Sexual harassment among employees and students at a large Swedish university: who are exposed, to what, by whom and where - a cross-sectional prevalence study.

BACKGROUND: Sexual harassment (SH) in the workplace is prevalent and associated with poor health. Universities are large workplaces with complex formal and informal power relations, which may influence the prevalence of SH. Although employees and students share the university context, few studies on SH have included both groups. The overall aim of the study was to investigate SH among employees and students at a large Swedish public university regarding types of harassment, prevalence in different groups, characteristics of the perpetrators, and the circumstances in which it occurs. METHODS: A cross-sectional analysis was performed, based on a web-based survey with 120 items that was sent out to all staff, including PhD students (N = 8,238) and students (N = 30,244) in November 2019. The response rate was 33% for staff and 32% for students. Exposure to SH was defined as having experienced at least one of ten defined SH behaviors during their work or studies. RESULTS: Among women, 24.5% of staff and 26.8% of students reported having been exposed to SH. The corresponding figures were 7.0% and 11.3% for male staff and students and 33.3% and 29.4% for non-binary individuals among staff and students. Unwelcome comments, suggestive looks or gestures, and 'inadvertent' brushing or touching were the three most common forms of reported harassment, both among staff and students. Attempted or completed rape had been experienced by 2.1% of female and 0.6% of male students. Male and female perpetrators were reported by about 80% and 15%, respectively, of exposed participants. Among staff most reported events occurred during the everyday operation of the university, while among students the majority of the events took place during social events linked to student life. When exposed to a perpetrator from the same group (staff or students), women reported more often being in a subordinate power position in relation to the perpetrator. CONCLUSIONS: The results indicate that sexual harassment is common in the university context, and interventions and case management routines of events should consider power relations between victim and perpetrator, as well as the various contexts within which sexual harassment takes place.

The role of social embeddedness for remaining in non-desired workplaces and mental health consequences: Results from Scania Public Health Cohort.

AIMS: The aim of the study was to investigate the role of social embeddedness on and off the job in relation to remaining in non-desired workplaces (NDWs) and the development of mental health. METHOD: The study used questionnaire data from the Scania Public Health cohort ( N=2410) that were collected in 2000 (T1), 2005 (T2) and 2010 (T3). Logistic regression models were calculated to probe how NDWs and social embeddedness factors measured at baseline (T1) related to NDWs five years later (T2), and to investigate how NDWs and social embeddedness factors at T2 related to poor mental health at T3. Synergy indices were calculated in both analyses to test for additive v. interactive effects between NDWs and social embeddedness factors on the outcomes. RESULTS: NDWs at baseline and low social embeddedness on and off the job was associated with NDWs at T2. For those in a desired workplace, low support from co-workers as well as low workplace affinity increased the risk to be in an NDW at T2. NDWs and low social embeddedness also associated with impaired mental health (T3). For those in an NDW, low support from co-workers as well as low workplace affinity increased the risk of poor mental health at T3. CONCLUSIONS: This study underlines the importance of social embeddedness for NDWs and the development of poor mental health over time. Particularly low social support from co-workers and low workplace affinity seem to be risk factors for future experience of an NDW and impaired mental health.

Snus (Swedish smokeless tobacco) use and risk of stroke: pooled analyses of incidence and survival.

BACKGROUND: Snus is a moist smokeless tobacco product with high nicotine content. Its use has a short-term effect on the cardiovascular system, but the relationship between snus use and stroke is unclear. OBJECTIVE: The aim of this study was to assess the associations between use of snus and incidence of and survival after stroke, both overall and according to subtypes. METHODS: Pooled analyses of eight Swedish prospective cohort studies were conducted, including 130 485 men who never smoked. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs) of incidence and death after diagnosis using Cox proportional hazard regression models and case fatality and survival using logistic regression and Kaplan-Meier methods, respectively. RESULTS: No associations were observed between the use of snus and the risk of overall stroke (HR 1.04, 95% CI 0.92-1.17) or of any of the stroke subtypes. The odds ratio (OR) of 28-day case fatality was 1.42 (95% CI 0.99-2.04) amongst users of snus who had experienced a stroke, and the HR of death during the follow-up period was 1.32 (95% CI 1.08-1.61). CONCLUSION: Use of snus was not associated with the risk of stroke. Hence, nicotine is unlikely to contribute importantly to the pathophysiology of stroke. However, case fatality was increased in snus users, compared with nonusers, but further studies are needed to determine any possible causal mechanisms.

