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1.  Chronic Obstructive Pulmonary Disease (COPD) During the Two Last Years of Life – A Retrospective Study of Decedents 
PLoS ONE  2013;8(12):e84110.
Background
Little is known about the management of patients suffering from chronic obstructive pulmonary disease (COPD) during the last years of life. The aim of the study was to describe how management of COPD is performed in Sweden during the last two years of life.
Methods
From the nationwide Cause of Death register all individuals with COPD as the underlying cause of death during two years were identified in one sparsely and one densely populated area of Sweden. Data were collected from medical records using a pre-defined protocol, especially developed for this purpose.
Results
Of 822 individuals with COPD as underlying cause of death, medical records from 729 were available. The COPD diagnosis was based on lung function measurements in approximately half of the patients and median age at COPD diagnosis was 74 years (range 34-95). Women died at younger age, median 78 years (range 52-96) than did men (80 years (51-99)). The median survival time from diagnosis to death was 6 years in men and women in both areas. Among women and men 8.3% and 4.3% were never smokers, respectively. The structure of COPD management differed between the two areas, with utilization of physiotherapists, dieticians and working therapists being more used in the northern area, likely because of differences in accessibility to care institutions.
Conclusions
In Sweden COPD is mostly diagnosed late in life and often not verified by lung function measurements. Opposite to the general population, women with COPD die at a lower age than men.
doi:10.1371/journal.pone.0084110
PMCID: PMC3868592  PMID: 24367631
2.  Health coaching to promote healthier lifestyle among older people at moderate risk for cardiovascular diseases, diabetes and depression: a study protocol for a randomized controlled trial in Sweden 
BMC Public Health  2013;13:199.
Background
The challenge of an aging population in the society makes it important to find strategies to promote health for all. The aim of this study is to evaluate if repeated health coaching in terms of motivational interviewing, and an offer of wide range of activities, will contribute to positive lifestyle modifications and health among persons aged 60–75 years, with moderately elevated risk for cardiovascular disease (CVD), diabetes, or mild depression.
Methods/Design
Men and women between 60 and 75 are recruited in four regions in Sweden if they fulfill one or more of the four inclusion criteria.
•Current reading of blood pressure (140-159/90-99) without medication.
•Current reading of blood sugar (Hba1c 42–52 mmol/mol) without medication.
•A current waist-circumference of ≥94 cm for men and ≥80 for women.
•A minor/mild depression (12–20 points) according to Montgomery-Åsberg Depression Rating Scale without medication.
Individuals with a worse result than inclusion criteria are treated according to regular guidelines at the PHCs and therefore not included. Exclusion criteria for the study are dementia, mental illness or other condition deemed unsuitable for participation.
All participants fill out a questionnaire at baseline, and at the 6-, 12- and 18-month follow-ups containing questions on demographic characteristics, social life, HRQoL, lifestyle habits, general health/medication, self-rated mental health, and sense of coherence. At the 12-month follow-up, the health coach will give each participant a second questionnaire to capture attitudes and perceptions related to health coaching and venues/activities offered.
Qualitative data will be collected twice to obtain a deeper understanding of perceptions and attitudes related to health and lifestyle/lifestyle modifications. A health economic assessment will be performed. Individual costs for health care utilisation will be collected and QALY-scores will be estimated.
Discussion
Several drawbacks can be identified when conducting research in real life. However, many of the identified problems can diminish the positive results of the intervention and if the intervention shows positive effects they might be underestimated.
Trial registration
Current Controlled Trials ISRCTN01396033.
doi:10.1186/1471-2458-13-199
PMCID: PMC3599987  PMID: 23497163
Life style changes; Prevention; Motivational interviewing; Older people; RCT; Health coaching; Health economics
3.  Community participation and sustainability – evidence over 25 years in the Västerbotten Intervention Programme 
Global Health Action  2012;5:10.3402/gha.v5i0.19166.
Background
Selection bias and declining participation rates are of concern in many long-term epidemiological studies. The Västerbotten Intervention Programme (VIP) was launched in 1985 as a response to alarming reports on elevated cardiovascular disease (CVD) mortality in Västerbotten County in Northern Sweden. The VIP invites women and men to a health examination and health counselling during the year of their 40th, 50th, and 60th birthdays.
Objective
To evaluate trends in participation rates and determinants of participation in the VIP from 1990 to 2006.
Design
Registry data on socio-economic status from Statistics Sweden, and mortality and hospitalisation data from the National Board of Health and Welfare, both covering the whole Swedish population, were linked to the VIP and analysed for participants and non-participants.
