Sociodemographic Disparities and Parity in Relation to Urinary Incontinence: A Nationwide Primary Healthcare Cohort Study (1997-2018).

OBJECTIVES: Urinary incontinence (UI) is a very common condition in the primary healthcare settings. Few studies have investigated whether sociodemographic factors are related to UI. This nationwide study aimed to investigate whether there is a relationship between sociodemographic factors and UI in women. METHODS: A nationwide open cohort study included 2,044,065 women aged 15-50 years. Several national population-based (Sweden) databases including nationwide primary healthcare data were used. The outcome was the time to the first event of any UI diagnosis during the study period (1997-2018). Cox regression models were used to test for associations between individual sociodemographic factors and UI. RESULTS: The study identified 44,250 UI events. These corresponded to 2.16% of the study population and an incidence rate (IR) per 1000 person-years of 1.85 (95% CI 1.84-1.87). In the fully adjusted model, a high age, low education level, and being born outside of Sweden were independently associated with a higher UI risk, while rural living was associated with a lower risk. The income level did not seem to have a large impact. Most notably, women born in the Middle East/North Africa and Latin America/Caribbean had a substantially higher risk of UI with HRs of 2.41 (95% CI 2.33-2.49) and 2.30 (95% CI 2.17-2.43), respectively. Parity was strongly and independently associated with UI. CONCLUSION: This study presents novel risk factors associated with UI. The findings provide new knowledge concerning the burden of this disease among women, which could be used to provide more equal healthcare for these patients in the future. Previous research allied with these findings suggests using a comprehensive approach targeting health disparities.

Cervical cancer among Swedish women with drug use disorders: A nationwide epidemiological study.

BACKGROUND/AIM: Cervical cancer incidence and mortality has decreased after introduction of national screening in Sweden, but women with drug use disorders (DUD) are less likely to participate in screening programs. We aimed to investigate cervical cancer incidence and mortality among women with DUD compared to the general female population in Sweden. METHODS: We conducted a cohort study based on Swedish national register data for the period January 1997-December 2015. Data was collected for 3,838,248 women aged 15-75 years of whom 50,858 had DUD. Adjusted hazard ratios (HRs) for incident and fatal cervical cancer were calculated for women with and without DUD using Cox regression analysis. RESULTS: DUD was significantly associated with incident cervical cancer (HR = 1.39, 95% confidence interval [CI] 1.39-1.61), but not fatal cervical cancer (HR = 1.25, 95% CI: 0.91-1.71), after adjusting for age, educational attainment, social welfare, region of residence, marital status and HIV infection. CONCLUSION: Women with DUD were thus identified as a risk group for incident cervical cancer, which calls for attention from clinicians and policy makers. It is possible that non-attendance in cancer screening and other healthcare seeking barriers may affect the risk of incident cervical cancer among women with DUD but more research on this topic is needed.

Neighborhood socioeconomic status and aortic stenosis: A Swedish study based on nationwide registries and an echocardiographic screening cohort.

BACKGROUND: Aortic stenosis (AS) is the most common valvular heart disease in developed countries, confers high mortality in advanced cases, but can effectively be reversed using endovascular or open-heart surgery. We evaluated the association between AS and neighborhood socioeconomic status (NSES). METHODS: We used Swedish population-based nationwide registers and an echocardiography screening cohort during the study period 1997-2014. NSES was determined by an established neighborhood deprivation index composed of education, income, unemployment, and receipt of social welfare. Multilevel adjusted logistic regression models determined the association between NSES and incident AS (according to ICD-10 diagnostic codes). RESULTS: The study population of men and women (n=6,641,905) was divided into individuals living in high (n = 1,608,815 [24%]), moderate (n = 3,857,367 [58%]) and low (n = 1,175,723 [18%]) SES neighborhoods. There were 63,227 AS cases in total. Low NSES (versus high) was associated with a slightly increased risk of AS (OR 1.06 [95% CI 1.03-1.08]) in the nationwide study population. In the echocardiography screening cohort (n = 1586), the association between low NSES and AS was markedly stronger (OR: 2.73 [1.05-7.12]). There were more previously undiagnosed AS cases in low compared to high SES neighborhoods (3.1% versus 1.0%). CONCLUSIONS: In this nationwide Swedish register study, low NSES was associated with a slightly increased risk of incident AS. However, the association was markedly stronger in the echocardiography screening cohort, which revealed an almost three-fold increase of AS among individuals living in low SES neighborhoods, possibly indicating an underdiagnosis of AS among these individuals.