Are time-trends of smoking among pregnant immigrant women in Sweden determined by cultural or socioeconomic factors?

BACKGROUND: The widening socioeconomic gap in smoking during pregnancy remains a challenge to the Swedish antenatal care services. However, the influence of cultural factors in explaining the socioeconomic differences in smoking during pregnancy is not clear among the immigrant women. The aim of this study was to investigate whether the development of smoking prevalence among pregnant immigrant women in Sweden followed the trajectory which could be expected from the stages of the global smoking epidemic model in the women's countries of origin, or not. METHODS: Delivery data on pregnancies in Sweden from 1982 to 2001 was collected from the Swedish Medical Birth Registry. From a total of 2,224,469 pregnant women during this period, all immigrant pregnant women (n = 234,731) were selected to this study. A logistic regression analysis and attributable fraction were used to investigate the association between smoking during pregnancy and the socioeconomic differences among immigrant women. RESULTS: Overall, the prevalence of smoking among pregnant immigrant women decreased from 30.3% in 1982 to 11.0% in 2001, albeit with remarkable differences between educational levels and country of origin. The greatest decline of absolute prevalence was recorded among low educated women (27.9%) and among other Nordic countries (17.9%). In relative terms, smoking inequalities increased between educational levels regardless of country of origin. The odds ratios for low educational level for women from other Nordic countries increased from 4.9 (95% CI 4.4-5.4) in 1982 to 13.4 (95% CI 11.2-16.2) in 2001, as compared to women with high education in the same group. Further, the total attributable fraction for educational difference increased from 55% in 1982 to 62% in 2001, demonstrating the strong effect of educational attainment. CONCLUSIONS: Our hypothesis that the socioeconomic time trend of smoking based on the stage of the world wide tobacco epidemic model related to country of origin of the immigrant women was not supported by our analyses. Our findings does not support a call for specific "culture sensitive" antismoking policies or interventions in Sweden or similar countries, but reinforce the existing evidence with a focus on women with a low educational level, regardless of cultural background.

Socioeconomic differences in smoking trends among pregnant women at first antenatal visit in Sweden 1982-2001: increasing importance of educational level for the total burden of smoking.

BACKGROUND: There was a decrease in smoking during early pregnancy in Swedish women between 1982 and 2001. We sought to determine whether there was a parallel decrease in socioeconomic inequality in smoking. METHODS: Registry data indicating educational level and smoking status at first antenatal visit in all 2,022,469 pregnancies in Sweden 1982-2001 were analysed. Prevalence differences, odds ratios based on prevalences and total attributable fractions were compared for five-year intervals. RESULTS: The prevalence differences of smoking showed a greater decrease at the lowest and middle educational level compared with the highest educational level (14.5%, 15.7% and 10.2%, respectively) indicating reduced inequality in absolute terms. However, odds ratios regarding low educational attainment versus high, increased from 5.6 to 14.2, signifying increased inequality in relative terms. Moreover, the total attributable fraction of low and intermediate educational level regarding smoking at first antenatal visit increased from 61% to 76% during the period studied. CONCLUSIONS: Smoking at first antenatal visit in Sweden between 1982 to 2001 decreased in a way that conclusions regarding trends in inequalities in smoking at first antenatal visit depend on the type of measure applied. However, using the measure of total attributable fraction, which takes into consideration the impact of the exposure on the individual as well as the effect of the varying size of the group of exposed, the growing importance of educational level for the behaviour in the population was demonstrated.

A multilevel analysis of condom use among adolescents in the European Union.

OBJECTIVES: This study examined which individual and national factors affect condom use among adolescents. STUDY DESIGN: Multilevel analysis. METHODS: This study reviewed the data on bullying, alcohol use and condom use provided by 18 European countries and subnational entities in the Health Behaviour in School-Aged Children survey. Another eight contextual variables were also analysed. Three multilevel logistic regression models were applied consecutively (analysing for crude geographical and school variance in condom use, adjusting for gender and adjusting all variables for one another). RESULTS: Among the 15-year-olds studied, 7.0% of the total variance in condom use was explained by school-related factors (intraschool-level correlation) and 5.8% by national/subnational factors. In the empty model, condom use was significantly associated with gender, alcohol consumption, predominant national religion and national prevalence of human immunodeficiency virus (HIV). In the full model, there was also a significant association with the Human Development Index ranking, gross domestic product, Gini coefficient and the Gender-related Development Index. CONCLUSIONS: This study suggests that while alcohol, gender, human development level, income, religion and HIV prevalence affect condom use in young Europeans, these factors do not explain all or even most of the variation. Nonetheless, since some of these factors are not traditionally associated with young people's sexual and reproductive health, these findings should enable more nuanced health policy programming.

