions to increase the level of physical activity among the young, people with low socioeconomic status, and those born outside Sweden are needed to reduce these social inequalities, and to improve the Swedish population's wellbeing.

Impact of a performance monitoring intervention on the timeliness of Hepatitis B birth dose vaccination in the Gambia: a controlled interrupted time series analysis.

INTRODUCTION: The Hepatitis B virus that can cause liver cancer is highly prevalent in the Gambia, with one in ten babies at risk of infection from their mothers. Timely hepatitis B birth dose administration to protect babies is very low in The Gambia. Our study assessed whether 1) a timeliness monitoring intervention resulted in hepatitis B birth dose timeliness improvements overall, and 2) the intervention impacted differentially among health facilities with different pre-intervention performances. METHODS: We used a controlled interrupted time series design including 16 intervention health facilities and 13 matched controls monitored from February 2019 to December 2020. The intervention comprised a monthly hepatitis B timeliness performance indicator sent to health workers via SMS and subsequent performance plotting on a chart. Analysis was done on the total sample and stratified by pre-intervention performance trend. RESULTS: Overall, birth dose timeliness improved in the intervention compared to control health facilities. This intervention impact was, however, dependent on pre-intervention health facility performance, with large impact among poorly performing facilities, and with uncertain moderate and weak impacts among moderately and strongly performing facilities, respectively. CONCLUSION: The implementation of a novel hepatitis B vaccination timeliness monitoring system in health facilities led to overall improvements in both immediate timeliness rate and trend, and was especially helpful in poorly performing health facilities. These findings highlight the overall effectiveness of the intervention in a low-income setting, and also its usefulness to aid facilities in greatest need of improvement.

Are doctors using more preventive medication for cardiovascular disease? A Swedish cross-sectional study.

BACKGROUND: Despite decreasing mortality from cardiovascular disease (CVD), there are persistent inequities in mortality between socioeconomic groups. Primary preventative medications reduce mortality in CVD; thus, inequitable treatments will contribute to unequal outcomes. Physicians might contribute to inequality by prescribing preventative medication for CVD to themselves in a biased manner. AIM: To determine whether primary medications for preventing CVD were prescribed inequitably between physicians and non-physicians. DESIGN AND SETTING: This retrospective study retrieved registry data on prescribed medications for all physicians in Sweden aged 45-74 years, during 2013, and for reference non-physician individuals, matched by sex, age, residence, and level of education. The outcome was any medication for preventing CVD, received at least once during 2013. METHOD: Age and the sex-specific prevalence of myocardial infarction (MI) among physicians and non-physicians were used as a proxy for the need for medication. Thereafter, to limit the analysis to preventative medication, we excluded individuals that were diagnosed with CVD or diabetes. To analyse differences in medication usage between physicians and matched non-physicians, we estimated odds ratios (ORs) with conditional logistic regression and adjusted for need and household income. RESULTS: MI prevalences were 5.7% for men and 2.3% for women, among physicians, and 5.4% for men and 1.8% for women, among non-physicians. We included 25,105 physicians and 44,366 non-physicians. The OR for physicians receiving any CVD preventative medication, compared to non-physicians, was 1.65 (95% confidence interval 1.59-1.72). CONCLUSION: We found an inequity in prescribed preventative CVD medications, which favoured physicians over non-physicians.

KEYPOINTSGroups with low socioeconomic status have lower rates of using medication that prevents cardiovascular disease, compared to groups with high socioeconomic status.Physicians are responsible for prescribing all medicines to prevent cardiovascular disease; thus, biased prescriptions could have effects on the equality of care in the population.Compared to individuals with equivalent education, physicians had higher rates of using medication that prevents cardiovascular disease.This study highlights the need for systematic population-based evaluation of CVD risk in order to promote equitable CVD outcomes.

Reducing or reproducing inequalities in health? An intersectional policy analysis of how health inequalities are represented in a Swedish bill on alcohol, drugs, tobacco and gambling.

