How equitable is vocational rehabilitation in Sweden? A review of evidence on the implementation of a national policy framework

Purpose. Under the national framework law in Sweden, all eligible people should have equal chances of receiving vocational rehabilitation. We aimed to review the evidence on (1) whether access to vocational rehabilitation is equitable in practice and (2) whether the outcomes vary for different groups in the population. Method. Systematic review of studies in Sweden that reported diagnostic or socio-demographic characteristics of people offered or taking up rehabilitation programmes and outcomes of such programmes for different diagnostic and socio-demographic groups. Searches of 11 relevant electronic databases, 15 organisational websites, citation searching and contact with experts in the field, for the period 1990–2009. Results. A total of 11 studies were included in the final review, six of which addressed review question (1) and seven addressed review question (2). All the six observational studies of access reported biased selection into vocational rehabilitation: greater likelihood for men, younger people, those with longer-term sick leave, those with lower income, employed rather than unemployed people and those with musculoskeletal and mental disorders or alcohol abuse. Having had a rehabilitation investigation also increased the likelihood of receiving vocational rehabilitation. Differential outcome of rehabilitation was reported in seven studies: outcomes were better for men, younger people, employed individuals, those with shorter sick leave and those with higher income. Selection into vocational rehabilitation was perceived as important for successful outcomes, but success also depended on the state of the local labour market. Conclusions. There is evidence of socio-demographic differences in access to and outcomes of vocational rehabilitation in Sweden, even though the national framework law is meant to apply to everyone. Few studies have deliberately measured differential access or outcomes, and there is a need for this kind of equity analysis of population-wide policies. Studies evaluating the effects of vocational rehabilitation must consider selection into the programmes for adequate interpretation of impact results

Physical activity and health related quality of life

Copyright @ 2012 Anokye et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been made available through the Brunel Open Access Publishing Fund.BACKGROUND: Research on the relationship between Health Related Quality of Life (HRQoL) and physical activity (PA), to date, have rarely investigated how this relationship differ across objective and subjective measures of PA. The aim of this paper is to explore the relationship between HRQoL and PA, and examine how this relationship differs across objective and subjective measures of PA, within the context of a large representative national survey from England. METHODS: Using a sample of 5,537 adults (40–60 years) from a representative national survey in England (Health Survey for England 2008), Tobit regressions with upper censoring was employed to model the association between HRQoL and objective, and subjective measures of PA controlling for potential confounders. We tested the robustness of this relationship across specific types of PA. HRQoL was assessed using the summary measure of health state utility value derived from the EuroQol-5 Dimensions (EQ-5D) whilst PA was assessed via subjective measure (questionnaire) and objective measure (accelerometer- actigraph model GT1M). The actigraph was worn (at the waist) for 7 days (during waking hours) by a randomly selected sub-sample of the HSE 2008 respondents (4,507 adults – 16 plus years), with a valid day constituting 10 hours. Analysis was conducted in 2010. RESULTS: Findings suggest that higher levels of PA are associated with better HRQoL (regression coefficient: 0.026 to 0.072). This relationship is consistent across different measures and types of PA although differences in the magnitude of HRQoL benefit associated with objective and subjective (regression coefficient: 0.047) measures of PA are noticeable, with the former measure being associated with a relatively better HRQoL (regression coefficient: 0.072). CONCLUSION: Higher levels of PA are associated with better HRQoL. Using an objective measure of PA compared with subjective shows a relatively better HRQoL.This project was funded by the NIHR Health Technology Assessment programme (project number 08/72/01)

Examining the impact of 11 long-standing health conditions on health-related quality of life using the EQ-5D in a general population sample

