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1.  Health-related quality of life for pre-diabetic states and type 2 diabetes mellitus: a cross-sectional study in Västerbotten Sweden 
Type 2 diabetes (T2D) decreases health-related quality of life, but there is a lack of information about the health status of people in pre-diabetic states. However, information on health utility weights (HUWs) for pre-diabetic states and T2D are essential to estimate the effect of prevention initiatives. We estimated and compared HUWs for healthy individuals, those with pre-diabetes and those with T2D in a Swedish population and evaluated the influence of age, sex, education and body mass index on HUWs.
Participants of the Västerbotten Intervention Program, Sweden, between 2002 and 2012, who underwent an oral glucose tolerance test or indicated they had T2D and who filled in the Short Form-36 questionnaire (SF-36) were included. Individuals were categorized as healthy, being in any of three different pre-diabetic states, or as T2D. The pre-diabetic states are impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or a combination of both (IFG&IGT). The SF-6D index was used to convert SF-36 responses to HUWs. HUWs were stratified by age, sex, education and body mass index. Beta regression analyses were conducted to estimate the effect of multiple risk factors on the HUWs.
In total, 55 882 individuals were included in the analysis. The overall mean HUW was 0.764. The mean HUW of healthy individuals was 0.768, 0.759 for those with IFG, 0.746 for those with IGT, 0.745 for those with IFG&IGT, and 0.738 for those with T2D. In the overall model, all variables except underweight vs. normal weight were significantly associated with HUW. Younger age, male sex, and higher education were associated with increased HUW. Normal weight, or being overweight was associated with elevated HUW, while obesity was associated with lower HUW.
Healthy individuals had higher HUWs than participants with T2D, while individuals with IFG, IGT or IFG&IGT had HUWs that ranged between those for NGT and T2D. Therefore, preventing the development of pre-diabetic states would improve health-related quality of life in addition to lowering the risk of developing T2D.
PMCID: PMC4212131  PMID: 25342083
Health utility; Normal glucose tolerance; Impaired fasting glucose; Impaired glucose tolerance; Type 2 diabetes mellitus; Sweden; SF-36; SF-6D; Health-related quality of life; Beta regression
2.  Regional intensive care transports: a prospective analysis of distance, time and cost for road, helicopter and fixed-wing ambulances 
There are three different types of ambulance systems, all of which can manage the same secondary intensive care patient transport mission: road ambulance, rotor-wing ambulance, and fixed-wing ambulance. We hypothesized that costs for specific transport distances would differ between systems. We aimed to analyze distances and observed times for ambulance intensive care secondary transport missions together with system costs to assess this.
We prospectively collected data for consecutive urgent intensive care transports into the regional tertiary care hospital in the northern region of Sweden. Distances and transport times were gathered, and a cost model was generated based on these together with fixed and operating costs from the three different ambulance systems. Distance-cost and time–cost estimations were then generated for each transport system.
Road ambulance cost relatively less for shorter distances (within 250 kilometers/155 miles) but were relatively time ineffective. The rotor-wing systems were most expensive regardless of distance; but were most time-effective up to 400–500 km (248–310 miles). Fixed-wing systems were more cost-effective for longer distance (300 km/186 miles), and time effective for transports over 500 km (310 miles).
In summary, based on an economic model developed from observed regional ICU patient transports, and cost estimations, different ambulance system cost-distances could be compared. Distance-cost and time results show that helicopters can be effective up to moderate ICU transport distances (400–500), though are expensive to operate. For longer ICU patient transports, fixed-wing transport systems are both cost and time effective compared to helicopter-based systems.
PMCID: PMC4055373  PMID: 24902480
Ambulance; Intensive care transport; Helicopter; Road ambulance; Fixed-wing ambulance; Health economics
3.  Equity in adherence to and effect of prenatal food and micronutrient supplementation on child mortality: results from the MINIMat randomized trial, Bangladesh 
BMC Public Health  2014;14:5.
Evidence is often missing on social differentials in effects of nutrition interventions. We evaluated the adherence to and effect of prenatal food and micronutrient supplementations on mortality before the age of five years in different social groups as defined by maternal schooling.
Data came from the MINIMat study (Maternal and Infant Nutrition Interventions, Matlab), a randomized trial of prenatal food supplementation (invitation early, about 9 weeks [E], or at usual time, about 20 weeks [U] of pregnancy) and 30 mg or 60 mg iron with 400 μgm folic acid, or multiple micronutrients (Fe30F, Fe60F, MMS) resulting in six randomization groups, EFe30F, UFe30F, EFe60F, UFe60F, EMMS, and UMMS (n = 4436). Included in analysis after omissions (fetal loss and out-migration) were 3625 women and 3659 live births of which 3591 had information on maternal schooling. The study site was rural Matlab, Bangladesh. The main stratifying variable was maternal schooling dichotomized as <6 years and ≥6 years. We used Cox proportional hazard model for survival analyses.
