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Background: Previous research has shown an association between cumulative economic hardships and various health outcomes. However, the cumulative effects of economic hardships in regard to gender differences have not been given enough attention. Methods: 1981 women and 1799 men were followed up over a period of 16 years (1981-1997), using data from the Swedish Survey of Living Conditions panel study. The temporal association between economic hardships and self-rated health, psychological distress and musculoskeletal disorders was analysed. Results: A dose-response effect on women's health was observed with increasing scores of cumulative exposure to financial stress but not with low income. Women exposed to financial stress at both T-1 and T-2 had an increased risk of 1.4-1.6 for all health measures compared with those who were not exposed. A similar consistent dose-response effect was not observed among men. Conclusions: There is a temporal relationship between cumulative economic hardships and health outcomes, and health effects differ by gender. Financial stress seems to be a stronger predictor of poor health outcomes than low income, particularly among women. Policies geared towards reducing health inequalities should recognise that long-term exposure to economic hardships damages health, and actions need to be taken with a gender perspective.

Background: Trust as a measure of social capital has been documented to be associated with health. Mediating factors for this association are not well investigated. Harmful alcohol consumption is believed to be one of the mediating factors. We hypothesized that low social capital defined as low institutional trust is associated with harmful alcohol consumption. Methods: Data from the 2006 Swedish National Survey of Public Health were used for analyses. The total study population comprised a randomly selected representative sample of 26.305 men and 30.584 women aged 16-84 years. Harmful alcohol consumption was measured using a short version the Alcohol Use Disorders Identification Test (AUDIT), developed and recommended by the World Health Organisation. Low institutional trust was defined based on trust in ten main welfare institutions in Sweden. Results: Independent of age, country of birth and socioeconomic circumstances, low institutional trust was associated with increased likelihood of harmful alcohol consumption (OR (men) = 1.52, 95% CI 1.34-1.70) and (OR (women) = 1.50, 95% CI 1.35-1.66). This association was marginally altered after adjustment for interpersonal trust. Conclusion: Findings of the present study show that lack of trust in institutions is associated with increased likelihood of harmful alcohol consumption. We hope that findings in the present study will inspire similar studies in other contexts and contribute to more knowledge on the association between institutional trust and lifestyle patterns. This evidence may contribute to policies and strategies related to alcohol consumption.

Background: Possible accumulative effects of a combined economic hardship's measure, including both income and non-income related economic hardships measures, on mental health has not been well investigated. The aim of this paper was to investigate; (i) independent associations between multiple measures of economic hardships and mental health problems, and (ii) associations between a combined economic hardships measure and mental health problems. Methods: We analysed data from the 2009 Swedish National Survey of Public Health comprising a randomly selected representative national sample combined with a randomly selected supplementary sample from four county councils and three municipalities consisting of 23,153 men and 28,261 women aged 16-84 years. Mental health problems included; psychological distress (GHQ-12), severe anxiety and use of antidepressant medication. Economic hardship was measured by a combined economic hardships measure including low household income, inability to meet expenses and lacking cash reserves. Results: The results from multivariate adjusted (age, country of birth, educational level, occupational status, employment status, family status and long term illness) logistic regression analysis indicate that self-reported current economic difficulties (inability to pay for ordinary bills and lack of cash reserves), were significantly associated with both women's and men's mental health problems (all indicators), while low income was not. In addition, we found a statistically significant graded association between mental health problems and levels of economic hardships. Conclusions: The findings indicate that indicators of self-reported current economic difficulties seem to be more strongly associated with poor mental health outcomes than the more conventional measure low income. Furthermore, the likelihood of mental health problems differed significantly in a graded fashion in relation to levels of economic hardships.

Social structures and socioeconomic patterns are the major determinants of population health. However, very few previous studies have simultaneously analysed the "social" and the "economic" indicators when addressing social determinants of health. We focus on the relevance of economic and social capital as health determinants by analysing various indicators. The aim of this paper was to analyse independent associations, and interactions, of lack of economic capital (economic hardships) and social capital (social participation, interpersonal and political/institutional trust) on various health outcomes. Data was derived from the 2009 Swedish National Survey of Public Health, based on a randomly selected representative sample of 23,153 men and 28,261 women aged 16-84 year, with a participation rate of 53.8%. Economic hardships were measured by a combined economic hardships measure including low household income, inability to meet expenses and lacking cash reserves. Social capital was measured by social participation, interpersonal (horizontal) trust and political (vertical/institutional trust) trust in parliament. Health outcomes included; (i) self-rated health, (i) psychological distress (GHQ-12) and (iii) musculoskeletal disorders. Results from multivariate logistic regression show that both measures of economic capital and low social capital were significantly associated with poor health status, with only a few exceptions. Significant interactive effects measured as synergy index were observed between economic hardships and all various types of social capital. The synergy indices ranged from 1.4 to 2.3. The present study adds to the evidence that both economic hardships and social capital contribute to a range of different health outcomes. Furthermore, when combined they potentiate the risk of poor health. (C) 2012 Elsevier Ltd. All rights reserved.

Mental health disorders are a rapidly growing public health problem. Despite the fact that lack of trust in the health-care system is considered to be an important determinant of health, there is scarcity of empirical evidence demonstrating its associations with health outcomes. This is the first study which aims to evaluate the association between trust in the health-care system and psychological distress. Cross-sectional study. The association between trust in the health-care system and psychological distress was analysed with multiple logistic regression analysis adjusting for other factors. A randomly selected representative sample of women and men aged 16-84 years from the Swedish population who responded to the 2006 Swedish National Survey of Public Health. A total of 26 305 men and 30 584 women participated in the study. None. The main outcome measure was psychological distress measured by the General Health Questionnaire. Very low trust in health-care services was associated with an increased risk for psychological distress among men (odds ratio = 1.59, 95% confidence intervals 1.25-2.02) and among women (odds ratio = 1.83, 95% confidence intervals 1.47-2.27) after controlling for age, country of birth, socioeconomic circumstances, long-term illness and interpersonal trust. Our results suggest that health-care system mistrust is associated with an increased likelihood of psychological distress. Although causal relationships cannot be established, patient mistrust of health-care providers may have detrimental implications on health. Public health policies should include strategies aimed at increasing access to health-care services, where trust plays a substantial role.

