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  • 1.
    Andersén, Åsa
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Social Medicine.
    Larsson, Kjerstin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Social Medicine.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Kristiansson, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Anderzén, Ingrid
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    The relationship between self-efficacy and transition to work or studies in young adults with disabilities2018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 46, no 2, p. 272-278Article in journal (Refereed)
    Abstract [en]

    Aim: To investigate perceived self-efficacy in unemployed young adults with disabilities and the association between self-efficacy and transition to work or studies.

    Methods: This prospective cohort study collected data through self-report questionnaires and registry data from a vocational rehabilitation project with young adults, aged 19-29 years. The Swedish Social Insurance Agency, the Swedish Public Employment Service and the participating municipalities identified potential participants to the study. A total of 531 participants were included in the study, of which 249 (47%) were available for analysis. Multinomial logistic regression models were carried out to estimate the associations between self-efficacy, demographic, health and employment status. The latter was coded as: “no transition to work or studies”, “transition to studies”, and “transition to work”.

    Results: A higher level of self-efficacy was associated with increased odds for “transition to work” (OR=2.37, p<0.05). This finding remained consistent when adjusting for possible confounders. The mean value of self-efficacy was low, and participants with lower self-efficacy reported worse self-rated health (p<0.001) compared with participants with higher self-efficacy.

    Conclusions: The results from this study suggest that self-efficacy should be addressed in vocational rehabilitation of young adults with disabilities in order to support their transition and integration into the labour market.

  • 2.
    Bean, Christopher
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences. School of Psychology, University of Adelaide, Australia.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Berg, Noora
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Hallqvist, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Hammarström, Anne
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Public Health.
    A 4-way decomposition analysis of poor social relations and depressive symptoms over the life-course2017In: European Journal of Public Health, Volume 27, Issue Suppl 3, 2017Conference paper (Refereed)
  • 3.
    Bean, Christopher
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Public Health.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Hallqvist, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Berg, Noora
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Public Health.
    Hammarström, Anne
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Public Health.
    Poor peer relations in adolescence, social support in early adulthood, and depressive symptoms in later adulthood: evaluating mediation and interaction using four-way decomposition analysis2019In: Annals of Epidemiology, ISSN 1047-2797, E-ISSN 1873-2585, Vol. 29, p. 52-59Article in journal (Refereed)
    Abstract [en]

    Purpose: Supportive social relations are associated with good mental health, yet few studies have considered the prospective importance of adolescent peer relations for adult mental health and the potential mechanisms involved.

    Methods: Participants (n=941) were sourced from the Northern Swedish Cohort, a prospective study comprising school students aged 16 in 1981. Integrating life course epidemiology with four-way decomposition analysis, this paper considers the controlled direct effect of poor peer relations at age 16 on depressive symptoms at age 43, the pure indirect effect mediated by the availability of social support at age 30, and potential interactions between the exposure and the mediator.

    Results: After controlling for gender, baseline depressive symptoms and parental socioeconomic position, poor peer relations at age 16 were associated with depressive symptoms at age 43, largely irrespective of social support at age 30. Nonetheless, poor peer relations in adolescence were associated with poorer social support at age 30, and mediation accounted for a modest proportion (pure indirect effect 10%) of the association between poor peer relations and depressive symptoms at age 43.

    Conclusions: Policies to foster constructive peer relations for adolescents at school are encouraged; such policies may promote both the availability of social support and better mental health across the life course.

  • 4.
    Berntsen, Sveinung
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Aaronson, Neil K
    Buffart, Laurien
    Börjeson, Sussanne
    Demmelmaier, Ingrid
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Hellbom, Maria
    Hojman, Pernille
    Igelström, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Johansson, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Experimental and Clinical Oncology.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Raastad, Truls
    Velikova, Galina
    Åsenlöf, P.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Physiotherapy.
    Nordin, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Design of a randomized controlled trial of physical training and cancer (Phys-Can) - the impact of exercise intensity on cancer related fatigue, quality of life and disease outcome2017In: BMC Cancer, ISSN 1471-2407, E-ISSN 1471-2407, Vol. 17, no 1, article id 218Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Cancer-related fatigue is a common problem in persons with cancer, influencing health-related quality of life and causing a considerable challenge to society. Current evidence supports the beneficial effects of physical exercise in reducing fatigue, but the results across studies are not consistent, especially in terms of exercise intensity. It is also unclear whether use of behaviour change techniques can further increase exercise adherence and maintain physical activity behaviour. This study will investigate whether exercise intensity affects fatigue and health related quality of life in persons undergoing adjuvant cancer treatment. In addition, to examine effects of exercise intensity on mood disturbance, adherence to oncological treatment, adverse effects from treatment, activities of daily living after treatment completion and return to work, and behaviour change techniques effect on exercise adherence. We will also investigate whether exercise intensity influences inflammatory markers and cytokines, and whether gene expressions following training serve as mediators for the effects of exercise on fatigue and health related quality of life.

    METHODS/DESIGN: Six hundred newly diagnosed persons with breast, colorectal or prostate cancer undergoing adjuvant therapy will be randomized in a 2 × 2 factorial design to following conditions; A) individually tailored low-to-moderate intensity exercise with or without behaviour change techniques or B) individually tailored high intensity exercise with or without behaviour change techniques. The training consists of both resistance and endurance exercise sessions under the guidance of trained coaches. The primary outcomes, fatigue and health related quality of life, are measured by self-reports. Secondary outcomes include fitness, mood disturbance, adherence to the cancer treatment, adverse effects, return to activities of daily living after completed treatment, return to work as well as inflammatory markers, cytokines and gene expression.