Overall, women having <6 years of schooling adhered more to food (81 vs. 69 packets, P=0.0001) but a little less to micronutrient (104 vs. 120 capsules, P = 0.0001) supplementation compared to women having more schooling, adjusted for maternal age (years), parity and body mass index (BMI, kg/m2) at week 8 pregnancy. Children of mothers with ≥6 years of schooling had lower under-five mortality, but the EMMS supplementation reduced the social difference in mortality risk (using standard program and schooling <6 years as reference; standard program and schooling ≥6 years HR 0.54, 95% CI 0.27-1.11; EMMS and schooling ≥6 years HR 0.28, 95% CI 0.12-0.70; EMMS and schooling <6 years HR 0.26, 95% CI 0.11-0.63), adjusted for maternal age (years), parity and body mass index (kg/m2) at week 8 pregnancy.
The combination of an early invitation to prenatal food supplementation and multiple micronutrient supplementation lowered mortality in children before the age of five years and reduced the gap in child survival chances between social groups. The pattern of adherence to the supplementations was complex; women with less education adhered more to food supplementation while those with more education had higher adherence to micronutrients.
Trial registration
PMCID: PMC3893435  PMID: 24393610
Equity; Child mortality; Food supplementation; Micronutrient supplementation; Adherence; Bangladesh
4.  Risk equations for the development of worsened glucose status and type 2 diabetes mellitus in a Swedish intervention program 
BMC Public Health  2013;13:1014.
Several studies investigated transitions and risk factors from impaired glucose tolerance (IGT) to type 2 diabetes mellitus (T2D). However, there is a lack of information on the probabilities to transit from normal glucose tolerance (NGT) to different pre-diabetic states and from these states to T2D. The objective of our study is to estimate these risk equations and to quantify the influence of single or combined risk factors on these transition probabilities.
Individuals who participated in the VIP program twice, having the first examination at ages 30, 40 or 50 years of age between 1990 and 1999 and the second examination 10 years later were included in the analysis. Participants were grouped into five groups: NGT, impaired fasting glucose (IFG), IGT, IFG&IGT or T2D. Fourteen potential risk factors for the development of a worse glucose state (pre-diabetes or T2D) were investigated: sex, age, education, perceived health, triglyceride, blood pressure, BMI, smoking, physical activity, snus, alcohol, nutrition and family history. Analysis was conducted in two steps. Firstly, factor analysis was used to find candidate variables; and secondly, logistic regression was employed to quantify the influence of the candidate variables. Bootstrap estimations validated the models.
In total, 29 937 individuals were included in the analysis. Alcohol and perceived health were excluded due to the results of the factor analysis and the logistic regression respectively. Six risk equations indicating different impacts of different risk factors on the transition to a worse glucose state were estimated and validated. The impact of each risk factor depended on the starting or ending pre-diabetes state. High levels of triglyceride, hypertension and high BMI were the strongest risk factors to transit to a worsened glucose state.
The equations could be used to identify individuals with increased risk to develop any of the three pre-diabetic states or T2D and to adapt prevention strategies.
PMCID: PMC3871001  PMID: 24502249
Diabetes mellitus, type 2; Pre-diabetic state; Prevention & control; Risk factors; Glucose; Sweden; Logistic models; Factor analysis, statistical; Early intervention; Life style
5.  The impact of economic growth on health care utilization: a longitudinal study in rural Vietnam 
In many developing countries, including Vietnam, out-of-pocket payment is the principal source of health financing. The economic growth is widening the gap between rich and poor people in many aspects, including health care utilization. While inequities in health between high- and low-income groups have been well investigated, this study aims to investigate how the health care utilization changes when the economic condition is changing at a household level.
We analysed a panel data of 11,260 households in a rural district of Vietnam. Of the sample, 74.4% having an income increase between 2003 and 2007 were defined as households with economic growth. We used a double-differences propensity score matching technique to compare the changes in health care expenditure as percentage of total expenditure and health care utilization from 2003 to 2005, from 2003 to 2007, and from 2005 to 2007, between households with and without economic growth.
Households with economic growth spent less percentage of their expenditure for health care, but used more provincial/central hospitals (higher quality health care services) than households without economic growth. The differences were statistically significant.
The results suggest that households with economic growth are better off also in terms of health services utilization. Efforts for reducing inequalities in health should therefore consider the inequality in income growth over time.
PMCID: PMC3605239  PMID: 23497015
Economic growth; Health care utilization; Household expenditure Vietnam
6.  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.
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.
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.
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.
PMCID: PMC3599987  PMID: 23497163
Life style changes; Prevention; Motivational interviewing; Older people; RCT; Health coaching; Health economics
7.  Health-related quality of life in adolescents with screening-detected celiac disease, before and one year after diagnosis and initiation of gluten-free diet, a prospective nested case-referent study 
BMC Public Health  2013;13:142.
Celiac disease (CD) is a chronic disorder in genetically predisposed individuals in which a small intestinal immune-mediated enteropathy is precipitated by dietary gluten. It can be difficult to diagnose because signs and symptoms may be absent, subtle, or not recognized as CD related and therefore not prompt testing within routine clinical practice. Thus, most people with CD are undiagnosed and a public health intervention, which involves screening the general population, is an option to find those with unrecognized CD. However, how these screening-detected individuals experience the diagnosis and treatment (gluten-free diet) is not fully understood. The aim of this study is to investigate the health-related quality of life (HRQoL) of adolescents with screening-detected CD before and one year after diagnosis and treatment.