Results
During 1990–2006, 117,710 individuals were eligible to participate in the VIP, and 40,472 of them were eligible to participate twice. There were 96,560 observations for participants and 61,622 for non-participants. The overall participation rate increased from 56 to 65%. Participants and non-participants had minimal differences in education and age. Initial small differences by sex and degree of urban residence decreased over time. Despite an increasing participation rate in all groups, those with low income or who were single had an approximately 10% lower participation rate than those with high or medium-income or who were married or cohabitating.
Conclusion
Sustainability of the VIP is based on organisational integration into primary health care services and targeting of the entire middle-aged population. This enables the programme to meet population expectations of health promotion and to identify high-risk individuals who are then entered into routine preventive health care services. This has the potential to increase participation rates, to minimise social selection bias, and to reinforce other community-based interventions.
doi:10.3402/gha.v5i0.19166
PMCID: PMC3525921  PMID: 23528041
health surveys; intervention; community participation; primary health care; selection bias
4.  Incidence of Type 1 Diabetes in Sweden Among Individuals Aged 0–34 Years, 1983–2007 
Diabetes Care  2011;34(8):1754-1759.
OBJECTIVE
To clarify whether the increase in childhood type 1 diabetes is mirrored by a decrease in older age-groups, resulting in younger age at diagnosis.
RESEARCH DESIGN AND METHODS
We used data from two prospective research registers, the Swedish Childhood Diabetes Register, which included case subjects aged 0–14.9 years at diagnosis, and the Diabetes in Sweden Study, which included case subjects aged 15–34.9 years at diagnosis, covering birth cohorts between 1948 and 2007. The total database included 20,249 individuals with diabetes diagnosed between 1983 and 2007. Incidence rates over time were analyzed using Poisson regression models.
RESULTS
The overall yearly incidence rose to a peak of 42.3 per 100,000 person-years in male subjects aged 10–14 years and to a peak of 37.1 per 100,000 person-years in female subjects aged 5–9 years and decreased thereafter. There was a significant increase by calendar year in both sexes in the three age-groups <15 years; however, there were significant decreases in the older age-groups (25- to 29-years and 30- to 34-years age-groups). Poisson regression analyses showed that a cohort effect seemed to dominate over a time-period effect.
CONCLUSIONS
Twenty-five years of prospective nationwide incidence registration demonstrates a clear shift to younger age at onset rather than a uniform increase in incidence rates across all age-groups. The dominance of cohort effects over period effects suggests that exposures affecting young children may be responsible for the increasing incidence in the younger age-groups.
doi:10.2337/dc11-0056
PMCID: PMC3142045  PMID: 21680725
5.  “Voices of Fear and Safety” Women’s ambivalence towards breast cancer and breast health: a qualitative study from Jordan 
BMC Women's Health  2012;12:21.
Background
Breast cancer is the leading cause of cancer mortality among Jordanian women. Breast malignancies are detected at late stages as a result of deferred breast health-seeking behaviour. The aim of this study was to explore Jordanian women’s views and perceptions about breast cancer and breast health.
Methods
We performed an explorative qualitative study with purposive sampling. Ten focus groups were conducted consisting of 64 women (aged 20 to 65 years) with no previous history and no symptoms of breast cancer from four governorates in Jordan. The transcribed data was analysed using latent content analysis.
Results
Three themes were constructed from the group discussions: a) Ambivalence in prioritizing own health; b) Feeling fear of breast cancer; and c) Feeling safe from breast cancer. The first theme was seen in women’s prioritizing children and family needs and in their experiencing family and social support towards seeking breast health care. The second theme was building on women’s perception of breast cancer as an incurable disease associated with suffering and death, their fear of the risk of diminished femininity, husband’s rejection and social stigmatization, adding to their apprehensions about breast health examinations. The third theme emerged from the women’s perceiving themselves as not being in the risk zone for breast cancer and in their accepting breast cancer as a test from God. In contrast, women also experienced comfort in acquiring breast health knowledge that soothed their fears and motivated them to seek early detection examinations.
Conclusions
Women’s ambivalence in prioritizing their own health and feelings of fear and safety could be better addressed by designing breast health interventions that emphasize the good prognosis for breast cancer when detected early, involve breast cancer survivors in breast health awareness campaigns and catalyse family support to encourage women to seek breast health care.
doi:10.1186/1472-6874-12-21
PMCID: PMC3526536  PMID: 22834874
6.  How to diagnose and classify diabetes in primary health care: Lessons learned from the Diabetes Register in Northern Sweden (DiabNorth) 
Objective
The objective was to create a diabetes register and to evaluate the validity of the clinical diabetes diagnosis and its classification.
