Adjusting for outcome risk factors in immigrant datasets: total or direct effects?

Background When quantifying differences in health outcomes between immigrants and non-immigrants, it is common practice to adjust for observed differences in outcome risk factors between the groups being compared. However, as some of these outcome risk factors may act as mediators on the causal path between the exposure and outcome, adjusting for these may remove effects of factors that characterize the immigrants rather than removing a bias between immigrants and non-immigrants. Methods This study investigates the underlying conditions for which adjusting for outcome risk factors in regression models can lead to the estimation of either total or direct effect for the difference in health outcomes between immigrants and non-immigrants. For this investigation, we use modern tools in causal inference to construct causal models that we believe are highly relevant in an immigrant dataset. In these models, the outcome risk factor is modeled either as a mediator, a selection factor, or a combined mediator/selection factor. Unlike mediators, selection factors are variables that affect the probability of being in the immigrant dataset and may contribute to a bias when comparing immigrants and non-immigrants. Results When the outcome risk factor acts both as a mediator and selection factor, the adjustment for the risk factor in regression models leads to the estimation of what is known as a “controlled” direct effect. When the outcome risk factor is either a selection factor or a mediator alone, the adjustment for the risk factor in regression models leads to the estimation of a total effect or a controlled direct effect, respectively. In all regression analyses, also adjusting for various confounding paths, including mediator-outcome confounding, may be necessary to obtain valid controlled direct effects or total effects. Conclusions Depending on the causal role of the outcome risk factors in immigrant datasets, regression adjustment for these may result in the estimation of either total effects or controlled direct effects for the difference in outcomes between immigrants and non-immigrants. Because total and controlled direct effects are interpreted differently, we advise researchers to clarify to the readers which types of effects are presented when adjusting for outcome risk factors in immigrant datasets.publishedVersio

Risk of Subsequent Preeclampsia by Maternal Country of Birth: A Norwegian Population-Based Study

In this nationwide population-based study, we investigated the associations of preeclampsia in the first pregnancy with the risk of preeclampsia in the second pregnancy, by maternal country of birth using data from the Medical Birth Registry of Norway and Statistics Norway (1990–2016). The study population included 101,066 immigrant and 544,071 non-immigrant women. Maternal country of birth was categorized according to the seven super-regions of the Global Burden of Disease study (GBD). The associations between preeclampsia in the first pregnancy with preeclampsia in the second pregnancy were estimated using log-binomial regression models, using no preeclampsia in the first pregnancy as the reference. The associations were reported as adjusted risk ratios (RR) with 95% confidence intervals (CI), adjusted for chronic hypertension, year of first childbirth, and maternal age at first birth. Compared to those without preeclampsia in the first pregnancy, women with preeclampsia in the first pregnancy were associated with a considerably increased risk of preeclampsia in the second pregnancy in both immigrant (n = 250; 13.4% vs. 1.0%; adjusted RR 12.9 [95% CI: 11.2, 14.9]) and non-immigrant women (n = 2876; 14.6% vs. 1.5%; adjusted RR 9.5 [95% CI: 9.1, 10.0]). Immigrant women from Latin America and the Caribbean appeared to have the highest adjusted RR, followed by immigrant women from North Africa and the Middle East. A likelihood ratio test showed that the variation in adjusted RR across all immigrant and non-immigrant groups was statistically significant (p = 0.006). Our results suggest that the association between preeclampsia in the first pregnancy and preeclampsia in the second pregnancy might be increased in some groups of immigrant women compared with non-immigrant women in Norway.publishedVersio

The ability of the Ages and Stages Questionnaire (ASQ) to indicate motor difficulties in infants in primary care

Introduction Delayed achievement of motor milestones may be an early indicator of motor difficulties. Parent-reported questionnaires may serve as an efficient, low-cost screening to identify infants in need of further clinical assessment, and thus be a helpful tool in busy health care centers. Purpose To examine the ability of the Ages and Stages Questionnaire, second edition (ASQ-2) to indicate motor difficulties in infants using the Infant Motor Profile (IMP) as the reference standard. Methods A cross-sectional design was applied to examine the correlation between parent-reported data of the ASQ-2 and data from physiotherapist assessment using IMP. Included were 432 mainly low-risk infants aged 3–12 months from primary care. Results Overall, ASQ-2 gross and fine motor scores did not correlate well with the IMP total or domain scores. The ASQ-2 gross motor cut point (> 2SD below the mean), showed 34.3% sensitivity and 96.7% specificity using the 15th percentile from IMP performance domain as reference standard. The positive predictive value to indicate motor difficulties was 48%. Conclusion The motor domains of ASQ-2 have poor ability to identify infants with motor difficulties as indicated by their IMP scores in low-risk infants.publishedVersio

