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Many multilevel logistic regression analyses of \"neighbourhood and health\" focus on interpreting measures of associations (e.g., odds ratio, OR). In contrast, multilevel analysis of variance is rarely considered. We propose an original stepwise analytical approach that distinguishes between \"specific\" (measures of association) and \"general\" (measures of variance) contextual effects. Performing two empirical examples we illustrate the methodology, interpret the results and discuss the implications of this kind of analysis in public health. We analyse 43,291 individuals residing in 218 neighbourhoods in the city of Malmö, Sweden in 2006. We study two individual outcomes (psychotropic drug use and choice of private vs. public general practitioner, GP) for which the relative importance of neighbourhood as a source of individual variation differs substantially. In Step 1 of the analysis, we evaluate the OR and the area under the receiver operating characteristic (AUC) curve for individual-level covariates (i.e., age, sex and individual low income). In Step 2, we assess general contextual effects using the AUC. Finally, in Step 3 the OR for a specific neighbourhood characteristic (i.e., neighbourhood income) is interpreted jointly with the proportional change in variance (i.e., PCV) and the proportion of ORs in the opposite direction (POOR) statistics. For both outcomes, information on individual characteristics (Step 1) provide a low discriminatory accuracy (AUC = 0.616 for psychotropic drugs; = 0.600 for choosing a private GP). Accounting for neighbourhood of residence (Step 2) only improved the AUC for choosing a private GP (+0.295 units). High neighbourhood income (Step 3) was strongly associated to choosing a private GP (OR = 3.50) but the PCV was only 11% and the POOR 33%. Applying an innovative stepwise multilevel analysis, we observed that, in Malmö, the neighbourhood context per se had a negligible influence on individual use of psychotropic drugs, but appears to strongly condition individual choice of a private GP. However, the latter was only modestly explained by the socioeconomic circumstances of the neighbourhoods. Our analyses are based on real data and provide useful information for understanding neighbourhood level influences in general and on individual use of psychotropic drugs and choice of GP in particular. However, our primary aim is to illustrate how to perform and interpret a multilevel analysis of individual heterogeneity in social epidemiology and public health. Our study shows that neighbourhood \"effects\" are not properly quantified by reporting differences between neighbourhood averages but rather by measuring the share of the individual heterogeneity that exists at the neighbourhood level.

The burden of depression and anxiety disorders is greater in women, and female sex hormones have been shown to affect mood. Psychological side effects of hormonal contraception (HC) are also a common complaint in the clinic, but few previous studies have investigated this subject. We therefore wanted to investigate whether use of HC was associated with adverse psychological health outcomes, and whether this association was modified by age. All women aged 12-30 years on 31 December 2010, residing in Sweden for at least four years and with no previous psychiatric morbidity (n = 815 662), were included. We followed the women from their first HC use (or 31 December 2010, if they were non-users) at baseline, until a prescription fill of psychotropic drugs or the end of the one-year follow-up. We performed age-stratified logistic regression models and estimated odds ratios (OR) to measure the association between different HC methods and psychotropic drug use, as well as the area under the receiver operating curve to estimate discriminatory accuracy of HC in relation to psychotropic drugs. Overall, we found an association between HC and psychotropic drugs (adjusted OR 1.34, 95% confidence interval [CI] 1.30-1.37). In the age-stratified analysis, the strongest association was found in adolescent girls (adjusted OR 3.46, 95% CI 3.04-4.94 for age 12 to 14 years), while it was non-existent for adult women. We conclude that hormonal contraception is associated with psychotropic drug use among adolescent girls, suggesting an adverse effect of HC on psychological health in this population.

We aimed to investigate the association between psychotropic drug use (proxy for psychological health) and Complex Regional Pain Syndrome (CRPS) type 1 and type 2 in upper and lower limbs. We also assessed the impact of demographic and socioeconomic factors. From a national record linkage database [4,706,821 individuals (25–64 years); CRPS type 1 = 809; type 2 = 225], prevalence ratios (PR), absolute risk (AR), and AR difference (ARD) [95% confidence intervals (CI)] were estimated by logistic and Cox regressions with constant time at risk. About 36% of CRPS individuals consumed psychotropic drugs (reference: general population 15%). Unadjusted PRs were two times higher in nerve injuries/disorders without CRPS [PR = 1.78; 95% CI: 1.73–1.82] and CRPS type 1 [2.33 (2.07–2.62)] and almost three times higher in CRPS type 2 [2.79 (2.27–3.42)]. Higher ARDs were observed in type 2, independent of level of income, and were higher for the high-income category. In type 2, ARDs were higher for middle-high/high occupational status levels. Higher ARDs were observed in nerve injuries/nerve disorders, CRPS type 1, and type 2 in immigrants, especially high for type 2. Regarding most age intervals, ARDs were higher for individuals with CRPS type 2. Individuals with CRPS, especially type 2, have high risk of impaired psychological health.