BACKGROUND: According to post-structural policy analyses, policies and interventions aiming at reducing social inequalities have been found to be part in producing and reifying such inequalities themselves. Given the central role of health inequalities on the public health policy agenda globally it seems important to examine the way policy on health inequalities may potentially counteract the goal of health equity. The aim of this intersectional policy analysis, was to critically analyze the representation of health inequalities in a government bill proposing a national strategy on alcohol, drugs, tobacco and gambling, to examine its performative power, and to outline alternative representations. METHOD: A post-structural approach to policy analysis was combined with an intersectional framework. The material was analyzed through an interrogating process guided by the six questions of the "What's the problem represented to be?" (WPR) approach. Thus, the underlying assumptions of the problem representation, its potential implications and historical background were explored. In a final step of the analysis we examined our own problem representations. RESULTS: The recommendations found in the gender and equity perspective of the bill represented the problem of health inequalities as a lack of knowledge, with an emphasis on quantitative knowledge about differences in health between population groups. Three underlying assumptions supporting this representation were found: quantification and objectivity, inequalities as unidimensional, and categorization and labelling. The analysis showed how the bill, by opting into these partly overlapping assumptions, is part of enacting a discourse on health inequalities that directs attention to specific subjects (e.g., vulnerable) with special needs (e.g., health care), in certain places (e.g., disadvantaged neighborhoods). It also showed how underlying processes of marginalization are largely neglected in the bill due to its focus on describing differences rather than solutions. Finally, we showed how different intersectional approaches could be used to complement and challenge this, potentially counteractive, problem representation. CONCLUSIONS: The problem representation of health inequalities and its underlying assumptions may have counteractive effects on health equity, and even though some of its strengths are raised, it seems to be profoundly entangled with a system resisting the kind of change that the bill itself advocates for. If carefully used, intersectionality has the potential to support a more comprehensive and inclusive equality-promoting public health policy and practice.

Intersectional equity in health care: assessing complex inequities in primary and secondary care utilization by gender and education in northern Sweden.

BACKGROUND: Knowledge remains scarce about inequities in health care utilization between groups defined, not only by single, but by multiple and intersecting social categories. This study aims to estimate intersectional horizontal inequities in health care utilization by gender and educational level in Northern Sweden, applying a novel methodological approach. METHODS: Data on participants (N = 22,997) aged 16-84 years from Northern Sweden came from the 2014 Health on Equal Terms cross sectional survey. Primary (general practitioner) and secondary (specialist doctor) health care utilization and health care needs indicators were self-reported, and sociodemographic information came from registers. Four intersectional categories representing high and low educated men, and high and low educated women, were created, to estimate intersectional (joint, referent, and excess) inequalities, and needs-adjusted horizontal inequities in utilization. RESULTS: Joint inequalities in primary care were large; 8.20 percentage points difference (95%CI: 6.40-9.99) higher utilization among low-educated women than high-educated men. Only the gender referent inequity remained after needs adjustment, with high- (but not low-) educated women utilizing care more frequently than high-educated men (3.66 percentage points difference (95%CI: 2.67-5.25)). In contrast, inequalities in specialist visits were dominated by referent educational inequalities, (5.69 percentage points difference (95%CI: 2.56-6.19), but with no significant horizontal inequity - by gender, education, or their combination - remaining after needs adjustment. CONCLUSION: This study suggests a complex interaction of gender and educational inequities in access to care in Northern Sweden, with horizontal equity observable for secondary but not primary care. The study thereby illustrates the unique knowledge gained from an intersectional perspective to equity in health care.

Self-rated health inequalities in the intersection of gender, social class and regional development in Spain: exploring contributions of material and psychosocial factors.

BACKGROUND: Inequalities in health across social class, gender and regional context in Spain are well-known; however, there is a lack of research examining how these dimensions of inequality interact. This study explores self-rated health (SRH) inequalities across intersectional positions of gender, social class and region, and the contribution of material and psychosocial factors to these inequalities. METHODS: Participants were drawn from the cross-sectional 2015 National Living Conditions Survey of Spanish residents aged 19-88 years (N = 27,215; 77% response rate). Eight intersectional positions were formed by combining dichotomous variables of gender, social class and regional development. Poisson regression was used to estimate intersectional inequalities in SRH as prevalence ratios, and the contributions of material and psychosocial factors. RESULTS: Results showed both cumulative and heterogeneous inequalities within and across intersectional positions. Inequalities in the intersection of social class and regional development were best explained by the joint contributions of material and psychosocial factors, while gender inequalities within non-manual social class were better explained by material factors alone. CONCLUSIONS: The results illustrate the complexity of interacting inequalities in health and their underpinnings in Spain. Local and national policies taking this complexity into account are needed to broadly improve equity in health in Spain.

