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The article intervenes in discussions on lay knowledge production about health in the Internet era, through the case of a group of women claiming that their use of copper intrauterine devices has led to systemic side effects. Based on online group interviews and written essays, we examine how women embracing these knowledge claims navigate various sources of information, focusing on the role of scientificity in these epistemic negotiations. The women were found to be involved in an active, scientifically oriented process of knowledge formation, which we refer to as a collective labour of scientific patchworking. Meanwhile, due to a perceived lack of scientifically based expertise on their condition, the women reported having little choice but turn to resources with weaker scientific foothold. We argue that the tendency to portray these women’s claims as unscientific simplifies the nature of lay knowledge production, potentially deepening divides between medical authorities and the public.

Aims: Swedish public health reports have repeatedly provided information about socio-economic inequalities in sedentary leisure time, despite that, in the interest of health equity, physical activity should be equally distributed in the population. Such public health reports, however, neither consider the intersection of multiple socio-demographic factors nor the individual heterogeneity around group averages. Drawing on intersectionality theory, this study aimed to revisit previous findings on sedentary leisure time from Swedish public health surveys and demonstrate how the analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can be used for analysing complex health inequalities. Methods: Using data from Swedish national public health surveys (2004–2015), we applied the AIHDA to define 72 intersectional groups by categories of age, gender, educational achievement, migration status and household composition. We then calculated (a) the absolute and relative risk of sedentary leisure time and (b) the discriminatory accuracy (DA) of the intersectional grouping. Results: The average risk of sedentary leisure time ranged from 5.8% among native-born, highly educated, young women living alone to 41.0% among immigrated young men, living alone, with low education. The risk was higher in strata comprising immigrated people with low education and lower in strata including native-born, highly educated people. However, the DA of the grouping was poor, indicating a substantial overlap of individual risk between groups. Conclusions: Using the AIHDA and drawing on intersectionality, this study provides an improved mapping of the socio-economic distribution of sedentary leisure time in Sweden, with the poor DA suggesting universal rather than targeted physical activity interventions.

Despite high gender equality ratings, Sweden shows a high prevalence of intimate partner violence against women (IPVAW). Suggested factors underlying this apparent paradox include backlash effects against women's empowerment. This study explores stories of backlash in interviews with 23 IPVAW survivors in Sweden. Thematic analysis identified categories of narrative segments referring to phenomena provoking violence; the victims’ resources, agency, breaking with gender norms and resistance, and the partner's feelings of subordination, while case-centered narrative analysis pointed to divergences between how these categories appear in the stories. The study underscores the complexity of links between gender (in)equality and IPVAW in Sweden.

Intimate partner violence against women (IPVAW) is a global public health issue often assumed to be associated with gender inequality. The so-called Nordic Paradox, the apparently contradictory co-existence of high levels of IPVAW and of gender equality in Nordic countries, has not been adequately explained. This study explores discussions about how this apparent paradox can be understood among 30 IPVAW professionals working in southern Sweden, through a thematic analysis of focus groups and individual and paired interviews. The analysis highlights complexities of gender (in)equality and its links with IPVAW in Sweden, of relevance for the addressing and prevention of IPVAW.

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.

Intimate partner violence against women (IPVAW) poses severe threats to women’s health and rights. This study investigates the role of country context and gender equality in shaping individual perceptions of the severity of IPVAW. Multilevel logistic regression analyses of a Eurobarometer survey on attitudes toward IPVAW from 27 EU states showed that male gender, young age, low education, low self-assessed social position and particularly perceiving IPVAW as uncommon were associated with perceiving IPVAW as less severe. The likelihood of perceiving IPVAW as less severe was higher in countries with low gender equality. Between-country variance accounted for 14% of the variability, while country-level gender equality accounted for 22% of the between-country variance. We conclude that efforts toward strengthening perceptions of IPVAW as a severe issue should focus on awareness-raising and on increasing country-level gender equality.

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.