Objectives Health-related quality of life (HRQoL) measures have been increasingly used in economic evaluations for policy guidance. We investigate the impact of 11 self-reported long-standing health conditions on HRQoL using the EQ-5D in a UK sample. Methods We used data from 13,955 patients in the South Yorkshire Cohort study collected between 2010 and 2012 containing the EQ-5D, a preference-based measure. Ordinary least squares (OLS), Tobit and two-part regression analyses were undertaken to estimate the impact of 11 long-standing health conditions on HRQoL at the individual level. Results The results varied significantly with the regression models employed. In the OLS and Tobit models, pain had the largest negative impact on HRQoL, followed by depression, osteoarthritis and anxiety/nerves, after controlling for all other conditions and sociodemographic characteristics. The magnitude of coefficients was higher in the Tobit model than in the OLS model. In the two-part model, these four long-standing health conditions were statistically significant, but the magnitude of coefficients decreased significantly compared to that in the OLS and Tobit models and was ranked from pain followed by depression, anxiety/nerves and osteoarthritis. Conclusions Pain, depression, osteoarthritis and anxiety/nerves are associated with the greatest losses of HRQoL in the UK population. The estimates presented in this article should be used to inform economic evaluations when assessing health care interventions, though improvements can be made in terms of diagnostic information and obtaining longitudinal data

Experience-based utility and own health state valuation for a health state classification system: why do it and how to do it

In the estimation of population value sets for health state classification systems such as the EQ-5D, there is increasing interest in asking respondents to value their own health state, sometimes referred to as "experienced-based utility values" or more correctly ownrather than hypothetical health states. Own health state values differ to hypothetical health state values, and this may be attributed to many reasons. This paper critically examines: whose values matter; why there is a difference between own and hypothetical values; how to measure own health state values; and why to use own health state values. Finally, the paper also examines other ways that own health state values can be taken into account, such as including the use of informed general population preferences that may better take into account experience-based values

Measuring Health Utilities in Children and Adolescents: A Systematic Review of the Literature.

BACKGROUND: The objective of this review was to evaluate the use of all direct and indirect methods used to estimate health utilities in both children and adolescents. Utilities measured pre- and post-intervention are combined with the time over which health states are experienced to calculate quality-adjusted life years (QALYs). Cost-utility analyses (CUAs) estimate the cost-effectiveness of health technologies based on their costs and benefits using QALYs as a measure of benefit. The accurate measurement of QALYs is dependent on using appropriate methods to elicit health utilities. OBJECTIVE: We sought studies that measured health utilities directly from patients or their proxies. We did not exclude those studies that also included adults in the analysis, but excluded those studies focused only on adults. METHODS AND FINDINGS: We evaluated 90 studies from a total of 1,780 selected from the databases. 47 (52%) studies were CUAs incorporated into randomised clinical trials; 23 (26%) were health-state utility assessments; 8 (9%) validated methods and 12 (13%) compared existing or new methods. 22 unique direct or indirect calculation methods were used a total of 137 times. Direct calculation through standard gamble, time trade-off and visual analogue scale was used 32 times. The EuroQol EQ-5D was the most frequently-used single method, selected for 41 studies. 15 of the methods used were generic methods and the remaining 7 were disease-specific. 48 of the 90 studies (53%) used some form of proxy, with 26 (29%) using proxies exclusively to estimate health utilities. CONCLUSIONS: Several child- and adolescent-specific methods are still being developed and validated, leaving many studies using methods that have not been designed or validated for use in children or adolescents. Several studies failed to justify using proxy respondents rather than administering the methods directly to the patients. Only two studies examined missing responses to the methods administered with respect to the patients' ages

Socioeconomic inequalities in suicide mortality in European urban areas before and during the economic recession