Immigration affects life and health in many different ways. The purpose of this study was to identify and analyze female Iranian immigrants' perception of various factors that influence their health over time. Data collection was based on semistructured interviews with 10 female Iranianimmigrants. Baseline interviews were conducted in 1996, with follow-up interviews in 2002. The results suggest that during the first decade after migration, female immigrants may overcome some health-related factors such as experiences of traumatic events. Other health determinants such as unemployment or experiences of discrimination and racism, however, were observed even two decades after migration.

Work-related health has been a focus of research since the rate of sickness-related absences began to increase in Sweden. The incidence of sickness-related absences and early retirement is higher among female immigrants than among others in the total population. This study is based on a questionnaire survey which was conducted in a municipality in Sweden. The study population consisted of 2 429 native and immigrant female employees. The aim was to study work-related health factors for female immigrants. The results of this study show that about 20% of female immigrants who participate in the survey have temporary employment while the proportion is 8% for native women. The perception of ethnic discrimination among female immigrants was three times as much as among native females. The results also show that 69% of female immigrants report having received no opportunity to discuss their wages with managers, in comparison to 63% of native females. About 40% of female immigrants and 35% of native women report that they do not get opportunities to upgrade their skills. Female immigrants over the age of 50 experience gender and ethnic discrimination and lack of access to skills training programs more often than younger immigrants. They also participate in health-care activities more often.

Aims: The purpose of this study was to explore work-related health factors amongst female immigrants in Sweden.

Methods: Qualitative methods were used in order to get the broadest possible picture of female immigrants’ perceptions on work-related health factors. Semi-structured interviews were conducted with twenty female immigrants who worked in different departments of a municipality adjacent to a large city in Sweden. Most of the interviewed women came from the Middle East, Africa and Latin America, while some came from eastern and southern Europe as well as Finland. The women had lived in Sweden for 5-27 years. Content analysis, which is based on analysis by topic, was used to analyse the data.

Results: Results from the interviews show that female immigrants perceived that work-related health is strongly associated with class. The three aspects of class that arose from this study were wage, professional status and their position within the organisations hierarchy. Other factors that were identified as being associated to work-related health were discrimination due to ethnicity and gender, unfavourable physical and psychosocial work environment and lack of training opportunities for upgrading their skills.

Conclusions: The public health implications of the findings in this study suggest that measures that ought to be taken to improve female immigrants working conditions and health are primarily systematic efforts to counteract discrimination because of gender and ethnicity in areas such as wage setting and opportunities for skill up-grade training. This should result in improved employment opportunities for female immigrants, particularly those who work in low status and low-paid jobs.

The purpose of this study was to analyze health in relation to unemployment and sick leave among immigrants from a gender perspective. Questionnaire, observations, and group discussions were used for data collection. The study group consisted of 60 unemployed persons with immigrant or refugee background, 30 women and 30 men. Slightly more than half of the participants considered theirhealth to be poor and experienced physical and/or mental disorders. The female participants in comparison to male participants experienced poorer health. The results show that there is a reciprocal influence between health, work, and migration. Immigration may cause poor health, which as a selection effect leads to unemployment and/or sick leave. Immigration may also bring about an inferior position in the labor market, which leads to poor health due to exposure effects. The influence on health is more marked for immigrant women than for immigrant men.

Objectives: To investigate gender differences in daily smoking prevalence in different age groups in southern Sweden. Methods: The 2004 public-health survey in Skane is a cross-sectional study. A total of 27,757 persons aged 18-80 years answered a postal questionnaire, which represents 59% of the random sample. A logistic regression model was used to investigate the associations between gender and daily smoking according to age. The multivariate analysis was performed to investigate the importance of possible confounders (country of origin, education, snus use, alcohol consumption, leisure-time physical activity, and BMI) on the gender differences in daily smoking in different age groups. Results: 14.9% of the men and 18.1% of the women were daily smokers. Middle-aged respondents were daily smokers to a significantly higher extent than young and old respondents. The prevalence of daily smoking also varied according to other demographic, socioeconomic, health related behaviour, and BMI characteristics. The crude odds ratios of daily smoking were 1.79 (1.42-2.26) among women compared to men in the 18-24 years age group, and 0.95 (0.80-1.12) in the 65-80 years age group. These odds ratios changed to 2.00 (1.49-2.67) and 0.95 (0.76-1.18), respectively, when all confounders were included. Conclusions: For the first time in Sweden women have a higher prevalence of daily smoking than men. The odds ratios of daily smoking are highest among women compared to men in the youngest age group of 18-24 years and the odds ratios decrease with increasing age. The findings point to a serious public health problem. Strategic interventions targeting young women's tobacco smoking are needed.