A prospective nested case-referent study was done involving Swedish adolescents who had participated in a CD screening study when they were in the sixth grade and about 12 years old. Screening-detected adolescents (n = 103) and referents without CD who participated in the same screening (n = 483) answered questionnaires at the time of the screening and approximately one year after the screening-detected adolescents had received their diagnosis that included the EQ-5D instrument used to measure health status and report HRQoL.
The HRQoL for the adolescents with screening-detected CD is similar to the referents, both before and one year after diagnosis and initiation of the gluten-free diet, except in the dimension of pain at follow-up. In the pain dimension at follow-up, fewer cases reported problems than referents (12.6% and 21.9% respectively, Adjusted OR 0.50, 95% CI 0.27-0.94). However, a sex stratified analysis revealed that the significant difference was for boys at follow-up, where fewer screening-detected boys reported problems (4.3%) compared to referent boys (18.8%) (Adjusted OR 0.17, 95% CI 0.04-0.73).
The findings of this study suggest that adolescents with unrecognized CD experience similar HRQoL as their peers without CD, both before and one year after diagnosis and initiation of gluten-free diet, except for boys in the dimension of pain at follow-up.
PMCID: PMC3585471  PMID: 23414483
Adolescents; Celiac disease; EQ-5D; Health-related quality of life; Screening; Screening-detected celiac disease
8.  Has Vietnam Health care funds for the poor policy favored the elderly poor? 
The elderly population is increasing in Vietnam. Access to health services for the elderly is often limited, especially for those in rural areas. User fees at public health care facilities and out-of-pocket payments for health care services are major barriers to access. With the aim of helping the poor access public health care services and reduce health care expenditures (HCE), the Health Care Funds for the Poor policy (HCFP) was implemented in 2002. The aim of this study is to investigate the impacts of this policy on elderly households.
Elderly households were defined as households which have at least one person aged 60 years or older. The impacts of HCFP on elderly household HCE as a percentage of total expenditure and health care utilization were assessed by a double-difference propensity score matching method using panel data of 3,957 elderly households in 2001, 2003, 2005 and 2007, of which 509 were classifies as “treated” (i.e. covered by the policy). Variables included in a logistic regression for estimating the propensity scores to match the treated with the control households, were household and household-head characteristics.
In the first time period (2001–2003) there were no significant differences between treated and controls. This can be explained by the delay in implementing the policy by the local governments. In the second (2001–2005) and third period (2001–2007) the utilizations of Communal Health Stations (CHS) and go-to-pharmacies were significant. The treated were using CHS and pharmacies more between 2001 and 2007 while control households decreased their use.
The main findings suggest HCFP met some goals but not all in the group of households having at least one elderly member. Utilization of CHS and pharmacies increased while the change in HCE as a proportion of total expenditures was not significant. To some extent, private health care and self-treatment are replaced by more utilization of CHS, indicating the poor elderly are better off. However, further efforts are needed to help them access higher levels of public health care (e.g. district health centers and provincial/central hospitals) and to reduce their HCE.
PMCID: PMC3514242  PMID: 22999637
Elderly; Health care funds for the poor; Vietnam
9.  A gluten-free diet effectively reduces symptoms and health care consumption in a Swedish celiac disease population 
BMC Gastroenterology  2012;12:125.
A gluten-free diet is the only available treatment for celiac disease. Our aim was to investigate the effect of a gluten-free diet on celiac disease related symptoms, health care consumption, and the risk of developing associated immune-mediated diseases.
A questionnaire was sent to 1,560 randomly selected members of the Swedish Society for Coeliacs, divided into equal-sized age- and sex strata; 1,031 (66%) responded. Self-reported symptoms, health care consumption (measured by health care visits and hospitalization days), and missed working days were reported both for the year prior to diagnosis (normal diet) and the year prior to receiving the questionnaire while undergoing treatment with a gluten-free diet. Associated immune-mediated diseases (diabetes mellitus type 1, rheumatic disease, thyroid disease, vitiligo, alopecia areata and inflammatory bowel disease) were self-reported including the year of diagnosis.
All investigated symptoms except joint pain improved after diagnosis and initiated gluten-free diet. Both health care consumption and missed working days decreased. Associated immune-mediated diseases were diagnosed equally often before and after celiac disease diagnosis.
Initiated treatment with a gluten-free diet improves the situation for celiac disease patients in terms of reduced symptoms and health care consumption. An earlier celiac disease diagnosis is therefore of great importance.
PMCID: PMC3482575  PMID: 22984893
10.  Can the impact of gender equality on health be measured? a cross-sectional study comparing measures based on register data with individual survey-based data 
BMC Public Health  2012;12:795.
The aim of this study was to investigate potential associations between gender equality at work and self-rated health.