The high prevalence of intimate partner violence against women (IPVAW) in countries with high levels of gender equality has been defined as the \"Nordic paradox\". In this study we compared physical and sexual IPVAW prevalence data in two countries exemplifying the Nordic paradox: Sweden (N = 1483) and Spain (N = 1447). Data was drawn from the European Union Agency for Fundamental Rights Survey on violence against women. To ascertain whether differences between these two countries reflect true differences in IPVAW prevalence, and to rule out the possibility of measurement bias, we conducted a set of analyses to ensure measurement equivalence, a precondition for appropriate and valid cross-cultural comparisons. Results showed that in both countries items were measuring two separate constructs, physical and sexual IPVAW, and that these factors had high internal consistency and adequate validity. Measurement equivalence analyses (i.e., differential item functioning, and multigroup confirmatory factor analysis) supported the comparability of data across countries. Latent means comparisons between the Spanish and the Swedish samples showed that scores on both the physical and sexual IPVAW factors were significantly higher in Sweden than in Spain. The effect sizes of these differences were large: 89.1% of the Swedish sample had higher values in the physical IPVAW factor than the Spanish average, and this percentage was 99.4% for the sexual IPVAW factor as compared to the Spanish average. In terms of probability of superiority, there was an 80.7% and 96.1% probability that a Swedish woman would score higher than a Spanish woman in the physical and the sexual IPVAW factors, respectively. Our results showed that the higher prevalence of physical and sexual IPVAW in Sweden than in Spain reflects actual differences and are not the result of measurement bias, supporting the idea of the Nordic paradox.

In light of the opioid epidemic in the United States, there is growing concern about the use of opioids in Sweden as it may lead to misuse and overuse and, in turn, severe public health problems. However, little is known about the distribution of opioid use across different demographic and socioeconomic dimensions in the Swedish general population. Therefore, we applied an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA), to obtain an improved mapping of the risk heterogeneity of and socioeconomic inequalities in opioid prescription receipt. Using data from 6,846,106 residents in Sweden aged 18 and above, we constructed 72 intersectional strata from combinations of gender, age, income, cohabitation status, and presence or absence of psychological distress. We modelled the absolute risk (AR) of opioid prescription receipt in a series of multilevel logistic regression models distinguishing between additive and interaction effects. By means of the Variance Partitioning Coefficient (VPC) and the area under the receiver operating characteristic curve (AUC), we quantified the discriminatory accuracy (DA) of the intersectional strata for discerning those who received opioid prescriptions from those who did not. The AR of opioid prescription receipt ranged from 2.77% (95% CI 2.69-2.86) among low-income men aged 18-34, living alone, without psychological distress, to 28.25% (95% CI 27.95-28.56) among medium-income women aged 65 and older, living alone, with psychological distress. In a model that conflated both additive and interaction effects, the intersectional strata had a fair DA for discerning opioid users from non-users (VPC = 13.2%, AUC = 0.68). However, in the model that decomposed total effects into additive and interaction effects, the VPC was very low (0.42%) indicating the existence of small interaction effects for a number of the intersectional strata. The intersectional MAIHDA approach aligns with the aims of precision public health, through improving the evidence base for health policy by increasing understanding of both health inequalities and individual heterogeneity. This approach is particularly relevant for socioeconomically conditioned outcomes such as opioid prescription receipt. We have identified intersections of social position within the Swedish population at greater risk for opioid prescription receipt.

Background Intersectionality theory combined with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can facilitate our understanding of health disparities. This enables the application of proportionate universalism for resource allocation in public health. Analyzing self-rated health (SRH) in Sweden, we show how an intersectional perspective allows for a detailed mapping of health inequalities while avoiding simplification and stigmatization based on indiscriminate interpretations of differences between group averages. Methods We analyzed participants ( n =133,244) in 14 consecutive National Public Health Surveys conducted in Sweden in 2004–2016 and 2018. Applying AIHDA, we investigated the risk of bad SRH across 12 intersectional strata defined by gender, income and migration status, adjusted by age and survey year. We calculated odds ratios (with 95% confidence intervals) to evaluate between-strata differences, using native-born men with high income as the comparison reference. We calculated the area under the receiver operating characteristic curve (AU-ROC) to evaluate the discriminatory accuracy of the intersectional strata for identifying individuals according to their SRH status. Results The analysis of intersectional strata showed clear average differences in the risk of bad SRH. For instance, the risk was seven times higher for immigrated women with low income (OR 7.00 [95% CI 6.14–7.97]) than for native men with high income. However, the discriminatory accuracy of the intersectional strata was small (AU-ROC=0.67). Conclusions The intersectional AIHDA approach provides more precise information on the existence (or the absence) of health inequalities, and can guide public health interventions according to the principle of proportionate universalism. The low discriminatory accuracy of the intersectional strata found in this study warrants universal interventions rather than interventions exclusively focused on strata with a higher average risk of bad SRH.