Parkinson's Disease Among Immigrant Groups and Swedish-Born Individuals: A Cohort Study of All Adults 50 Years of Age and Older in Sweden.

BACKGROUND: There is a lack of studies of Parkinson's disease (PD) in immigrants. OBJECTIVE: To study the association between country of birth and incident PD in immigrants in Sweden versus Swedish-born individuals. METHODS: Study population included all adults aged 50 years and older in Sweden (n = 2775736). PD was defined as having at least one registered diagnosis of PD in the National Patient Register. The incidence of PD in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, neighbourhood socioeconomic status and co-morbidity. RESULTS: Totally 35833 individuals had an incident diagnosis of PD (20401 men and 15432 women). Incidence rates per 100,000 person-years were for all Swedish-born 95.9 and for all foreign-born 60.1; for all men 112.3 and for all women 73.4, with a male to female ratio of 1.53, with the highest incidence rates for the group 80-84 years of age. After adjusting for potential confounders, the overall relative risk of PD was lower in immigrant men (HR 0.78; 95% CI 0.74-0.82) and women (HR 0.92; 95% CI 0.87-0.98). Among immigrant subgroups, a higher risk of PD was found among women from Finland (HR 1.13; 95% CI 1.05-1.23). CONCLUSION: In general, the risk of PD was lower in first-generation immigrant men and women compared to Swedish-born. The only group with a higher risk of PD was women from Finland.

Neighborhood Deprivation and Risks of Autoimmune Disorders: A National Cohort Study in Sweden.

Background: No study to date, as far as we know, has analyzed the potential effect of neighborhood-level deprivation on autoimmune disorders (ADs), when adjusted for individual-level characteristics. Methods: A total of 5.4 million individuals from 8363 neighborhoods, comprising the whole Swedish population (ages 25-74 years), were followed for the period 1 January 2000, until admission due to diagnosis of ADs during the period of the study, or the conclusion of the study (31 December 2010). We used a neighborhood deprivation index, constructed from variables such as low education, low income, unemployment, and social welfare assistance, to assess the level of neighborhood deprivation. Multilevel logistic regression was used in the analysis with individual level characteristics at the first level and level of neighborhood deprivation at the second level. Results: A significant association between level of neighborhood deprivation and ADs was found. The crude odds were 1.32 (95% confidence interval 1.27-1.36) for those residing in the high-deprived neighborhoods compared to those living in low-deprivation neighborhoods. In the full model, where individual level characteristics were taken into account, the odds of ADs were 1.18 (1.14-1.22) in the most deprived neighborhoods. Certain Ads-angiitis hypersensitive (5.14), ankylosing spondylitis (1.66), celiac disease (1.65), Crohn's disease (1.21), diabetes mellitus type 1 (1.45), Graves's disease (1.13), Hashimoto thyroiditis (1.51), psoriasis (1.15), rheumatoid arthritis (1.15), sarcoidosis (1.20), and systemic sclerosis (1.27)-remained significantly associated with high level of neighborhood deprivation after adjustment for the individual-level variables. Conclusion: This study is the largest to date analyzing the potential influence of neighborhood deprivation on ADs. Our results indicate that neighborhood deprivation may affect risk of ADs, independent of individual level sociodemographic characteristics. For health care policies, both individual and neighborhood level approaches seem to be of importance.

Socioeconomic factors, body mass index and bariatric surgery: a Swedish nationwide cohort study.

BACKGROUND: Bariatric surgery is considered to be the most effective method of weight loss today. The aim of the present Swedish study, which was performed in a country that has universal health care, was to investigate if there is an association between socioeconomic factors and bariatric surgery by taking body mass index (BMI) into account. METHODS: In this prospective cohort study, BMI data were collected for the period 1985-2010 from the Military Service Conscription Register (for men) and from the Medical Birth Register in the first trimester (for women). The follow-up period started in 2005 and continued until 2012. Age-standardized cumulative incidence rates (CR) of bariatric surgery were compared between different BMI groups by considering individual variables. We analyzed the association between the individual variables and bariatric surgery using Cox proportional hazard models. RESULTS: In the study population of 814,703 women and 787,027 men, a total of 7433 women and 1961 men underwent bariatric surgery. In women, the hazard ratios (HRs) for bariatric surgery were higher for low and middle income and educational levels, compared to high income and educational levels. In men, the highest HR for bariatric surgery was found among those with a high income. The HRs when comparing the different socioeconomic groups in those with BMI > 40 kg/m2 showed no significant results, except for middle education in women. CONCLUSION: Differences in bariatric surgery between socioeconomic groups were found, favoring those with a low socioeconomic status. However, very few socioeconomic differences were found amongst those who had a BMI > 40 kg/m2. This indicates that the Swedish healthcare system seems to have achieved equal access to health care for bariatric surgery.