Applying an equity lens to tobacco-control policies and their uptake in six Western-European countries.

We identified policies that may be effective in reducing smoking among socioeconomically disadvantaged groups, and examined trends in their level of application between 1985 and 2000 in six western-European countries (Sweden, Finland, the United Kingdom, the Netherlands, Germany, and Spain). We located studies from literature searches in major databases, and acquired policy data from international data banks and questionnaires distributed to tobacco policy organisations/researchers. Advertising bans, smoking bans in workplaces, removing barriers to smoking cessation therapies, and increasing the cost of cigarettes have the potential to reduce socioeconomic inequalities in smoking. Between 1985 and 2000, tobacco control policies in most countries have become more targeted to decrease the smoking behaviour of low-socioeconomic groups. Despite this, many national tobacco-control strategies in western-European countries still fall short of a comprehensive policy approach to addressing smoking inequalities.

Trends in smoking behaviour between 1985 and 2000 in nine European countries by education.

OBJECTIVE: To examine whether trends in smoking behaviour in Western Europe between 1985 and 2000 differed by education group. DESIGN: Data of smoking behaviour and education level were obtained from national cross sectional surveys conducted between 1985 and 2000 (a period characterised by intense tobacco control policies) and analysed for countries combined and each country separately. Annual trends in smoking prevalence and the quantity of cigarettes consumed by smokers were summarised for each education level. Education inequalities in smoking were examined at four time points. SETTING: Data were obtained from nine European countries: Norway, Sweden, Denmark, Finland, the United Kingdom, the Netherlands, Germany, Italy, and Spain. PARTICIPANTS: 451 386 non-institutionalised men and women 25-79 years old. MAIN OUTCOME MEASURES: Smoking status, daily quantity of cigarettes consumed by smokers. RESULTS: Combined country analyses showed greater declines in smoking and tobacco consumption among tertiary educated men and women compared with their less educated counterparts. In country specific analyses, elementary educated British men and women, and elementary educated Italian men showed greater declines in smoking than their more educated counterparts. Among Swedish, Finnish, Danish, German, Italian, and Spanish women, greater declines were seen among more educated groups. CONCLUSIONS: Widening education inequalities in smoking related diseases may be seen in several European countries in the future. More insight into effective strategies specifically targeting the smoking behaviour of low educated groups may be gained from examining the tobacco control policies of the UK and Italy over this period.

No association between female circumcision and prolonged labour: a case control study of immigrant women giving birth in Sweden.

OBJECTIVE: Several authors' associate female genital circumcision with obstructed and prolonged labour, but the World Health Organization recently stated that no scientific evidence confirms such a relationship. The object of this study was to compare the duration of the second stage of labour between circumcised and non-circumcised women in a high-income community in Europe. METHODS: Sixty-eight circumcised nulliparous women originally from the Horn of Africa were compared to a group of 2486 non-circumcised nulliparous who gave birth at a university hospital setting in Sweden, 1990-1996. Defibulation was routinely performed during labour. FINDINGS: Circumcised women were found to have had second stage labour, which was significantly statistically shorter (35/53 min, respectively, p < or = 0.001) and a lower risk of prolonged labour than the non-circumcised group. CONCLUSIONS: Prolonged labour does not seem to be associated to female genital circumcision in affluent societies with high standards of obstetric care.

Low birth weight is associated with elevated systolic blood pressure in adolescence: a prospective study of a birth cohort of 149378 Swedish boys.

