Questioning the discriminatory accuracy of broad migrant categories in public health: self-rated health in Sweden

Intersectional inequities in colorectal cancer screening attendance in Sweden: Using decision trees for intersectional matrix reduction

Colorectal cancer (CRC) represents a significant health burden worldwide, with existing inequities in incidence and mortality. In Sweden, CRC screening programmes have varied regionally since the mid-2000s, but the significance of organised screening for counteracting complex inequities in screening attendance has not been investigated. This study aimed to assess patterns of inequities in lifetime CRC screening attendance in the Swedish population aged 60-69 years by identifying intersectional strata at higher risk of never attending CRC screening. The research question is answered using decision trees to reduce the complexity of a full intersectional matrix into a reduced intersectional matrix for risk estimation. Participants were drawn from the cross-sectional 2019 European Health Interview Survey (N = 9,757, response rate: 32.52%). The Conditional Inference Tree (CIT) (AUC = 0.7489, F-score = 0.7912, depth = 4, significance level = 0.05) identified region of residence (opportunistic vs organised screening), country of origin, gender, age and income as relevant variables in explaining lifetime CRC screening attendance in Sweden. Then, Poisson regression with robust standard errors estimated that EU-born women living in opportunistic screening regions belonging to the 2nd income quintile had the highest risk of never attending CRC screening (PR = 8.54, p < 0.001), followed by EU-born men living in opportunistic screening regions (PR = 7.41, p < 0.001) compared to the reference category (i.e. people aged 65-69 living in organised screening regions). In contrast, only age-related differences in attendance were found in regions with organised screening (i.e. people aged 60-64 living in regions with organised screening (PR = 2.01, p < 0.05)). The AUC of the reduced intersectional matrix model (0.7489) was higher than the full intersectional matrix model (0.6959) and slightly higher than the main effects model (0.7483), demonstrating intersectional effects of the reduced intersectional matrix compared with the main effects model and better discriminatory accuracy than the full intersectional matrix. In conclusion, regions with long-established organised CRC screening programmes display more limited socio-demographic inequities than regions with opportunistic CRC screening. This suggests that organised screening may be a crucial policy instrument to improve equity in CRC screening, which, in the long run, has the potential to prevent inequities in colorectal cancer mortality. Moreover, decision trees appear to be valuable statistical tools for efficient data-driven simplification of the analytical and empirical complexity that epidemiological intersectional analysis conventionally entails.

Perceived discrimination and refraining from seeking physician's care in Sweden: an intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA)

BACKGROUND

Discrimination may further impede access to medical care for individuals in socially disadvantaged positions. Sociodemographic information and perceived discrimination intersect and define multiple contexts or strata that condition the risk of refraining from seeking physician's care. By applying analysis of individual heterogeneity and discriminatory accuracy (AIHDA) we aimed to improve the mapping of risk by considering both strata average risk differences and the accuracy of such strata risks for distinguishing between individuals who did or did not refrain from seeking physician's care.

METHODS

We analysed nine annual National Public Health Surveys (2004, 2007-2014) in Sweden including 73,815 participants. We investigated the risk of refraining from seeking physician's care across 64 intersectional strata defined by sex, education, age, country of birth, and perceived discrimination. We calculated strata-specific prevalences and prevalence ratios (PR) with 95% confidence intervals (CI), and the area under the receiver operating characteristic curve (AUC) to evaluate the discriminatory accuracy (DA).

RESULTS

Discriminated foreign-born women aged 35-49 with a low educational level show a six times higher risk (PR = 6.07, 95% CI 5.05-7.30) than non-discriminated native men with a high educational level aged 35-49. However, the DA of the intersectional strata was small (AUC = 0.64). Overall, discrimination increased the absolute risk of refraining from seeking physician's care, over and above age, sex, and educational level.

CONCLUSIONS

AIHDA disclosed complex intersectional inequalities in the average risk of refraining from seeking physician's care. This risk was rather high in some strata, which is relevant from an individual perspective. However, from a population perspective, the low DA of the intersectional strata suggests that potential interventions to reduce such inequalities should be universal but tailored to the specific contextual characteristics of the strata. Discrimination impairs access to healthcare.