End-Stage Kidney Diseases in Immigrant Groups: A Nationwide Cohort Study in Sweden.

BACKGROUND: Our aim was to study the association between the country of birth and incident end-stage kidney disease (ESKD) in several immigrant groups in Sweden, using individuals born in Sweden or with Swedish-born parents as referents. METHODS: A cohort study of first- and second-generation immigrants residing in Sweden between January 1, 1998 and December 31, 2012 was performed. Outcomes were defined as having at least one registered diagnosis of ESKD in the National Patient Register. The incidence of ESKD in different immigrant groups was used in the Cox regression models to estimate hazard ratios (HRs) and 95% CIs. All models were stratified by sex and adjusted for age, geographical residence, educational level, marital status, and neighbourhood socioeconomic status. RESULTS: Compared to their referents, higher incidence rates and HRs of ESKD (HR; 95% CI) were observed in general among foreign-born men (1.10; 1.04-1.16) and women (1.12; 1.04-1.21) but not among second-generation immigrants (persons born in Sweden with foreign-born parents). A particularly high -incidence was noted among men and women from -East-European countries, as well as from non-European regions. A lower incidence of ESKD was noted among men from Finland. CONCLUSIONS: We observed substantial differences in incidence of ESKD between immigrant groups and the Swedish-born population, which may be clinically relevant when monitoring preventive measures in patient subgroups with a higher risk of deteriorating kidney disease, and suggest higher attention to hypertension and diabetes control in immigrants. Mechanisms attributable to the migration process or ethnic differences may lead to an increased risk of ESKD.

Is familial risk for depression confounded by individual and familial socioeconomic factors and neighborhood environmental factors? A 7-year follow-up study in Sweden.

Family history of depression is an important risk factor for depression. The aim of this study was to examine whether the effect of family history of depression is confounded by individual and familial socioeconomic factors (i.e., country of origin, educational attainment, family income and mobility) and neighborhood environmental factors (i.e., neighborhood deprivation and neighborhood social capital). The study population comprised 188,907 individuals aged 20-44 years from a nationwide sample of primary care centers in Sweden. Among these individuals, 22,014 with a first event of depression (6,486 men and 15,528 women) were identified during the 7-year follow-up period. Family history of depression was defined as depression in at least one parent. Cross-classified multilevel logistic regression models were used to calculate odds ratios with 95% credible intervals. Increased familial odds were observed after adjustment for individual and familial socioeconomic factors and neighborhood environmental factors for both men and women. Our results suggest that family history of depression is an independent risk factor for depression. Offspring of parents with depression are important targets for disease prevention, regardless of individual and familial socioeconomic factors and neighborhood environmental factors.

Socio-demographic factors and long-term use of benzodiazepines in patients with depression, anxiety or insomnia.

Former studies that have attempted to characterize individual socio-demographic factors associated with long-term benzodiazepine use were based on relatively small sample sizes and/or self-reported data. Our aim was to clarify this using large-scale primary health care data from Sweden. The present study covered 71 primary health care centres containing individual-level data from a total of 919, 941 individuals who visited a primary health care centre (PHCC) during the period 2001-2007. From this database we selected individuals 25 years or older with depression, anxiety and/or insomnia and who were prescribed a benzodiazepine within 0-90 as well as 91-270 days after their first clinical diagnosis of depression, anxiety and/or insomnia. Older age (OR, 2.92, 95% CI, 2.28-3.84), middle SES (OR, 1.22, 95% CI, 1.08-1.38), being on social welfare (OR, 1.40, 95% CI, 1.23-1.62) and not being married were associated with higher long-term benzodiazepine use. The PHCCs only explained a small part of the individual variation in long-term benzodiazepine use. Awareness of the impact on long-term benzodiazepine use of certain individual-level socio-demographic factors is important for health care workers and decision-makers who should aim at targeting general interventions at all primary health care centres.