OBJECTIVES: To determine the association between birth weight and systolic blood pressure (SBP) in male adolescents at the age of 18 years. DESIGN: A prospective study by means of a register linkage between the Swedish Medical Birth Register and the national register for conscript testing before military service. METHODS: From the birth registry we collected data on birth weight, gestational age, maternal age and parity for 149378 individuals. At conscript testing, subjects were given a physical examination, and weight, height, and mean blood pressure were recorded after 5-10 min rest. RESULTS: Mean+/-SD birth weight was 3543+/-551 g after a mean of 39.7+/-2.0 gestational weeks. Mean+/-SD blood pressure at the conscript testing was 128.8+/-10.9/65.2+/-10.6 mmHg. SBP, but not diastolic blood pressure, differed significantly (test for trend, P< 0.001) between birth weight strata (deciles), with a higher SBP in strata with lower birth weight. A difference in birth weight of 1000 g decreased SBP by 0.8 mmHg. This was most pronounced in subjects with a rapid growth development (n = 1057), coming from the lowest decile of birth weight and reaching to the highest decile of body mass index, in a very consistent manner. The odds ratio for being in the top decile of SBP was 1.55 (95% confidence interval 1.32-1.81) for this growth 'catch-up' group compared with the rest of the cohort. CONCLUSIONS: Birth weight was inversely associated with SBP in a large cohort of young men in their late teens. This supports the notion of a programming effect of fetal growth retardation in utero on haemodynamic regulation in early adult life.

Increased susceptibility to stress at a psychological assessment of stress tolerance is associated with impaired fetal growth.

BACKGROUND: This study aims to investigate the relationship between birthweight and psychological function, as evaluated by the results of a psychological conscript interview and assessment in young males, including an evaluation of stress susceptibility. METHODS: We performed a retrospective cohort study based on linked birth registry data and data from an assessment of psychological function during evaluation for military service. In all, 90 651 young males born 1973-1975, for whom birth record data were obtained from the Swedish Medical Birth Register, were investigated in addition to psychological stress susceptibility during their conscript evaluation in 1991-1994. The assessment of psychological functioning score, including the assessment of stress susceptibility, was used as the dependent variable in a multiple regression analysis in combination with the following independent variables: birthweight, adult weight, head circumference at birth, month of birth, gestational age, maternal parity, and maternal age. RESULTS: The mean value was 5.1 (SD 1.9) on the psychological assessment scale (range 1-9) of psychological level of functioning including evaluation of stress susceptibility, and 5.3 (1.6) on the general psychological performance (leadership) profile. A positive association was seen between birthweight and better assessment results up to a level of about 4000 g birthweight, but above that an inverse association was seen. Positive correlations (P < 0.001) were seen between psychological assessment score results and birthweight (r = 0.07), gestational age (0.03), head circumference (0.05), and maternal age (0.11), but inverse correlations with maternal parity (-0.11) and birth month of the offspring (-0.04). In multiple regression analyses, the strongest independent correlations were seen between increasing assessment scores and maternal age and birthweight (positive), as well as with maternal parity and offspring adult weight (negative). CONCLUSION: Young males at conscript testing show a better general psychological functioning score derived from psychological assessment, including evaluation of stress susceptibility, with increasing birthweight up to 4200 g. Above that birthweight an inverse association is noticed. Impaired fetal growth is predictive of suboptimal psychological functioning and increased stress susceptibility in males during early adult life.

Socioeconomic differences in fat intake in a middle-aged population: report from the Malmö Diet and Cancer Study.

BACKGROUND: The objective was to investigate whether socioeconomic differences in fat intake may explain socioeconomic differences in cardiovascular diseases. METHODS: The Malmö Diet and Cancer Study is a prospective cohort study. The baseline examinations used in the present cross-sectional study were undertaken in 1992-1994. Dietary habits were assessed using a modified diet history method consisting of a 7-day menu book and a 168-item questionnaire. A subpopulation of 11 837 individuals born 1926-1945 was investigated. This study examined high fat intake, defined as >35.9% among men and >34.8% among women (25% quartile limit) of the proportion of the non-alcohol energy intake contributed by fat. The subfractions saturated, mono-unsaturated and poly-unsaturated fatty acids and the P:S ratio (polyunsaturated/saturated fatty acids) were analysed in the same way. The uppermost quartile (75%) of total and subgroup fat intake was also studied. Socioeconomic differences before and after adjustment for low energy reporting (LER), defined as energy intake below 1.2 x Basal Metabolic Rate, were examined. RESULTS: No socioeconomic differences in fat intake were seen between the SES groups, except for self-employed men, and male and female pensioners. Approximately 20% in most SES groups were LER. The LER and body mass index were strongly related. The SES pattern of fat intake remained unchanged after adjustment for age, country of origin and LER in a logistic regression model. The results for the subfractions of fat and the P:S ratio did not principally differ from the total fat results. CONCLUSIONS: This study provides no evidence that fat intake contributes to the inverse socioeconomic differences in cardiovascular diseases.

