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Background The aim of this paper is to examine the link between severity in exposure to parental problem drinking in a Swedish national population sample of children aged 15–16 years. Specifically, we assessed whether the risk of poor health, poor relationships and a problematic school situation increase with severity in exposure to parental problem drinking. Methods National population survey from 2017 with a representative sample of 5 576 adolescents born in 2001. Logistic regression models were used to estimate odds ratios (ORs) with 95% confidence intervals (95% CIs). A short version of The Children of Alcoholics Screening Test, CAST-6, was used to identify children with problem-drinking parents. Health status, social relations and school situation were assessed by well-established measures. Results The risk of having poor health, poor school performance and poor social relations increased with severity of parental problem drinking. The risk was lowest among children least severely affected (Crude models ranged from OR: 1.2, 95% CI 1.0–1.4 to OR: 2.2, 95% CI 1.8–2.6) and highest among children most severely affected (Crude models ranges from OR: 1.7, 95% CI 1.3–2.1 to OR: 6.6, 95% CI 5.1–8.6). The risk became lower when adjusting for gender and socioeconomic position but were still higher compared to children without problem-drinking parents. Conclusions Appropriate screening and intervention programs are necessary for children with problem-drinking parents especially when exposure is severe but also at mild forms of exposure. [ABSTRACT FROM AUTHOR]

There are three main areas of social and economic policy that influence health: the welfare state, industrial organization (unions), and labor regulation. Public health literature and analysis traditionally focuses on the taxing and spending of the welfare state. This paper presents highlights from the extensive literature in political economy in order to argue that industrial relations and workplace regulation are political and crucial to public health. The routes by which they influence public health include wage inequality, workplace health and safety, political engagement and investment in human capital. The magnitude of impact can be impressive: the United Kingdom's taxation and spending have about as much redistributive impact as that of Sweden, but that is not enough to compensate for the inequality produced by the UK's liberal labor market. The trend across wealthy countries has been to weaker unions and less workplace regulation and we can see this as a likely cause of public health problems and health inequalities into the future. [ABSTRACT FROM AUTHOR]

Background: Gambling products differ in terms of their harm potential. Products are also constantly developing and changing. However, little research has addressed changes and trends in the types of gambling that are associated with harms. The current study explores trends in the gambling product categories identified as harmful in longitudinal helpline data from three Nordic countries. Methods: We use data collected by national helplines in Denmark (StopSpillet), Finland (Peluuri) and Sweden (Stödlinjen) in their daily operations (N = 46 646). The data consist of information collected on gamblers and concerned significant others who have contacted these helplines between January 2019 and December 2022. We analyse which gambling products are mentioned as harmful by clients. The analysis uses linear regression with the interaction term (country) times time regressed over the outcome variable (proportion per month). Results: The results show that an increased share of contacts concern online gambling. Online casino products have become the most harmful category across contexts. The share of reported harms from online betting and new emerging online forms is also increasing. The share of land-based products as a reported source of harms has decreased across 2019-22. Conclusions: The results suggest that online gamlbing environments, and particularly online casino products, are associated with increasing harms to help-seekers. The harmfulness of different gambling products may not be stable, but change over time. Further harm prevention efforts are needed to address the online gambling field, including emerging formats. [ABSTRACT FROM AUTHOR]