    DISCUSSION: The study will contribute to our understanding of the value of exercise and exercise intensity in reducing fatigue and improving health related quality of life and, potentially, clinical outcomes. The value of behaviour change techniques in terms of adherence to and maintenance of physical exercise behaviour in persons with cancer will be evaluated.

    TRIAL REGISTRATION: NCT02473003 , October, 2014.

  • 5.
    Bjelland, Elisabeth Krefting
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Owe, Katrine Mari
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Kristiansson, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Vangen, Siri
    Eberhard-Gran, Malin
    Pelvic pain after childbirth: a longitudinal population study2016In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 157, no 3, p. 710-716Article in journal (Refereed)
    Abstract [en]

    In this longitudinal population study, the aims were to study associations of mode of delivery with new onset of pelvic pain and changes in pelvic pain scores up to 7-18 months after childbirth. We included 20,248 participants enrolled in the Norwegian Mother and Child Cohort Study (1999-2008) without preexisting pelvic pain in pregnancy. Data were obtained by four self-administered questionnaires and linked to the Medical Birth Registry of Norway. A total of 4.5% of the women reported new onset of pelvic pain 0-3 months postpartum. Compared to unassisted vaginal delivery, operative vaginal delivery was associated with increased odds of pelvic pain (adjusted odds ratio 1.30; 95% confidence interval: 1.06-1.59). Planned and emergency cesarean deliveries were associated with reduced odds of pelvic pain (adjusted odds ratio 0.48; 95% confidence interval: 0.31-0.74 and adjusted odds ratio 0.65; 95% confidence interval: 0.49-0.87, respectively). Planned cesarean delivery, young maternal age, and low Symptom Checklist-8 scores were associated with low pelvic pain scores after childbirth. A history of pain was the only factor associated with increased pelvic pain scores over time (P=0.047). We conclude that new onset of pelvic pain after childbirth was not commonly reported, particularly following cesarean delivery. Overall, pelvic pain scores were rather low at all time points and women with a history of pain reported increased pelvic pain scores over time. Hence, clinicians should follow up women with pelvic pain after a difficult childbirth experience, particularly if they have a history of pain.

  • 6.
    Drevin, Jennifer
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Hallqvist, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Sonnander, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Research in Disability and Habilitation. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience.
    Rosenblad, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical diabetology and metabolism.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Bjelland, Elisabeth Krefting
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Childhood abuse and unplanned pregnancies: a cross-sectional study of women in the Norwegian Mother and Child Cohort Study.2019In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To study if childhood emotional, physical and sexual abuse are determinants for having an unplanned pregnancy, if the categories of abuse interact, and if a potential bias due to the selection of the participants (collider stratification bias) could explain the effect of childhood abuse.

    DESIGN: A cross-sectional study.

    SETTING: The study is based on the Norwegian Mother and Child Cohort Study (MoBa) and uses data from the Medical Birth Registry of Norway.

    SAMPLE: Women participating in the MoBa for the first time, ≥18 years of age who responded to questions regarding childhood abuse and pregnancy planning (n = 76 197).

    METHODS: Data were collected using questionnaires. We conducted analyses using modified Poisson regressions and the relative excess risks due to interaction (RERI). Sensitivity analyses were performed.

    MAIN OUTCOME MEASURE: An unplanned pregnancy (yes/no).

    RESULTS: Exposure to childhood emotional (adjusted relative risk (RR) 1.14, 95% CI 1.10-1.19), physical (adjusted RR 1.11, 95% CI 1.04-1.18) and sexual (adjusted RR 1.20, 95% CI 1.14-1.27) abuse increased the risk of having an unplanned pregnancy. The effects could not be explained by the collider stratification bias. The different combinations of categories of abuse did not show any interaction effects.

    CONCLUSIONS: Childhood emotional, physical and sexual abuses separately increase the risk of having an unplanned pregnancy. The results indicate that victims of childhood abuse are in greater need of support to achieve their reproductive goals.

    TWEETABLE ABSTRACT: Childhood abuse increases the risk of having an unplanned pregnancy. #reproductivehealth #epitwitter.

  • 7.
    Gunningberg, Lena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Sedin, Inga-Maj
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Andersson, Sara
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial2017In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 72, p. 53-59Article in journal (Refereed)
    Abstract [en]

    Background: Pressure ulcers cause suffering to patients and costs to society. Reducing pressure at the interface between the patient's body and the support surface is a valid clinical intervention for reducing the risk of pressure ulcers. However, studies have shown that knowledge of how to reduce pressure and shear and to prevent pressure ulcers is lacking. Objective: To evaluate the effect of a pressure mapping system on pressure ulcer prevalence and incidence in a hospital setting. Design: Pragmatic randomised controlled trial. Setting: A geriatric/internal medical ward with 26 beds in a Swedish university hospital. Participants: 190 patients were recruited (intervention: n = 91; control: n = 99) over a period of 9 months. Patients were eligible if they were over 50 years old, admitted to the ward between Sunday 4 pm and Friday 4 pm, and expected to stay in the ward >= 3 days. Intervention: The continuous bedside pressure mapping system displays the patient's pressure points in real-time colour imagery showing how pressure is distributed at the body mat interface. The system gives immediate feedback to staff about the patient's pressure points, facilitating preventive interventions related to repositioning. It was used from admittance to discharge from the ward (or 14 days at most). Both intervention and control groups received standard pressure ulcer prevention care. Results: No significant difference in the prevalence and incidence of pressure ulcers was shown between intervention and control groups. The prevalence of pressure ulcers in the intervention group was 24.2% on day 1 and 28.2% on day 14. In the control group the corresponding numbers were 18.2% and 23.8%. Seven of 69 patients (10.1%) in the intervention group and seven of 81 patients (8.6%) in the control group who had no pressure ulcers on admission developed category 1 and category 2 ulcers during their hospital stay. The incidence rate ratio between the intervention and control groups was 1.13 (95% CI: 0.34-3.79). Conclusions: This study failed to demonstrate a beneficial effect of a pressure mapping system on pressure ulcer prevalence and incidence. However, the study could have increased staff awareness and focus on pressure ulcer prevention, thus affecting the prevalence and incidence of pressure ulcers in a positive way in both study groups. It is important to further investigate the experience of the multidisciplinary team and the patients regarding their use of the pressure mapping system, as well as strengths and weaknesses of the system.