Background The objectives of this study were to investigate the relation between coronary risk factors, exercise testing parameters, and the presence of angiographically significant coronary artery disease (CAD) (>50% luminal stenosis) in female patients previously hospitalized for an acute CAD event. Methods and Results All women younger than age 66 years in the greater Stockholm area in Sweden who were hospitalized for acute coronary syndromes during a 3-year period were recruited, Besides collection of clinical parameters, coronary angiography and a symptom-limited exercise test were performed in 228 patients 3 to 6 months after the index hospitalization. The mean age was 56 +/- 7 years. Angiographically nonsignificant CAD (stenosis <50%) was verified in 37% of the patients; significant CAD was found in 63%. The clinical parameters that showed the strongest relation with the presence of significant CAD after adjusting for age were history of myocardial infarction (odds ratio [OR] 4.91, 95% confidence interval [CI] 2.35 to 7.49), history of diabetes mellitus (OR 3.83, 95% Cl 1.63 to 14.31), serum high-density lipoprotein cholesterol <1.4 mmol/L (OR 2.11, 95% Cl 1.20 to 3.72), and waist-to-hip ratio >0.85 (OR 1.78, 95% Cl 1.02 to 3.10). A low exercise capacity and associated low change of rate-pressure product from rest to peak exercise were the only exercise testing parameters that were significantly related to angiographically verified significant CAD (<90% of the predicted maximal work capacity adjusted for age and weight, OR 1.91, 95% CI 1.04 to 3.50). Conclusions In female patients recovering from unstable CAD, exercise capacity was the only exercise testing parameter of value in the prediction of significant CAD. The consideration of certain clinical characteristics and coronary risk factors offer better or complementary information when deciding on further coronary assessment.

Background: Healthcare utilization has particular relevance as a public health and development issue. Unlike material and human capital, there is little empirical evidence on the utility of social resources in overcoming barriers to healthcare utilization in a developing country context. We sought to assess the relevance of social resources in overcoming barriers to healthcare utilization. Study Objective: To explore community perceptions among three different wealth categories on factors influencing healthcare utilization in Eastern Uganda. Methods: We used a qualitative study design using Focus Group Discussions (FGD) to conduct the study. Community meetings were initially held to identify FGD participants in the different wealth categories, ('least poor', 'medium' and 'poorest') using poverty ranking based on ownership of assets and income sources. Nine FGDs from three homogenous wealth categories were conducted. Data from the FGDs was analyzed using content analysis revealing common barriers as well as facilitating factors for healthcare service utilization by wealth categories. The Health Access Livelihood Framework was used to examine and interpret the findings. Results: Barriers to healthcare utilization exist for all the wealth categories along three different axes including: the health seeking process; health services delivery; and the ownership of livelihood assets. Income source, transport ownership, and health literacy were reported as centrally useful in overcoming some barriers to healthcare utilization for the 'least poor' and 'poor' wealth categories. The 'poorest' wealth category was keen to utilize free public health services. Conversely, there are perceptions that public health facilities were perceived to offer low quality care with chronic gaps such as shortages of essential supplies. In addition to individual material resources and the availability of free public healthcare services, social resources are perceived as important in overcoming utilization barriers. However, there are indications that having access to social resources may compensate for the lack of material resources in relation to use of health care services mainly for the least poor wealth category. Conclusion: The differential patterning of social resources may explain or contribute to the persisting inequities in health care utilization. Additional research using quantitative analytical methods is needed to test the robustness of the contribution of social resources to the utilization of and access to healthcare services.

Objective: The aim of this study was to investigate the effect of marital and job stress on depressive symptoms in middle aged women with coronary heart disease (CHD) and healthy women who were cohabiting and currently working. Method: Data were obtained from the Stockholm Female Coronary Risk (FemCorRisk) Study, a population-based case-control study, comprising all women aged 65 years or younger who were admitted for an acute event of CHD between 1991 and 1994. For each patient, an age-matched healthy control was recruited. Marital stress was assessed by a structured interview developed in our research laboratory and work stress by the Karasek demand-control questionnaire. Depressive symptoms were measured by a questionnaire derived from Pearlin et al. [J. Health Soc. Behav. 22 (1981) 337], which was validated by the Beck Depression Inventory. Results: Depressive symptoms were twice as common in women with as in women without coronary disease: Marital stress was statistically significantly associated with depressive symptoms, even after controlling for age, educational level, menopausal status, body mass index (BMI), sedentary lifestyle, cigarette smoking and severity of heart failure symptoms. In both groups, depressive symptoms increased with increasing exposure to marital stress in a graded fashion. Work stress was not associated with depressive symptoms after multivariate adjustment. Conclusions: Marital stress but not work stress is independently related to depressive symptoms in women. Women with coronary disease react similarly to marital stress as healthy women, but depart from a higher level of depression, which may. be explained by their poorer health status. (C) 2003 Elsevier Science Inc. All rights reserved.

Background Studies have previously shown that psychosocial stress, related to both work and family, is associated with the increased risk of coronary heart disease (CHD) morbidity and mortality. The objective of this study was to examine how social relations are affected by marital stress and work stress in a population-based sample of Swedish women with CHD. Method Data was obtained from the Stockholm Female Coronary Risk Study, comprising 292 women aged 65 years or younger, with a mean age of 56 (SD = 7) years admitted for an acute event of CHD and examined 3-6 months after hospitalization. Marital and work stress was assessed using the Stockholm Marital Stress Scale and the Swedish version of the Karasek demand-control questionnaire, respectively. Condensed versions of the Interview Schedule for Social Interaction (ISSI) and of Interpersonal Support Evaluation List (ISEL) were used to assess social relations and social support. Results Marital stress was associated with less social integration (P< 0.001), less appraisal support (P< 0.001), a lower sense of belonging (P<0.01) and less tangible support (P< 0.01) even after controlling for work stress. Adjustment for age, socioeconomic status (education and occupational status) did not alter these results significantly. Work stress did not show statistically significant effects on any of the measured social relations. Conclusion The present study showed that marital stress influenced women's social relations. These results suggest that marital stress needs to be further investigated not only as an independent but also as an interactive risk factor for women with CHD. J Cardiovasc Risk 10:201-206 (C) 2003 Lippincott Williams Wilkins.