Few studies have assessed the impact of the financial crisis on inequalities in suicide mortality in European urban areas. The objective of the study was to analyse the trend in area socioeconomic inequalities in suicide mortality in nine European urban areas before and after the beginning of the financial crisis. This ecological study of trends was based on three periods, two before the economic crisis (2000-2003, 2004-2008) and one during the crisis (2009-2014). The units of analysis were the small areas of nine European cities or metropolitan areas, with a median population ranging from 271 (Turin) to 193 630 (Berlin). For each small area and sex, we analysed smoothed standardized mortality ratios of suicide mortality and their relationship with a socioeconomic deprivation index using a hierarchical Bayesian model. Among men, the relative risk (RR) comparing suicide mortality of the 95th percentile value of socioeconomic deprivation (severe deprivation) to its 5th percentile value (low deprivation) were higher than 1 in Stockholm and Lisbon in the three periods. In Barcelona, the RR was 2.06 (95% credible interval: 1.24-3.21) in the first period, decreasing in the other periods. No significant changes were observed across the periods. Among women, a positive significant association was identified only in Stockholm (RR around 2 in the three periods). There were no significant changes across the periods except in London with a RR of 0.49 (95% CI: 0.35-0.68) in the third period. Area socioeconomic inequalities in suicide mortality did not change significantly after the onset of the crisis in the areas studied

Health Risk or Resource? Gradual and Independent Association between Self-Rated Health and Mortality Persists Over 30 Years

Background: Poor self-rated health (SRH) is associated with increased mortality. However, most studies only adjust for few health risk factors and/or do not analyse whether this association is consistent also for intermediate categories of SRH and for follow-up periods exceeding 5–10 years. This study examined whether the SRH-mortality association remained significant 30 years after assessment when adjusting for a wide range of known clinical, behavioural and socio-demographic risk factors. Methods: We followed-up 8,251 men and women aged ≥16 years who participated 1977–79 in a community based health study and were anonymously linked with the Swiss National Cohort (SNC) until the end of 2008. Covariates were measured at baseline and included education, marital status, smoking, medical history, medication, blood glucose and pressure. Results: 92.8% of the original study participants could be linked to a census, mortality or emigration record of the SNC. Loss to follow-up 1980–2000 was 5.8%. Even after 30 years of follow-up and after adjustment for all covariates, the association between SRH and all-cause mortality remained strong and estimates almost linearly increased from “excellent” (reference: hazard ratio, HR 1) to “good” (men: HR 1.07 95% confidence interval 0.92–1.24, women: 1.22, 1.01–1.46) to “fair” (1.41, 1.18–1.68; 1.39, 1.14–1.70) to “poor”(1.61, 1.15–2.25; 1.49, 1.07–2.06) to “very poor” (2.85, 1.25–6.51; 1.30, 0.18–9.35). Persons answering the SRH question with “don't know” (1.87, 1.21–2.88; 1.26, 0.87–1.83) had also an increased mortality risk; this was pronounced in men and in the first years of follow-up. Conclusions: SRH is a strong and “dose-dependent” predictor of mortality. The association was largely independent from covariates and remained significant after decades. This suggests that SRH provides relevant and sustained health information beyond classical risk factors or medical history and reflects salutogenetic rather than pathogenetic pathways

Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study

BACKGROUND: Multiple rib fractures and unstable thoracic cage injuries are common in blunt trauma. Surgical management of rib fractures has received increasing attention in recent years and the aim of this 1-year, prospective study was to assess the long-term effects of surgery. METHODS: Fifty-four trauma patients with median Injury Severity Score 20 (9–66) and median New Injury Severity Score 34 (16–66) who presented with multiple rib fractures and flail chest, and underwent surgical stabilization with plate fixation were recruited. Patients responded to a standardized questionnaire concerning pain, local discomfort, breathlessness and use of analgesics and health-related quality of life (EQ-5D-3 L) questionnaire at 6 weeks, 3 months, 6 months and 1 year. Lung function, breathing movements, range of motion and physical function were measured at 3 months, 6 months and 1 year. RESULTS: Symptoms associated with pain, breathlessness and use of analgesics significantly decreased from 6 weeks to 1 year following surgery. After 1 year, 13 % of patients complained of pain at rest, 47 % had local discomfort and 9 % used analgesics. The EQ-5D-3 L index increased from 0.78 to 0.93 and perceived overall health state increased from 60 to 90 % (p < 0.0001) after 6 weeks to 1 year. Lung function improved significantly with predicted Forced vital capacity and Peak expiratory flow increasing from 86 to 106 % (p = 0.0002) and 81 to 110 % (p < 0.0001), respectively, from 3 months to 1 year after surgery. Breathing movements and range of motion tended to improve over time. Physical function improved significantly over time and the median Disability rating index was 0 after 1 year. CONCLUSIONS: Patients with multiple rib fractures and flail chest show a gradual improvement in symptoms associated with pain, quality of life, mobility, disability and lung function over 1 year post surgery. Therefore, the final outcome of surgery cannot be assessed before 1 year post-operatively