Design
The diabetes register was created by linkage of databases in primary and secondary care, the pharmaceutical database, and ongoing population-based health surveys in the county. Diagnosis and classification were validated by specialists in diabetology or general practitioners with special competence in diabetology. Analysis of autoantibodies associated with type 1 diabetes was used for classification. Setting. Primary and secondary health care in the county of Västerbotten, Sweden.
Patients
Patients with diabetes (median age at diagnosis 56 years, inter quartile range 50–60 years) who had participated in the Västerbotten Intervention Programme (VIP) and accepted participation in a diabetes register.
Results
Of all individuals with diabetes in VIP, 70% accepted to participate in the register. The register included 3256 (M/F 1894/1362) diabetes patients. The vast majority (95%) had data confirming the diabetes diagnoses according to WHO recommendations. Unspecified diabetes was the most common (54.6%) classification by the general practitioners. After assessment by specialists and analysis of autoantibodies the majority were classified as type 2 diabetes (76.8%). Type 1 diabetes was the second largest group (7.2%), including a sub-group of patients with latent autoimmune diabetes (4.8%).
Conclusion
It was concluded that it is feasible to create a diabetes register based on information in medical records in general practice. However, special attention should be paid to the validity of the diabetes diagnosis and its classification.
doi:10.3109/02813432.2012.675565
PMCID: PMC3378009  PMID: 22643152
Diabetes; classification; register; primary health care
7.  Screening of women for intimate partner violence: a pilot intervention at an outpatient department in Tanzania 
Global Health Action  2011;4:10.3402/gha.v4i0.7288.
Intimate partner violence (IPV) is a public health problem in Tanzania with limited health care interventions.
Objectives
To study the feasibility of using an abuse screening tool for women attending an outpatient department, and describe how health care workers perceived its benefits and challenges.
Methods
Prior to screening, 39 health care workers attended training on gender-based violence and the suggested screening procedures. Seven health care workers were arranged to implement screening in 3 weeks, during March–April 2010. For screening evaluation, health care workers were observed for their interaction with clients. Thereafter, focus group discussions (FGDs) were conducted with 21 health care workers among those who had participated in the training and screening. Five health care workers wrote narratives. Women's responses to screening questions were analyzed with descriptive statistics, whereas qualitative content analysis guided analysis of qualitative data.
Results
Of the 102 women screened, 78% had experienced emotional, physical, or sexual violence. Among them, 62% had experienced IPV, while 22% were subjected to violence by a relative, and 9.2% by a work mate. Two-thirds (64%) had been abused more than once; 14% several times. Almost one-quarter (23%) had experienced sexual violence. Six of the health care workers interacted well with clients but three had difficulties to follow counseling guidelines. FGDs and narratives generated three categories Just asking feels good implied a blessing of the tool; what next? indicated ethical dilemmas; and fear of becoming a 'women hospital’ only indicated a concern that abused men would be neglected.
Conclusions
Screening for IPV is feasible. Overall, the health care workers perceived the tool to be advantageous. Training on gender-based violence and adjustment of the tool to suit local structures are important. Further studies are needed to explore the implications of including abuse against men and children in future screening.
doi:10.3402/gha.v4i0.7288
PMCID: PMC3200434  PMID: 22028679
intimate partner violence; health care workers; abuse screening; Tanzania
8.  Cumulative Risk, Age at Onset, and Sex-Specific Differences for Developing End-Stage Renal Disease in Young Patients With Type 1 Diabetes 
Diabetes  2010;59(7):1803-1808.
OBJECTIVE
This study aimed to estimate the current cumulative risk of end-stage renal disease (ESRD) due to diabetic nephropathy in a large, nationwide, population-based prospective type 1 diabetes cohort and specifically study the effects of sex and age at onset.
RESEARCH DESIGN AND METHODS
In Sweden, all incident cases of type 1 diabetes aged 0–14 years and 15–34 years are recorded in validated research registers since 1977 and 1983, respectively. These registers were linked to the Swedish Renal Registry, which, since 1991, collects data on patients who receive active uremia treatment. Patients with ≥13 years duration of type 1 diabetes were included (n = 11,681).