Impact of neighborhood resources on cardiovascular disease: a nationwide six-year follow-up.

BACKGROUND: Living in a socially deprived neighborhood is associated with lifestyle risk factors, e.g., smoking, physical inactivity and unhealthy diet, as well as an increased risk of cardiovascular disease, i.e., coronary heart disease and stroke. The aim was to study whether the odds of cardiovascular disease vary with the neighbourhood availability of potentially health-damaging and health-promoting resources. METHODS: A nationwide sample of 2 040 826 men and 2 153 426 women aged 35-80 years were followed for six years for first hospitalization of coronary heart disease or stroke. Neighborhood availability of health-damaging resources (i.e., fast-food restaurants and bars/pubs) and health-promoting resources (i.e., health care facilities and physical activity facilities) were determined by use of geographic information systems (GIS). RESULTS: We found small or modestly increased odds ratios (ORs) for both coronary heart disease and stroke, related to the availability of both health-damaging and health-promoting resources. For example, in women, the unadjusted OR (95 % confidence interval) for stroke in relation to availability of fast-food restaurants was 1.18 (1.15-1.21). Similar patterns were observed in men, with an OR = 1.08 (1.05-1.10). However, the associations became weaker or disappeared after adjustment for neighborhood-level deprivation and individual-level age and income. CONCLUSIONS: This six year follow-up study shows that neighborhood availability of potentially health-damaging as well as health-promoting resources may make a small contribution to the risk of coronary heart disease and stroke. However, most of these associations were attenuated or disappeared after adjustment for neighborhood-level deprivation and individual-level age and income. Future studies are needed to further examine factors in the causal pathway between neighborhood deprivation and cardiovascular disease.

Neighborhood socioeconomic characteristics and statin medication in patients with myocardial infarction: a Swedish nationwide follow-up study.

BACKGROUND: Coronary heart disease (CHD) and myocardial infarction (MI) are associated with neighborhood-level socioeconomic status (SES). Statins are important drugs for secondary prevention of MI. However, no study has determined whether neighborhood-level SES is associated with statin medication in MI patients. We aimed to determine whether there is a difference in statin medication rate in MI patients across different levels of neighborhood SES. METHODS: All patients in Sweden, diagnosed with incident MI from January 1st, 2000 until December 31(st) 2010, were followed (n = 116,840). Of these, 89.7 % received statin medication. Data were analyzed by multilevel logistic regression, with individual-level characteristics (age, marital status, family income, educational attainment, country of origin, urban/rural status and comorbidities/chronic conditions related to MI) as covariates. RESULTS: Low neighborhood-level SES was significantly associated with low statin medication rate (Odds Ratio 0.80). In the full model, which took into account individual-level socioeconomic characteristics and MI comorbidities, the odds no longer remained significant. CONCLUSIONS: Individual-level approaches may be most important in health care policies regarding statin medication in MI patients.

Long-term effects of neighbourhood deprivation on diabetes risk: quasi-experimental evidence from a refugee dispersal policy in Sweden.

BACKGROUND: Although studies have shown associations between neighbourhood quality and chronic disease outcomes, such associations are potentially confounded by the selection of different types of people into different neighbourhood environments. We sought to identify the causal effects of neighbourhood deprivation on type 2 diabetes risk, by comparing refugees in Sweden who were actively dispersed by government policy to low-deprivation, moderate-deprivation, or high-deprivation neighbourhoods. METHODS: In this quasi-experimental study, we analysed national register data for refugees who arrived in Sweden aged 25-50 years, at a time when the government policy involved quasi-random dispersal of refugees to neighbourhoods with different levels of poverty and unemployment, schooling, and social welfare participation. Individuals in our sample were assigned to a neighbourhood categorised as high deprivation (≥1 SD above the mean), moderate deprivation (within 1 SD of the mean), or low deprivation (≥1 SD below the mean). The primary outcome was new diagnosis of type 2 diabetes between Jan 1, 2002, and Dec 31, 2010. We used multivariate logistic and linear regressions to assess the effects of neighbourhood deprivation on diabetes risk, controlling for potential confounders affecting neighbourhood assignment and assessing effects of cumulative exposure to different neighbourhood conditions. FINDINGS: We included data for 61 386 refugees who arrived in Sweden during 1987-91 and who were assigned to one of 4833 neighbourhoods. Being assigned to an area deemed high deprivation versus low deprivation was associated with an increased risk of diabetes (odds ratio [OR] 1·22, 95% CI 1·07-1·38; p=0·001). In analyses that included fixed effects for assigned municipality, the increased diabetes risk was estimated to be 0·85 percentage points (95% CI -0·030 to 1·728; p=0·058). Neighbourhood effects grew over time such that 5 years of additional exposure to high-deprivation versus low-deprivation neighbourhoods was associated with a 9% increase in diabetes risk. INTERPRETATION: This study makes use of a pre-existing governmental natural experiment to show that neighbourhood deprivation increased the risk of diabetes in refugees in Sweden. This finding has heightened importance in the context of the current refugee crisis in Europe. FUNDING: US National Heart, Lung, and Blood Institute, US National Center for Advancing Translational Sciences, US National Institute on Minority Health and Health Disparities, Swedish Research Council.