Geographical and sociodemographic differences in statin dispensation after acute myocardial infarction in Sweden: a register-based prospective cohort study applying analysis of individual heterogeneity and discriminatory accuracy (AIHDA) for basic comparisons of healthcare quality

BACKGROUND

In Sweden, as in many other countries, official monitoring of healthcare quality is mostly focused on geographical disparities in relation to a desirable benchmark. However, current evaluations could be improved by considering: (1) The intersection of other relevant axes of inequity like age, sex, income and migration status; and (2) The existence of individual heterogeneity around averages. Therefore, using an established quality indicator (ie, dispensation of statins after acute myocardial infarction, AMI), we valuate both geographical and sociodemographic inequalities and illustrate how the analysis of individual heterogeneity and discriminatory accuracy (AIHDA) enhances such evaluations.

POPULATION AND METHODS

We applied AIHDA and calculated the area under the receiver operating characteristics curve (AUC) of regional and sociodemographic differences in the statin dispensations of 35 044 patients from 21 Swedish regions and 24 sociodemographic strata who were discharged from the hospital with an AMI diagnosis between January 2011 and December 2013. Following the Swedish National Board of Health and Welfare, we used a benchmark value of 90%.

RESULTS

Dispensation of stains after AMI in Sweden did not reach the desired target of 90%. Regional differences were absent/very small (AUC=0.537) while sociodemographic differences were small (AUC=0.618). Women, especially those with immigrant background and older than 65 years, have the lowest proportions of statin dispensations after AMI.

CONCLUSIONS

As the AUC statistics are small, interventions trying to achieve the benchmark value should be universal. However, special emphasis should nevertheless be directed towards women, especially older women with immigrant backgrounds.

Mapping sociodemographic and geographical differences in human papillomavirus non-vaccination among young girls in Sweden

AIMS

Human papillomavirus (HPV) vaccination plays a key role in the prevention of cervical cancer. Yet, disparities in HPV vaccination in Sweden have persisted. Previous research on such disparities has typically focused on singular sociodemographic variables and measures of average risk. Using a multi-categorical approach and drawing on intersectionality theory, this study aimed to provide a more precise mapping of HPV non-vaccination among girls in different sociodemographic groups and geographical areas in Sweden during 2013-2020.

METHODS

Using nationwide register data, we conducted a multi-categorical analysis of individual heterogeneity and discriminatory accuracy complemented by a multilevel geographical analysis. We mapped HPV non-vaccination prevalence across 54 strata defined by parental income, education and country of birth, and urban versus rural place of residence. We also disentangled municipal and regional influences on HPV non-vaccination.

RESULTS

HPV non-vaccination was more common in groups with a low income, a low education and an immigration background, whereas among those with an immigration background, the association between income, education and HPV non-vaccination was more complex. Geographical differences were found between municipalities. However, the discriminatory accuracy of the sociodemographic and geographical groups was weak, and 50% of the non-vaccination cases were observed in eight strata, of which some are among those with low risk.

CONCLUSIONS

Our findings underscore the importance of universal yet tailored approaches, including providing adequate information about HPV vaccination in Swedish and other languages, and of health-care professionals displaying sensitivity to patients' and parents' questions or needs.

An intersectional analysis providing more precise information on inequities in self-rated health

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.

Precision public health: Mapping socioeconomic disparities in opioid dispensations at Swedish pharmacies by Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA)

BACKGROUND

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.

METHODS AND FINDINGS

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.

CONCLUSIONS

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.

[Migration and health in Germany-available data sources]

BACKGROUND

Migration background plays an important role in analyses of health inequalities in Germany. The heterogeneity of people with and without migration background requires a differentiated recording of migration-related characteristics. The latest overview of representative data sources from the Health Reporting (GBE) that included information on migration background was compiled in 2008.

AIM

The aim of this article is to describe existing data sources reporting the health situation of people with and without a migration background.

MATERIALS AND METHODS

Starting from the websites and publications of owners of GBE data, representative studies and routine data sources were identified. All sources that consider at least one migration-related characteristic were included. For all included studies, migration-related characteristics, information on the social situation, and health-related indicators were collected.

RESULTS

A total of 46 data sources (including 19 routine data sources and 27 studies) were included. The most common indicators of the migration background are nationality (n = 36) and the country of birth (n = 29). Health-related indicators cover a wide range of issues.