RESULTS
During a median time of follow-up of 20 years, 127 patients had developed ESRD due to diabetic nephropathy. The cumulative incidence at 30 years of type 1 diabetes duration was low, with a male predominance (4.1% [95% CI 3.1–5.3] vs. 2.5% [1.7–3.5]). In both male and female subjects, onset of type 1 diabetes before 10 years of age was associated with the lowest risk of developing ESRD. The highest risk of ESRD was found in male subjects diagnosed at age 20–34 years (hazard ratio 3.0 [95% CI 1.5–5.7]). In female subjects with onset at age 20–34 years, the risk was similar to patients' diagnosed before age 10 years.
CONCLUSIONS
The cumulative incidence of ESRD is exceptionally low in young type 1 diabetic patients in Sweden. There is a striking difference in risk for male compared with female patients. The different patterns of risk by age at onset and sex suggest a role for puberty and sex hormones.
doi:10.2337/db09-1744
PMCID: PMC2889782  PMID: 20424230
9.  Community perceptions of intimate partner violence - a qualitative study from urban Tanzania 
BMC Women's Health  2011;11:13.
Background
Intimate partner violence against women is a prevailing public health problem in Tanzania, where four of ten women have a lifetime exposure to physical or sexual violence by their male partners. To be able to suggest relevant and feasible community and health care based interventions, we explored community members' understanding and their responses to intimate partner violence.
Methods
A qualitative study using focus group discussions with 75 men and women was conducted in a community setting of urban Tanzania. We analysed data using a grounded theory approach and relate our findings to the ecological framework of intimate partner violence.
Results
The analysis resulted in one core category, "Moving from frustration to questioning traditional gender norms", that denoted a community in transition where the effects of intimate partner violence had started to fuel a wish for change. At the societal level, the category "Justified as part of male prestige" illustrates how masculinity prevails to justify violence. At the community level, the category "Viewed as discreditable and unfair" indicates community recognition of intimate partner violence as a human rights concern. At the relationship level, the category "Results in emotional entrapment" shows the shame and self-blame that is often the result of a violent relationship. At the individual level, the risk factors for intimate partner violence were primarily associated with male characteristics; the category "Fed up with passivity" emerged as an indication that community members also acknowledge their own responsibility for change in actions.
Conclusions
Prevailing gender norms in Tanzania accept women's subordination and justify male violence towards women. At the individual level, an increasing openness makes it possible for women to report, ask for help, and become proactive in suggesting preventive measures. At the community level, there is an increased willingness to intervene but further consciousness-raising of the human rights perspective of violence, as well as actively engaging men. At the macro level, preventive efforts must be prioritized through re-enforcement of legal rights, and provision of adequate medical and social welfare services for both survivors and perpetrators.
doi:10.1186/1472-6874-11-13
PMCID: PMC3094305  PMID: 21501506
10.  Effectiveness of maternal referral system in a rural setting: a case study from Rufiji district, Tanzania 
Background
The functional referral system is important in backing-up antenatal, labour and delivery, and postnatal services in the primary level of care facilities. The aim of this study was to evaluate the effectiveness of the maternal referral system through determining proportion of women reaching the hospitals after referral advice, appropriateness of the referral indications, reasons for non-compliance and to find out if compliance to referrals makes a difference in the perinatal outcome.
Methods
A follow-up study was conducted in Rufiji rural district in Tanzania. A total of 1538 women referred from 18 primary level of care facilities during a 13 months period were registered and then identified at hospitals. Those not reaching the hospitals were traced and interviewed.
Results
Out of 1538 women referred 70% were referred for demographic risks, 12% for obstetric historical risks, 12% for prenatal complications and 5.5% for natal and immediate postnatal complications. Five or more pregnancies as well as age <20 years were the most common referral indications. The compliance rate was 37% for women referred due to demographic risks and more than 50% among women referred in the other groups. Among women who did not comply with referral advice, almost half of them mentioned financial constraints as the major factor. Lack of compliance with the referral did not significantly increase the risk for a perinatal death.
Conclusion
Majority of the maternal referrals were due to demographic risks, where few women complied. To improve compliance to maternal referrals there is need to review the referral indications and strengthen counseling on birth preparedness and complication readiness.
doi:10.1186/1472-6963-10-326
PMCID: PMC3003655  PMID: 21129178
11.  Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs 
Background
The high rate of antenatal care attendance in sub-Saharan Africa, should facilitate provision of information on signs of potential pregnancy complications. The aim of this study was to assess quality of antenatal care with respect to providers' counselling of pregnancy danger signs in Rufiji district, Tanzania.