Neighbourhood socioeconomic status and coronary heart disease in individuals between 40 and 50†years.

OBJECTIVE: The incidence of myocardial infarction (MI) has decreased in general but not among younger middle-aged adults. We performed a cohort study of the association between neighbourhood socioeconomic status (SES) at the age of 40 and risk of MI before the age of 50 years. METHODS: All individuals in Sweden were included in the year of their 40th birthday, if it occurred between 1998 and 2010. National registers were used to categorise neighbourhood SES into high, middle and low, and to retrieve information on incident MI and coronary heart disease (CHD). Cox regression models, adjusted for marital status, education level, immigrant status and region of residence, provided an estimate of the HRs and 95% CIs for MI or CHD. RESULTS: Out of 587 933 men and 563 719 women, incident MI occurred in 2877 (0.48%) men and 932 (0.17%) women; and CHD occurred in 4400 (0.74%) men and 1756 (0.31%) women during a mean follow-up of 5.5 years. Using individuals living in middle-SES neighbourhoods as referents, living in high-SES neighbourhoods was associated with lower risk of MI in both sexes (HR (95% CI): men: 0.72 (0.64 to 0.82), women: 0.66 (0.53 to 0.81)); living in low-SES neighbourhoods was associated with a higher risk of MI (HR (95% CI): men: 1.31 (1.20 to 1.44), women: 1.28 (1.08 to 1.50)). Similar risk estimates for CHD were found. CONCLUSIONS: The results of our study suggest an increased risk of MI and CHD among residents from low-SES neighbourhoods and a lower risk in those from high-SES neighbourhoods compared with residents in middle-SES neighbourhoods.

Neighborhood Deprivation and Risk of Age-Related Eye Diseases: A Follow-up Study in Sweden.

PURPOSE: To examine whether there is an association between neighborhood deprivation and age-related eye diseases, particularly macular degeneration, cataract, diabetes-related eye complications, and glaucoma. METHODS: The study population comprised a nationwide sample of 2,060,887 men and 2,250,851 women aged 40 years or older living in Sweden who were followed from 1 January 2000 until the first hospitalization/outpatient registration for age-related eye disease during the study period, death, emigration, or the end of the study period on 31 December 2010. Multilevel logistic regression was used to estimate the association between neighborhood deprivation and age-related eye diseases. RESULTS: In men, the odds ratio (OR) for age-related eye diseases for those living in high-deprivation neighborhoods compared to those living in low-deprivation neighborhoods remained significant after adjustment for potential confounding factors (macular degeneration, OR 1.08, 95% confidence interval [CI] 1.03-1.12; cataract, OR 1.31, 95% CI 1.26-1.35; diabetes-related eye complications, OR 1.36, 95% CI 1.30-1.43; glaucoma, OR 1.11, 95% CI 1.06-1.15). In women, similar patterns were observed (macular degeneration, OR 1.11, 95% CI 1.07-1.15; cataract, OR 1.36, 95% CI 1.31-1.40; diabetes-related eye complications, OR 1.50, 95% CI 1.42-1.59; glaucoma, OR 1.12, 95% CI 1.08-1.17). CONCLUSION: Our results suggest that neighborhood deprivation is associated with age-related eye diseases in both men and women. These results implicate that individual- as well as neighborhood-level factors are important for preventing age-related eye diseases.