Knowledge about risks for overuse of psychoactive analgesics in patients having primary surgery for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, is limited. We investigated if patients with those nerve entrapment disorders have a higher risk of overuse of psychoactive analgesics (i.e., opioids and gabapentinoid drugs) before, after, and both before and after surgery than observed in the general population after accounting for demographical and socioeconomic factors. Using a large record linkage database, we analysed 5,966,444 individuals (25–80 years), residing in Sweden December 31st, 2010–2014, of which 31,380 underwent surgery 2011–2013 for CTS, UNE, or both, applying logistic regression to estimate relative risk (RR) and 95% confidence interval (CI). Overall, overuse of the psychoactive analgesics was low in the general population. Compared to those individuals, unadjusted RR (95% CI) of overuse ranged in patients between 2.77 (2.57–3.00) with CTS after surgery and 6.21 (4.27–9.02) with both UNE and CTS after surgery. These risks were only slightly reduced after adjustment for demographical and socioeconomic factors. Patients undergoing surgery for CTS, UNE, or both, have a high risk of overuse of psychoactive analgesics before, after, and both before and after surgery.

We aimed (i) to gain a better understanding of the demographic and socioeconomical distribution of ADHD risk in Sweden; and (ii) to contribute to the critical discussion on medicalization, i.e., the tendency to define and treat behavioural and social problems as medical entities. For this purpose, we analysed the risk of suffering from ADHD in the whole Swedish population aged between 5 and 60 years, across 96 different strata defined by combining categories of gender, age, income, and country of birth. The stratified analysis evidenced considerable risk heterogeneity, with prevalence values ranging from 0.03% in high income immigrant women aged 50–59, to 6.18% in middle income immigrant boys aged 10–14. Our study questions the established idea that behavioural difficulties conceptualized as ADHD should be primarily perceived as a neurological abnormality. Rather, our findings suggest that there is a strong sociological component behind how some individuals become impaired and subject to medicalization.

Background Monitoring of healthcare quality is typically focused on differences between group averages in relation to a desirable benchmark. However, we need to consider ( i ) the existence of interconnected socioeconomic axes of inequality like age, sex, income, and country of birth and ( ii ) individual heterogeneity around group averages. Additionally, ( iii ) we need clear criteria to quantify group differences. By applying the framework analysis of individual heterogeneity and discriminatory accuracy (AIHDA) on an established quality indicator (potentially inappropriate medication (PIM)), we illustrate how to achieve these improvements and how to avoid both unnecessary group stigmatization and false expectations. Methods We analyzed 731,339 individuals, ≥  75-year-old belonging to 36 socioeconomic strata defined by the intersection of age, sex, income, and country of birth, who were alive and residing in the 21 regions Swedish during 2011. We calculated PIM prevalences and evaluate the discriminatory accuracy (DA) of the socioeconomic and geographical group differences using the area under the ROC curve (AUC). The benchmark value was defined as a prevalence of 19%. Results In Sweden, the prevalence of PIM was 24% among ≥  75-year-olds and regionally it ranged between 21% and 27%. Immigrant 80–84-year-old women with low income had the highest prevalence (29%). All strata including women had higher prevalence than those including men. However, the regional (AUC = 0.520) and socioeconomic (AUC = 0.544) differences were very small. For instance, in the five socioeconomic strata with the lowest prevalence there were about 8,000 more cases of PIM than in the five strata with the highest prevalence of PIM. Conclusion The prevalence of PIM was higher than the desired benchmark value. There were disparities between group averages, but overall, the regional and socioeconomic differences were very small as informed by their low AUC values. Therefore, interventions to reduce PIM in Sweden should be universal rather than only targeted at the regions and socioeconomic strata with the highest PIM prevalence.

Maternal smoking during pregnancy (SDP) seems associated with reduced birthweight in the offspring. This observation, however, is based on conventional epidemiological analyses, and it might be confounded by unobserved maternal characteristics related to both smoking habits and offspring birth weight. Therefore, we apply a quasi-experimental sibling analysis to revisit previous findings. Using the Swedish Medical Birth Register, we identified 677,922 singletons born between 2002 and 2010 from native Swedish mothers. From this population, we isolated 62,941 siblings from 28,768 mothers with discrepant habits of SDP. We applied conventional and mother-specific multilevel linear regression models to investigate the association between maternal SDP and offspring birthweight. Depending on the mother was light or heavy smoker and the timing of exposition during pregnancy (i.e., first or third trimester), the effect of smoking on birthweight reduction was between 6 and 78 g less marked in the sibling analysis than in the conventional analysis. Sibling analysis showed that continuous smoking reduces birthweight by 162 grams for mothers who were light smokers (1 to 9 cigarettes per day) and 226 g on average for those who were heavy smokers throughout the pregnancy in comparison to non-smoker mothers. Quitting smoking during pregnancy partly counteracted the smoking-related birthweight reduction by 1 to 29 g, and a subsequent smoking relapse during pregnancy reduced birthweight by 77 to 83 g. The sibling analysis provides strong evidence that maternal SDP reduces offspring birthweight, though this reduction was not as great as that observed in the conventional analysis. Our findings support public health interventions aimed to prevent SDP and to persuade those who already smoke to quit and not relapse throughout the pregnancy. Besides, further analyses are needed in order to explain the mechanisms through which smoking reduces birthweight and to identify other maternal characteristics that are common causes of both birthweight reduction and maternal smoking.