Income inequalities in leisure time physical inactivity in northern Sweden: A decomposition analysis.

Aims: Increasing income inequalities in leisure time physical inactivity have been reported in the relatively socially equal setting of northern Sweden. The present report seeks to contribute to the literature by exploring the contribution of different factors to the income inequalities in leisure time physical inactivity in northern Sweden. Methods: This study was based on the 2014 Health on Equal Terms survey, distributed in the four northernmost counties of Sweden. The analytical sample consisted of 21,000 respondents aged 16-84. Six thematic groups of explanatory variables were used: demographic variables, socioeconomic factors, material resources, family-, psychosocial conditions and functional limitations. Income inequalities in leisure time physical inactivity were decomposed by Wagstaff-type decomposition analysis. Results: Income inequalities in leisure time physical inactivity were found to be explained to a considerable degree by health-related limitations and unfavourable socioeconomic conditions. Material and psychosocial conditions seemed to be of moderate importance, whereas family and demographic characteristics were of minor importance. Conclusions: This study suggests that in order to achieve an economically equal leisure time physical inactivity, policy may need to target the two main barriers of functional limitations and socioeconomic disadvantages.

Widespread and widely widening? Examining absolute socioeconomic health inequalities in northern Sweden across twelve health indicators.

BACKGROUND: Socioeconomic inequalities in health is a widely studied topic. However, epidemiological research tends to focus on one or a few outcomes conditioned on one indicator, overlooking the fact that health inequalities can vary depending on the outcome studied and the indicator used. To bridge this gap, this study aims to provide a comprehensive picture of the patterns of socioeconomic health inequalities in Northern Sweden over time, across a range of health outcomes, using an 'outcome-wide' epidemiological approach. METHOD: Cross-sectional data from three waves of the 'Health on Equal Terms' survey, distributed in 2006, 2010 and 2014 were used. Firstly, socioeconomic inequalities by income and education for twelve outcomes (self-rated health, self-rated dental health, overweight, hypertension, diabetes, long-term illness, stress, depression, psychological distress, smoking, risky alcohol consumption, and physical inactivity) were examined by calculating the Slope Index of Inequality. Secondly, time trends for each outcome and socioeconomic indicator were estimated. RESULTS: Income inequalities increased for psychological distress and physical inactivity in men as well as for self-rated health, overweight, hypertension, long-term illness, and smoking among women. Educational inequalities increased for hypertension, long-term illness, and stress (the latter favouring lower education) in women. The only instance of decreasing income inequalities was seen for long-term illness in men, while education inequalities decreased for long-term illness in men and poor self-rated health, poor self-rated dental health, and smoking in women. CONCLUSION: Patterns of absolute socioeconomic inequalities in health vary by health and socioeconomic indicator, as well as between men and women. Overall, trends appear more stagnant in men while they fluctuate in women. Income inequalities seem to be generally greater than educational inequalities when looking across several different health indicators, a message that can only be derived from this type of outcome-wide study. These disparate findings suggest that generalised and universal statements about the development of health inequalities can be too simplistic and potentially misleading. Nonetheless, despite inequalities being complex, they do exist and tend to increase. Thus, an outcome-wide approach is a valuable method which should be utilised to generate evidence for prioritisations of policy decisions.

What drives us apart? Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults.