2861 employees in 21 companies were invited to participate in a survey. The mean response rate was 49.2%. The questionnaire contained 65 questions, mainly on gender equality and health. Two logistic regression analyses were conducted to assess associations between (i) self-rated health and a register-based company gender equality index (OGGI), and (ii) self-rated health and self-rated gender equality at work.
Even though no association was found between the OGGI and health, women who rated their company as “completely equal” or “quite equal” had higher odds of reporting “good health” compared to women who perceived their company as “not equal” (OR = 2.8, 95% confidence interval = 1.4 – 5.5 and OR = 2.73, 95% CI = 1.6-4.6). Although not statistically significant, we observed the same trends in men. The results were adjusted for age, highest education level, income, full or part-time employment, and type of company based on the OGGI.
No association was found between gender equality in companies, measured by register-based index (OGGI), and health. However, perceived gender equality at work positively affected women’s self-rated health but not men’s. Further investigations are necessary to determine whether the results are fully credible given the contemporary health patterns and positions in the labour market of women and men or whether the results are driven by selection patterns.
PMCID: PMC3503856  PMID: 22985388
Gender equality; Self-rated health; Companies
11.  Willingness to use and pay for options of care for community-dwelling older people in rural Vietnam 
The proportion of people in Vietnam who are 60 years and over has increased rapidly. The emigration of young people and impact of other socioeconomic changes leave more elderly on their own and with less family support. This study assesses the willingness to use and pay for different models of care for community-dwelling elderly in rural Vietnam.
In 2007, people aged 60 and older and their family representatives, living in 2,240 households, were randomly selected from the FilaBavi Demographic Surveillance Site. They were interviewed using structured questionnaires to assess dependence in activities of daily living (ADLs), willingness to use and to pay for day care centres, mobile care teams, and nursing centres. Respondent socioeconomic characteristics were extracted from the FilaBavi repeated census. Percentages of those willing to use models and the average amount (with 95% confidence intervals) they are willing to pay were estimated. Multivariate analyses were performed to measure the relationship of willingness to use services with ADL index and socioeconomic factors. Four focus group discussions were conducted to explore people's perspectives on the use of services. The first discussion group was with the elderly. The second discussion group was with their household members. Two other discussion groups included community association representatives, one at the communal level and another at the village level.
Use of mobile team care is the most requested service. The fewest respondents intend to use a nursing centre. Households expect to use services for their elderly to a greater extent than do the elderly themselves. Willingness to use services decreases when potential fees increase. The proportion of respondents who require that services be free-of-charge is two to three times higher than the proportion willing to pay full cost. Households are willing to pay more than the elderly for day care and nursing centres. The elderly are more willing to pay for mobile teams than are their households. Age group, sex, literacy, marital status, living arrangement, living area, working status, poverty, household wealth and dependence in ADLs are factors related to willingness to use services.
Community-centric elderly care will be used and partly paid for by individuals if it is provided by the government or associations. Capacity building for health professional networks and informal caregivers is essential for developing formal care models. Additional support is needed for the most vulnerable elderly to access services.
PMCID: PMC3305522  PMID: 22333517
12.  Measuring the value of older people's production: a diary study 
The productive capacity of retired people is usually not valued. However, some retirees produce much more than we might expect. This diary-based study identifies the activities of older people, and suggests some value mechanisms. One question raised is whether it is possible to scale up this diary study into a larger representative study.
Diaries kept for one week were collected among 23 older people in the north of Sweden. The texts were analysed with a grounded theory approach; an interplay between ideas and empirical data.
Some productive activities of older people must be valued as the opportunity cost of time or according to the market value, and others must be valued with the replacement cost. In order to make the choice between these methods, it is important to consider the societal entitlement. When there is no societal entitlement, the first or second method must be used; and when it exists, the third must be used.
An explicit investigation of the content of the entitlement is needed to justify the choice of valuation method for each activity. In a questionnaire addressing older people's production, each question must be adjusted to the type of production. In order to fully understand this production, it is important to consider the degree of free choice to conduct an activity, as well as health-related quality of life.
PMCID: PMC3295658  PMID: 22230745
old; production; entitlement; intergenerational fairness; informal care
13.  Elderly care in daily living in rural Vietnam: Need and its socioeconomic determinants 
BMC Geriatrics  2011;11:81.
The proportion of older people is increasing rapidly in Vietnam. The majority of the elderly live in rural areas. Their health status is generally improving but this is less pronounced among the most vulnerable groups. The movement of young people for employment and the impact of other socioeconomic changes leave more elderly on their own and with less family support. This study aims to assess the daily care needs and their socioeconomic determinants among older people in a rural setting.
In 2007, people aged 60 years and older, living in 2,240 households, were randomly selected from the FilaBavi Demographic Surveillance System (DSS). They were interviewed using structured questionnaires to assess needed support in activities of daily living (ADLs). Individuals were interviewed about the presence of chronic illnesses that had been diagnosed by a physician. Participant socioeconomic characteristics were extracted from the FilaBavi repeat census. The repeat census used a repeat of the same survey methods and questions as the original FilaBavi DSS. Distributions of study participants by socioeconomic group, supports needed, levels of support received, types of caregivers, and the ADL index were described. Multivariate analyses were performed to identify socioeconomic determinants of the ADL index.