Aims: The study was undertaken to assess the cost-effectiveness of the Chlamydia Monday, 2007. This is a community-based intervention aimed at reducing the prevalence of chlamydia by information and increased availability of testing, treatment and contact tracing in Stockholm. The aim was to analyze the cost-effectiveness by estimating costs, savings and effects on health associated with the intervention, and to determine if cost-effectiveness varies between men and women. Methods: A societal perspective was adopted, meaning all significant costs and consequences were taken into consideration, regardless of who experienced them. A cost-effectiveness model was constructed including costs of the intervention, savings due to avoiding potential costs associated with medical sequels of chlamydia infection, and health gains measured as quality adjusted life years (QALY). Sensitivity analyses were done to explore model and result uncertainty. Results: Total costs were calculated to be (sic)66,787.21; total savings to (sic)30,370.14; and total health gains to 9.852324 QALYs (undiscounted figures). The discounted cost per QALY was (sic)8,346.05 ((sic)10,810.77/QALY for women and (sic)6,085.35/QALY for men). Sensitivity analyses included changes in effectiveness, variation of prevalence, reduced risk of sequel progression, inclusion of prevented future production loss and shortened duration for chronic conditions. The cost per QALY was consistently less than (sic)50,000, which is often regarded as cost-effective in a Swedish context. Conclusions: The Chlamydia Monday has been demonstrated by this study to be a cost-effective intervention and should be considered a wise use of society's resources.

BACKGROUND: GPS alarms aim to support users in independent activities. Previous systematic reviews have reported a lack of clear evidence of the effectiveness of GPS alarms for the health and welfare of users and their families and for social care provision. As GPS devices are currently being implemented in social care, it is important to investigate whether the evidence of their clinical effectiveness remains insufficient. Standardized evidence frameworks have been developed to ensure that new technologies are clinically effective and offer economic value. The frameworks for analyzing existing evidence of the clinical effectiveness of GPS devices can be used to identify the risks associated with their implementation and demonstrate key aspects of successful piloting or implementation.

OBJECTIVE: The principal aim of this study is to provide an up-to-date systematic review of evidence based on existing studies of the effects of GPS alarms on health, welfare, and social provision in the care of older adults compared with non-GPS-based standard care. In addition, the study findings were assessed by using the evidence standards framework for digital health technologies (DHTs) established by the National Institute for Health and Care Excellence (NICE) in the United Kingdom.

METHODS: This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Primary studies published in peer-reviewed journals and gray literature from January 2005 to August 2020 were identified through searches in 13 databases and several sources of gray literature. Included studies had individuals (aged ≥50 years) who were receiving social care for older adults or for persons with dementia; used GPS devices as an intervention; were performed in Canada, the United States, European Union, Singapore, Australia, New Zealand, Hong Kong, South Korea, or Japan; and addressed quantitative outcomes related to health, welfare, and social care. The study findings were analyzed by using the NICE framework requirements for active monitoring DHTs.

RESULTS: Of the screened records, 1.6% (16/986) were included. Following the standards of the NICE framework, practice evidence was identified for the tier 1 categories Relevance to current pathways in health/social care system and Acceptability with users, and minimum evidence was identified for the tier 1 category Credibility with health, social care professionals. However, several evidence categories for tiers 1 and 2 could not be assessed, and no clear evidence demonstrating effectiveness could be identified. Thus, the evidence required for using DHTs to track patient location according to the NICE framework was insufficient.

CONCLUSIONS: Evidence of the beneficial effects of GPS alarms on the health and welfare of older adults and social care provision remains insufficient. This review illustrated the application of the NICE framework in analyses of evidence, demonstrated successful piloting and acceptability with users of GPS devices, and identified implications for future research.

Plasma fibrinogen is an independent risk factor for coronary heart disease (CHD) in men; however, its role in women is less clear. We examined the ability of plasma fibrinogen to predict CHD in a community-based, case-control study of women aged 65 years or younger living in the greater Stockholm area. Cases were all patients hospitalized for an acute coronary event between February 1991 and February 1994. Controls were randomly selected from the city census and were matched to cases by age and catchment area. Plasma fibrinogen was measured 3 to 6 months after hospitalization by using a fibrinogen assay based on fibrinogen polymerization time measurement. Of the 292 consecutive cases, 110 (37%) were hospitalized for an acute myocardial infarction and 182 (63%) for angina pectoris. The mean age+/-SD in both patients and controls was 56+/-7 years. Mean levels of plasma fibrinogen in patients and controls were 3.66+/-0.81 and 3.25+/-0.64 g/L (P<0.0001), respectively. The age-adjusted odds ratio (OR) for CHD in the highest versus the lowest quartile of plasma fibrinogen was 6.0 (95% confidence interval [CI], 3.5 to 10.4). After adjustment for age, cigarette smoking, body mass index, systolic blood pressure, total cholesterol, high density lipoprotein cholesterol, triglycerides, and educational level, the OR was 3.0 (95% CI, 1.6 to 5.5). Further adjustment for C-reactive protein yielded the same result. In both premenopausal and postmenopausal women, the multivariate adjusted ORs were 7.0 (95% CI, 1.8 to 28.3) and 2.1 (95% CI, 1.0 to 4.4), respectively. These results provide evidence that plasma fibrinogen is associated with an excess risk of CHD in women.

OBJECTIVE: This study was conducted to investigate associations between psychosocial risk factors, including social isolation, anger and depressive symptoms, and heart rate variability in healthy women.

METHODS: The study group consisted of 300 healthy women (median age 57.5 years) who were representative of women living in the greater Stockholm area. For the measurement of social isolation, a condensed version of the Interpersonal Support Evaluation List was used and household size assessed. Anger was measured by the anger scales previously used in the Framingham study and depressive symptoms by a questionnaire derived from Pearlin. Health behaviors were measured by means of standard questionnaires. From 24-hour ambulatory electrocardiographic monitoring, both time and frequency domain measures were obtained: SDNN index (mean of the SDs of all normal to normal intervals for all 5-minute segments of the entire recording), VLF power (very low frequency power), LF power (low frequency power), HF power (high frequency power), and the LF/HF ratio (low frequency by high frequency ratio) were computed.