  • 8.
    Isaksson, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Blomqvist, Paula
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Government.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Risk selection in primary care: a cross-sectional fixed effect analysis of Swedish individual data2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 10, article id e020402Article in journal (Refereed)
    Abstract [en]

    Objective To assess socioeconomic differences between patients registered with private and public primary healthcare centres.

    Design Population-based cross-sectional study controlling for municipality and household.

    Setting Swedish population-based socioeconomic data collected from Statistics Sweden linked with individual registration data from all 21 Swedish regions.

    Participants All individuals residing in Sweden on 31 December 2015 (n=9 851 017) were included in the study.

    Primary outcome measures Registration with private versus public primary healthcare centres.

    Results After controlling for municipality and household, individuals with higher socioeconomic status were more likely to be registered with a private primary healthcare provider. Individuals in the highest income quantile were 4.9 percentage points (13.7%) more likely to be registered with a private primary healthcare provider compared with individuals in the lowest income quantile. Individuals with 1–3 years of higher education were 4.7 percentage points more likely to be registered with a private primary healthcare provider compared with those with an incomplete primary education.

    Conclusions The results show that there are notable differences in registration patterns, indicating a skewed distribution of patients and health risks between private and public primary healthcare providers. This suggests that risk selection behaviour occurs in the reformed Swedish primary healthcare system, foremost through location patterns.

  • 9.
    Marklund, Matti
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Rosqvist, Fredrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Lindroos, Anna Karin
    Natl Food Agency, Uppsala, Sweden;Univ Gothenburg, Dept Internal Med & Clin Nutr, Gothenburg, Sweden.
    Eriksson, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical diabetology and metabolism.
    Vessby, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Oscarsson, Jan
    AstraZeneca Gothenburg, Molndal, Sweden.
    Lind, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology.
    Risérus, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Interrelationships Between Fatty Acid Composition in Plasma Cholesterol Esters and Phospholipids in Men and Women: A Pooled Analysis2017In: Annals of Nutrition and Metabolism, ISSN 0250-6807, E-ISSN 1421-9697, Vol. 71, p. 372-372Article in journal (Other academic)
  • 10.
    Marklund, Matti
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Rosqvist, Fredrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Lindroos, Anna Karin
    Natl Food Agcy, Uppsala, Sweden.;Univ Gothenburg, Dept Internal Med & Clin Nutr, Gothenburg, Sweden..
    Eriksson, Jan W.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical diabetology and metabolism. en..
    Vessby, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Oscarsson, Jan
    AstraZeneca R&D, Gothenburg, Sweden..
    Lind, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology.
    Risérus, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Fatty Acid Proportions in Plasma Cholesterol Esters and Phospholipids Are Positively Correlated in Various Swedish Populations2017In: Journal of Nutrition, ISSN 0022-3166, E-ISSN 1541-6100, Vol. 147, no 11, p. 2118-2125Article in journal (Refereed)
    Abstract [en]

    Background: Fatty acid (FA) proportions in cholesterol esters (CEs) and plasma phospholipids are widely used as dietary biomarkers. Information on how proportions in these fractions correlate could have implications for interpretation and use of FA biomarkers in observational and interventional studies. Objective: We investigated correlations between FA proportions in CEs and phospholipids in free-living individuals and assessed how diet-induced alterations of FA proportions correlate between fractions. Methods: Spearman's rank correlation coefficients (rs) between FA proportions (percentage of total FAs) in circulating CEs and phospholipids were calculated separately in 8 individual study populations including Swedish females and males (N = 2052; age range: 11-84 y), and pooled by inverse-variance weighted meta-analysis. In addition, study populations were stratified by age, sex, body mass index (BMI; in kg/m(2)), and diabetes status, and strata-specific rs were pooled by meta-analysis. In 2 randomized trials (N = 79) in which dietary saturated FAs were isocalorically replaced with unsaturated FAs, treatment-wise calculations of rs were conducted between FA changes in CEs and phospholipids. Results: Overall, FA proportions in CEs and phospholipids correlated well and especially strongly for polyunsaturated FAs (PUFAs), with pooled rs (95% CIs) ranging from 0.74 (0.72, 0.76) for a-linolenic acid to 0.92 (0.91, 0.93) for eicosapentaenoic acid. Weak correlations (pooled rs <0.4) were observed only for palmitic acid and stearic acid, with pooled rs (95% CIs): 0.29 (0.24, 0.33) and 0.30 (0.25, 0.34), respectively. Overall, correlations were not affected by age, sex, BMI, or diabetes status. Strong correlations (r(s) >= 0.6) between diet-induced FA changes in CEs and phospholipids were observed for most PUFAs. Conclusions: Proportions of most FAs in CEs and phospholipids ranked individuals similarly, suggesting that FA proportions in these fractions can be used interchangeably in populations of diverse age, sex, body composition, and diabetes status. Caution is advised, however, when comparing results from studies assessing palmitic acid or stearic acid in different lipid fractions.