Background The European Union has used Healthy Life Years (HLY) as an indicator to monitor the health of its aging populations. Scholarly and popular interest in HLY across countries has grown, particularly regarding the ranking of countries. It is important to note that HLY is based on self-assessments of activity limitations, raising the possibility that it might be influenced by differences in health reporting behaviours between populations, a phenomenon known as differential item functioning (DIF). Methods We estimated DIF-adjusted HLY at age 50 for Belgium, France, Germany, Greece, Italy, the Netherlands, Spain, and Sweden to determine the extent to which differences in HLY might be influenced by reporting heterogeneity across countries. We used anchoring vignettes, taken from the 2004 Survey of Health, Ageing and Retirement in Europe, to estimate DIF-adjusted prevalence rates of activity limitations measured by the Global Activity Limitations Indicator (GALI). The Sullivan method was used to calculate DIF-adjusted HLY. Results Changes in HLY before and after adjustment ranged from a 1.20-year decrease for men in Italy to a 1.61-year increase for women in Spain. Adjustment for DIF produced changes in the rankings of the countries by HLY, with upward and downward movements of up to three positions. Conclusion Our results show that DIF is likely to affect HLY estimates, thereby posing a challenge to the validity of comparisons of HLY across European countries. The findings suggest that HLY should be used to monitor population health status within a country, rather than to make comparisons across countries. [ABSTRACT FROM AUTHOR]

Background Individuals of lower socioeconomic status generally have higher healthcare expenditures than individuals of higher socioeconomic status. However, little is known about how expenditures are distributed across socioeconomic groups over a lifetime, once accounting for differences in life expectancy. This study describes how lifetime healthcare expenditures are distributed across age, sex and socioeconomic groups in Sweden while adjusting for differences in life expectancy. Methods Healthcare utilization from 2016 were linked to demographic and socioeconomic data for a random sample of individuals aged 20 and above in the four largest Swedish regions (n  = 440 659). Mortality data were used to estimate income- and sex-specific survival rates. Expected lifetime healthcare expenditures were estimated by combining survival rates with mean healthcare expenditures over age, by sex, and income quintile. Results We find that expected lifetime healthcare expenditures are highest among the first (lowest) income quintile despite their evident lower life expectancy. Expected lifetime expenditures were 17.9% (16.8%) higher in the first income quintile compared to the fifth (highest) quintile for women (men). Individuals in the first income quintile had higher expected lifetime expenditures for all care categories except for primary care. Conclusion We conclude that despite a lower life expectancy, the quintile of the lowest socioeconomic status still had higher lifetime healthcare expenditures. [ABSTRACT FROM AUTHOR]

Background The coronavirus disease 2019 (COVID-19) pandemic and measures to prevent the spread of the virus challenged public health practice at the local level in Sweden. The objective of this study was to explore the impact of the pandemic on the prevention of alcohol, drugs and tobacco (ADT) in Sweden during 2020–21 considering socio-demographic context. Methods Data were collected through the Public Health Agency's survey on ADT prevention in Swedish municipalities (N  = 290). This study used data from 2020 and 2021, with a response rate of 90% and 88%, respectively. Survey data were analyzed in logistic regression models (odds ratios, P  < 0.05, 95% confidence intervals) against variables of education level, income level and population size from national registers. Results A majority (n  = 198, 76%) of the municipalities reported a decrease in ADT prevention during the pandemic. No correlation between the decrease in ADT prevention and socio-demographic conditions was detected. A majority (2020: n  = 165, 63%; 2021: n  = 174, 68%) of the municipalities also reported that ADT prevention was adapted, however less common in smaller municipalities and municipalities where residents had lower levels of education and lower incomes. Conclusion ADT prevention carried out by municipalities in Sweden was initially (2020) deeply affected by the preventive strategies against COVID-19. Adaptation of activities was less common in municipalities with more vulnerable socio-demographic situation. In policy, practice and research, the findings are important not only for continued progress on the national goal of equity in health but also for preparedness for future crises. [ABSTRACT FROM AUTHOR]