BACKGROUND: Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented; however, there is a lack of research examining the social processes driving these complex inequalities. Using an intersectional framework, the current study examines key processes contributing to inequalities in smoking between four intersectional groups by education and sexual orientation. METHODS: The sample (28,362 adults) was obtained from Wave 2 (2014-2015) of the Population Assessment of Tobacco and Health (PATH) Study. Four intersectional positions were created by education (high- and low-education) and sexual orientation (heterosexual or lesbian, gay, bisexual, or queer/questioning (LGBQ). The joint inequality, the referent socio-economic inequality, and the referent sexual orientation inequality in smoking were decomposed by demographic, material, tobacco marketing-related, and psychosocial factors using non-linear Oaxaca decomposition. RESULTS: Material conditions made the largest contribution to the joint inequality (9.8 percentage points (p.p.), 140.9%), referent socio-economic inequality (10.01 p.p., 128.4%), and referent sexual orientation inequality (4.91 p.p., 59.8%), driven by annual household income. Psychosocial factors made the second largest contributions to the joint inequality (2.12 p.p., 30.3%), referent socio-economic inequality (2.23 p.p., 28.9%), and referent sexual orientation inequality (1.68 p.p., 20.5%). Referent sexual orientation inequality was also explained by marital status (20.3%) and targeted tobacco marketing (11.3%). CONCLUSION: The study highlights the pervasive role of material conditions in inequalities in cigarette smoking across multiple dimensions of advantage and disadvantage. This points to the importance of addressing material disadvantage to reduce combined socioeconomic and sexual orientation inequalities in cigarette smoking.

Languishing in the crossroad? A scoping review of intersectional inequalities in mental health.

The concept of intersectionality has gradually been introduced to health inequality research, adding depth and breadth to the way inequalities in health are approached. We conducted a scoping review with the purpose to systematically map, describe and analyze the literature about intersectional inequalities in mental health. For eligibility, the study had to analyze and report inequality defined by combinations of socioeconomic position, gender, race/ethnicity, sexual orientation or religion. The mental health outcome had to be measured as self-reported symptoms assessed through validated scales, or disorders assessed through diagnostic interviews. The search strategy was applied in two databases and the screening process yielded 20 studies. The interaction of intersectional positions showed no consistent patterns in mental health across studies, but both synergistic and antagonistic effects were observed. In most studies an absolute measure of inequality was used and few studies analyzed factors potentially explaining the intersectional inequalities. Taken together, the findings of this review highlight the value of assessing intersectional inequalities across population groups for priority setting and action on mental health inequalities.

Underpinnings of entangled ethnical and gender inequalities in obesity in Cochabamba-Bolivia: an intersectional approach.

BACKGROUND: Social inequalities in obesity have been observed not only by gender but also between ethnic groups. Evidence on combined dimensions of inequality in health, and specifically including indigenous populations, is however scarce, and presents a particularly daunting challenge for successful prevention and control of obesity in Bolivia, as well as worldwide. OBJECTIVE: The aims of this study were i) to examine intersectional inequalities in obesity and ii) to identify the factors underlying the observed intersectional inequalities. METHODS: An intersectional approach study was employed, using the information collected in a cross-sectional community-based survey. The sample consisted of youth and adults with permanent residence in Cochabamba department (N = 5758), selected through a multistage sampling technique. An adapted version of the WHO-STEPS survey was used to collect information about Abdominal obesity and risk factors associated. Four intersectional positions were constructed from gender (woman vs. men) and ethnic group (indigenous vs. mestizo). Joint and excess intersectional disparities in obesity were estimated as absolute prevalence differences between binary groups, using binomial regression models. The Oaxaca-Blinder decomposition was applied to estimate the contributions of explanatory factors underlying the observed intersectional disparities, using Oaxaca command in Stata software v15.1. RESULTS: The prevalence of abdominal obesity had a higher prevalence in mestizos (men 35.01% and women 30.71%) as compared to indigenous (men 25.38% and women 27.75%). The joint disparity was estimated at 7.26 percentage points higher prevalence in the doubly advantaged mestizo men than in the doubly disadvantaged indigenous women. The gender referent disparity showed that mestizo-women had a higher prevalence than indigenous-women. The ethnic referent disparity showed that mestizo-men had a higher prevalence than indigenous men. The behavioural risk factors were the most important to explain the observed inequalities, while differences in socioeconomic and demographic factors played a less important role. CONCLUSION: Our study illustrates that abdominal obesity is not distributed according to expected patterns of structural disadvantage in the intersectional space of ethnicity and gender in Bolivia. In the Cochabamba case, a high social advantage was related to higher rates of abdominal obesity, as well as the behavioural risk factors associated with them.