RESULTS: Social isolation and inability to relieve anger by talking to others were associated with decreased heart rate variability. Depressive symptoms were related only to the LF/HF ratio. Adjusting for age, menopausal status, exercise and smoking habits, history of hypertension, and BMI did not substantially change the results.

CONCLUSIONS: These findings suggest heart rate variability to be a mediating mechanism that could explain at least part of the reported associations between social isolation, suppressed anger, and health outcomes.

Aims Several studies have reported that women with coronary heart disease have a poorer prognosis than men. Psychosocial factors, including social isolation and depressive symptoms have been suggested as a possible cause. However. little is known; about these factors and their independent predictive value in women. Therefore, we investigated the prognostic impact of depression, lack of social integration and their interaction in the Stockholm Female Coronary Risk Study. Methods and Results Two hundred and ninety-two women patients aged 30 to 65 years and admitted for an acute coronary event between 1991 and 1994, were followed for 5 years from baseline assessments, which were performed between 3 and 6 months after admission. Lack of social integration and depressive symptoms, assessed at baseline by standardized questionnaires, were associated with recurrent events. including cardiovascular mortality, acute myocardial infarction and revascularization procedures (percutaneous transluminal coronary angioplasty and coronary artery bypass grafting). Adjusting for age, diagnosis at index event. symptoms of heart failure, diabetes mellitus, high density lipoprotein (HDL) cholesterol, history of hypertension, systolic blood pressure, smoking, sedentary lifestyle, body mass index, and severity of angina pectoris symptoms. the hazard ratio associated with low (lowest quartile) as compared to high social integration (upper quartile) was 2.3 (95% CI 1.2-4.5) and the hazard ratio associated with two or more (upper three quartiles) as compared to one or no depressive symptoms was 1.9 (95% CI 1.02-3 6). Conclusions The presence of two or more depressive symptoms and lack of social integration independently predicted recurrent cardiac events in women with coronary heart disease. Women who were free of both these risk factors, had the best prognosis. (C) 2000 The European Society of Cardiology.

Background Both social isolation and the metabolic syndrome are independently associated with greater than normal cardiovascular risk. Design A population-based cross-sectional study of middle-aged Swedish women. Methods The study group consisted of 300 healthy women (aged 31-65 years) who were representative of women living in the greater Stockholm area. Social isolation was measured by using a condensed Version of the Interpersonal Support Evaluation List. Health behaviours were assessed and a full serum-lipid-level and haemostatic profile was obtained by standardized methods, The metabolic syndrome was defined as the presence of two or more of these components: fasting serum level of glucose greater than or equal to 7.0 mmol/l, arterial blood pressure greater than or equal to 160/90 mmHg, fasting serum level of triglycerides greater than or equal to 1.7 mmol/l or high-density lipoprotein < 1.0 mmol/l, or both, and central obesity (waist:hip ratio > 0.85 or body mass index > 30 kg/m(2), or both), Results After adjustment for age, menopausal status, educational level, smoking, exercise habits and consumption of alcohol, the risk ratio for the metabolic syndrome for women in the lower compared with women in the upper social-support quartile was 3.5 (95% confidence interval 1.1-11.4), whereas that of women in the two middle quartiles was 2.2 (95% confidence interval 0.67-7.2; P for trend 0.02). Conclusions Social isolation was associated with the metabolic syndrome for these middle-aged women. The findings suggest that the metabolic syndrome and its components may be mediators of the reported association between social isolation and cardiovascular disease, (C) 1999 Lippincott Williams & Wilkins.

Objective: Several studies have reported an inverse relationship between cholesterol levels and death from violent causes, including suicide. Because depression and depressive symptoms are associated with suicide and trauma, the relation between cholesterol and depressive symptoms is of interest. The objective of the present study was to examine this relationship in a group of healthy women. The second main objective of the study was to investigate the association between cholesterol and other psychosocial factors (social support, Vital exhaustion, and stressful life-events), which are known to be related to depression. Method: The study group consisted of 300 healthy women raged 31 to 65 years who were representative of women living in the greater Stockholm area. Depressive symptoms were measured by a nine-item questionnaire derived from Pearlin. For the measurement of social support a modified version of the Interview Schedule for Social Interaction was used. Health behaviors were measured by means of standard questionnaires. Lipids were analyzed by enzymatic and immunoturbidometric methods. Results: Women with a low serum cholesterol, defined as the lowest tenth of the cholesterol distribution (less than or equal to 4.7 mmol/1), reported significantly more depressive symptoms. In addition, depressive symptoms showed a significant inverse linear association with high-density lipoprotein (HDL). In multivariate models, which adjusted for smoking, alcohol consumption, exercise habits, body-mass index, waist-hip ratio, menopausal status, age, and educational level, these associations remained significant. In addition, when analyzed in relation to other psychosocial factors, low cholesterol was found to be strongly associated with lack of social support. This association was not explained by depressive symptoms. Conclusions: Low cholesterol levels in middle-aged healthy Swedish women were associated with a higher prevalence of depressive symptoms and with lack of social support. These findings may constitute a possible mechanism for the association found between low cholesterol and increased mortality, particularly suicide.