Work-related psychosocial factors and carotid atherosclerosis.

BACKGROUND: In order to better understand the role of work environment in the earlier stages of the cardiovascular disease process, we wanted to investigate the influence of work-related psychosocial factors on preclinical atherosclerosis. METHODS: Cross-sectional data was used to examine the association between psychological job demands, job decision latitude, and carotid atherosclerosis in 2658 vocationally-active Swedish men and women, ages 46-65, from the general population. Odds ratios of carotid plaque prevalence and carotid artery intima-media thickness (IMT), determined by B-mode ultrasound, were estimated across combinations of job demands and decision latitude. RESULTS: Women in job situations with high demands and low decision latitude ('job strain') showed a high plaque prevalence odds (odds ratio [OR] = 1.68, 95% CI: 1.14, 2.48), and a thicker IMT in the carotid bifurcation area (mean difference: 0.15 mm, 95% CI: 0.07, 0.23) compared with women in job situations with low demands and high decision latitude ('relaxed'). Adjustment for covariates only slightly reduced the magnitude of these associations. No such associations were seen in men. However, women in job situations with high demands and high decision latitude ('active') also showed high odds for carotid plaque, and a thicker IMT in the carotid bifurcation, compared with women in 'relaxed' job situations. In men, those in 'active' job situations had a low carotid plaque prevalence odds, while IMT in the carotid bifurcation did not differ from those in 'relaxed' job situations. Results showed only weak associations with IMT in the common carotid artery (CCA) in both men and women. CONCLUSION: The specific hypothesis that high job demands interact synergistically with low decision latitude in the development of carotid atherosclerosis could not be supported in this study, neither in men nor in women. Instead a more complex pattern of interaction between job demands and decision latitude was shown.

The association between violence victimisation and common symptoms in Swedish women.

STUDY OBJECTIVE: To investigate the association between violence and abuse suffered by women during childhood or adult life, and the manifestation of a high level of common physical and mental symptoms. DESIGN, SETTING AND PARTICIPANTS: A questionnaire was sent to a random population of women, 40 to 50 years of age, living in a rural Swedish community. The response rate was 81.7 per cent (397 women). Odds ratios were used to estimate bivariate associations between the experience of violence/abuse and common symptoms. Multiple logistic regression analyses were used to test for confounding and effect modification. MAIN RESULTS: The experience of violence or abuse during childhood was reported by 32.2 per cent of the women, while 15.6 per cent reported being abused as an adult. In both cases, these experiences reached statistical significance in their association with a high level of common symptoms (OR=1.67; 95% CI 1. 08, 2.49 and OR=2.26; 95%CI 1.30, 3.92, respectively). The associations between childhood and as well adult experience of violence or abuse and common symptoms were largely independent of potential confounders such as unemployment, job strain, social support, and sense of coherence. The combined exposure to adult violence/abuse and low psychosocial coping resources, such as low social support or a low level of sense of coherence, considerably increased the odds ratio for common symptoms and a synergistic effect seemed to exist. CONCLUSION: Violence or abuse experience is an important factor when considering illness manifestations in terms of common symptoms in women 40 to 50 years of age.

Common symptoms in middle aged women: their relation to employment status, psychosocial work conditions and social support in a Swedish setting.

STUDY OBJECTIVE: Over the past few decades there has been a growing interest among researchers, in women's overall life circumstances and their relation to women's health status. For example, paid employment has been considered an important part of women's living conditions in Western societies as the number of women entering the labour market has grown constantly over the past decades. When comparing men's and women's health, one of the most consistent findings is a higher rate of symptoms among women. The most commonly reported symptoms in women are depressive symptoms, symptoms of bodily tension and chronic pain from muscles and joints. The aim of this study was to investigate whether socioeconomic factors, employment status, psychosocial work conditions and social network/support are associated with middle aged women's health status in terms of common symptoms. DESIGN: A mailed questionnaire was used in a cross sectional design assessing socioeconomic factors, employment status, psychosocial work conditions according to the demand/control model, social network/support and an index based on the 15 most frequent symptoms presented by middle aged women when seeking health care. SETTING: A rural community with 13,200 inhabitants in the western part of Sweden. PARTICIPANTS: Women were randomly selected from the general population in the study area, 40 to 50 years of age. The response rate was 81.7 per cent. MAIN RESULTS: Women who were non-employed had a significantly increased odds of a high level of common symptoms (OR = 2.82; 95% confidence intervals 1.69, 4.70), as well as women exposed to job strain (OR = 3.27; 1.92, 5.57), independently of the level of social network/support. Furthermore, exposure to low social support, low social anchorage or low social participation independently showed significantly increased odds of a high level of common symptoms (OR = 2.75; 1.71, 4.42; OR = 2.91; 1.81, 4.69 and OR = 1.69; 1.10, 2.61, respectively). CONCLUSIONS: Work related factors, such as non-employment and job strain, and circumstances within the private sphere, such as social network/support, seem equally important for middle aged women's health status. These findings ought to have important policy implications and also to be of major importance in a primary health care setting when meeting women who seek health care because of common symptoms.