Access for all? Assessing vertical and horizontal inequities in healthcare utilization among young people in northern Sweden.

BACKGROUND: Previous studies in Sweden have detected socioeconomic inequities in access to healthcare services. However, there is limited information regarding access in younger populations. The aim of this study was to explore vertical and horizontal inequities in access to healthcare services in young adults in the north of Sweden. METHODS: The study used data from the Health on Equal Terms survey (age group 16-24 years, n = 2726) for the health and healthcare variables and from national registers for the sociodemographic characteristics. Self-rated healthcare utilization was measured as visits to general practitioners, youth clinics and nurses. Crude and multivariable binomial regression analysis, stratified by sex, was used to assess vertical equity, adjusting for sociodemographic characteristics, and horizontal equity, adjusting for need variables. RESULTS: Vertical inequity was detected for all three healthcare services (youth clinics, general practitioners and nurses), with variations for men and women. Horizontal inequities were also found for both men and women in relation to all three healthcare services. CONCLUSIONS: These findings suggest that both vertical and horizontal inequities in access exist for young people in northern Sweden and that the associations between sociodemographic characteristics and healthcare utilization are complex and need further investigation.

The moderating effect of income on the relationship between body mass index and health-related quality of life in Northern Sweden.

Objectives: This study aimed to investigate the relationship between body mass index (BMI) and health-related quality of life (HRQoL) and whether this relationship is influenced by the level of income in Northern Sweden. Overweight and obesity are rising major public health problems which also affect HRQoL. While socioeconomic inequalities in health are persisting or increasing in many countries, including Sweden, little attention has been paid to the more complex roles of income in relation to health. Methods: Data were drawn from a 2014 cross-sectional survey from Northern Sweden (Health on Equal Terms), comprising individuals aged 20-84 years (N = 20,082 individuals included for analysis). BMI and HRQoL were self-reported and individual disposable income in 2012 was retrieved from population registers. Multiple linear regressions were performed with HRQoL scores regressed on BMI and income, their interaction and additional covariates. Results: The underweight, overweight and obesity groups reported significantly lower HRQoL compared to the normal weight group. Moreover, the relationship between BMI and HRQoL varied significantly by level of income, with a stronger association among those with the lowest level of income. Conclusions: Income has a role as an effect modifier in the relationship between BMI and HRQoL that can be construed as an indirect income inequality. Efforts to promote HRQoL in populations should consider the different impact of being overweight and obese in different socioeconomic groups.

Trends in educational and income inequalities in cardiovascular morbidity in middle age in Northern Sweden 1993-2010.

Aims: Research is scarce regarding studies on income and educational inequality trends in cardiovascular disease in Sweden. The aim of this study was to assess trends in educational and income inequalities in first hospitalizations due to cardiovascular disease (CVD) from 1993 to 2010 among middle-aged women and men in Northern Sweden. Methods: The study comprised repeated cross-sectional register data from year 1993-2010 of all individuals aged 38-62 years enrolled in the Västerbotten Intervention Programme (VIP). Data included highest educational level, total earned income and first-time hospitalization for CVD from national registers. The relative and slope indices of inequality (RII and SII, respectively) were used to estimate educational and income inequalities in CVD for six subsamples for women and men, and interaction analyses were used to estimate trends across time periods. Results: Educational RII and SII were stable in women, while they decreased in men. Income inequalities in CVD developed differently compared with educational inequalities, with RII and SII for both men and women increasing during the study period, the most marked for RII in women rising from 1.52 in the 1990s to 2.62 in the late 2000s. Conclusions: The trend of widening income inequalities over 18 years in the middle-aged in Northern Sweden, in the face of stable or even decreasing educational inequalities, is worrisome from a public health perspective, especially as Swedish authorities monitor socioeconomical inequalities exclusively by education. The results show that certain social inequalities in CVD rise and persist even within a traditionally egalitarian welfare regime.