Objectives. Low heart rate variability (HRV) is associated with poor prognosis after acute coronary events in men. In women, the prognostic impact is not well documented. The objective of this study was to assess the long-term predictive power of HRV on mortality amongst middle-aged women with coronary heart disease (CHD). Design, Settings and Subjects. Consecutive women below 65 years hospitalized for an acute coronary syndrome during a 3-year period in Stockholm were examined for cardiovascular prognostic factors including HRV, and followed for a median of 9 years. An ambulatory 24-h electrocardiograph was recorded during normal activities, 3-6 months after hospitalization. SDNN index (mean of the standard deviations of all normal to normal intervals for all 5-min segments of the entire recording) and the following frequency domain parameters were assessed: total power, high-frequency (HF) power, low-frequency (LF) power, very-low frequency (VLF) power and LF/HF ratio. Using Cox proportional hazards regression, the hazard ratios (HR) for each 25% decrease of the HRV parameters were assessed. Results. After controlling for the independent, significant predictors of mortality amongst the clinical variables, the following HRV parameters were found to be significant predictors of all-cause mortality: SDNN index [HR 1.56, 95% confidence intervals (CI) 1.19-2.05], total power (HR 1.21, 95% CI 1.08-1.35), VLF power (HR 1.22, 95% CI 1.09-1.36), LF power (HR 1.18 95%, CI 1.07-1.30) and HF power (HR 1.18, 95% CI 1.05-1.33). The results were essentially the same when cardiovascular mortality was used as end-points. The HRV parameters were stronger predictors of mortality in the first 5 years following the index event. Conclusion. Low HRV is a predictor of long-term mortality amongst middle-aged women with CHD when measured 3-6 months after hospitalization for an acute coronary syndrome, even after controlling for established clinical prognostic markers.

Background: Globalization-related measures to liberalize trade and stimulate export production were applied in Uganda in the late 1980s, including in the coffee production sector, to revitalize agricultural production, increase incomes to farmers and improve rural food security. Objective: To explore the different effects of such measures on the health and dietary outcomes of female coffee and food small holder farmers in Uganda. Methods: We gathered evidence through a cross-sectional comparative interview survey of 190 female coffee producers and 191 female food producers in Ntungamo district. The study mostly employed quantitative methods of data collection, targeting the sampled households. We also utilized qualitative data; collected three months after the household survey data had been collected and their analysis had been accomplished. Using qualitative interviews based on an unstructured interview guide, extra qualitative information was collected from key informants at national, district and community levels. This was among other underlying principles to avoid relying on snapshot information earlier collected at household level in order to draw valid and compelling conclusions from the study. We used indicators of production, income, access to food and dietary patterns, women's health and health care. Of the two groups selected from the same area, female coffee producers represented a higher level of integration into liberalised export markets. Results: Document review suggests that, although Uganda's economy grew in the period, the household economic and social gains after the liberalization measures may have been less than expected. In the survey carried out, both food and coffee producers were similarly poor, involved in small-scale production, and of a similar age and education level. Coffee producers had greater land and livestock ownership, greater access to inputs and higher levels of income and used a wider variety of markets than food producers, but they had to work longer hours to obtain these economic returns, and spent more cash on health care and food from commercial sources. Their health outcomes were similar to those of the food producers, but with poorer dietary outcomes and greater food stress. Conclusions: The small-scale women farmers who are producing food cannot rely on the economic infrastructure to give them support for meaningful levels of production. However, despite having higher incomes than their food producing counterparts, the evidence showed that women who are producing coffee in Uganda as an export commodity cannot rely on the income from their crops to guarantee their health and nutritional wellbeing, and that the income advantage gained in coffee-producing households has not translated into consistently better health or food security outcomes. Both groups have limited levels of autonomy and control to address these problems.

Women-focused development initiatives have become a controversial issue connected with women's health and welfare. Previous studies indicated that development initiatives might increase women's workload, family conflict, and marital violence. This study explored the gendered characteristics of a development initiative Rural Mother Center in Bangladesh. Data incorporated policy document and interviews of social workers working with the mother centers in two northwest subdistricts. The qualitative content analysis of data emerged a general theme of expanding women's responsibility while maintaining male privilege explaining gendered design and practice of the development initiative. The theme was supported by two gendered categories related to the design: (a) essentializing women's participation; (b) maintaining traditional gender, and four categories related to the practice; (c) inadequate gender knowledge and skills; (d) reinforcing traditional gender; (e) using women for improving office performance; and (f) upholding male privilege. The study suggests that though women-focused development initiatives need to be embraced with gender-redistributive policies, the social workers should be trained for attaining gender-transformative motivation and competencies.

In this study, we explored the implications of a groundwater development project on women's workload and their experience of marital violence in a Bangladesh village. We believe that the project facilitated irrigation water but also that it resulted in seasonal domestic water shortages. Men used deep motorized pumps for irrigation, and women used shallow handpumps for domestic purposes. Many handpumps dried out, so women had to walk to distant wells. This increased their workload and challenged their possibilities of fulfilling household obligations, thereby increasing the risk of normative marital male violence against women as a punishment for their failure.

Without taking masculine issues into account, women's participation in development initiatives does not always guarantee their empowerment, health, and welfare in a male-dominated society. This study aimed to explore men's perceptions of women's participation in development (WPD) in rural Bangladesh. In adopting a qualitative approach, the study examined 48 purposively selected married and unmarried men aged 20-76 years in three northwest villages. Data collection was accomplished through four focus group discussions (FGDs) with 43 men clustered into four groups and through individual interviews with five other men. A qualitative content analysis of the data revealed an overall theme of feeling challenged by fears and hopes, indicating variations in men's views on women's participation in development initiatives as represented by three main categories: (a) fearing the loss of male authority, (b) recognizing women's roles in enhancing family welfare, and (c) valuing women's independence. In the context of dominant patriarchal traditions in Bangladesh, these findings provide new insight into dynamics and variations of men's views, suggesting a need to better engage men during different stages of women-focused development initiatives.

This chapter begins with a brief description of the purpose of the book, which is to provide a survey of current and emerging global threats to health and to analyze the collective and institutional responses to globalization. It also addresses the role of key intergovernmental institutions (the World Bank, the IMF, the WTO, the World Health Organization (WHO), and the Group of Eight Nations (G8)) in protecting-or, some claim, threatening-the health of the global public. The chapter then discusses the concept of "globalization", and globalization through history. An overview of the subsequent chapters is presented.

This chapter describes trends in global poverty and inequality during the recent era of globalization. The first section reviews the evidence on global trends in poverty during the past two decades. The second section examines the evidence on trends in income inequality. The third section summarizes the current debates concerning whether the forces of globalization-in particular, increased trade and the closer integration of developing countries into the global economy-are responsible for the observed trends in poverty and inequality. The final section draws out some implications of globalization for the future of poverty and inequality in the world.