Aims: Antimicrobial resistance presents an increasingly serious threat to global public health, which is directly related to how antibiotic medication is used in society. Actions aimed towards the optimised use of antibiotics should be implemented on equal terms and according to the needs of the population. Previous research results on differences in antibiotic use between socio-economic and demographic groups in Sweden are not entirely coherent, and have typically focused on the effects of singular socio-economic variables. Using an intersectional approach, this study provides a more precise analysis of how the dispensation of antibiotic medication was distributed across socio-economic and demographic groups in Sweden in 2016-2017. Methods: Using register data from a nationwide cohort and adopting an intersectional analysis of individual heterogeneity and discriminatory accuracy, we map the dispensation of antibiotics according to age, sex, country of birth and income. Results: While women and high-income earners had the highest antibiotic dispensation prevalence, no large differences in the dispensation of antibiotics were identified between socio-economic groups. Conclusions: Public-health interventions aiming to support the reduced and optimised use of antibiotics should be directed towards the whole Swedish population rather than towards specific groups. Correspondingly, an increased focus on socio-economic or demographic factors is not warranted in interventions aimed at improving antibiotic prescription patterns among medical practitioners. Funding Agencies|Pufendorf Institute for Advanced Studies, Lund University (Theme: Post-Antibiotic Futures), Vetenskapsradet [2017-01321]

The aim of this study was to understand the reasons why Spain has one of the lowest prevalence rates of intimate partner violence against women (IPVAW) in the European Union. Using a qualitative and inductive research approach, a total of five focus groups ( n = 19) and 10 unstructured interviews with key informants were conducted. Three main categories were identified as possible explanations of the relatively low prevalence of IPVAW in Spain: law and policy, social awareness, and cultural patterns. Lessons learned and implications to improve future macrolevel intervention and prevention strategies are discussed.

Background Gender equality is widely accepted as an important explanatory factor for the occurrence of intimate partner violence (IPV) against women. However, the relationship is not straightforward, as high country-level gender equality is not always associated with lower IPV prevalence. We apply ‘multilevel analysis of individual heterogeneity and discriminatory accuracy’ (MAIHDA) to (i) quantify the extent to which the country of residence determines individual risk of IPV and (ii) investigate the association between country-level gender equality and individual experience of IPV, and to which extent this association explains the observed between-country differences. Methods Using data from the 2012 European Union Agency for Fundamental Rights survey on violence against women we applied MAIHDA to analyse experiences of physical and sexual IPV among 42 000 women living in the EU. We fitted three consecutive models, and calculated specific individual contextual effects (measures of association) as well as the general contextual effects (measures of variance) and the discriminatory accuracy (DA). Results Our findings show that the relationship between experiences of IPV and country-level gender equality is weak and heterogeneous. The general contextual effect is small and the DA is low, indicating that country boundaries are rather irrelevant for understanding the individual risk of IPV. Conclusions Findings from the present study do not imply that that gender equality is unimportant in relation to IPV, but rather that information on country of residence or country-level gender equality does not discriminate very well with regards to individual experiences of IPV in cross-national comparisons.

Dominant narratives of prescription opioid misuse (POM) in the U.S. have portrayed it as an issue primarily affecting White communities. In this study we explore POM as reported in data from the 2015 National Survey on Drug Use and Health, using an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). We map the risk of POM through a series of multilevel models with individuals (N = 43,409) nested within strata formed by the intersections of gender, race/ethnicity, income, and age. We find meaningful heterogeneity between and within strata. The ten strata with the greatest risk for POM were comprised of individuals identifying as White, African American, and non-White Hispanic, and included individuals of low, medium, and high income. We uncover intersections of social position with high risk for POM that are often excluded from dominant narratives, including young high-income African American women. Intersectional approaches are essential for advancing our understanding of health inequalities and unfolding epidemics such as that of POM in the U.S.

While HPV vaccination uptake in Sweden is quite high, at around 80%, vaccine hesitancy remains an issue in countries throughout Europe. The latter can be related to a contemporary context of increased contestation of expert knowledge and of a large share of information on health-related issues including vaccination today being soughtThe validated survey questionnaire was distributed to adult women in Sweden (Our results show a positive attitude toward HPV vaccination overall. Still, some degree of HPV vaccine hesitancy was indicated by 33.8% of the respondents, and more pronounced hesitancy by 7.6%. Regarding vaccination in general, a very positive attitude was indicated by 55%. HPV vaccine hesitancy was associated with low education and low income and strongly associated with a lack of confidence in healthcare and other societal institutions. It was also correlated with a self-assessed lack of access to, and ability to assess the origin, quality and reliability of, information about the HPV vaccine.Efforts to provide transparent information about HPV vaccination should be combined with healthcare providers being open to discuss vaccine concerns with patients and avoiding practices that do not promote trust.