DISCUSSION

Routine data sources continue to collect little information on the migration background (usually only nationality) and thus constrain migration-differentiated analyses of the health situation. Survey data allow for more nuanced analysis. However, the actual analysis possibilities and content knowledge of the respective data sources were not the subject of this article.

Are 'low socioeconomic status' and 'religiousness' barriers to minority women's use of contraception? A qualitative exploration and critique of a common argument in reproductive health research

OBJECTIVE

'Low socioeconomic status' and 'religiousness' appear to have gained status as nearly universal explanatory models for why women in minority groups are less likely to use contraception than other women in the Scandinavian countries. Through interviews with pious Muslim women with immigrant background, living in Denmark and Sweden, we wanted to gain empirical insights that could inform a discussion about what 'low socioeconomic status' and 'religiousness' might mean with regard to women's reproductive decisions.

DESIGN

Semi-structured interviews were conducted in Denmark and Sweden between 2013 and 2016.

FINDINGS

We found that a low level of education and a low income were not necessarily obstacles for women's use of contraception; rather, these were strong imperatives for women to wait to have children until their life circumstances become more stable. Arguments grounded in Islamic dictates on contraception became powerful tools for women to substantiate how it is religiously appropriate to postpone having children, particularly when their financial and emotional resources were not yet established.

CONCLUSION

We have shown that the dominant theory that 'low socioeconomic status' and 'religiousness' are paramount barriers to women's use of contraception must be problematized. When formulating suggestions for how to provide contraceptive counseling to women in ethnic and religious minority groups in Denmark and Sweden, one must also take into account that factors such as low financial security as well as religious convictions can be strong imperatives for women to use contraception.

IMPLICATIONS FOR PRACTICE

This study can help inform a critical discussion about the difficulties of using broad group-categorizations for understanding individuals' health-related behavior, as well as the validity of targeted interventions towards large heterogeneous minority groups in Scandinavian contraceptive counseling.

Methods for analytic intercategorical intersectionality in quantitative research: Discrimination as a mediator of health inequalities

RATIONALE

Intersectionality as a theoretical framework has gained prominence in qualitative research on social inequity. Intercategorical quantitative applications have focused primarily on describing health or social inequalities across intersectional groups, coded using cross-classified categories or interaction terms. This descriptive intersectionality omits consideration of the mediating processes (e.g., discrimination) through which intersectional positions impact outcome inequalities, which offer opportunities for intervention.

OBJECTIVE

We argue for the importance of a quantitative analytic intersectionality. We identify methodological challenges and potential solutions in structuring studies to allow for both intersectional heterogeneity in outcomes and in the ways that processes such as discrimination may cause these outcomes for those at different intersections.

METHOD

To incorporate both mediation and exposure-mediator interaction, we use VanderWeele's three-way decomposition methodology, adapt the interpretation for application to analytic intersectionality studies, and present a step-by-step analytic approach. Using online panel data collected from Canada and the United States in 2016 (N = 2542), we illustrate this approach with a statistical analysis of whether and to what extent observed inequalities in psychological distress across intersections of ethnoracial group and sexual or gender minority (SGM) status may be explained by past-year experiences of day-to-day discrimination, assessed using the Intersectional Discrimination Index (InDI).

RESULTS AND CONCLUSIONS

We describe actual and adjusted intersectional inequalities in psychological distress and decompose them to identify three component effects for each of 11 intersectional comparison groups (e.g., Indigenous SGM), versus the reference intersectional group that experienced the lowest levels of discrimination (white non-SGM). These reflect the expected inequality in outcome: 1) due to membership in the more discriminated-against group, if its members had experienced the same lower levels of discrimination as the reference intersection; 2) due to unequal levels of discrimination; and 3), due to unequal effects of discrimination. We present considerations for use and interpretation of these methods.