Ethnic differences in self reported health in Malmö in southern Sweden.

STUDY OBJECTIVE: The aim of this study was to investigate ethnic differences in self reported health in the city of Malmö, Sweden, and whether these differences could be explained by psychosocial and economic conditions. DESIGN/SETTING/PARTICIPANTS: The public health survey in Malmö 1994 was a cross sectional study. A total of 5600 people aged 20-80 years completed a postal questionnaire. The participation rate was 71%. The population was categorised according to country of origin: born in Sweden, other Western countries, Yugoslavia, Poland, Arabic speaking countries and all other countries. The multivariate analysis was performed using a logistic regression model in order to investigate the importance of possible confounders on the differences by country of origin in self reported health. Finally, variables measuring psychosocial and economic conditions were introduced into the model. MAIN RESULTS: The odds ratios of having poor self reported health were significantly higher among men born in other Western countries, Yugoslavia, Arabic speaking countries and in the category all other countries, as well as among women born in Yugoslavia, Poland and all other countries, compared with men and women born in Sweden. The multivariate analysis including age and education did not change these results. A huge reduction of the odds ratios was observed for men and women born in Yugoslavia, Arabic speaking countries and all other countries, and for women born in Poland after the introduction of the social network, social support and economic factors into the multivariate model. CONCLUSIONS: There were significant ethnic group differences in self reported health. These differences were greatly reduced by psychosocial and economic factors, which suggest that these factors may be important determinants of self rated health in certain minority groups.

HIV infection: social network, social support, and CD4 lymphocyte values in infected homosexual men in Malmö, Sweden.

STUDY OBJECTIVE: The aim was to determine if there is an association between social network and social support and the CD4 cell count in HIV infected homosexual men. DESIGN: The study was cross sectional. A structured questionnaire assessing psychosocial factors such as social network and social support was administered at interview. Information on CD4 cell counts and HIV symptoms were obtained from participants' medical records. SETTING: The study population consisted of all HIV seropositive homosexual and bisexual men who had not been diagnosed as having AIDS seen at the Department of Infectious Diseases, the only hospital clinic in the city of Malmö (230,000 inhabitants), Sweden that provides care for HIV infected patients. PARTICIPANTS: Altogether 47 (68%) of 69 men in the population agreed to be interviewed. MAIN RESULTS: A low CD4 cell count was found more frequently in men with low social participation scores (OR 3.3; 95% CI 1.0, 11), in those with a low adequacy of social participation (OR 3.8; 95% CI 1.1, 13), and in men with low material support scores (OR 3.9; 95% CI 1.1, 13). After adjustment for age and time of awareness of the HIV infection, the two former associations remained statistically significant. CONCLUSIONS: These results, if reproduced in a longitudinal study, might suggest that psychosocial factors can affect an individual's immune system.

Survival after initial hospitalisation for heart failure: a multilevel analysis of patients in Swedish acute care hospitals.