Introduction: Antidepressants are among the most commonly prescribed drugs in Sweden. However, we lack detailed knowledge on the socioeconomic and demographic distribution of antidepressant use in the population. To fill this gap, we performed an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy. Methods: Analysing all Swedish residents older than 10 years ( n=8,190,990), we measured the absolute risk of antidepressant use across 144 intersectional strata defined by combinations of age, gender, income, country of birth and psychiatric diagnosis. We calculated the strata-specific absolute risk of antidepressant use in a series of multilevel logistic regression models. By means of the variance partitioning coefficient and the area under the receiver operating characteristic curve, we quantified the discriminatory accuracy of the intersectional contexts (i.e. strata) for discerning those who use antidepressants from those who do not. Results: The absolute risk of antidepressant use ranged between 0.93% and 24.78% among those without a psychiatric diagnosis, and between 21.41% and 77.56% among those with a psychiatric diagnosis. Both the variance partitioning coefficient of 41.88% and the area under the receiver operating characteristic curve of 0.81 were considerable. Conclusions: Besides overt psychiatric diagnoses, our study shows that antidepressant use is mainly conditioned by age, which might express the embodiment of socioeconomic conditions across the individual life course. Our analysis provides a detailed and highly discriminatory mapping of the heterogeneous distribution of antidepressant use in the Swedish population, which may be useful in public health management.

BackgroundIntersectionality theory combined with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can facilitate our understanding of health disparities. This enables a more precise application of proportionate universalism for resource allocation in public health. Analyzing self-rated general health 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. MethodsWe analyzed responses (n=133,244) to 14 consecutive National Public Health Surveys conducted in Sweden in 2004–2016 and 2018. Applying AIHDA, we investigated the risk of bad self-rated general health across 12 intersectional strata defined by gender, income and migration status, adjusted by age and survey year. We calculated prevalence ratios (with 99% confidence intervals) to evaluate between-strata differences, using native men with high income as the comparison reference. We calculated the area under the receiver operating characteristic curve (AUC) to evaluate the discriminatory accuracy of the intersectional strata. ResultsThe analysis of intersectional strata showed a clear social gradient where the risk of bad self-rated health among immigrated women with low income was six times higher (PR 6.01 [99% CI 5.32–6.79]) than that of native men with high income. A large degree of heterogeneity was present, however, as the discriminatory accuracy of the intersectional strata for identifying individuals according to their self-assessed general health status was relatively low (AUC=0.674).ConclusionsAn intersectional AIHDA approach provides more precise information on the distribution of bad self-assessed general health in the population and could thus guide public health interventions according to the principle of proportionate universalism.

Despite being rated as some of the world’s most gender equal countries, Sweden and neighboring Nordic nations show high rates of intimate partner violence against women (IPVAW). As the news media contribute to the shaping of public attitudes, this article pursues a two-step discourse analysis of how IPVAW was represented in seven Swedish newspapers during 2018. Although an individualistic discourse on IPVAW was found to be most prevalent, articles where perpetrators were presented as non-Swedish more frequently contained a structural framing of IPVAW. This confirms previously noted tendencies toward individualization and othering of IPVAW in Sweden.

Mental ill-health has been termed the pandemic of the 21st century, and a large share of those exposed do not receive treatment. Many people with depression, anxiety and other mental health problems consult complementary or alternative medicine (CAM), and CAM is used in conventional psychiatric care, in Sweden and in other countries. However, the extent to which CAM is used in psychiatric care, and for what purposes, are largely unknown. This study is based on a survey distributed to all heads of regional, municipal, private and governmental health care units treating persons with psychiatric symptoms across Sweden in 2019. CAM was reportedly used by 62% of the 489 responding health care units, for symptoms including anxiety, sleep disturbances and depression. Main motivations for CAM use were symptom relief, meeting patients' requests and reduced demand for pharmaceutical medication. Very few respondents reported side effects. The most common reason for interrupting CAM use at a unit was a lack of trained professionals. This study confirms the need for further research about CAM, and for CAM education and training among healthcare professionals.