The majority of older people do not need of support for each specific ADL item. Dependence in instrumental or intellectual ADLs was more common than for basic ADLs. People who need total help were less common than those who need some help in most ADLs. Over three-fifths of those who need help receive enough support in all ADL dimensions. Children and grandchildren are the main caregivers. Age group, sex, educational level, marital status, household membership, working status, household size, living arrangement, residential area, household wealth, poverty status, and chronic illnesses were determinants of daily care needs in old age.
Although majority of older people who needed help received enough support in daily care, the need of care is more demanded in disadvantaged groups. Future community-based, long-term elderly care should focus on instrumental and intellectual ADLs among the general population of older people, and on basic ADLs among those with chronic illnesses. Socioeconomic determinants of care needs should be addressed in future interventions.
PMCID: PMC3239225  PMID: 22136507
14.  Estimating the cost-effectiveness of lifestyle intervention programmes to prevent diabetes based on an example from Germany: Markov modelling 
Type 2 diabetes mellitus (T2D) poses a large worldwide burden for health care systems. One possible tool to decrease this burden is primary prevention. As it is unethical to wait until perfect data are available to conclude whether T2D primary prevention intervention programmes are cost-effective, we need a model that simulates the effect of prevention initiatives. Thus, the aim of this study is to investigate the long-term cost-effectiveness of lifestyle intervention programmes for the prevention of T2D using a Markov model. As decision makers often face difficulties in applying health economic results, we visualise our results with health economic tools.
We use four-state Markov modelling with a probabilistic cohort analysis to calculate the cost per quality-adjusted life year (QALY) gained. A one-year cycle length and a lifetime time horizon are applied. Best available evidence supplies the model with data on transition probabilities between glycaemic states, mortality risks, utility weights, and disease costs. The costs are calculated from a societal perspective. A 3% discount rate is used for costs and QALYs. Cost-effectiveness acceptability curves are presented to assist decision makers.
The model indicates that diabetes prevention interventions have the potential to be cost-effective, but the outcome reveals a high level of uncertainty. Incremental cost-effectiveness ratios (ICERs) were negative for the intervention, ie, the intervention leads to a cost reduction for men and women aged 30 or 50 years at initiation of the intervention. For men and women aged 70 at initiation of the intervention, the ICER was EUR27,546/QALY gained and EUR19,433/QALY gained, respectively. In all cases, the QALYs gained were low. Cost-effectiveness acceptability curves show that the higher the willingness-to-pay threshold value, the higher the probability that the intervention is cost-effective. Nonetheless, all curves are flat. The threshold value of EUR50,000/QALY gained has a 30-55% probability that the intervention is cost-effective.
Lifestyle interventions for primary prevention of type 2 diabetes are cost-saving for men and women aged 30 or 50 years at the start of the intervention, and cost-effective for men and women aged 70 years. However, there is a high degree of uncertainty around the ICERs. With the conservative approach adopted for this model, the long-term effectiveness of the intervention could be underestimated.
PMCID: PMC3256095  PMID: 22099547
Diabetes mellitus; health care costs; health care economics and organisations; primary prevention; life style; early intervention; decision making
15.  Delay to celiac disease diagnosis and its implications for health-related quality of life 
BMC Gastroenterology  2011;11:118.
To determine how the delay in diagnosing celiac disease (CD) has developed during recent decades and how this affects the burden of disease in terms of health-related quality of life (HRQoL), and also to consider differences with respect to sex and age.
In collaboration with the Swedish Society for Coeliacs, a questionnaire was sent to 1,560 randomly selected members, divided in equal-sized age- and sex strata, and 1,031 (66%) responded. HRQoL was measured with the EQ-5D descriptive system and was then translated to quality-adjusted life year (QALY) scores. A general population survey was used as comparison.
The mean delay to diagnosis from the first symptoms was 9.7 years, and from the first doctor visit it was 5.8 years. The delay has been reduced over time for some age groups, but is still quite long. The mean QALY score during the year prior to initiated treatment was 0.66; it improved after diagnosis and treatment to 0.86, and was then better than that of a general population (0.79).
The delay from first symptoms to CD diagnosis is unacceptably long for many persons. Untreated CD results in poor HRQoL, which improves to the level of the general population if diagnosed and treated. By shortening the diagnostic delay it is possible to reduce this unnecessary burden of disease. Increased awareness of CD as a common health problem is needed, and active case finding should be intensified. Mass screening for CD might be an option in the future.
PMCID: PMC3233515  PMID: 22060243
16.  Gender equality in couples and self-rated health - A survey study evaluating measurements of gender equality and its impact on health 
Men and women have different patterns of health. These differences between the sexes present a challenge to the field of public health. The question why women experience more health problems than men despite their longevity has been discussed extensively, with both social and biological theories being offered as plausible explanations. In this article, we focus on how gender equality in a partnership might be associated with the respondents' perceptions of health.