Methods
A cross-sectional study was conducted in 18 primary health facilities. Thirty two providers were observed providing antenatal care to 438 pregnant women. Information on counselling on pregnancy danger signs was collected by an observer. Exit interviews were conducted to 435 women.
Results
One hundred and eighty five (42%) clients were not informed of any pregnancy danger signs. The most common pregnancy danger sign informed on was vaginal bleeding 50% followed by severe headache/blurred vision 45%. Nurse auxiliaries were three times more likely to inform a client of a danger sign than registered/enrolled nurses (OR = 3.7; 95% CI: 2.1-6.5) and Maternal Child Health Aides (OR = 2.3: 95% CI: 1.3-4.3) and public health nurses (OR = 2.5; CI: 1.4-4.2) were two times more likely to provide information on danger signs than registered/enrolled nurses. The clients recalled less than half of the pregnancy danger signs they had been informed during the interaction.
Conclusion
Two out of five clients were not counselled on pregnancy danger signs. The higher trained cadre, registered/enrolled nurses were not informing majority of clients pregnancy danger signs compared to the lower cadres. Supportive supervision should be made to enhance counselling of pregnancy danger signs. Nurse auxiliaries should be encouraged and given chance for further training and upgrading to improve their performance and increase human resource for health.
doi:10.1186/1471-2393-10-35
PMCID: PMC2907301  PMID: 20594341
12.  Rural Tanzanian women's awareness of danger signs of obstetric complications 
Background
Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess women's awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania.
Methods
A total of 1118 women who had been pregnant in the past two years were interviewed. A list of medically recognized potentially life threatening obstetric signs was obtained from the responses given. Chi- square test was used to determine associations between categorical variables and multivariate logistic regression analysis was used to identify factors associated with awareness of obstetric danger signs.
Results
More than 98% of the women attended antenatal care at least once. Half of the women knew at least one obstetric danger sign. The percentage of women who knew at least one danger sign during pregnancy was 26%, during delivery 23% and after delivery 40%. Few women knew three or more danger signs. According to multivariate logistic regression analysis having secondary education or more increased the likelihood of awareness of obstetric danger signs six-fold (OR = 5.8; 95% CI: 1.8–19) in comparison with no education at all. The likelihood to have more awareness increased significantly by increasing age of the mother, number of deliveries, number of antenatal visits, whether the delivery took place at a health institution and whether the mother was informed of having a risks/complications during antenatal care.
Conclusion
Women had low awareness of danger signs of obstetric complications. We recommend the following in order to increase awareness of danger signs of obstetrical complications: to improve quality of counseling and involving other family members in antenatal and postnatal care, to use radio messages and educational sessions targeting the whole community and to intensify provision of formal education as emphasized in the second millennium development goal.
doi:10.1186/1471-2393-9-12
PMCID: PMC2667432  PMID: 19323836
13.  Early life environment and snoring in adulthood 
Respiratory Research  2008;9(1):63.
Background
To our knowledge, no studies of the possible association of early life environment with snoring in adulthood have been published. We aimed to investigate whether early life environment is associated with snoring later in life.
Methods
A questionnaire including snoring frequency in adulthood and environmental factors in early life was obtained from 16,190 randomly selected men and women, aged 25–54 years, in Sweden, Norway, Iceland, Denmark and Estonia (response rate 74%).
Results
A total of 15,556 subjects answered the questions on snoring. Habitual snoring, defined as loud and disturbing snoring at least 3 nights a week, was reported by 18%. Being hospitalized for a respiratory infection before the age of two years (adjusted odds ratio (OR) = 1.27; 95% confidence interval (CI) 1.01–1.59), suffering from recurrent otitis as a child (OR = 1.18; 95%CI 1.05–1.33), growing up in a large family (OR = 1.04; 95%CI 1.002–1.07) and being exposed to a dog at home as a newborn (OR = 1.26; 95%CI 1.12–1.42) were independently related to snoring later in life and independent of a number of possible confounders in adulthood. The same childhood environmental factors except household size were also related with snoring and daytime sleepiness combined.
Conclusion
The predisposition for adult snoring may be partly established early in life. Having had severe airway infections or recurrent otitis in childhood, being exposed to a dog as a newborn and growing up in a large family are environmental factors associated with snoring in adulthood.
doi:10.1186/1465-9921-9-63
PMCID: PMC2536663  PMID: 18721453
14.  How effective is screening for breast cancer?  
BMJ : British Medical Journal  2000;321(7262):647-648.
PMCID: PMC1118537  PMID: 10987748

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