Socioeconomic, ethnic and gender disparities in Chronic Obstructive Pulmonary Disease (COPD) risk are well established but no studies have applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) within an intersectional framework to study this outcome. We study individuals at the first level of analysis and combinations of multiple social and demographic categorizations (i.e., intersectional strata) at the second level of analysis. Here we used MAIHDA to assess to what extent individual differences in the propensity of developing COPD are at the intersectional strata level. We also used MAIHDA to determine the degree of similarity in COPD incidence of individuals in the same intersectional stratum. This leads to an improved understanding of risk heterogeneity and of the social dynamics driving socioeconomic and demographic disparities in COPD incidence. Using data from 2,445,501 residents in Sweden aged 45–65, we constructed 96 intersectional strata combining categories of age, gender, income, education, civil- and migration status. The incidences of COPD ranged from 0.02% for young, native males with high income and high education who cohabited to 0.98% for older native females with low income and low education who lived alone. We calculated the intra-class correlation coefficient (ICC) that informs on the discriminatory accuracy of the categorizations. In a model that conflated additive and interaction effects, the ICC was good (20.0%). In contrast, in a model that measured only interaction effects, the ICC was poor (1.1%) suggesting that most of the observed differences in COPD incidence across strata are due to the main effects of the categories used to construct the intersectional matrix while only a minor share of the differences are attributable to intersectional interactions. We found conclusive interaction effects. The intersectional MAIHDA approach offers improved information to guide public health policies in COPD prevention, and such policies should adopt an intersectional perspective., Highlights • We use multilevel analysis of individual heterogeneity and discriminatory accuracy. • There is a clear difference in COPD incidence between intersectional strata. • Intersectionality improves mapping of socioeconomic differences in COPD incidence. • Preventive measures should be based on intersectional rather than classic analyses.

Background: Research has long suggested that a large and possibly growing number of people use complementary or alternative medicine (CAM). However, in many countries, such as Sweden, national and regional research on CAM use is still very limited. Existing prevalence studies are few and characterized by low comparability. This study aims to contribute towards addressing this knowledge gap. Methods: A web-based survey measured the use of and attitude towards CAM and conventional medicine in the southernmost Swedish province of Scania, while taking part in the development of a measurement tool for the standardized study of CAM use within the European Union (EU; I-CAM-Q). Results: 71% of the respondents (n = 1,534) reported having used some form of CAM in the past year. CAM consumption here includes visits to CAM providers, use of natural remedies, and use of self-help methods. Reported use was more common among women, younger age groups, and people with tertiary education. 69% of the respondents stated that collaboration between conventional medicine and complementary medicine should increase. The survey's response rate was 31%. Conclusions: The study confirms that CAM forms a considerable part of the health care offered to and used by the population. In the face of the existing lack of national and regional data on CAM usage, it affirms the importance of furthered investigation of CAM consumption, policy, practice, regulation, and education.

The global public health problem of intimate partner violence against women (IPVAW) is typically tied to gender inequality. Contrary to what would be expected, however, a 2012 survey conducted by the European Union Agency for Fundamental Rights (FRA) showed lifetime prevalence rates of IPVAW in the Nordic countries which were among the highest of the 28 EU member states, despite these countries being rated as some of the most gender‐equal in the world. The aim of this article is to enable a furthered understanding of this Nordic Paradox through providing an overview of knowledge about IPVAW in Sweden in relation to the apparent paradox. It assembles information on IPVAW prevalence, on Sweden's legal and policy framework, on perceived remaining challenges and limitations in responses to IPVAW, and on potential explanations for the Nordic Paradox as expressed in previous research. We conclude that a clear resolution to the Nordic Paradox has not yet been established. Further research is therefore needed. (Less)

ObjectiveInvestigating demographic and socioeconomic factors as intersecting rather than as separate dimensions may improve our understanding of the heterogeneous distribution of type 2 diabetes in the population. However, this complexity has scarcely been investigated and we still do not know the accuracy of these factors for predicting type 2 diabetes. Improved understanding of the demographic and socioeconomic disparities predicting type 2 diabetes risk in the population would contribute to more precise and effective public health interventions.Research design and methodsWe analyzed the risk of type 2 diabetes among 4 334 030 individuals aged 40–84 years who by 2010 had resided in Sweden for at least 5 years. We stratified the study population into 120 strata defined by categories of age, gender, income, education, and immigration status. We calculated measures of absolute risk (prevalence) and relative risk (prevalence ratio), and quantified the discriminatory accuracy of the information for predicting type 2 diabetes in the population.ResultsThe distribution of type 2 diabetes risk in the population was highly heterogeneous. For instance, immigrated men aged 70–79 years with low educational achievement and low income had a risk around 32 times higher than native women aged 40–49 years with high income and high educational achievement (ie, 17.6% vs 0.5%). The discriminatory accuracy of the information was acceptable.ConclusionA more detailed, intersectional mapping of socioeconomic and demographic distribution of type 2 diabetes can assist in public health management aiming to reduce the prevalence of the disease.

BackgroundIn 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 findingsUsing 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.ConclusionsThe 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.

