Juan Merlo

Juan Merlo
Lund University | LU · Department of Clinical Sciences, Malmö

Tenure Professor, MD, PhD

About

327
Publications
34,980
Reads
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12,544
Citations
Additional affiliations
January 2010 - March 2010
Statens folkhälsoinstitut
Statens folkhälsoinstitut
Position
  • Consultant
June 2006 - present
Region Skåne
Position
  • Senior Consultant in Social Medicine
June 2006 - present
Faculty of Medicine, Lund University, Malmö, Sweden
Position
  • Professor (Full)

Publications

Publications (327)
Article
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 demon...
Article
In this issue of the Journal, Dundas et al. (Am J Epidemiol. 2014;000(00):000-000) apply a hitherto infrequent multilevel analytical approach: multiple membership multiple classification (MMMC) models. Specifically, by adopting a life-course approach, they use a multilevel regression with individuals cross-classified in different contexts (i.e., fa...
Article
We performed a multilevel analysis (including individuals, households, census tracts, municipalities and provinces) on a 10% sample (N=230,978) from the Longitudinal Database of the Andalusian Population (LDAP). We aimed to investigate place effects on 8-year individual mortality risk. Moreover, besides calculating association (yielding odds ratios...
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Background and Aim Many multilevel logistic regression analyses of “neighbourhood and health” focus on interpreting measures of associations (e.g., odds ratio, OR). In contrast, multilevel analysis of variance is rarely considered. We propose an original stepwise analytical approach that distinguishes between “specific” (measures of association) an...
Article
Previous work identifying determinants of co-occurrence of behavioral risk factors have focused on their association with individuals' characteristics with scant attention paid to their relationship to contextual factors. Data came from 21,007 individuals ≥15 years of age who participated in the cross-sectional 2011–2012 Spanish National Health Sur...
Article
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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 intersecti...
Article
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Objectives: To determine the general contextual effect of the department in the variation of Cesarean section in Colombia in 2016, and their individual and contextual related factors. Methods: Cross-sectional study based on a birth cohort. We used the birth certificate database from January 1 to December 31, 2016. Three multilevel logistic models...
Article
Background In a nationwide cohort the potentially protective association between allergy and complicated appendicitis was analysed, and the influence of seasonal antigens, antihistamine treatment, and timing of allergy onset assessed. Methods Some 1 112 571 children born between 2000 and 2010 were followed from birth until the end of 2014. A cross...
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Objectives From a reproductive justice framework, we aimed to investigate how a possible association between hormonal contraceptive (HC) and antidepressants use (as a proxy for depression) is distributed across intersectional strata in the population. We aimed to visualise how intersecting power dynamics may operate in combination with HC use to in...
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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 Ana...
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I denna debattartikel argumenterar vi för att socioekonomiska riskfaktorer bör beaktas i fler kvalitetsregister.
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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 per...
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Objectives Socioeconomic disparities in smoking prevalence remain a challenge to public health. The objective of this study was to present a simple methodology that displays intersectional patterns of smoking and quantify heterogeneities within groups to avoid inappropriate and potentially stigmatising conclusions exclusively based on group average...
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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...
Article
We estimated the discriminatory power of area of residence (census tract) on the prevalence of main risk factors for chronic diseases. Results, based on a sample of 21,007 participants from the 2011–2012 National Health Survey of Spain, show a differential influence of the geosocial environment on the four health risk factors. Accounting for census...
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Intimate partner violence against women (IPVAW) poses severe threats to women’s health and rights. This study investigates the role of country con- text 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...
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Objective To describe a novel strategy, Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate hospital performance, by analysing differences in 30-day mortality after a first-ever acute myocardial infarction (AMI) in Sweden. Design Cross-classified study. Setting 68 Swedish hospitals. Participants 43 24...
Article
Background Heavy drinking (HD) and binge drinking (BD) exhibit marked differences in their relationships with contextual‐level factors imbedded in geographical areas of residence. The objective is to identify sociodemographic factors, both at the individual and at the contextual level, associated with these 2 main hazardous consumption patterns. M...
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Sociodemographic inequalities in the occurrence of low back pain (LBP) are well-studied. This study aimed to examine complex sociodemographic inequalities in the risk LBP consultation in the population from a socioeconomical intersectional perspective. Using register data, we identified 458,852 individuals aged 35-75 years residing in Skåne in 2013...
Preprint
Full-text available
Background Intersectionality 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 h...
Preprint
Full-text available
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 inters...
Preprint
Full-text available
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 inters...
