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Objective It is not fully understood whether and how socioeconomic status (SES) has a prognostic impact in patients with heart failure (HF). We assessed SES and its association with patient characteristics and outcomes in a contemporary and well-characterised HF cohort.

Methods Socioeconomic risk factors (SERF) were defined in the Swedish HF Registry based on income (low vs high according to the annual median value), education level (no degree/compulsory school vs university/secondary school) and living arrangement (living alone vs cohabitating).

Results Of 44 631 patients, 21% had no, 33% one, 30% two and 16% three SERF. Patient characteristics strongly and independently associated with lower SES were female sex and no specialist referral. Additional independent associations were older age, more severe HF, heavier comorbidity burden, use of diuretics and less use of HF devices. Lower SES was associated with higher risk of HF hospitalisation/mortality, and overall cardiovascular and non-cardiovascular events. These associations persisted after extensive adjustment for patient characteristics, treatments and care. The magnitude of the association increased linearly with the increasing number of coexistent SERF: HR (95% CI) 1.09 (1.05 to 1.13) for one, 1.16 (1.12 to 1.20) for two and 1.22 (1.18 to 1.28) for three SERF (p<0.01).

Conclusions In a contemporary and well-characterised HF cohort and after comprehensive adjustment for confounders, lower SES was linked with multiple factors such as less use of HF devices and age, but most strongly with female sex and lack of specialist referral; and associated with greater risk of morbidity/mortality.

Background: The risk of heart failure is disproportionately high among the socioeconomically disadvantaged. Furthermore, socioeconomically deprived patients are at risk of inequitable access to heart failure treatment and poor outcomes. Non-employment as a risk factor in this respect has not previously been studied at the level of the individual. The aim of this register-based cohort study was to analyse equity in access to renin-angiotensin system blockers and mortality, by employment status and educational level. 

Methods: The study population consisted of Swedish patients aged 20–64 years hospitalised for heart failure in July 2006–December 2010, without a heart failure hospitalisation within one year or more before index hospitalisation and without renin-angiotensin system blocker dispensation in the 6 months preceding index hospitalisation. Non-access to renin-angiotensin system blockers, measured as drug dispensations, was investigated by employment status and educational level through logistic regression. Cox regression models were used to obtain hazard ratios for all-cause death by educational level and employment status. Interaction analysis was used to test whether associations between access to treatment and mortality differed by employment status. 

Results: Among the 3,874 patients, 1,239 (32%) were women. The median age was 57 years. Fifty-three percent were employed. The non-employed patients had more comorbidity and lower access (68%) to renin-angiotensin system blockers compared with the employed (82%). The adjusted odds ratio for non-access to renin-angiotensin system blockers among the non-employed was 1.76. Non-employment was associated with an adjusted hazard ratio of 1.76 for death. Low educational level was associated with a higher death risk. Mortality was highest among the non-employed without access to renin-angiotensin system blockers and the association between access to renin-angiotensin system blockers and survival was slightly weaker in this group.

Conclusions: Non-employment and low educational level were associated with elevated mortality in heart failure. Non-employment was a risk factor for lower access to evidence-based treatment, and among the non-employed access to treatment was associated with a slightly smaller risk reduction than among the employed. The results underscore that clinicians need to be aware of the importance of socioeconomic factors in heart failure care. 

Background Immigrants are at increased risk of HIV infection in Europe and at risk of delayed diagnosis. In Sweden, Thailand belongs to one of the three most common countries of origin among immigrants diagnosed with HIV. This study investigated the need and use of sexual and reproductive health (SRH) services among Thai women residing in Sweden. Use of contraceptives and HIV testing in Thailand was also investigated to understand if this influences utilisation of SRH services in Sweden.

METHODS: A cross-sectional study using postal questionnaire to all Thai-born women (age 23-60) in Stockholm, residing in Sweden since 2014. The response rate was 52.3% (n= 266). Bivariate and multivariate logistic regression analyses were used.