Do cardiovascular disease prevention programs in northern Sweden impact on population health? An interrupted time series analysis.

BACKGROUND: Cardiovascular disease (CVD) is the main cause of morbidity and mortality in Sweden. This study aims to assess the impact of a CVD intervention implemented in 1993 in northern Sweden on the reduction of premature ischemic heart disease (IHD) morbidity and mortality in women and men during the period 1987-2013. METHODS: An ecological controlled interrupted time series design, with pre-intervention period defined as 1987-1993 and post-intervention period 1994-2013 was carried out. For each year, IHD events, stratified by sex, were retrieved from national registers. RESULTS: Impressive reductions on IHD premature morbidity and mortality were observed to a similar degree in both the intervention county and the other comparison counties across the last 27 years. Significant differences in the pre-post intervention trends indicating the intervention group had smaller reductions than expected from its pre-intervention trend and the trend of control counties were found among men for both IHD morbidity and mortality. A similar pattern was observed among women but without significant differences. CONCLUSIONS: Taken together, the data do not support that the intervention has contributed to an additional reduction on IHD morbidity and mortality, above and beyond that which is already seen in neighbouring counties without similar programs.

Unsafe and unequal: a decomposition analysis of income inequalities in fear of crime in northern Sweden.

BACKGROUND: Fear of crime is not solely an individual concern, but as a social determinant of health structured by gender it also poses a threat to public health. Social inequalities are thought to represent a breeding ground for fear of crime, which subsequently may contribute to social inequalities in health. However, little research has focused on social inequalities in fear of crime, particularly in Sweden where the level of fear of crime and income and gender inequalities are comparatively low. With a conceptual model as a point of departure, the present study aimed to estimate and decompose income-related inequalities and explore gender differences in fear of crime in northern Sweden. METHODS: Participants (N = 22,140; 10,220 men and 11,920 women aged 16 to 84 years) came from the Health on Equal Terms cross-sectional survey with linked register data, carried out in the four northernmost counties of Sweden in 2014. Disposable income was used as the socio-economic indicator, fear of crime as the binary outcome variable, and sociodemographic characteristics, residential context, socio-economic and material conditions and psychosocial conditions as explanatory factors. Concentration curve and concentration index were used to estimate the income inequality in fear of crime, and decomposition analysis to identify the key determinants of the inequalities, in collapsed and gender-stratified analyses. RESULTS: Substantial gender differences were found in the prevalence of fear of crime (20.8% in women and 3.5% and men) and among the contributing factors to fear of crime. Additionally, the analyses revealed considerable income inequalities in fear of crime in the northern Swedish context (C = - 0.219). Gender, socio-economic and material, and psychosocial conditions explained the most in income inequalities of fear of crime in the total population. CONCLUSIONS: The existing gender and socio-economic inequities need to be approached as a greater structural problem to mitigate inequalities in fear of crime. Further research is needed to reveal more aspects of income inequalities in fear of crime and to develop efforts to create safe environments for all.

Decomposition of gendered income-related inequalities in multiple biological cardiovascular risk factors in a middle-aged population.