"Vital exhaustion," characterized by fatigue, irritability, and demoralization, precedes new and recurrent coronary events. Biological mechanisms explaining this association are not fully understood. The objective was to investigate the relationship between vital exhaustion, lifestyle, and lipid profile. Vital exhaustion, smoking, body mass index (BMI), alcohol consumption, exercise capacity, and serum lipids were determined in 300 healthy women, aged 56.4 +/- 7.1 years. No statistically significant associations were found between vital exhaustion and lifestyle variables. Divided into quartiles, vital exhaustion was inversely related to high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A1 in a linear fashion after adjustment for age, BMI, exercise capacity, and alcohol consumption. A multivariate-adjusted vital exhaustion-score in the top quartile, as compared to one in the lowest, was associated with 12% lower HDL-C and 8% lower apolipoprotein A1 (p < .05). In conclusion, alterations in lipid metabolism may be a possible mediating mechanism between vital exhaustion and coronary heart disease. The impact of lifestyle variables was weak.

The objective of this study was to investigate the prospective impact of vital exhaustion on recurrence after acute myocardial infarction (AMI) in women. Women ≤ 65 years, mean age = 55.30, SD = 7. 63, N = 110, consecutively admitted to a coronary care unit with AMI were examined after three-six months, and followed for five years. Vital exhaustion was assessed using an early version of the Maastricht Questionnaire. A recurrent event was defined as cardiac death, AMI or a revascularization procedure. Forty-five recurrent events were found (in 41% of the study group). One standard deviation (8.4 points) increase of vital exhaustion scores was associated with a 53 % increased risk of a new event and a score above the median was associated with a hazard ratio of 2.24 (95% CI 1.21-4.14). These results remained after adjusting severity of chest pain and significant coronary stenosis. In conclusion, it was found that vital exhaustion is a marker of poor prognosis in women with AMI. The relationship appears to be independent of signs of underlying disease, including severity of chest pain and significant coronary stenosis.

BACKGROUND: The need to assess the effectiveness and value of interventions involving digital health and health and welfare technologies is becoming increasingly important due to the rapidly growing development of these technologies and their areas of application. Systematic reviews of scientific literature are a mainstay of such assessment, but publications outside the realm of traditional scientific bibliographic databases-known as gray literature-are often not included. This is a disadvantage, particularly apparent in the health and welfare technology (HWT) domain. OBJECTIVE: The aim of this article is to investigate the significance of gray literature in digital health and HWT when reviewing literature. As an example, the impact of including gray literature to the result of two systematic reviews in HWT is examined. METHODS: In this paper, we identify, discuss, and suggest methods for including gray literature sources when evaluating effectiveness and appropriateness for different review types related to HWT. The analysis also includes established sources, search strategies, documentation, and reporting of searches, as well as bias and credibility assessment. The differences in comparison to scientific bibliographic databases are elucidated. We describe the results, challenges, and benefits of including gray literature in 2 examples of systematic reviews of HWT. RESULTS: In the 2 systematic reviews described in this paper, most included studies came from context-specific gray literature sources. Gray literature contributed to the overall result of the reviews and corresponded well with the reviews' aims. The assessed risk of bias of the included studies derived from gray literature was similar to the included studies from other types of sources. However, because of less standardized publication formats, assessing and extracting data from gray literature studies were more time-consuming and compiling statistical results was not possible. The search process for gray literature required more time and the reproducibility of gray literature searches were less certain due to more unstable publication platforms. CONCLUSIONS: Gray literature is particularly relevant for digital health and HWT but searches need to be conducted systematically and reported transparently. This way gray literature can broaden the range of studies, highlight context specificity, and decrease the publication bias of reviews of effectiveness of HWT. Thus, researchers conducting systematic reviews related to HWT should consider including gray literature based on a systematic approach.

Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic1,2. Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches1, while maintaining proven prevention measures using a vaccines-plus approach2 that employs a range of public health and financial support measures to complement vaccination. Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities3 in the management of pandemic responses. The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end.

Background: The hypothesis that a high income inequality on a societal level is associated with poor health outcomes has been both rejected and accepted in empirical studies. Whether the influence of economic circumstances on health operates at the individual level or societal level has important implications on policy and intervention alternatives. The objective of this study was to analyse the relationship between income inequality and mortality in Swedish municipalities and if the relationship varies depending on the mean income or on the time-lag between income inequality and mortality. Methods: The study was based on register data on mean income and income inequality (Gini coefficients) from Statistics Sweden 1982 and 1998, aggregated on the municipality level. Data on age-standardised death rates per 100,000 persons were obtained for 1983, 1988, 1993, 1998 and 2002. The analysis on 1998 was a test of the robustness of the results. Results: The relationship between high income inequality in 1982 and mortality in 1983 was negative with a similar relationship in 1998. Using latency periods, the results show a decreasing trend of mortality in relation to higher Gini coefficients. A positive relationship between Gini and mean income implies that municipalities with larger income distribution also had a higher mean income and vice versa. Conclusions: High income inequality does not have a negative effect on mortality in Swedish municipalities. The municipalities with high income inequality have also high mean income as opposed to many other countries. The income level seems to be more substantial for mortality than the income inequality.