A randomized controlled trial on the effect of blue-blocking glasses compared to partial blue-blockers on melatonin profile among nulliparous women in third trimester of the pregnancy

Objective In pregnancy melatonin regulates circadian rhythms, induce sleep, and has a neuroprotective positive effect on fetal development. Artificial blue light in the evening delays and suppresses melatonin production. Thus, we investigated the effect of blocking blue light on the melatonin profile. Methods A randomized controlled trial (n=30 blue-blocking glasses vs. n=30 control glasses with partial blue-blocking effect) including healthy nulliparous pregnant women in the beginning of the third trimester. Salivary melatonin and subjective sleep were measured before and after two weeks of intervention/control condition. Saliva was sampled at 30-min intervals from 3 h before normal bedtime. Melatonin onset was set at 4.0 pg/ml. Results Due to missing data melatonin onset was estimated for 47 participants. At posttreatment, melatonin onset advanced by 28 min in the blue-blocking group compared with the control condition (p=.019). Melatonin levels were significantly higher, favoring the blue-blocking glass condition, at clock time 20:00, 21:00 and 22:00 h, and for sample number 3 and 4. The phase angle (time interval) between melatonin onset and sleep bedtime and sleep onset time increased within the blue blocking group (+45 min and +41 min, respectively), but did not reach statistical significance compared to control condition (+13 min and +26 min, respectively). Conclusion Blocking blue light in the evening had a positive effect on the circadian system with an earlier onset and rise of melatonin levels in healthy nulliparous pregnant women. This demonstrated the effectiveness and feasibility of a simple non-pharmacological chronobiological intervention during pregnancy.publishedVersio

A randomized controlled trial on the effects of blue-blocking glasses compared to partial blue-blockers on sleep outcomes in the third trimester of pregnancy

Objective Sleep disturbances are common in pregnancy. Blocking blue light has been shown to improve sleep and may be a suitable intervention for sleep problems during pregnancy. The present study investigated the effects of blue light blocking in the evening and during nocturnal awakenings among pregnant women on primary sleep outcomes in terms of total sleep time, sleep efficiency and mid-point of sleep. Methods In a double-blind randomized controlled trial, 60 healthy nulliparous pregnant women in the beginning of the third trimester were included. They were randomized, using a random number generator, either to a blue-blocking glass intervention (n = 30) or to a control glass condition constituting partial blue-blocking effect (n = 30). Baseline data were recorded for one week and outcomes were recorded in the last of two intervention/control weeks. Sleep was measured by actigraphy, sleep diaries, the Bergen Insomnia Scale, the Karolinska Sleepiness Scale and the Pre-Sleep Arousal Scale. Results The results on the primary outcomes showed no significant mean difference between the groups at posttreatment, neither when assessed with sleep diary; total sleep time (difference = .78[min], 95%CI = -19.7, 21.3), midpoint of sleep (difference = -8.9[min], 95%CI = -23.7, 5.9), sleep efficiency (difference = -.06[%], 95%CI = -1.9, 1.8) and daytime functioning (difference = -.05[score points], 95%CI = -.33, .22), nor by actigraphy; total sleep time (difference = 13.0[min], 95%CI = -9.5, 35.5), midpoint of sleep (difference = 2.1[min], 95%CI = -11.6, 15.8) and sleep efficiency (difference = 1.7[%], 95%CI = -.4, 3.7). On the secondary outcomes, the Bergen Insomnia Scale, the Karolinska Sleepiness Scale and the Pre-Sleep Arousal Scale the blue-blocking glasses no statistically significant difference between the groups were found. Transient side-effects were reported in both groups (n = 3). Conclusions The use of blue-blocking glasses compared to partially blue-blocking glasses in a group of healthy pregnant participants did not show statistically significant effects on sleep outcomes. Research on the effects of blue-blocking glasses for pregnant women with sleep-problems or circadian disturbances is warranted.publishedVersio

Nutritional risk, nutrition plan and risk of death in older health care service users with chronic diseases: A register-based cohort study