RESULTS: The majority reported a significant need for information related to SRH services. Most of the women using contraception (70%) bought their contraceptives in Thailand. In total, 60% of the women had been HIV-tested at some point in their lives; the majority were tested in Thailand. Women who had been HIV-tested in Thailand were more likely to also have been tested in Sweden. Significant differences in contraception use, participation in contraceptive counselling and having had an HIV test were found between groups of younger and older women.

CONCLUSIONS: Our findings imply that age is an important factor to understand women's need and use of SRH services in Sweden versus Thailand. Furthermore, women's lack of knowledge and reported need for SRH information needs to be considered when making policies and strategies to increase access to SRH services.

Purpose: Investigate effectiveness by gender and age and equity implications of treatment with renin‐angiotensin system blockade (RASb) in heart failure (HF) patients.

Methods: In this population‐based register study, we used inpatient data from 2006 to 2010 for patients age 20 years or older with no HF hospitalisation for minimum of 1 year before an index hospitalisation. A wash‐out period for RASb of 6 months preceding admission was used.

Hospital data were linked with drug dispensation data and cause of death data. The associations between time‐dependent RASb exposure and all‐cause death and HF death, respectively, were examined by Cox regression models. Interactions by gender and age were also investigated on the multiplicative and additive scales.

Results: Thirty thousand seven hundred twenty‐one patients were analysed. Fifty‐one percent were women. Median age was 83. Fifty‐three percent of women and 64% of men received RASb after the index hospitalisation. Younger patients were more likely to receive RASb than older ones. One‐year mortality was 28%. RASb was associated with an overall hazard ratio (HR) for all‐cause death of 0.72 (95% confidence interval 0.69‐0.75), and an HR of 0.85 (0.77‐0.93) for HF death. Interaction analyses showed HRs for all‐cause death associated with RASb between 0.12 (0.10‐0.13) in the youngest, and 0.80 (0.76‐0.84) in the oldest patients.

Conclusions: RASb appeared effective for women and men and for patients of all ages in this hospitalised HF cohort. No gender difference in effectiveness was found. RASb exposure was low overall, indicating a need for improved adherence to treatment guidelines. Treatment with RASb may be inequitable for women and older patients.

BACKGROUND: Owing to communication challenges and a lack of knowledge about the health care system, refugees may be at risk of having limited health literacy, meaning that they will have problems in achieving, understanding, appraising and using health information or navigating in the health care system. The aim of this study was to explore experiences and needs concerning health related information for newly arrived refugees in Sweden.

METHODS: A qualitative design with a focus group methodology was used. The qualitative content analysis was based on seven focus group discussions, including 28 Arabic and Somali speaking refugees.

RESULTS: Four categories emerged. 'Concrete instructions and explanations' includes appreciation of knowledge about how to act when facing health problems. 'Contextual knowledge' comprises experienced needs of information about the health care system, about specific health risks and about rights in health issues. 'A variation of sources' describes suggestions as to where and how information should be given. 'Enabling communication' includes the wish for more awareness among professionals from a language and cultural point of view.

CONCLUSION: Concrete instructions and explanations are experienced as valuable and applicable. Additional information about health issues and the health care system is needed. Information concerning health should be spread by a variety of sources. Health literate health organizations are needed to meet the health challenges of refugees, including professionals that emphasize health literacy.

Aims: Health-related behaviours are associated with social relationships. Adolescence is a time when healthy and unhealthy behaviours are established. There is a need to investigate adolescents’ views on how social relationships are related to health-related behaviours of adolescents in the Scandinavian welfare system. This study aimed to explore Swedish adolescents’ experiences and thoughts of how social relationships in different social environments are related to health-related behaviours.

Methods: A total of 36 adolescents aged 15–16 years were interviewed in seven focus-group sessions. Qualitative content analysis was used for analysis of the transcribed interviews.