Neighborhood deprivation and lung cancer incidence and mortality: a multilevel analysis from Sweden.

BACKGROUND: Neighborhood deprivation has been implicated in lung cancer but no study has simultaneously analyzed the potential effect of neighborhood deprivation on both lung cancer incidence and mortality, after adjusting for individual-level socioeconomic factors, and comorbidities. The aim of this study was to analyze whether there is an association between neighborhood deprivation and incidence and mortality rates of lung cancer, beyond individual-level characteristics. DESIGN: The incident and mortality cases of lung cancer were determined in the entire Swedish population aged over 50 (3.2 million individuals) between 2000 and 2010. Multilevel logistic regression was used in the analysis with individual-level characteristics (age, marital status, family income, education, immigration status, urban/rural status, mobility, and comorbidities) at the first level and level of neighborhood deprivation at the second level. A neighborhood deprivation index, constructed from the variables education, income, unemployment, and welfare assistance, was used to assess the level of neighborhood deprivation. RESULTS: There was a strong association between level of neighborhood deprivation and incidence and mortality of lung cancer. In the fully adjusted model, the odds of lung cancer were 1.27 and 1.32, respectively, in the most deprived neighborhood. The between-neighborhood variance (i.e., the random intercept) was over 1.96 times the standard error in all models, indicating that there were significant differences in incidence and mortality rates of lung cancer between neighborhoods. CONCLUSIONS: Results suggest that neighborhood deprivation is associated with incident and mortality cases of lung cancer in Sweden, independently of individual-level characteristics.

Neighbourhood deprivation, individual-level familial and socio-demographic factors and diagnosed childhood obesity: a nationwide multilevel study from Sweden.

OBJECTIVES: To examine whether there is an association between neighbourhood deprivation and diagnosed childhood obesity, after accounting for family- and individual-level socio-demographic characteristics. METHODS: An open cohort of all children aged 0-14 years was followed between January 1, 2000 and December 31, 2010. Childhood residential locations were geocoded and classified according to neighbourhood deprivation. Data were analysed by multilevel logistic regression, with family- and individual-level characteristics at the first level and level of neighbourhood deprivation at the second level. RESULTS: During the study period, among a total of 948,062 children, 10,799 were diagnosed with childhood obesity. Age-adjusted cumulative incidence for diagnosed childhood obesity increased with increasing level of neighbourhood deprivation. Incidence of diagnosed childhood obesity increased with increasing neighbourhood-level deprivation across all family and individual-level socio-demographic categories. The odds ratio (OR) for diagnosed childhood obesity for those living in high-deprivation neighbourhoods versus those living in low-deprivation neighbourhoods was 2.44 (95% confidence interval (CI) = 2.22-2.68). High neighbourhood deprivation remained significantly associated with higher odds of diagnosed childhood obesity after adjustment for family- and individual-level socio-demographic characteristics (OR = 1.70, 95% CI = 1.55-1.89). Age, middle level family income, maternal marital status, low level education, living in large cities, advanced paternal and maternal age, family history of obesity, parental history of diabetes, chronic obstructive pulmonary disease, alcoholism and personal history of diabetes were all associated with higher odds of diagnosed childhood obesity. CONCLUSIONS: Our results suggest that neighbourhood characteristics affect the odds of diagnosed childhood obesity independently of family- and individual-level socio-demographic characteristics.

Neighborhood linking social capital as a predictor of psychiatric medication prescription in the elderly: a Swedish national cohort study.

OBJECTIVES: Little is known about the association between neighborhood linking social capital and psychiatric medication in the elderly. The present study analyzes whether there is an association between linking social capital (a theoretical concept describing the amount of trust between individuals and societal institutions) and prescription of antipsychotics, anxiolytics, hypnotics/sedatives, antidepressants, or anti-dementia drugs. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: The entire Swedish population aged 65+, a total of 1,292,816 individuals, were followed from 1 July 2005 until first prescription of psychiatric medication, death, emigration, or the end of the study on 31 December 2010. Small geographic units were used to define neighborhoods. The definition of linking social capital was based on mean voting participation in each neighborhood unit, categorized in three groups. Multilevel logistic regression was used to estimate odds ratios (ORs) and between-neighborhood variance in three different models. RESULTS: There was an inverse association between the level of linking social capital and prescription of psychiatric medications (except for anti-dementia drugs). The associations decreased, but remained significant, after accounting for age, sex, family income, marital status, country of birth, and education level (except for antidepressants). The OR for prescription of antipsychotics in the crude model was 1.65 (95% CI 1.53-1.78) and decreased, but remained significant (OR = 1.26; 95% CI 1.17-1.35), after adjustment for the individual-level sociodemographic variables. CONCLUSIONS: Decision-makers should take into account the potentially negative effect of linking social capital on psychiatric disorders when planning sites of primary care centers and psychiatric clinics, as well as other kinds of community support for elderly patients with such disorders.