Article
Full-text available
Background: While discontinuation of COPD maintenance medication is a known problem, the proportion of patients with discontinuation and its geographical and sociodemographic distribution are so far unknown in Sweden. Therefore, we analyse this question by applying an innovative approach called multilevel analysis of individual heterogeneity and d...
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Background One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variati...
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A first step when fitting multilevel models to continuous responses is to explore the degree of clustering in the data. Researchers fit variance-component models and then report the proportion of variation in the response that is due to systematic differences between clusters. Equally they report the response correlation between units within a clus...
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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...
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Aims: Experiencing an acute myocardial infarction (AMI) is a life-threatening event and use of statins can reduce the probability of recurrence and improve long term survival. However, the effectiveness of statins in the real-world setting may be lower than the reported efficacy in randomized clinical trials. Therefore, we aimed to investigate whe...
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Background Hospital performance, presented as the comparison of average measurements, dismisses that hospital outcomes may vary across types of patients. We aim at drawing out the relevance of accounting for patient heterogeneity when reporting on hospital performance. Methods An observational study on administrative data from virtually all 2009 h...
Preprint
Full-text available
A first step when fitting multilevel models to continuous responses is to explore the degree of clustering in the data. Researchers fit variance-component models and then report the proportion of variation in the response that is due to systematic differences between clusters or equally the response correlation between units within a cluster. These...
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Full-text available
Objective Investigating 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 di...
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Background and objectives: Despite the biological plausibility of the association between heavy metal exposure and mental health disorders, epidemiological evidence remains scarce. The objective was to estimate the association between heavy metals and metalloids in soil and the prevalence of mental disorders in the adult population of Spain. Meth...
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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 genera...
Article
Intersectional MAIHDA involves applying multilevel models in order to estimate intercategorical inequalities. The approach has been validated thus far using both simulations and empirical applications, and has numerous methodological and theoretical advantages over single-level approaches, including parsimony and reliability for analyzing high-dime...
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Background: Thirty-day mortality after hip fracture is widely used when ranking hospital performance, but the reliability of such hospital ranking is seldom calculated. We aimed to quantify the variation in 30-day mortality across hospitals and to determine the hospital general contextual effect for understanding patient differences in 30-day mort...
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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)....
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The epidemiological analysis of geographical inequalities in individual outcomes is a fundamental theme in public health research. However, many traditional studies focus on analysing area differences in averages outcomes, disregarding individual variation around such averages. In doing so, these studies may produce misleading information and lead...
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The high prevalence of intimate partner violence against women (IPVAW) in countries with high levels of gender equality has been defined as the “Nordic paradox”. In this study we compared physical and sexual IPVAW prevalence data in two countries exemplifying the Nordic paradox: Sweden (N = 1483) and Spain (N = 1447). Data was drawn from the Europe...
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Background Studies assessing institutional performance regarding quality of care are frequently performed using single-level statistical analyses investigating differences between provider averages of various quality indicators. However, such analyses are insufficient as they do not consider patients’ heterogeneity around those averages. Hence, we...
Article
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 inter-sectionali...
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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 intersectionalit...
Data
Estimated differences between intersectional strata average BMI values and the overall population average BMI. Predicted strata effects from both models are sorted by values of model 1 from the lowest to the highest values. Values considered conclusive are specified with *. Shaded cells represent the minimum and maximum values of the predicted stra...
Article
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Purpose: To identify overuse of methylphenidate and to investigate patterns of overuse in relation to sociodemographic and clinical characteristics. Patients and methods: Swedish national, pharmacy dispensing data were analyzed for all 56,922 individuals aged 6-79 years, who filled a methylphenidate prescription between 2010 and 2011. Overuse was...
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Background Intimate partner violence against women (IPVAW) is a global and preventable public health problem. Public attitudes, such as victim-blaming, are important for our understanding of differences in the occurrence of IPVAW, as they contribute to its justification. In this paper, we focus on victim-blaming attitudes regarding IPVAW within the...