Background. In 2003, the Swedish Parliament adopted a cross-sectorial national public health policy based on the social determinants of health, with an overarching aim - to create societal conditions that will ensure good health, on equal terms, for the entire population - and eleven objective domains. At that time the policy was globally unique, and serves as guidance for public health practice at the national, regional and local levels. The development of the public health policy and the determinants of health are presented regularly in various reports by the Swedish National Institute of Public Health. This supplement is a condensed version of the 174-page Public Health Policy Report 2010, the second produced since the national policy was adopted in 2003. Methods. In order to provide a holistic approach to analysing implemented measures and providing new recommendations within the eleven objective domains of the Swedish national public health policy, we have divided these in three strategic areas. These are: Good Living Conditions, Health-Promoting Living Environments and Living Habits, and Alcohol, Illicit Drugs, Doping, Tobacco and Gambling, each described in the respective introductions for Chapters 3-5. The production of the report was supported by a common analytical model that clarified the societal prerequisites for health in the eleven objective domains. These are factors that can be influenced by political actions in order to create a change. Economic analyses have also been developed to provide a priority basis for political decisions. Analyses of the development of public health determinants were based on data from the National Public Health Survey and data delivered from about 15 various national agencies. Measures that have been implemented between 2004 and 2009 are analysed in details, as the basis for new recommendations for future measures. Results. The introduction describes Swedish public health policy in the new millennium and how it has developed, the role of the Swedish National Institute of Public Health and other important stakeholders. Approaches, models and methods used in carrying out the commission to produce the public health policy report are also described. In the following chapters, the trends of important determinants of public health, in relation to the overarching aim and the 11 objective domains as grouped in the three strategic areas, are analysed. The final chapter presents the proposed prioritisation for the large number of recommendations that were made, and a presentation of the annual costs of ill health in Sweden. These are compared with the costs of implementing recommended measures. The final chapter also describes how the Public Health Policy Report 2010 was received and lists the recommendations that the Swedish Government has taken action on as of September 2012. Conclusions. Public health trends have generally been stable or positive, although health inequalities persist. Economic analyses demonstrate that ill-health in Sweden costs 12 billion SEK every year, yet a large amount of this ill-health can be prevented. Sixty-eight recommendations were presented in the report. The government's response to recommendations has been very positive; approximately 60% of the recommendations in the three strategic areas have been adopted less than two years after the Public Health Policy Report 2010 was published.

Aim: This paper explores, through a review of literature, the link between globalisation and nutritional outcomes in Sub-Saharan Africa, focusing on the pathways of women's occupational roles on the food produced, consumed, and secured for households. Methods: Following a framework linking globalisation and health, we drew evidence from peer reviewed, cross-national or large scale studies, official sources, reviews, online scientific databases, and case studies, published between 1990 and 2009. Results: Publications cite improved technology, information, know how, normative commitments to and resources for human development, returns from access to investment in agriculture for low-income women producers, and urban employment opportunities reducing social discrimination and improving opportunities for household food security, particularly if access to these benefits is reinforced by national policy. However, many more publications cite negative consequences, including in falling national and local food self-sufficiency, livelihood and nutritional losses, widening inequalities, and in declining or insecure access to production inputs, markets, incomes, local foods, and healthcare. These effects are documented to increase time and resource burdens for women, with negative consequences for their own and their families' health and nutrition. Conclusions: The evidence suggests that globalisation-related economic and trade policies have, on balance, been associated with shifts in women's occupational roles and resources that contribute to documented poor nutritional outcomes in Africa. These trends call for public policies that address such positive and negative effects for women and for improved monitoring of such gender and socio-economic trends, especially at the household and community level, in the tracking of the Millennium Development Goals.

We evaluated the Swedish National Public Health Policy to determine its impact on public health priorities and practice at regional and local levels between 2004 and 2013. We conducted a survey by questionnaire in February 2013 among Swedish county councils/regions (n = 19/21), and municipalities (n = 219/290). The National Public Health Policy facilitated systematic public health practice, particularly for planning, for high priority concerns, including conditions during childhood and adolescence, physical activity, and tobacco prevention. Respondents expressed need for a comprehensive monitoring system with comparable indicators nationwide and explicit measurable objectives. To ensure effective monitoring and follow-up, the measurable outcomes need direct relevance to decision making and high-priority public health issues addressing Sweden's "overarching public health goal" - to create societal conditions for good health on equal terms for the entire population.

Background: Health and welfare technologies (HWTs) are interventions that aim at maintaining or promoting health, well-being, quality of life, and increasing efficiency in the service delivery system of welfare, social, and health care services, while improving the working conditions of the staff. Health and social care must be evidence-based according to national policy, but there are indications that evidence for HWT effectiveness is lacking in related Swedish municipal work processes. Objective: This study aimed to investigate whether the evidence is used when Swedish municipalities procure, implement, and evaluate HWT, and if so, the kinds of evidence and the manner of their use. The study also aimed to identify if municipalities currently receive adequate support in using evidence for HWT, and if not, what support is desired. Methods: An explanatory sequential mixed methods design was used with quantitative surveys and subsequent semistructured interviews with officials in 5 nationally designated “model” municipalities regarding HWT implementation and use. Results: In the past 12 months, 4 of 5 municipalities had required some form of evidence during procurement processes, but the frequency of this varied and often consisted of references from other municipalities instead of other objective sources. Formulating requirements or requests for evidence during procurement was viewed as difficult, and gathered evidence was often only assessed by procurement administration personnel. In total, 2 of 5 municipalities used an established process for the implementation of HWT, and 3 of 5 had a plan for structured follow-up, but the use and dissemination of evidence within these were varying and often weakly integrated. Standardized processes for follow-up and evaluation across municipalities did not exist, and those processes used by individual municipalities were described as inadequate and difficult to follow. Most municipalities desired support for using evidence when procuring, establishing evaluation frameworks for, and following up effectiveness of HWT, while all municipalities suggested tools or methods for this kind of support. Conclusions: Structured use of evidence in procurement, implementation, and evaluation of HWT is inconsistent among municipalities, and internal and external dissemination of evidence for effectiveness is rare. This may establish a legacy of ineffective HWT in municipal settings. The results suggest that existing national agency guidance is not sufficient to meet current needs. New, more effective types of support to increase the use of evidence in critical phases of municipal procurement and implementation of HWT are recommended.