STUDY OBJECTIVE: Although national variation in short-term prognosis (that is, 30 day mortality) after a patient's first hospitalisation for heart failure may depend on individual differences between patients, dissimilarities in hospital practices may also influence prognosis. This study, therefore, sought to disentangle patient determinants from institutional factors that might explain such variation. DESIGN: A multilevel logistic regression modelling was performed with patients (1st level) nested in hospitals (2nd level). Institutional effects (that is, 2nd level variance and intra-hospital correlation) were calculated unadjusted and adjusted for specific patient (that is, age and previous diseases) and institutional (that is, size of hospital) characteristics. Patients were followed up until death or 30 days from hospital admission. SETTING: Hospitals in Sweden. PATIENTS: The study identified all the 20420 men and 17923 women (ages 65 to 85) admitted to the 90 acute care hospitals in Sweden during the period 1992-1995 for their first hospitalisation attributable to heart failure. MAIN RESULTS: Patient age and previous diseases (particularly senile dementia) were major determinants of impaired prognosis. Institutional factors explained only 1.6% and 2.3% of the total variation in 30 day mortality in men and women, respectively. These modest institutional effects remained after adjusting for patient age and previous diseases, but were in part explained by hospital size. CONCLUSIONS: National variation in short-term prognosis after an initial hospitalisation for heart failure was mainly explained by differences between patients, with hospital factors playing a minor part. Of the latter, hospital size seemed to emerge as one determinant (that is, the greater the number of patients, the better the individual prognosis).

Psychosocial resources and persistent smoking in early pregnancy--a population study of women in their first pregnancy in Sweden.

STUDY OBJECTIVE: To test the stress hypothesis by characterising women during their first pregnancy who continue to smoke in early pregnancy in comparison with women who quit smoking, with special reference to psychosocial factors like social network, social support, demands, and control in work and daily life. DESIGN: The study is based on a cohort of primigravidas followed during pregnancy. Data were collected by self administered questionnaires during the pregnant womens' first antenatal visit at about 12 weeks. SETTING: The study was performed in the antenatal clinics in the city of Malmö, Sweden. PARTICIPANTS: The participants were all primigravidas living in the city of Malmö, Sweden, over a one year period, 1991-92. A total of 872 (87.7%) of the 994 invited women agreed to participate. The population of this study on smoking includes all primigravidas who at the time of conception were smoking (n = 404, 46.3%). MAIN RESULTS: At the first antenatal visit (63.6% (n = 257) of the prepregnancy smokers were still smoking (a total smoking prevalence of 29.5%). The pregnant smokers were on average younger and had a lower educational level. The highest relative risk (RR) of continued smoking was found among unmarried women RR 2.7 (95% confidence interval) (1.5, 4.8), women having unplanned pregnancies RR 2.2 (1.2, 4.0) and those with a low social participation RR 1.6 (1.0, 2.7), low instrumental support RR 2.6 (1.2, 6.0), low support from the child's father RR 2.1 (1.0, 4.2) and those exposed to job strain RR = 2.3 (1.1, 4.8). The associations were independent of potential confounders such as age, educational level, nationality, cohabiting status, passive smoking, and previous years of smoking. CONCLUSIONS: This study supports the stress hypothesis. Smoking can be one way women handle stress when demands become too great. In order to reduce smoking among pregnant women, maternity centre resources need to be focused more on women with low psychosocial resources who are at highest risk for continued smoking. It is also important to involve actively the woman's partner or other important people in the woman's social network.

Diastolic blood pressure and area of residence: multilevel versus ecological analysis of social inequity.

STUDY OBJECTIVES: To study geographical differences in diastolic blood pressure and the influence of the social environment (census percentage of people with low educational achievement) on individual diastolic blood pressure level, after controlling for individual age and educational achievement. To compare the results of multilevel and ecological analyses. DESIGN: Cross sectional analysis performed by multilevel linear regression modelling, with women at the first level and urban areas at the second level, and by single level ecological regression using areas as the unit of analysis. SETTING: Malmö, Sweden (population 250 000). PARTICIPANTS: 15 569 women aged 45 to 73, residing in 17 urban areas, who took part in the Malmö Diet and Cancer Study (1991-1996). MAIN RESULTS: In the "fixed effects" multilevel analysis, low educational achievement at both individual (beta=1.093, SE=0.167) and area levels (beta=2.966, SE=1.250) were independently associated with blood pressure, although in the "random effects" multilevel analysis almost none of the total variability in blood pressure across persons was attributable to areas (intraclass correlation=0.3%). The ecological analysis also found an association between the area educational variable and mean diastolic blood pressure (beta=4.058, SE=1.345). CONCLUSIONS: The small intraclass correlation found indicated very marginal geographical differences and almost no influence of the urban area on individual blood pressure. However, these slight differences were enough to detect an effect of the social environment on blood pressure. The ecological study overestimated the associations found in the "fixed" effects multilevel analysis, and neither distinguished individual from area levels nor provided information on the intraclass correlation. Ecological analyses are inadequate to evaluate geographical differences in health.