This study was a cross-sectional survey with 1400 respondents. We measured gender equality using two different measures: 1) a self-reported gender equality index, and 2) a self-perceived gender equality question. The aim of comparison of the self-reported gender equality index with the self-perceived gender equality question was to reveal possible disagreements between the normative discourse on gender equality and daily practice in couple relationships. We then evaluated the association with health, measured as self-rated health (SRH). With SRH dichotomized into 'good' and 'poor', logistic regression was used to assess factors associated with the outcome. For the comparison between the self-reported gender equality index and self-perceived gender equality, kappa statistics were used.
Associations between gender equality and health found in this study vary with the type of gender equality measurement. Overall, we found little agreement between the self-reported gender equality index and self-perceived gender equality. Further, the patterns of agreement between self-perceived and self-reported gender equality were quite different for men and women: men perceived greater gender equality than they reported in the index, while women perceived less gender equality than they reported. The associations to health were depending on gender equality measurement used.
Men and women perceive and report gender equality differently. This means that it is necessary not only to be conscious of the methods and measurements used to quantify men's and women's opinions of gender equality, but also to be aware of the implications for health outcomes.
PMCID: PMC3167759  PMID: 21871087
gender equality; health; index; gender differences
17.  Sickness absence in gender-equal companies A register study at organizational level 
BMC Public Health  2011;11:548.
The differences in sickness absence between men and women in Sweden have attracted a great deal of interest nationally in the media and among policymakers over a long period. The fact that women have much higher levels of sickness absence has been explained in various ways. These explanations are contextual and one of the theories points to the lack of gender equality as an explanation. In this study, we evaluate the impact of gender equality on health at organizational level. Gender equality is measured by an index ranking companies at organizational level; health is measured as days on sickness benefit.
Gender equality was measured using the Organizational Gender Gap Index or OGGI, which is constructed on the basis of six variables accessible in Swedish official registers. Each variable corresponds to a key word illustrating the interim objectives of the "National Plan for Gender Equality", implemented by the Swedish Parliament in 2006. Health is measured by a variable, days on sickness benefit, also accessible in the same registers.
We found significant associations between company gender equality and days on sickness benefit. In gender-equal companies, the risk for days on sickness benefit was 1.7 (95% CI 1.6-1.8) higher than in gender-unequal companies. The differences were greater for men than for women: OR 1.8 (95% CI 1.7-2.0) compared to OR 1.4 (95% CI 1.3-1.5).
Even though employees at gender-equal companies had more days on sickness benefit, the differences between men and women in this measure were smaller in gender-equal companies. Gender equality appears to alter health patterns, converging the differences between men and women.
PMCID: PMC3155915  PMID: 21745375
18.  The Incremental Cost-Effectiveness of Engaging Private Practitioners to Refer Tuberculosis Suspects to DOTS Services in Jogjakarta, Indonesia 
We aimed to evaluate the incremental cost-effectiveness of engaging private practitioners (PPs) to refer tuberculosis (TB) suspects to public health centers in Jogjakarta, Indonesia. Effectiveness was assessed for TB suspects notified between May 2004 and April 2005. Private practitioners referred 1,064 TB suspects, of which 57.5% failed to reach a health center. The smear-positive rate among patients reaching a health center was 61.8%. Two hundred eighty (280) out of a total of 1,306 (21.4%) new smear-positive cases were enrolled through the PPs strategy. The incremental cost-effectiveness ratio per smear-positive case successfully treated for the PPs strategy was US$351.66 (95% CI 322.84–601.33). On the basis of an acceptability curve using the National TB control program's willingness-to-pay threshold (US$448.61), we estimate the probability that the PPs strategy is cost-effective at 66.8%. The strategy of engaging PPs was incrementally cost-effective, although under specific conditions, most importantly a well-functioning public directly observed treatment, short-course (DOTS) program.
PMCID: PMC2877424  PMID: 20519613
19.  Health-related quality of life, and its determinants, among older people in rural Vietnam 
BMC Public Health  2010;10:549.
The proportion of people in Vietnam aged 60 and above has increased rapidly in recent decades. However, there is a lack of evidence, particularly in rural settings, on their health-related quality of life (HRQoL) within the context of socioeconomic changes and health-sector reform in the country. This study assesses the level and determinants of HRQoL in a rural district in order to provide evidence for designing and implementing appropriate health policies.
In 2007, 2,873 people aged 60+ living in 2,240 households randomly selected from the FilaBavi demographic surveillance site (DSS) were interviewed using a generic EQ-5D questionnaire to assess their HRQoL. Socioeconomic characteristics of the people and their households were extracted from the DSS's re-census that year, and the EQ-5D index was calculated based on the time trade-off tariff. Multilevel-multivariate linear regression analysis was performed to measure the affect of socioeconomic factors on HRQoL.
The EQ-5D index at old age was found to be 0.876 (95%CI: 0.870-0.882). Age between 60-69 or 70-79 years, position as household head, working until old age, literacy, and belonging to better wealth quintiles are determinants of higher HRQoL. Ageing has a primary influence on the deterioration of HRQoL at older ages, mainly due to reduction in physical rather than mental functions. Educational disparity in HRQoL is low, and exists mostly between basic and higher levels of education. Being a household head and working at old age are advantageous for attaining better quality of life in physical rather than psychological terms. Economic conditions affect HRQoL through sensory rather than physical utilities. Long-term living conditions more likely affect HRQoL than short-term economic conditions.