Background and aims Nutritional risk in older health care service users is a well-known challenge. Nutritional risk screening and individualised nutrition plans are common strategies for preventing and treating malnutrition. The aim of the current study was to investigate whether nutritional risk is associated with an increased risk of death and whether a nutrition plan to those at nutritional risk could reduce this potential risk of death in community health care service users over 65 years of age. Methods We conducted a register-based, prospective cohort study on older health care service users with chronic diseases. The study included persons ≥65 years of age receiving health care services from all municipalities in Norway from 2017 to 2018 (n = 45,656). Data on diagnoses, nutritional risk, nutrition plan and death were obtained from the Norwegian Registry for Primary Health Care (NRPHC) and the Norwegian Patient Registry (NPR). We used Cox regression models to estimate the associations of nutritional risk and use of a nutrition plan with the risk of death within three and six months. Analyses were performed within the following diagnostic strata: chronic obstructive pulmonary disease (COPD), dementia, type 2 diabetes, stroke, osteoporosis and heart failure. The analyses were adjusted for age, gender, living situation and comorbidity. Results Of the 45,656 health care service users, 27,160 (60%) were at nutritional risk, and 4437 (10%) and 7262 (16%) died within three and six months, respectively. Among those at nutritional risk, 82% received a nutrition plan. Health care service users at nutritional risk had an increased risk of death compared to health care service users not at nutritional risk (13% vs 5% and 20% vs 10% at three and six months). Adjusted hazard ratios (HRs) for death within six months were 2.26 (95% confidence interval (CI): 1.95, 2.61) for health care service users with COPD, 2.15 (1.93, 2.41) for those with heart failure, 2.37 (1.99, 2.84) for those with osteoporosis, 2.07 (1.80, 2.38) for those with stroke, 2.65 (2.30, 3.06) for those with type 2 diabetes and 1.94 (1.74, 2.16) for those with dementia. The adjusted HRs were larger for death within three months than death within six months for all diagnoses. Nutrition plans were not associated with the risk of death for health care service users at nutritional risk with COPD, dementia or stroke. For health care service users at nutritional risk with type 2 diabetes, osteoporosis or heart failure, nutrition plans were associated with an increased risk of death within both three and six months (adjusted HR 1.56 (95% CI: 1.10, 2.21) and 1.45 (1.11, 1.88) for type 2 diabetes; 2.20 (1.38, 3.51) and 1.71 (1.25, 2.36) for osteoporosis and 1.37 (1.05, 1.78) and 1.39 (1.13, 1.72) for heart failure). Conclusions Nutritional risk was associated with the risk of earlier death in older health care service users with common chronic diseases in the community. Nutrition plans were associated with a higher risk of death in some groups in our study. This may be because we could not control sufficiently for disease severity, the indication for providing a nutrition plan or the degree of implementation of nutrition plans in community health care.publishedVersio

Are infants exposed to antimicrobials during the first 3 months of life at increased risk of recurrent use? An explorative data-linkage study

Objectives: To investigate whether infants exposed to antimicrobials in hospital during the first 3 months of life had an increased risk of ambulatory antimicrobial use during the following year compared with infants not exposed to antimicrobials during the first 3 months of life. Methods: Norwegian cohort study of infants less than 3 months consisting of one group exposed to antimicrobials recruited during hospitalization and one group not exposed to antimicrobials. Ten unexposed infants were matched with one exposed infant according to county of residence, birth year and month, and sex. The Norwegian Prescription Database was applied to register antimicrobial use from the month after discharge and 1 year onward. We defined comorbidity based on antimicrobials prescribed as reimbursable prescriptions due to underlying diseases. Results: Of 95 infants exposed to antimicrobials during the first 3 months of life, 23% had recurrent use compared with 14% use in 950 unexposed infants [relative risk (RR) = 1.7 (95% CI = 1.1–2.5) and comorbidity-adjusted RR = 1.4 (95% CI = 0.9–2.2)]. The recurrence use rate in exposed term infants (≥37 weeks, n = 70) was 27% compared with 12% in their unexposed matches [RR 2.3 = (95% CI = 1.4–3.7) and comorbidity-adjusted RR = 1.9 (95% CI = 1.2–3.2). Of 25 exposed preterm infants, 3 (12%) had recurrent use. The total antimicrobial prescription rate was 674/1000 in the exposed group and 244/1000 in the unexposed group [incidence rate ratio = 2.8 (95% CI = 1.6–4.9)]. Conclusions: Infants exposed to antimicrobials during the first 3 months of life had an increased risk of recurrent use during the following year. This increased risk also appeared in term infants without infection-related comorbidity.publishedVersio