  • 11.
    Martinell, Mats
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Hallqvist, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Dorkhan, Mozhgan
    Groop, Leif
    Rosengren, Anders
    Storm, Petter
    Stålhammar, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Education, immigration and income as risk factors for hemoglobin A1c >70 mmol/mol when diagnosed with type 2 diabetes or latent autoimmune diabetes in adult: a population-based cohort study2017In: BMJ Open Diabetes Research and Care, Vol. 5, no 1Article in journal (Refereed)
    Abstract [en]

    Objectives The aim of this research is to study education, income and immigration as risk factors for high hemoglobin A1c (HbA1c &gt;70 mmol/mol (8.6%)) when diagnosed with type 2 diabetes (T2D) or latent autoimmune diabetes in the adult (LADA).Research design and methods Patients were included from the All New Diabetics in Scania study (2008-2013). Level of education, disposable income and immigration year were retrieved from the longitudinal integrated database for labour market research (LISA) register compiled by Statistics Sweden. Logistic regression models were used to estimate ORs for HbA1c &gt;70 mmol/mol (8.6%) at diagnosis.Results A total of 3794 patients with incident T2D (n=3 525) or LADA (n=269) were included. Patients with T2D with a low (<=9 years) or medium (10-12 years) levels of education were more likely to have high HbA1c at diagnosis compared with patients with T2D with a high (&gt;12 years) level of education (OR 1.34, 95% CI 1.08 to1.66, OR 1.26, 95% CI 1.03 to 1.54). Low-income patients with T2D (&lt;60% of median) were more likely to have high HbA1c at diagnosis compared with high-income patients withT2D (&gt;150% of median) (OR 1.35, 95% CI 1.02 to 1.79).Conclusions Patients with lower levels of education or low income and are more likely to have HbA1c is &gt;70 mmol/mol (8.6%) when diagnosed with T2D. An understanding of how socioeconomic position influences the clinical presentation at diagnosis may facilitate screening programs designed to target populations at risk for delayed diagnosis.

  • 12.
    Norlund, Fredrika
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Olsson, Erik MG
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Held, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Svärdsudd, Kurt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Gulliksson, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Burell, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Psychological mediators related to clinical outcome in cognitive behavioural therapy for coronary heart disease: A sub-analysis from the SUPRIM trial2017In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 24, no 9, p. 917-925Article in journal (Refereed)
    Abstract [en]

    Background:The Secondary Prevention in Uppsala Primary Healthcare Project (SUPRIM) was a randomized controlledtrial of a group-based cognitive behavioural therapy stress management programme for patients with coronary heartdisease. The project was successful in reducing the risk of fatal or non-fatal first recurrent cardiovascular events. The aimof this study was to analyse the effect of cognitive behavioural therapy on self-rated stress, somatic anxiety, vitalexhaustion and depression and to study the associations of these factors with the reduction in cardiovascular events.

    Methods:A total of 362 patients were randomly assigned to intervention or usual care groups. The psychologicaloutcomes were assessed five times during 24 months and analysed using linear mixed models. The mediating roles of theoutcomes were analysed using joint modelling of the longitudinal and time to event data.

    Results:The intervention had a positive effect on somatic anxiety (p<0.05), reflecting a beneficial development overtime compared with the controls. Stress, vital exhaustion and depression did not differ between the groups over time.Mediator analysis suggested that somatic anxiety may have mediated the effect of treatment on cardiovascular events.

    Conclusions:The intervention had a small positive effect on somatic anxiety, but did not affect stress, vital exhaustionor depression in patients with coronary heart disease. Somatic anxiety was associated with an increased risk of cardio-vascular events and might act as a partial mediator in the treatment effect on cardiovascular events. However, themechanisms between the intervention and the protective cardiovascular outcome remain to be identified.

  • 13.
    Olsson, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Norlund, Fredrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Burell, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Gulliksson, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Karlsson, Bo
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Svärdsudd, K
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Held, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    The effect of group-based cognitive behavioral therapy on inflammatory biomarkers in patients with coronary disease: results from the SUPRIM-trial2018In: Upsala Journal of Medical Sciences, Supplement, ISSN 0300-9726, Vol. 123, no 3, p. 167-173Article in journal (Refereed)
    Abstract [en]

    Background: The Secondary Prevention in Uppsala Primary Healthcare Project (SUPRIM) is a prospective randomized controlled trial of a group-based cognitive behavioral therapy (CBT) stress management program for coronary heart disease (CHD) patients. The intervention reduced the risk of fatal or non-fatal first recurrent cardiovascular (CV) events. The aim of the present study was to analyze if the positive effects of the CBT program on clinical outcomes could have been mediated by changes in biomarkers for inflammation.

    Methods: Altogether 362 patients with CHD were randomly assigned to intervention or usual care. The inflammatory biomarkers (VCAM-1, TNF-R1, TNF-R2, PTX3, and hs-CRP) were serially assessed at five time points every six months from study start until 24 months later, and analyzed with linear mixed models.

    Results: Baseline levels of the inflammatory markers were near normal, indicating a stable phase. The group-based CBT stress management program did not significantly affect the levels of inflammatory biomarkers in patients with CHD. Three out of five (VCAM-1, TNF-R2, and PTX3) inflammatory biomarkers showed a slight increase over time in both study groups, and all were positively associated with age.