Socioeconomic differences in body mass index in Spain: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy

Many studies have demonstrated the existence of simple, unidimensional socioeconomic gradients in body mass index (BMI). However, in the present paper we move beyond such traditional analyses by simultaneously considering multiple demographic and socioeconomic dimensions. Using the Spanish National Health Survey 2011–2012, we apply intersectionality theory and multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to analyze 14,190 adults nested within 108 intersectional strata defined by combining categories of gender, age, income, educational achievement and living situation. We develop two multilevel models to obtain information on stratum-specific BMI averages and the degree of clustering of BMI within strata expressed by the intra-class correlation coefficient (ICC). The first model is a simple variance components analysis that provides a detailed mapping of the BMI disparities in the population and measures the accuracy of stratum membership to predict individual BMI. The second model includes the variables used to define the intersectional strata as a way to identify stratum-specific interactions. The first model suggests moderate but meaningful clustering of individual BMI within the intersectional strata (ICC = 12.4%). Compared with the population average (BMI = 26.07 Kg/m2), the stratum of cohabiting 18-35-year-old females with medium income and high education presents the lowest BMI (-3.7 Kg/m2), while cohabiting 36-64-year-old females with low income and low education show the highest BMI (+2.6 Kg/m2). In the second model, the ICC falls to 1.9%, suggesting the existence of only very small stratum specific interaction effects. We confirm the existence of a socioeconomic gradient in BMI. Compared with traditional analyses, the intersectional MAIHDA approach provides a better mapping of socioeconomic and demographic inequalities in BMI. Because of the moderate clustering, public health policies aiming to reduce BMI in Spain should not solely focus on the intersectional strata with the highest BMI, but should also consider whole population polices.

The tyranny of the averages and the indiscriminate use of risk factors in public health: The case of coronary heart disease

Modern medicine is overwhelmed by a plethora of both established risk factors and novel biomarkers for diseases. The majority of this information is expressed by probabilistic measures of association such as the odds ratio (OR) obtained by calculating differences in average “risk” between exposed and unexposed groups. However, recent research demonstrates that even ORs of considerable magnitude are insufficient for assessing the ability of risk factors or biomarkers to distinguish the individuals who will develop the disease from those who will not. In regards to coronary heart disease (CHD), we already know that novel biomarkers add very little to the discriminatory accuracy (DA) of traditional risk factors. However, the value added by traditional risk factors alongside simple demographic variables such as age and sex has been the subject of less discussion. Moreover, in public health, we use the OR to calculate the population attributable fraction (PAF), although this measure fails to consider the DA of the risk factor it represents. Therefore, focusing on CHD and applying measures of DA, we re-examine the role of individual demographic characteristics, risk factors, novel biomarkers and PAFs in public health and epidemiology. In so doing, we also raise a more general criticism of the traditional risk factors’ epidemiology. We investigated a cohort of 6103 men and women who participated in the baseline (1991–1996) of the Malmö Diet and Cancer study and were followed for 18 years. We found that neither traditional risk factors nor biomarkers substantially improved the DA obtained by models considering only age and sex. We concluded that the PAF measure provided insufficient information for the planning of preventive strategies in the population. We need a better understanding of the individual heterogeneity around the averages and, thereby, a fundamental change in the way we interpret risk factors in public health and epidemiology.

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There is a plethora of differences in “average” risk between exposed and unexposed groups of individuals.

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Individual heterogeneity around average values is seldom considered in Public Health.

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Measures of discriminatory accuracy (DA) informs on the underlying individual heterogeneity.

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Most know risk factors and other categorizations associated with diseases have low DA.

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We need a fundamental change in the way we investigate risk factors and other categorizations in Public Health.

Health, Well-Being and Energy Poverty in Europe: A Comparative Study of 32 European Countries

Despite growing pan-European interest in and awareness of the wide-ranging health and well-being impacts of energy poverty-which is characterised by an inability to secure adequate levels of energy services in the home-the knowledge base is largely British-centric and dominated by single-country studies. In response, this paper investigates the relationship between energy poverty, health and well-being across 32 European countries, using 2012 data from the European Quality of Life Survey. We find an uneven concentration of energy poverty, poor health, and poor well-being across Europe, with Eastern and Central Europe worst affected. At the intersection of energy poverty and health, there is a higher incidence of poor health (both physical and mental) amongst the energy poor populations of most countries, compared to non-energy poor households. Interestingly, we find the largest disparities in health and well-being levels between energy poor and non-energy poor households occur within relatively equal societies, such as Sweden and Slovenia. As well as the unique challenges brought about by rapidly changing energy landscapes in these countries, we also suggest the relative deprivation theory and processes of social comparison hold some value in explaining these findings.