Antibiotic use in children before, during and after hospitalisation

Purpose To investigate ambulatory antibiotic use in children during 1 year before and 1 year after in-hospital antibiotic exposure compared to children from the general population that had not received antibiotics in-hospital. Methods Explorative data-linkage cohort study from Norway of children aged 3 months to 17 years. One group had received antibiotics in-Hospital (H+), and one group had not received antibiotics in-hospital (H-). The H+ group was recruited during admission in 2017. Using the Norwegian Population Registry, 10 children from the H- group were matched with one child from the H+ group according to county of residence, age and sex. We used the Norwegian Prescription Database to register antibiotic use 1 year before and 1 year after the month of hospitalisation. Results Of 187 children in the H+ group, 83 (44%) received antibiotics before hospitalisation compared to 288/1870 (15%) in the H- group, relative risk (RR) 2.88 (95% confidence interval 2.38–3.49). After hospitalisation, 86 (46%) received antibiotics in the H+ group compared to 311 (17%) in the H- group, RR 2.77 (2.30–3.33). Comorbidity-adjusted RR was 2.30 (1.84–2.86) before and 2.25 (1.81–2.79) after hospitalisation. RR after hospitalisation was 2.55 (1.99–3.26) in children 3 months-2 years, 4.03 (2.84–5.71) in children 3–12 years and 2.07 (1.33–3.20) in children 13–17 years. Conclusions Children exposed to antibiotics in-hospital had two to three times higher risk of receiving antibiotics in ambulatory care both before and after hospitalisation. The link between in-hospital and ambulatory antibiotic exposure should be emphasised in future antibiotic stewardship programs.publishedVersio

Women's negative childbirth experiences and socioeconomic factors: results from The Babies Born Better survey

Introduction/Purpose: To investigate the association between women's socioeconomic status and overall childbirth experience and to explore how women reporting an overall negative birth experience describe their experiences of intrapartum care. Methods: We used both quantitative and qualitative data from the Babies Born Better (B3) survey version 2, including a total of 8317 women. First, we performed regression analyses to explore the association between women's socioeconomic status and labor and birth experience, and then a thematic analysis of three open-ended questions from women reporting a negative childbirth experience (n = 917). Results: In total 11.7% reported an overall negative labor and birth experience. The adjusted odds ratio (OR) of a negative childbirth experience was elevated for women with non-tertiary education, for unemployed, students and those not married or cohabiting. Women with lower subjective living standard had an adjusted OR of 1.70 (95% confidence interval [CI] 1.44–2.00) for a negative birth experience, compared with those with average subjective living standard. The qualitative analysis generated three themes: (1) uncompassionate care – lack of sensitivity and empathy, (2) impersonal care – feeling objectified, and (3) critical situations – feeling unsafe and loss of control. Conclusions: Important socioeconomic disparities in women's childbirth experiences exist even in the Norwegian setting. Women reporting a negative childbirth experience described disrespect and mistreatment as well as experiences of insufficient attention and lack of awareness of individual and emotional needs during childbirth. The study shows that women with lower socioeconomic status are more exposed to these types of experiences during labor and birth

Women’s negative childbirth experiences and socioeconomic factors: results from the Babies Born Better survey

Objective To investigate the association between women's socioeconomic status and overall childbirth experience and to explore how women reporting an overall negative birth experience describe their experiences of intrapartum care. Methods We used both quantitative and qualitative data from the Babies Born Better (B3) survey version 2, including a total of 8,317 women. First, we performed regression analyses to explore the association between women’s socioeconomic status and labour and birth experience, and then a thematic analysis of three open-ended questions from women reporting a negative childbirth experience (n=917). Results In total 11.7% reported an overall negative labour and birth experience. The adjusted odds ratio (OR) of a negative childbirth experience was elevated for women with non-tertiary education, for unemployed, students and not married or cohabiting. Women with lower subjective living standard had an adjusted OR of 1.70 (95% CI 1.44-2.00) for a negative birth experience, compared with those with average subjective living standard. The qualitative analysis generated three themes: 1) Uncompassionate care: lack of sensitivity and empathy, 2) Impersonal care: feeling objectified, and 3) Critical situations: feeling unsafe and loss of control. Conclusion Important socioeconomic disparities in women’s childbirth experiences exist even in the Norwegian setting. Women reporting a negative childbirth experience described disrespect and mistreatment as well as experiences of insufficient attention and lack of awareness of individual and emotional needs during childbirth. The study shows that women with lower socioeconomic status are more exposed to these types of experiences during labour and birth