    Conclusion: Group-based CBT stress management did not affect biomarkers for inflammation in patients with CHD. It is therefore unlikely that inflammatory processes including these biomarkers were mediating the effect the CBT program had on the reduction in CV events. The close to normal baseline levels of the biomarkers and the lack of elevated psychological distress symptoms indicate a possible floor effect which may have influenced the results.

    Keywords: Biomarkers, CBT, CHD, inflammation, stress management

  • 14.
    Peterson, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Lagali, N.
    Linkoping Univ, Dept Clin & Expt Med, Sect Ophthalmol, Linkoping, Sweden..
    Dahlin, L. B.
    Hand Surg Lund Univ, Dept Translat Med, Malmo, Sweden.;Skane Univ Hosp, Dept Hand Surg, Malmo, Sweden..
    Rolandsson, O.
    Umea Univ, Dept Publ Hlth & Clin Med, Sect Family Med, Umea, Sweden..
    Association between HbA1c and peripheral neuropathy in a 10-year follow-up study of people with normal glucose tolerance, impaired glucose tolerance and Type 2 diabetes2017In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 34, no 12, p. 1756-1764Article in journal (Refereed)
    Abstract [en]

    Aims: To explore the association between HbA(1c) and sural nerve function in a group of people with normal glucose tolerance, impaired glucose tolerance or Type 2 diabetes.

    Methods: We conducted a 10-year follow-up study in 87 out of an original 119 participants. At study commencement (2004), 64 men and 55 women (mean age 61.1 years) with normal glucose tolerance (n=39), impaired glucose tolerance (n=29), or Type 2 diabetes (n=51) were enrolled. At the 2014 follow-up (men, n=46, women, n=41; mean age 71.1 years), 36, nine and 42 participants in the normal glucose tolerance, impaired glucose tolerance and Type 2 diabetes categories, respectively, were re-tested. Biometric data and blood samples were collected, with an electrophysiological examination performed on both occasions.

    Results: At follow-up, we measured the amplitude of the sural nerve in 74 of the 87 participants. The mean amplitude had decreased from 10.9 V (2004) to 7.0 mu V (2014; P<0.001). A 1% increase in HbA(1c) was associated with a similar to 1% average decrease in the amplitude of the sural nerve, irrespective of group classification. Crude and adjusted estimates ranged from -0.84 (95% CI -1.32, -0.37) to -1.25 (95% CI -2.31, -0.18). Although the mean conduction velocity of those measured at both occasions (n=73) decreased from 47.6 m/s to 45.8 m/s (P=0.009), any association with HbA(1c) level was weak. Results were robust with regard to potential confounders and missing data.

    Conclusions: Our data suggest an association between sural nerve amplitude and HbA(1c) at all levels of HbA(1c). Decreased amplitude was more pronounced than was diminished conduction velocity, supporting the notion that axonal degeneration is an earlier and more prominent effect of hyperglycaemia than demyelination.

  • 15.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Estimating the variance of a propensity score matching estimator: A new look at right heart catheterisation data2014Report (Other academic)
    Abstract [en]

    This study considers the implementation of a variance estimator when estimating the asymptotic variance of a propensity score matching estimator for the average treatment effect. We investigate the role of smoothing parameters in the variance estimator and propose using local linear estimation. Simulations demonstrate that large gains can be made in terms of mean squared error by properly selecting smoothing parameters and that local linear estimation may lead to a more efficient estimator of the asymptotic variance. The choice of smoothing parameters in the variance estimator is shown to be crucial when evaluating the effect of right heart catheterisation, i.e. we show either a negative effect on survival or no significant effect depending on the choice of smoothing parameters.

  • 16.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Estimating the variance of a propensity score matching estimator for the average treatment effect2018In: Observational Studies, Vol. 4, p. 71-96Article in journal (Refereed)
    Abstract [en]

    This study considers variance estimation when estimating the asymptotic variance of a propensity score matching estimator for the average treatment effect.  We investigate the role of smoothing parameters in a variance estimator based on matching.   We also study the properties of estimators using local linear estimation. Simulations demonstrate that large gains can be made in terms of mean squared error, bias and coverage rate by properly selecting smoothing parameters.  Alternatively, a residual-based local linear estimator could be used as an estimator of the asymptotic variance.   The variance estimators are implemented in analysis to evaluate the effect of right heart catheterisation.

  • 17.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Some approximations of the logistic distribution with application to the covariance matrix of logistic regression2014In: Statistics and Probability Letters, ISSN 0167-7152, E-ISSN 1879-2103, Vol. 85, p. 63-68Article in journal (Refereed)
    Abstract [en]

    In this paper, we show that a two-component normal mixture model provides a good approximation to the logistic distribution. This approximation is an improvement over using the normal distribution and is comparable to using the t-distribution as approximating distributions. The results from using the mixture model is exemplified by finding an approximative analytic expression for the covariance matrix of logistic regression using normally distributed random regressors.

  • 18.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Some Approximations of the Logistic Distribution with Approximation to the Covariance Matrix Logistic Regression2013Report (Other academic)
  • 19.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Some Aspects of Propensity Score-based Estimators for Causal Inference2014Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    This thesis consists of four papers that are related to commonly used propensity score-based estimators for average causal effects.

    The first paper starts with the observation that researchers often have access to data containing lots of covariates that are correlated. We therefore study the effect of correlation on the asymptotic variance of an inverse probability weighting and a matching estimator. Under the assumptions of normally distributed covariates, constant causal effect, and potential outcomes and a logit that are linear in the parameters we show that the correlation influences the asymptotic efficiency of the estimators differently, both with regard to direction and magnitude. Further, the strength of the confounding towards the outcome and the treatment plays an important role.