The discipline of epidemiology, which holds major influence on public health policy as well as on clinical medical practice, has in recent decades to a large extent been concerned with the identification of factors and markers of risk for disease. Much health information and intervention is thus informed by a wealth of studies on a variety of risk factors, of which the individual is encouraged to keep informed and to be responsible about. Meanwhile, risk factor epidemiology has been subject to intense debate, both within and outside the discipline. The following review offers an overview of critical intradisciplinary debates. It then opens discussion on three partially overlapping areas where social theory has been called upon to contribute to epidemiological inquiry, namely analysis of macro-social determinants of health and disease, of categories of human difference and of embodiment. The review ends with, and is motivated by, a plea for further integration of and dialogue between epidemiology and social theory.

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.

Intersectionality theory calls for the understanding of race/ethnicity, sex/gender and class as interlinked. Intersectional analysis can contribute to public health both through furthering understanding of power dynamics causing health disparities, and by pointing to heterogeneities within, and overlap between, social groups. The latter places the usefulness of social categories in public health under scrutiny. Drawing on McCall we relate the first approach to categorical and the second to anti-categorical intersectionality. Here, we juxtapose the categorical approach with traditional between-group risk calculations (e.g. odds ratios) and the anti-categorical approach with the statistical concept of discriminatory accuracy (DA), which is routinely used to evaluate disease markers in epidemiology. To demonstrate the salience of this distinction, we use the example of racial/ethnic identification and its value for predicting influenza vaccine uptake compared to other conceivable ways of organizing attention to social differentiation. We analyzed data on 56,434 adults who responded to the NHFS. We performed logistic regressions to estimate odds ratios and computed the area under the receiver operating characteristic curve (AU-ROC) to measure DA. Above age, the most informative variables were education and household poverty status, with race/ethnicity providing minor additional information. Our results show that the practical value of standard racial/ethnic categories for making inferences about vaccination status is questionable, because of the high degree of outcome variability within, and overlap between, categories. We argue that, reminiscent of potential tension between categorical and anti-categorical perspectives, between-group risk should be placed and understood in relationship to measures of DA, to avoid the lure of misguided individual-level interventions.

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., Highlights • There is a plethora of differences in “average” risk between exposed and unexposed groups of individuals. • Individual heterogeneity around average values is seldom considered in Public Health. • Measures of discriminatory accuracy (DA) informs on the underlying individual heterogeneity. • Most know risk factors and other categorizations associated with diseases have low DA. • We need a fundamental change in the way we investigate risk factors and other categorizations in Public Health.

Critical debates within the science of (social) epidemiology concern the relative lackof social theory in epidemiological research and the low discriminatory accuracy (DA)of much epidemiological knowledge on factors and markers of risk for disease.Against this background, this thesis integrates intersectionality theory intoepidemiological study. The purposes are to improve the understanding ofheterogeneities in population groups and thus increase DA, and to incorporate atheoretical framework that directs attention toward power dynamics driving theproduction of health disparities as well as toward their measurement. Anintersectionality perspective is incorporated into empirical study of risk for ischemicheart disease in Sweden, and of influenza vaccination uptake in the US. A categoricalintersectionality perspective is operationalized through assessment of difference inaverage risk between intersectional strata. The measurement of the DA of the socialand racial/ethnic categorizations used is aligned to an anti-categorical intersectionality perspective, as this DA is found to be low due to heterogeneities within and/or overlaps between groups.Despite the integration of intersectionality theory, the DA of the social andracial/ethnic categories under study remains low. Such measurements of low DApoint to a current limitation in knowledge about causation mechanisms andindividual heterogeneity in (social) epidemiology. This project has therefore beenpartially driven by an interest in other possible ontological ways of understandinghealth, risk and prevention of disease, found in complementary or alternative forms ofmedicine (CAM). The thesis includes a pilot study measuring the use of, andattitudes towards, CAM and conventional medicine in Skåne, the southernmostprovince of Sweden.

Intimate partner violence against women (IPVAW) is a major public health problem in countries around the world, including the Nordic region. Contrary to what would be expected, as the Nordic countries are rated among the most gender equal in the world, survey data suggests that the lifetime prevalence rates of IPVAW in Sweden and neighboring Nordic countries are among the highest in the EU. This phenomenon, which has been termed the Nordic paradox, requires elucidation. The aim of this review is to explore what previous qualitative studies, based on interviews with or field observations of victims, perpetrators, or professionals working in the area, primarily in Sweden, have to teach us about the nature of this paradox. Three interrelated themes are discussed. The first is how gender equality is perceived and addressed as linked, or not, to IPVAW in Swedish research and practice. The second is how violence tends to be othered, for example, through assumptions that violence is perpetrated by foreign rather than Swedish men. The third is how causal mechanisms of IPVAW have been described, typically with reference to norms and dynamics of masculinity, femininity, and heterosexual interaction.