Article
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To be relevant for public health, a context (e.g., neighborhood, school, hospital) should influence or affect the health status of the individuals included in it. The greater the influence of the shared context, the higher the correlation of subject outcomes within that context is likely to be. This intra-context or intra-class correlation is of su...
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The burden of depression and anxiety disorders is greater in women, and female sex hormones have been shown to affect mood. Psychological side effects of hormonal contraception (HC) are also a common complaint in the clinic, but few previous studies have investigated this subject. We therefore wanted to investigate whether use of HC was associated...
Data
Association between use of different hormonal contraceptives and a first time use of psychotropic drugs. Odds ratios (OR) with 95% confidence intervals (CI) and area under the curve (AUC), stratified on adolescents and adults, for the association between use of different hormonal contraceptives and a first time use of psychotropic drugs within a on...
Data
Sensitivity analysis. Sensitivity analysis excluding women with certain diagnosis. Odds ratios (OR) with 95% confidence intervals (CI) for the use of hormonal contraceptives (HC) (ATC G02BA, G02BB, G03AA, G03AB, G03AC) and use of psychotropic drugs (ATC N05B, N05C, N06A) within a one-year follow-up after baseline (2010–2011) in 815 662 Swedish wome...
Data
Prevalence of different hormonal contraceptive methods in our cohort. Prevalence of different hormonal contraceptive methods in 2010–2011 by contraceptive type in our cohort of 815 662 Swedish women aged 12–39. All combined HC contain estrogen in addition to progesterone, except for G03AA14 (Zoely), which contains estradiol. (DOCX)
Data
AUC change. Change in area under the receiver operating curve (AUC) with addition of hormonal contraceptive use to a model containing individual predictors. Age stratified change in the area under the curve for use of psychotropic drugs when adding information on use of hormonal contraceptives (ATC G02BA, G02BB, G03AA, G03AB, G03AC) to a model alre...
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Chronic handicap in early life may have a long-term impact on children’s psychosocial well-being. Here, we investigated whether Brachialis Plexus Birth Injury (BPBI)—an unpredictable injury at birth—is associated with worse mental health later on, as indicated by prescription and use of psychotropic drugs in adolescence. We explored further whether...
Article
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The ability to draw statistical inferences from test results may be generally limited among physicians. A new way of presenting statistics, called natural frequencies, has been shown to improve this ability. The current study is the first to investigate this effect in Sweden, involving senior medical students. An intra-individual cross-over design...
Article
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 comb...
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Purpose: The purpose of this study is to investigate the relationship between sociodemographic factors and pharmacy dispensing of medications for erectile dysfunction (ED) in the general population of middle-aged and elderly men. By considering a number of medical conditions that could promote or contraindicate use of ED medication, the analysis c...
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Purpose To evaluate the general contextual effect (GCE) of the hospital department on one-year mortality in Swedish and Danish patients with heart failure (HF) by applying a multilevel analysis of individual heterogeneity. Methods Using the Swedish patient register, we obtained data on 36,943 patients who were 45–80 years old and admitted for HF t...
Article
Background: Analyzing Body Mass Index as a didactical example, the study by Evans, Williams, Onnela, and Subramanian (EWOS study) introduce a novel methodology for the investigation of socioeconomic disparities in health. By using multilevel analysis to model health inequalities within and between strata defined by the intersection of multiple soc...
Article
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Multilevel data occur frequently in many research areas like health services research and epidemiology. A suitable way to analyze such data is through the use of multilevel regression models. These models incorporate cluster-specific random effects that allow one to partition the total variation in the outcome into between-cluster variation and bet...
Research
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Enkätstudie om användning av samt inställning till alternativ eller komplementär medicin (AKM) i Skåne under 2015
Article
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Background Preeclampsia (PE) is associated with a high risk of perinatal morbidity and mortality. However, there is no consensus in the definition of high-risk women. Aim To question current definition of high PE risk and propose a definition that considers individual heterogeneity to improves risk classification. Methods A stratified analysis by...
Data
Discriminatory accuracy of specific bivariate combinations of risk factor for preeclampsia in the overall population of pregnancies without major risk factors. (DOCX)
Data
Discriminatory accuracy of specific bivariate combinations of risk factor for preeclampsia in multiparous and primiparous pregnancies without major risk factors. (DOCX)
Data
Characteristics of included and missing data among multiparous and primiparous women. (DOCX)
Data
Bivariate interaction effect between parity and each risk factors in multiple logistic regression models. One interaction term was included in each model. Previous preeclampsia was considered a dummy variable with three categories: yes or no in multiparous and no applicable in primiparous. (DOCX)
Data
Association between number of clinical risk factor and the risk of PE in both primiparous and multiparous adjusted by smoking, education and family situation. (DOCX)
Article
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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 contr...