Results: Two themes – social context and personal management – emerged. Swedish adolescents describe that their health-related behaviours as being partly shaped by their own personal management but mainly by the social contexts that surround them. Social contexts were expressed as playing a role in the adolescents’ health-related behaviours, as they provide fellowship, pressure, dependability and engagement. Fellowship with friends and family was expressed as providing healthy behaviours and high levels of well-being. Fellowship with friends was particularly important for physical activity. Close relationships were stated to influence health-related behaviours. Pressure from friends, teachers and social media were described as mainly influencing unhealthy behaviours and, to some extent, low levels of well-being. However, adolescents’ personal ability illustrated how adolescents shaped their own health-related behaviours.

Conclusions: The study results contribute to the understanding of Swedish adolescents’ views on how social relationships can shape their health-related behaviours. The findings may be useful to school professionals in supporting adolescents to improve well-being and healthy behaviours.

Background: Antimicrobial resistance is considered one of the major threats to global health. The emergence of resistant microorganisms is a consequence of irrational use of antibiotics. In Turkey, the consumption of antibiotics is relatively high and antibiotics are among the most commonly used drugs. However, Turkey has adopted new, more restrictive policies and regulations on antibiotics. In addition, Turkish migrants to EU countries, such as Germany, the Netherlands and Sweden, may encounter health systems that promote a more restrictive and rational antibiotic use. The objective of this paper was to explore the variation in implemented policies related to rational antibiotic use that citizens in Turkey and Turkish migrants in Germany, the Netherlands and Sweden are subjected to and to discuss the implications for the promotion of rational antibiotic use. Data were collected through focus groups and individual interviews with citizens, physicians and pharmacists in the four countries. In total, 130 respondents were interviewed. Content analysis was used.

Results: Three relevant themes were identified: Implementation of regulations and recommendations, Access to antibiotics and Need for health communication. Irrational use of antibiotics was reported mainly in Turkey. While it had become less likely to get antibiotics without a prescription, non-prescribed antibiotics remained a problem in Turkey. In the three EU countries, there were also alternative ways of getting antibiotics. Low levels of knowledge about the rational antibiotic use were reported in Turkey, while there were several sources of information on this in the EU countries. Communication with and trust in physicians were considered to be important. There were also system barriers, such as lacking opportunities for physicians to manage care in accordance with current evidence in Turkey and factors limiting access to care in EU countries.

Conclusions: Several fields of importance for promoting rational antibiotic use were identified. There is a need for harmonisation of health-related regulations and policy programmes. Antibiotics should only be available with a prescription. Programmes for rational antibiotic use should be implemented on a broad scale, in medical care, at pharmacies and in the population. Methods for health communication and patient-centred care should be further developed and implemented in this field.

ObjectivesDue to strong transnational ties, the use of and demand for antibiotics among Turkish migrants in Germany may be influenced by cultural aspects of antibiotic use in Turkey. Research on the use of antibiotics among Turkish migrants in Germany, however, is scarce. The aim of this study was to find out how Turkish migrants in Germany use antibiotics, whether and how knowledge, underlying motives and attitudes influence demand and how Turkish migrants interact with medical professionals. Materials and methodsUsing a qualitative approach, behavioural patterns and logic of action of adult Turkish migrants were identified. We carried out semi-structured focus group interviews with adults of Turkish origin residing in Germany and expert interviews with family physicians and pharmacists. The interviews were analysed by means of content analysis. ResultsWhile younger migrants had a generally positive, but cautious attitude towards the use of antibiotics, older migrants often showed exaggerated, unrealistic expectations resulting from a lack of factual knowledge. Overall, participants adopted a passive role in the patient-provider relationship. This led to a perpetuation of significant knowledge gaps. ConclusionsOlder Turkish migrants who have less factual knowledge show exaggerated expectations concerning the effectiveness of antibiotics. In conjunction with a passive patient role, resulting in information needs not being satisfied, this can affect the patient-provider relationship. A more active communication by physicians and information materials sensitive to the needs of migrants can positively influence the interaction between migrant patients and medical professionals.