BACKGROUND: Socioeconomic inequalities in cardiovascular disease seem to widen or endure in Sweden. However, research on inequalities in antecedent cardiovascular risk factors (CVRFs), and particularly what underpins them, is scarce. The present study aimed 1) to estimate income-related inequalities in eight biological cardiovascular risk factors in Swedish middle-aged women and men; and 2) to examine the contribution of demographic, socioeconomic, behavioural and psychosocial determinants to the observed inequalities. METHODS: Participants (N = 12,481) comprised all 40- and 50-years old women and men who participated in the regional Västerbotten Intervention Programme in Northern Sweden during 2008, 2009 and 2010. All participants completed a questionnaire on behavioural and psychosocial conditions, and underwent measurements with respect to eight CVRFs (body mass index; waist circumference; total cholesterol; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol; triglycerides; systolic/diastolic blood pressure; glucose tolerance). Data on cardiovascular risk, psychosocial and health behaviours were linked to national register data on income and other socioeconomic and demographic factors. To estimate income inequalities in each CVRF concentration indexes were calculated, and to examine the contribution of the underlying determinants to the observed inequalities a Wagstaff-type decomposition analysis was performed separately for women and men. RESULTS: Health inequalities ranged from small to substantial with generally greater magnitude in women. The highest inequalities among women were seen in BMI, triglycerides and HDL-cholesterol (Concentration index = - 0.1850; - 0.1683 and - 0.1479 respectively). Among men the largest inequalities were seen in glucose regulation, BMI and abdominal obesity (Concentration index = - 0.1661; - 0.1259 and - 0.1172). The main explanatory factors were, for both women and men socioeconomic conditions (contributions ranging from 54.8 to 76.7% in women and 34.0-72.6% in men) and health behaviours (contributions ranging from 6.9 to 20.5% in women and 9.2 to 26.9% in men). However, the patterns of specific dominant explanatory factors differed between CVRFs and genders. CONCLUSION: Taken together, the results suggest that the magnitude of income-related inequalities in CVRFs and their determinants differ importantly between the risk factors and genders, a variation that should be taken into consideration in population interventions aiming to prevent inequalities in manifest cardiovascular disease.

Time trends in absolute and relative socioeconomic inequalities in leisure time physical inactivity in northern Sweden.

AIMS: The aim was to investigate the time trends in educational, occupational, and income-related inequalities in leisure time physical inactivity in 2006, 2010, and 2014 in northern Swedish women and men. METHODS: This study was based on data obtained from the repeated cross-sectional Health on Equal Terms survey of 2006, 2010, and 2014. The analytical sample consisted of 20,667 (2006), 31,787 (2010), and 21,613 (2014) individuals, aged 16-84. Logistic regressions were used to model the probability of physical inactivity given a set of explanatory variables. Slope index of inequality (SII) and relative index of inequality (RII) were used as summary measures of the social gradient in physical inactivity. The linear trend in inequalities and difference between gender and years were estimated by interaction analyses. RESULTS: The year 2010 displayed the highest physical inactivity inequalities for all socioeconomic position indicators, but educational and occupational inequalities decreased in 2014. However, significant positive linear trends were found in absolute and relative income inequalities. Moreover, women had significantly higher RII of education in physical inactivity in 2014 and significantly higher SII and RII of income in physical inactivity in 2010, than did men in the same years. CONCLUSIONS: The recent reduction in educational and occupational inequalities following the high inequalities around the time of the great recession in 2010 suggests that the current policies might be fairly effective. However, to eventually alleviate inequities in physical inactivity, the focus of the researchers and policymakers should be directed toward the widening trends of income inequalities in physical inactivity.

Whose income is more important: mine, yours or ours? Income inequality and mental health in northern Sweden.

Background: Three main explanations of the relationship between income and population health have been identified: the absolute, the contextual and the relative income hypotheses. The evidence about their relevance particularly in egalitarian societies is, however, inconsistent. This study aimed to test the three hypotheses in relation to psychological distress in northern Sweden. Methods: Data come from the 2014 cross-sectional survey from the four northern-most counties in Sweden, and included people aged 25-84 years (n = 21 004). Psychological distress was measured by the General Health Questionnaire-12 and income information came from population registers. Absolute income was operationalized by individual disposable income, contextual income as the municipal-level Gini coefficient and relative income by the Yitzhaki index. Prevalence ratios (PR) were calculated from log-binomial regression analyses. Results: A gradient in poor mental health was observed across quintiles of individual income, with the poorest substantially more likely to report poor health compared with the highest quintile (PR = 1.56; 95% CI = 1.19, 2.04). Second, municipalities in the quintiles 2-3 of the Gini coefficient had a better mental health compared with those in the most equal municipalities. Third, a gradient in poor mental health across quintiles of relative deprivation was also found, with the most deprived quintile the most likely to report poor health (PR = 1.37; 95% CI = 1.06, 1.76). Conclusion: This study suggests a strong, moderate and lack of support for the absolute, relative and contextual income effect hypotheses, respectively. Interventions targeting a reduction in the individual income gap may be necessary in order to reduce psychosocial distress differences in northern Sweden.