Intersectionality and risk for ischemic heart disease in Sweden: Categorical and anti-categorical approaches

Intersectionality theory can contribute to epidemiology and public health by furthering understanding of power dynamics driving production of health disparities, and increasing knowledge about heterogeneities within, and overlap between, social categories. Drawing on McCall, we relate the first of these potential contributions to categorical intersectionality and the second to anti-categorical intersectionality. Both approaches are used in study of risk of ischemic heart disease (IHD), based on register data on 3.6 million adults residing in Sweden by 2010, followed for three years. Categorical intersectionality is here coupled with between-group differences in average risk calculation, as we use intersectional categorizations while estimating odds ratios through logistic regressions. The anti-categorical approach is operationalized through measurement of discriminatory accuracy (DA), i.e., capacity to accurately categorize individuals with or without a certain outcome, through computation of the area under the curve (AUC). Our results show substantial differences in average risk between intersectional groupings. The DA of social categorizations is found to be low, however, due to outcome variability within and overlap between categories. We argue that measures of DA should be used for proper interpretation of differences in average risk between social (or any other) categories. Tension between average between-group risk and the DA of categorizations, which can be related to categorical and anti-categorical intersectional analyses, should be made explicit and discussed to a larger degree in epidemiology and public health.

[Migration: A neglected dimension of inequalities in health?]

Over the past 70 years, several million people have immigrated into Germany-from different countries of origin and for different reasons. The categories used by society to label immigrants ("guest workers", "persons with a migration background") have changed over time. This change has occurred in parallel with changes in the societal attitude towards immigrants and in their legal position. There is unequivocal evidence that the forms that migration takes, in addition to the societal responses towards immigrants, have an effect on their health. The spectrum of migration to Germany is likely to remain fluent because of the continuing process of globalization; also, societal responses to migration will change over time. Thus, migration will continue to pose challenges to society and to health. Only through continuous attentiveness will it be possible to identify, and then avoid or reduce, health disadvantages faced by persons with a migration background.

Appropriate assessment of ethnic differences in adolescent use of psychotropic medication: multilevel analysis of discriminatory accuracy

OBJECTIVE

In the present study, we used a multilevel approach to investigate the role of maternal country of birth (MCOB) in predicting adolescent use of psychotropic medication in Sweden.

DESIGN

Using the Swedish Medical Birth Register we identified all 428,314 adolescents born between 1987 and 1990 and who were residing in Sweden in the year they turned 18. We applied multilevel logistic regression analysis with adolescents (level 1) nested within MCOBs (level 2). Measures of association (odds ratio) and measures of variance (intra-class correlation (ICC)) were calculated, as well as the discriminatory accuracy by calculating the area under the Receiver Operator Characteristic (AU-ROC) curve.

RESULTS

In comparison with adolescents with Swedish-born mothers, adolescents with mothers born in upper-middle, lower-middle and low-income countries were less likely to use psychotropic medication. However, the variance between MCOBs was small (ICC = 2.5 in the final model) relative to the variation within MCOBs. This was confirmed by an AU-ROC value of 0.598.

CONCLUSIONS

Even though we found associations between MCOB and adolescent use of psychotropic medication, the small ICC and AU-ROC indicate that MCOB appears to be an inaccurate context for discriminating adolescent use of psychotropic medication in Sweden.

Social and health epidemiology of immigrants in Germany: past, present and future

Germany has experienced different forms of immigration for many decades. At the end of and after the Second World War, refugees, displaced persons and German resettlers constituted the largest immigrant group. In the 1950s, labor migration started, followed by family reunification. There has been a constant migration of refugees and asylum seekers reaching peaks in the early 1990s as well as today. Epidemiological research has increasingly considered the health, and the access to health care, of immigrants and people with migration background. In this narrative review we discuss the current knowledge on health of immigrants in Germany. The paper is based on a selective literature research with a focus on studies using representative data from the health reporting system.

Our review shows that immigrants in Germany do not suffer from different diseases than non-immigrants, but they differ in their risk for certain diseases, in the resources to cope with theses risk and regarding access to treatment. We also identified the need for differentiation within the immigrant population, considering among others social and legal status, country of origin and duration of stay. Though most of the studies acknowledge the need for differentiation, the lack of data currently rules out analyses accounting for the existing diversity and thus a full understanding of health inequalities related to migration to Germany.