HRQoL at old age is at a high level, and varies substantially according to socioeconomic factors. Its determinants should be addressed in social and health policies designed to improve health of older people, especially among the most vulnerable groups.
PMCID: PMC2944376  PMID: 20831822
20.  Measuring the time costs of exercise: a proposed measuring method and a pilot study 
The cost of time spent on exercise is an important factor in societal-perspective health economic analyses of interventions aimed at promoting physical activity. However, there are no existing measuring methods for estimating time costs. The aim of this article is to describe a way to measure the costs of time spent on physical activity. We propose a model for measuring these time costs, and present the results of a pilot study applying this model to different groups of exercisers.
We began this investigation by developing a model for measuring the time spent on exercise, based on the most important theoretical frameworks for valuing time. In the model, the value of utility in anticipation (expected health benefits) of performing exercise is expressed in terms of health-related quality of life. With this approach, the cost of the time spent on exercise is defined as the value of utility in use of leisure activity forgone minus the value of utility in use of exercise. Utility in use for exercise is valued in comparison with utility in use for leisure activity forgone and utility in use for work.
To put the model into practice, we developed a questionnaire with the aim of investigating the valuations made by exercisers, and applied this questionnaire among more experienced and less experienced exercisers.
Less experienced exercisers valued the time spent on exercise as being equal to 26% of net wages, while more experienced exercisers valued this time at 7% of net wages (p < 0.001). The higher time costs seen among the less experienced exercisers correlated to a less positive experience of exercise and a more positive experience of the lost leisure activity. There was a significant inverse correlation between the costs of time spent on exercise, and the frequency and duration of regular exercise.
The time spent on exercise is an important factor in interventions aimed at promoting physical activity, and should be taken into consideration in cost-effectiveness analyses. The proposed model for measuring the costs of the time spent on exercise seems to be a better method than the previously-used assumptions of time costs.
PMCID: PMC2875204  PMID: 20459761
21.  Missed opportunity for standardized diagnosis and treatment among adult Tuberculosis patients in hospitals involved in Public-Private Mix for Directly Observed Treatment Short-Course strategy in Indonesia: a cross-sectional study 
The engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment Short-Course (DOTS) strategy has increased rapidly internationally - including in Indonesia. In view of the rapid global scaling-up of hospital engagement, we aimed to estimate the proportion of outpatient adult Tuberculosis patients who received standardized diagnosis and treatment at outpatients units of hospitals involved in the PPM-DOTS strategy.
A cross-sectional study using morbidity reports for outpatients, laboratory registers and Tuberculosis patient registers from 1 January 2005 to 31 December 2005. By quota sampling, 62 hospitals were selected. Post-stratification analysis was conducted to estimate the proportion of Tuberculosis cases receiving standardized management according to the DOTS strategy.
Nineteen to 53% of Tuberculosis cases and 4-18% of sputum smear positive Tuberculosis cases in hospitals that participated in the PPM-DOTS strategy were not treated with standardized diagnosis and treatment as in DOTS.
This study found that a substantial proportion of TB patients cared for at PPM-DOTS hospitals are not managed under the DOTS strategy. This represents a missed opportunity for standardized diagnoses and treatment. A combination of strong individual commitment of health professionals, organizational supports, leadership, and relevant policy in hospital and National Tuberculosis Programme may be required to strengthen DOTS implementation in hospitals.
PMCID: PMC2881058  PMID: 20459665
22.  Remaining life expectancy among older people in a rural area of Vietnam: trends and socioeconomic inequalities during a period of multiple transitions 
BMC Public Health  2009;9:471.
Better understanding of the trends and disparities in health at old age in terms of life expectancy will help to provide appropriate responses to the growing needs of health and social care for the older population in the context of limited resources. As a result of rapid economic, demographic and epidemiological changes, the number of people aged 60 and over in Vietnam is increasing rapidly, from 6.7% in 1979 to 9.2% in 2006. Life expectancy at birth has increased but not much are known about changes in old ages. This study assesses the trends and socioeconomic inequalities in RLE at age 60 in a rural area in an effort to highlight this vulnerable group and to anticipate their future health and social needs.
An abridged life table adjusted for small area data was used to estimate cohort life expectancies at old age and the corresponding 95% confidence intervals from longitudinal data collected by FilaBavi DSS during 1999-2006, which covered 7,668 people at age 60+ with 43,272 person-years, out of a total of 64,053 people with 388,278 person-years. Differences in life expectancy were examined according to socioeconomic factors, including socio-demographic characteristics, wealth, poverty and living arrangements.
Life expectancies at age 60 have increased by approximately one year from the period 1999-2002 to 2003-2006. The increases are observed in both sexes, but are significant among females and relate to improvements among those who belong to the middle and upper household wealth quintiles. However, life expectancy tends to decrease in the most vulnerable groups. There is a wide gap in life expectancy according to poverty status and living arrangements, and the gap by poverty status has widened over the study period. The gender gap in life expectancy is consistent across all socioeconomic groups and tends to be wider amongst the more disadvantaged population.