Unemployment and retirement and ill-health: a cross-sectional analysis across European countries

Objective To determine the associations between different measures of health and labor market position across ten European countries. Methods We studied 11,462 participants of the Survey on Health and Ageing in Europe (SHARE) who were 50–64 years old. Logistic regression was used to calculate the associations between health and other determinants and being retired, unemployed, or a homemaker. Results A large variation across European countries was observed for the proportion of persons 50–65 years with paid employment, varying among men from 42% in Austria to 75% in Sweden and among women from 22% in Italy to 69% in Sweden. Among employed workers 18% reported a poor health, whereas this proportion was 37% in retirees, 39% in unemployed persons, and 35% in homemakers. A perceived poor health was strongly associated with non-participating in labor force in most European countries. A lower education, being single, physical inactivity and a high body mass index were associated with withdrawal from the labor force. Long-term illnesses such as depression, stroke, diabetes, chronic lung disease, and musculoskeletal disease were significantly more common among those persons not having paid employment. Conclusion In many European countries a poor health, chronic diseases, and lifestyle factors were associated with being out of the labor market. The results of this study suggest that in social policies to encourage employment among older persons the role of ill-health and its influencing factors needs to be incorporated

Does a short-term intervention promote mental and general health among young adults? – An evaluation of counselling

<p>Abstract</p> <p>Background</p> <p>Since 1988, self-reported mental health problems in Sweden have increased more among young people than in any other age group. Young adults aged 18 – 29 with minor mental health problems were welcomed to four (at most) counselling sessions led by psychotherapists. The present study aimed to evaluate the method's appropriateness and usefulness.</p> <p>Methods</p> <p>The study population was recruited consecutively during six months (N = 74) and consisted of 59 women and 15 men. Fifty-one, 46 women and five men, met the criterion for a <it>personal semi-structured interview </it>three months post intervention. Self-assessed health data were collected on three occasions using the General Health Questionnaire (GHQ-12), Pearlin's Personal Mastery Scale and two items from the Swedish Living Conditions Surveys. Thirteen women and six men were not statistically assessed due to incomplete data, but were <it>interviewed by telephone</it>. Four men refused to be interviewed and became <it>dropouts</it>.</p> <p>Results</p> <p>The largest group of the study population had long been troubled by their problem(s): 43 percent for over three years and 28 percent for over one year. Among those <it>personally interviewed</it>, 76 percent reported psychological distress (> 3 GHQ points) before the counselling. After the counselling, GHQ-12 distress decreased by 50 percent while mastery and perceived health status increased significantly. A majority experienced an improved life situation, found out something new about themselves and could make use of the sessions afterwards. Personal participant session contentment was about 70 percent and all counsellees would recommend the intervention to a friend. Those <it>interviewed by telephone </it>were not statistically assessed due to incomplete health data. Their personal contentment was just under 50 percent, though all except one would recommend the counselling to a friend. Their expectations of the intervention were more result-orientated compared to the more process-directed personally-interviewed group.</p> <p>Conclusion</p> <p>This evaluation shows a clear improvement in self-rated mental and general health, mastery and control in the group completing the study agreement. The intervention seems to be effective for young adults with minor mental health problems, but due to the skewed gender-distribution it is unclear if the method is appropriate for men. After the proposed internal quality improvements, this short-term counselling could enhance mental and general health among young people.</p