    The second paper extends the first paper in that the estimators are studied under the more realistic setting of using the estimated propensity score. We also relax several assumptions made in the first paper, and include the doubly robust estimator. Again, the results show that the correlation may increase or decrease the variances of the estimators, but we also observe that several aspects influence how correlation affects the variance of the estimators, such as the choice of estimator, the strength of the confounding towards the outcome and the treatment, and whether constant or non-constant causal effect is present.

    The third paper concerns estimation of the asymptotic variance of a propensity score matching estimator. Simulations show that large gains can be made for the mean squared error by properly selecting smoothing parameters of the variance estimator and that a residual-based local linear estimator may be a more efficient estimator for the asymptotic variance. The specification of the variance estimator is shown to be crucial when evaluating the effect of right heart catheterisation, i.e. we show either a negative effect on survival or no significant effect depending on the choice of smoothing parameters.  

    In the fourth paper, we provide an analytic expression for the covariance matrix of logistic regression with normally distributed regressors. This paper is related to the other papers in that logistic regression is commonly used to estimate the propensity score.

    List of papers
    1. Effects of correlated covariates on the asymptotic efficiency of matching and inverse probability weighting estimators for causal inference
    Open this publication in new window or tab >>Effects of correlated covariates on the asymptotic efficiency of matching and inverse probability weighting estimators for causal inference
    2015 (English)In: Statistics (Berlin), ISSN 0233-1888, E-ISSN 1029-4910, Vol. 49, no 4, p. 795-814Article in journal (Refereed) Published
    Abstract [en]

    In observational studies, the overall aim when fitting a model for the propensity score is to reduce bias for an estimator of the causal effect. To make the assumption of an unconfounded treatment plausible researchers might include many, possibly correlated, covariates in the propensity score model. In this paper, we study how the asymptotic efficiency of matching and inverse probability weighting estimators for average causal effects change when the covariates are correlated. We investigate the case with multivariate normal covariates, a logistic model for the propensity score and linear models for the potential outcomes and show results under different model assumptions. We show that the correlation can both increase and decrease the large sample variances of the estimators, and that the correlation affects the asymptotic efficiency of the estimators differently, both with regard to direction and magnitude. Moreover, the strength of the confounding towards the outcome and the treatment plays an important role.

    Keywords
    correlation, efficiency bound, observational study, propensity score
    National Category
    Probability Theory and Statistics
    Research subject
    Statistics
    Identifiers
    urn:nbn:se:uu:diva-226274 (URN)10.1080/02331888.2014.925899 (DOI)000357649900005 ()
    Note

    Funding: Institute for Evaluation of Labour Market and Education Policy, Sweden

    Available from: 2014-06-14 Created: 2014-06-14 Last updated: 2017-12-05Bibliographically approved
    2. Correlation and efficiency of propensity score-based estimators for average causal effects
    Open this publication in new window or tab >>Correlation and efficiency of propensity score-based estimators for average causal effects
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Propensity score based-estimators are commonly used to estimate causal effects in evaluation research. To reduce bias in observational studies researchers might be tempted to include many, perhaps correlated, covariates when estimating the propensity score model. Taking into account that the propensity score is estimated, this study investigates how the efficiency of matching, inverse probability weighting and doubly robust estimators change under the case of correlated covariates. Propositions regarding the large sample variances under certain assumptions of the data generating process are given. The propositions are supplemented by several numerical large sample and finite sample results from a wide range of models. The results show that the correlation may increase or decrease the variances of the estimators. There are several factors that influence how correlation affects the variance of the estimators, including the choice of estimator, the strength of the confounding towards outcome and treatment, and whether a constant or non-constant treatment effect is present.

    Keywords
    doubly robust, inverse probability weighting, matching, observational study
    National Category
    Probability Theory and Statistics
    Research subject
    Statistics
    Identifiers
    urn:nbn:se:uu:diva-229340 (URN)
    Available from: 2014-08-06 Created: 2014-08-06 Last updated: 2014-08-29Bibliographically approved
    3. Estimating the variance of a propensity score matching estimator: A new look at right heart catheterisation data
    Open this publication in new window or tab >>Estimating the variance of a propensity score matching estimator: A new look at right heart catheterisation data
    2014 (English)Report (Other academic)
    Abstract [en]

    This study considers the implementation of a variance estimator when estimating the asymptotic variance of a propensity score matching estimator for the average treatment effect. We investigate the role of smoothing parameters in the variance estimator and propose using local linear estimation. Simulations demonstrate that large gains can be made in terms of mean squared error by properly selecting smoothing parameters and that local linear estimation may lead to a more efficient estimator of the asymptotic variance. The choice of smoothing parameters in the variance estimator is shown to be crucial when evaluating the effect of right heart catheterisation, i.e. we show either a negative effect on survival or no significant effect depending on the choice of smoothing parameters.