Linking social capital and mortality in the elderly: a Swedish national cohort study.

OBJECTIVES: Our objective was to examine the association between neighborhood linking social capital (a concept describing the amount of trust between individuals and societal institutions) and all-cause and cause-specific mortality in the elderly. DESIGN: The entire Swedish population aged 65+, a total of 1,517,336 men and women, was followed from 1 January 2002 until death, emigration, or the end of the study on 31 December 2010. Small geographic units were used to define neighborhoods. The definition of linking social capital was based on neighborhood voting participation rates, categorized into three groups. Multilevel logistic regression was used to estimate odds ratios (ORs) and between-neighborhood variance in three different models. RESULTS: The results showed an overall association between linking social capital and all-cause mortality. The significant OR of 1.53 in the group with low linking social capital decreased, but remained significant (OR=1.27), after accounting for age, sex, family income, marital status, country of birth, education level, and region of residence. There were also significant associations between linking social capital and cause-specific mortality in coronary heart disease, psychiatric disorders, cancer, stroke, chronic lower respiratory diseases, type 2 diabetes, and suicide. CONCLUSION: There are associations between low linking social capital and mortality from chronic disorders and suicide in the elderly population. Community support for elderly people living in neighborhoods with low levels of linking social capital may need to be strengthened.

Neighborhood, family, and childhood and adolescent epilepsy: a nationwide epidemiological study from Sweden.

PURPOSE: To examine whether neighborhood deprivation increases the odds of hospital registration for childhood and adolescent epilepsy, after accounting for family- and individual-level sociodemographic characteristics. METHODS: An open cohort of all children aged 2-17 years was followed between January 1, 2000 and December 31, 2010. Children's residential addresses were geocoded and classified according to neighborhood deprivation. Data were analyzed by multilevel logistic regression, with family- and individual-level characteristics at the first level and level of neighborhood deprivation at the second level. RESULTS: During the study period, among a total of 1,020,766 children, 9309 (0.9%) were registered with childhood and adolescent epilepsy. Age-adjusted cumulative hospital rates of childhood and adolescent epilepsy increased with increasing neighborhood-level deprivation across all family- and individual-level sociodemographic categories. The odds ratio (OR) for hospital registration for childhood and adolescent epilepsy for those living in high-deprivation neighborhoods versus those living in low-deprivation neighborhoods was 1.15. High level deprivation remained significantly associated with higher odds of childhood and adolescent epilepsy after adjustment for family- and individual-level sociodemographic characteristics (OR=1.12, 95% CI=1.04-1.21, p=0.003). CONCLUSIONS: Our results suggest that neighborhood characteristics modestly affect the odds of hospital registration for childhood and adolescent epilepsy independently of family- and individual-level sociodemographic characteristics.

Depression, neighborhood deprivation and risk of type 2 diabetes.

Neighborhood characteristics have been associated with both depression and diabetes, but to date little attention has been paid to whether the association between depression and diabetes varies across different types of neighborhoods. This prospective study examined the relationship between depression, neighborhood deprivation, and risk of type 2 diabetes among 336,340 adults from a national-representative sample of primary care centers in Sweden (2001-2007). Multi-level logistic regression models were used to assess associations between depression and risk of type 2 diabetes across affluent and deprived neighborhoods. After accounting for demographic, individual-level socioeconomic, and health characteristics, depression was significantly associated with risk of diabetes (odds ratio (OR): 1.10, 95% confidence interval (CI): 1.06-1.14), as was neighborhood deprivation (OR for high vs. low deprivation: 1.66, 95% CI: 1.22-1.34). The interaction term between depression and neighborhood deprivation was non-significant, indicating that the relationship between depression and diabetes risk is similar across levels of neighborhood socioeconomic deprivation.