There is a trend of increasing life expectancy among older people in rural areas of Vietnam. Inequalities in life expectancy exist between socioeconomic groups, especially between different poverty levels and also patterns of living arrangements. These inequalities should be addressed by appropriate social and health policies with stronger targeting of the poorest and most disadvantaged groups.
PMCID: PMC2803493  PMID: 20017933
23.  Parental share in public and domestic spheres: a population study on gender equality, death, and sickness 
Study objective
Examine the relation between aspects of gender equality and population health based on the premise that sex differences in health are mainly caused by the gender system.
All Swedish couples (98 240 people) who had their first child together in 1978.
The exposure of gender equality is shown by the parents' division of income and occupational position (public sphere), and parental leave and temporary child care (domestic sphere). People were classified by these indicators during 1978–1980 into different categories; those on an equal footing with their partner and those who were traditionally or untraditionally unequal. Health is measured by the outcomes of death during 1981–2001 and sickness absence during 1986–2000. Data are obtained by linking individual information from various national sources. The statistical method used is multiple logistic regressions with odds ratios as estimates of relative risks.
Main results
From the public sphere is shown that traditionally unequal women have decreased health risks compared with equal women, while traditionally unequal men tend to have increased health risks compared with equal men. From the domestic sphere is indicated that both women and men run higher risks of death and sickness when being traditionally unequal compared with equal.
Understanding the relation between gender equality and health, which was found to depend on sex, life sphere, and inequality type, seems to require a combination of the hypotheses of convergence, stress and expansion.
PMCID: PMC2566239  PMID: 16790834
death; gender equality; parenthood; sickness
24.  A cost-utility analysis of nursing intervention via telephone follow-up for injured road users 
Traffic injuries can cause physical, psychological, and economical impairment, and affected individuals may also experience shortcomings in their post-accident care and treatment. In an earlier randomised controlled study of nursing intervention via telephone follow-up, self-ratings of health-related quality of life were generally higher in the intervention group than in the control group.
To evaluate the cost-effectiveness of nursing intervention via telephone follow-up by examining costs and quality-adjusted life years (QALYs).
A randomised controlled study was conducted between April 2003 and April 2005. Car occupants, cyclists, and pedestrians aged between 18 and 70 years and attending the Emergency Department of Umeå University Hospital in Sweden after an injury event in the traffic environment were randomly assigned to an intervention (n = 288) or control group (n = 280). The intervention group received routine care supplemented by nursing via telephone follow-up during half a year, while the control group received routine care only. Data were collected from a mail survey using the non-disease-specific health-related quality of life instrument EQ5D, and a cost-effectiveness analysis was performed including the costs of the intervention and the QALYs gained.
Overall, the intervention group gained 2.60 QALYs (260 individuals with an average gain of 0.01 QALYs). The car occupants gained 1.54 QALYs (76 individuals, average of 0.02). Thus, the cost per QALY gained was 16 000 Swedish Crown (SEK) overall and 8 500 SEK for car occupants.
Nursing intervention by telephone follow-up after an injury event, is a cost effective method giving improved QALY to a very low cost, especially for those with minor injuries.
Trial registration
This trial registration number is: ISRCTN11746866.
PMCID: PMC2705356  PMID: 19515265
25.  People's willingness to pay for health insurance in rural Vietnam 
The inequity caused by health financing in Vietnam, which mainly relies on out-of-pocket payments, has put pre-payment reform high on the political agenda. This paper reports on a study of the willingness to pay for health insurance among a rural population in northern Vietnam, exploring whether the Vietnamese are willing to pay enough to sufficiently finance a health insurance system.
Using the Epidemiological Field Laboratory for Health Systems Research in the Bavi district (FilaBavi), 2070 households were randomly selected for the study. Existing FilaBavi interviewers were trained especially for this study. The interview questionnaire was developed through a pilot study followed by focus group discussions among interviewers. Determinants of households' willingness to pay were studied through interval regression by which problems such as zero answers, skewness, outliers and the heaping effect may be solved.
Households' average willingness to pay (WTP) is higher than their costs for public health care and self-treatment. For 70–80% of the respondents, average WTP is also sufficient to pay the lower range of premiums in existing health insurance programmes. However, the average WTP would only be sufficient to finance about half of total household public, as well as private, health care costs. Variables that reflect income, health care need, age and educational level were significant determinants of households' willingness to pay. Contrary to expectations, age was negatively related to willingness to pay.
Since WTP is sufficient to cover household costs for public health care, it depends to what extent households would substitute private for public care and increase utilization as to whether WTP would also be sufficient enough to finance health insurance. This study highlights potential for public information schemes that may change the negative attitude towards health insurance, which this study has uncovered. A key task for policy makers is to win the trust of the population in relation to a health insurance system, particularly among the old and those with relatively low education.
PMCID: PMC2527552  PMID: 18691440

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