    Publisher
    p. 50
    Series
    Working paper / Department of Statistics, Uppsala University ; 2014:3
    Keywords
    average treatment effect, causal inference, kernel, local linear
    National Category
    Probability Theory and Statistics
    Research subject
    Statistics
    Identifiers
    urn:nbn:se:uu:diva-229146 (URN)
    Available from: 2014-08-06 Created: 2014-08-01 Last updated: 2014-09-11Bibliographically approved
    4. Some approximations of the logistic distribution with application to the covariance matrix of logistic regression
    Open this publication in new window or tab >>Some approximations of the logistic distribution with application to the covariance matrix of logistic regression
    2014 (English)In: Statistics and Probability Letters, ISSN 0167-7152, E-ISSN 1879-2103, Vol. 85, p. 63-68Article in journal (Refereed) Published
    Abstract [en]

    In this paper, we show that a two-component normal mixture model provides a good approximation to the logistic distribution. This approximation is an improvement over using the normal distribution and is comparable to using the t-distribution as approximating distributions. The results from using the mixture model is exemplified by finding an approximative analytic expression for the covariance matrix of logistic regression using normally distributed random regressors.

    Keywords
    Density, Gaussian, Mixture, Normal, t -distribution
    National Category
    Probability Theory and Statistics
    Research subject
    Statistics
    Identifiers
    urn:nbn:se:uu:diva-221566 (URN)10.1016/j.spl.2013.11.007 (DOI)000331665000009 ()
    Available from: 2014-04-01 Created: 2014-04-01 Last updated: 2017-12-05Bibliographically approved
  • 20.
    Pingel, Ronnie
    et al.
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Waernbaum, Ingeborg
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik; Institutet för arbetsmarknads- och utbildningspolitisk utvärdering, IFAU.
    Correlation and Efficiency of Propensity Score-based Estimators for Average Causal Effects2017In: Communications in statistics. Simulation and computation, ISSN 0361-0918, E-ISSN 1532-4141, Vol. 46, no 5, p. 3458-3478Article in journal (Refereed)
    Abstract [en]

    Propensity score based-estimators are commonly used to estimate causal effects in evaluationresearch. To reduce bias in observational studies researchers might be tempted to include many, perhaps correlated, covariates when estimating the propensity score model. Taking into account that the propensity score is estimated, this study investigates how the efficiency of matching, inverse probability weighting and doubly robust estimators change under the case of correlated covariates. Propositions regarding the large sample variances under certain assumptions on the data generating process are given. The propositions are supplemented by several numerical large sample and finite sample results from a wide range of models. The results show that the covariate correlations may increase or decrease the variances of the estimators. There are several factors that influence how correlation affects the variance of the estimators, including the choice of estimator, the strength of the confounding towards outcome and treatment, and whether a constant or non-constant causal effect is present.

  • 21.
    Pingel, Ronnie
    et al.
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Waernbaum, Ingeborg
    Umeå universitet.
    Correlation and efficiency of propensity score-based estimators for average causal effectsManuscript (preprint) (Other academic)
    Abstract [en]

    Propensity score based-estimators are commonly used to estimate causal effects in evaluation research. To reduce bias in observational studies researchers might be tempted to include many, perhaps correlated, covariates when estimating the propensity score model. Taking into account that the propensity score is estimated, this study investigates how the efficiency of matching, inverse probability weighting and doubly robust estimators change under the case of correlated covariates. Propositions regarding the large sample variances under certain assumptions of the data generating process are given. The propositions are supplemented by several numerical large sample and finite sample results from a wide range of models. The results show that the correlation may increase or decrease the variances of the estimators. There are several factors that influence how correlation affects the variance of the estimators, including the choice of estimator, the strength of the confounding towards outcome and treatment, and whether a constant or non-constant treatment effect is present.

  • 22.
    Pingel, Ronnie
    et al.
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Waernbaum, Ingeborg
    Umeå universitet.
    Effects of correlated covariates on the asymptotic efficiency of matching and inverse probability weighting estimators for causal inference2015In: Statistics (Berlin), ISSN 0233-1888, E-ISSN 1029-4910, Vol. 49, no 4, p. 795-814Article in journal (Refereed)
    Abstract [en]

    In observational studies, the overall aim when fitting a model for the propensity score is to reduce bias for an estimator of the causal effect. To make the assumption of an unconfounded treatment plausible researchers might include many, possibly correlated, covariates in the propensity score model. In this paper, we study how the asymptotic efficiency of matching and inverse probability weighting estimators for average causal effects change when the covariates are correlated. We investigate the case with multivariate normal covariates, a logistic model for the propensity score and linear models for the potential outcomes and show results under different model assumptions. We show that the correlation can both increase and decrease the large sample variances of the estimators, and that the correlation affects the asymptotic efficiency of the estimators differently, both with regard to direction and magnitude. Moreover, the strength of the confounding towards the outcome and the treatment plays an important role.

  • 23.
    Schlager, Angela
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Ahlqvist, Kerstin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Rasmussen-Barr, Eva
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Physiotherapy, Huddinge, Sweden.
    Bjelland, Elisabeth Krefting
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Akershus Univ Hosp, Dept Obstet & Gynecol, Lorenskog, Norway.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Olsson, Christina
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Physiotherapy, Huddinge, Sweden;Stockholm Cty Council, Acad Primary Healthcare Ctr, Huddinge, Sweden.
    Nilsson-Wikmar, Lena
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Physiotherapy, Huddinge, Sweden;Stockholm Cty Council, Acad Primary Healthcare Ctr, Huddinge, Sweden.
    Kristiansson, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Inter- and intra-rater reliability for measurement of range of motion in joints included in three hypermobility assessment methods2018In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 19, article id 376Article in journal (Refereed)
    Abstract [en]

    Background: Comparisons across studies of generalized joint hypermobility are often difficult since there are several classification methods and methodological differences in the performance exist. The Beighton score is most commonly used and has been tested for inter- and intra-rater reliability. The Contompasis score and the Hospital del Mar criteria have not yet been evaluated for reliability. The aim of this study was to investigate the inter- and intra-rater reliability for measurements of range of motion in joints included in these three hypermobility assessment methods using a structured protocol.

    Methods: The study was planned in accordance with guidelines for reporting reliability studies. Healthy adults were consecutively recruited (49 for inter-and 29 for intra-rater assessments). Intra-class correlations, two-way random effects model, (ICC 2.1) with 95% confidence intervals, standard error of measurement, percentage of agreement, Cohen's Kappa () and prevalence-adjusted bias-adjusted kappa were calculated for single-joint measured in degrees and for total scores.

    Results: The inter- and intra-rater reliability in total scores were ICC 2.1: 0.72-0.82 and 0.76-0.86 and for single-joint measurements in degrees 0.44-0.91 and 0.44-0.90, respectively. The difference between ratings was within 5 degrees in all but one joint. Standard error of measurement ranged from 1.0 to 6.9 degrees. The inter- and intra-rater reliability for prevalence of positive hypermobility findings the Cohen's for total scores were 0.54-0.78 and 0.27-0.78 and in single joints 0.21-1.00 and 0.19-1.00, respectively. The prevalence- and bias adjusted Cohen's , increased all but two values.

    Conclusions: Following a structured protocol, the inter- and intra-rater reliability was good-to-excellent for total scores and in all but two single joints, measured in degrees. The inter- and intra-rater reliability for prevalence of positive hypermobility findings was fair-to-almost perfect for total scores and slight-to-almost-perfect in single joints.By using a structured protocol, we attempted to standardize the assessment of range of motion in clinical and in research settings. This standardization could be helpful in the first part of the process of standardizing the tests thus avoiding that assessment of GJH is based on chance.

  • 24.
    Wallert, John
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Olsson, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Norlund, Fredrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Leosdottir, Margrét
    Department of Cardiology, Skåne University Hospital and Department of Clinical Sciences Malmö, Lund University.
    Burell, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Held, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Attending Heart School and long-term outcome after myocardial infarction: A decennial SWEDEHEART registry study2019In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The Heart School is a standard component of cardiac rehabilitation after myocardial infarction in Sweden. The group-based educational intervention aims to improve modifiable risks, in turn reducing subsequent morbidity and mortality. However, an evaluation with respect to mortality is lacking.

    AIMS: Using linked population registries, we estimated the association of attending Heart School with both all-cause and cardiovascular mortality, two and five years after admission for first-time myocardial infarction.

    METHODS: Patients with first-time myocardial infarction (<75 years) were identified as consecutively registered in the nationwide heart registry, SWEDEHEART (2006-2015), with >99% complete follow-up in the Causes of Death registry for outcome events. Of 192,059 myocardial infarction admissions, 47,907 unique patients with first-time myocardial infarction surviving to the first cardiac rehabilitation visit constituted the study population. The exposure was attending Heart School at the first cardiac rehabilitation visit 6-10 weeks post-myocardial infarction. Data on socioeconomic status was acquired from Statistics Sweden. After multiple imputation, propensity score matching was performed. The association of exposure with mortality was estimated with Cox regression and survival curves.

    RESULTS: After matching, attending Heart School was associated (hazard ratio (95% confidence interval)) with a markedly lower risk of both all-cause (two-year hazard ratio = 0.53 (0.44-0.64); five-year hazard ratio = 0.62 (0.55-0.69)) and cardiovascular (0.50 (0.38-0.65); 0.57 (0.47-0.69)) mortality. The results were robust in several sensitivity analyses.

    CONCLUSIONS: Attending Heart School during cardiac rehabilitation is associated with almost halved all-cause and cardiovascular mortality after first-time myocardial infarction. The result warrants further investigation through adequately powered randomised trials.

  • 25.
    Wikman, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Ljungman, Lisa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Pingel, Ronnie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Hagedoorn, Mariët
    University of Groningen, Department of Health Psychology.
    Sanderman, Robbert
    University of Groningen, Department of Health Psychology.
    von Essen, Louise
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Cernvall, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    The interdependence of posttraumatic stress symptoms in parental dyads during and after their child’s treatment for cancer2017In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 56, no 12, p. 1698-1704Article in journal (Refereed)
    Abstract [en]

    Background: Cancer in a child is highly distressing and some parents are at increased risk for developing posttraumatic stress symptoms (PTSS). However, the interdependence of PTSS in parental dyads has rarely been accounted for. The aim was to explore the dyadic relationship of PTSS in parents of children diagnosed with cancer.

    Material and methods: The sample includes 150 parents (75 dyads) of 75 children diagnosed with cancer in Sweden during 2002–2004, with follow-up until one year after end of treatment. Data on PTSS from six assessments were included. The first three assessments were carried out during treatment and the remaining after end of treatment. Actor-partner interdependence models were estimated using a structural equation modeling approach to explore the dyadic relationship of PTSS. Actor effects refer to intra-individual dependency over time, and partner effects refer to inter-individual dependency over time, i.e., how much an individual’s symptom levels are affected by their partner’s symptom levels at the previous assessment.

    Results: Results show both actor and partner effects during the child’s treatment. Only an actor effect remained following end of treatment where level of PTSS at one assessment was associated with the level of PTSS at the subsequent assessment. The association between mothers’ and fathers’ PTSS did not remain after end of treatment.

    Conclusions: Parents appear to react as an interdependent emotional system during the child’s treatment but this effect disappears after end of treatment. Results suggest psychological interventions for parents during the child’s cancer treatment should also be sensitive to and address the influence that distress in one partner may have on the other.

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