Background Estimating excess mortality and years of life lost (YLL) attributed to coronavirus disease 19 (COVID-19) infection provides a comprehensive picture of the mortality burden on society. We aimed to estimate the impact of the COVID-19 pandemic on age- and sex-specific excess mortality and YLL in Sweden during the first 17 months of the pandemic. Methods In this population-based observational study, we calculated age- and sex-specific excess all-cause mortality and excess YLL during 2020 and the first 5 months of 2021 and cause-specific death [deaths from cardiovascular disease (CVD), cancer, other causes and deaths excluding COVID-19] in 2020 compared with an average baseline for 2017–19 in the whole Swedish population. Results COVID-19 deaths contributed 9.9% of total deaths (98 441 deaths, 960 305 YLL) in 2020, accounting for 75 151 YLL (7.7 YLL/death). There were 2672 (5.7%) and 1408 (3.0%) excess deaths, and 19 141 (3.8%) and 3596 (0.8%) excess YLL in men and women, respectively. Men aged 65–110 years and women aged 75–110 years were the greatest contributors. Fewer deaths and YLL from CVD, cancer and other causes were observed in 2020 compared with the baseline adjusted to the population size in 2020. Conclusions Compared with the baseline, excess mortality and YLL from all causes were experienced in Sweden during 2020, with a higher excess observed in men than in women, indicating that more men died at a younger age while more women died at older ages than expected. A notable reduction in deaths and YLL due to CVD suggests a displacement effect from CVD to COVID-19. [ABSTRACT FROM AUTHOR]

Background To improve health, intersectoral cooperation is often advocated. However, only few studies have reported health effects of this approach. Sweden has adopted a national public health policy (NPHP), which focuses on intersectoral primary prevention of disorders and injuries. Aim To investigate the effects of the NPHP, on child and adolescent health in Sweden during the period 2000–19. Methods In the first step, the most important improvements in disorders and injuries, assessed as DALYs and incidences , were identified using the GBD Compare database. In the second step, primary prevention methods for these disorders and injuries were identified. In the third step, the relative importance of various government agents for these preventive measures was assessed using Google searches. Results Out of 24 groups of causes of disease or injury, only two groups demonstrated an incidence decrease: neoplasms and transport injuries. Leukaemia neoplasms might be prevented by reducing parental smoking, reducing outdoor air pollution and having the mother take folate supplements before getting pregnant. Transport injuries might be prevented by speed restrictions, and physically separating pedestrians from vehicle transport. Most of the primary prevention work was done by government agencies, like the Swedish Transport Agency, which worked independently of the National Institute of Public Health. Conclusion Governmental agencies outside the health carried out most of the effective primary preventive efforts, almost independently of the NPHP. [ABSTRACT FROM AUTHOR]

Background: OECD countries over the past two decades have implemented a range of labour market integration initiatives to improve the employment chances of disabled and chronically ill individuals. This article presents a systematic review and evidence synthesis on effectiveness of government interventions to influence employers’ employment practices concerning disabled and chronically ill individuals in five OECD countries. A separate paper reports on interventions to influence the behaviour of employees. Methods: Electronic and grey literature searches to identify all empirical studies reporting employment effects and/or process evaluations of government policies aimed at changing the behaviour of employers conducted between 1990 and 2008 from Canada, Denmark, Norway, Sweden and the UK. Results: Few studies provided robust evaluations of the programmes or their differential effects and selection of participants into programmes may distort the findings of even controlled studies. A population-level effect of legislation to combat discrimination by employers could not be detected. Workplace adjustments had positive impacts on employment, but low uptake. Financial incentives such as wage subsidies can work if they are sufficiently generous. Involving employers in return-to-work planning can reduce subsequent sick leave and be appreciated by employees, but this policy has not been taken up with the level of intensity that is likely to make a difference. Some interventions favour the more advantaged disabled people and those closer to the labour market. Conclusions: Future evaluations need to pay more attention to differential impact of interventions, degree of take-up, non-stigmatizing implementation and wider policy context in each country. [ABSTRACT FROM AUTHOR]

Background: Revising existing health related-quality of life (HRQoL) instruments used among adults with the intention of making them child-friendly enables the collection of similar HRQoL data in children, adolescents and adults. The aim of this article is to describe and discuss the development process of a Swedish child-friendly pilot version of the EQ-5D instrument. Methods: We modified the existing Swedish EQ-5D adult version to make it child-friendly. Within a multidisciplinary research group, we investigated linguistic and interpretation issues by performing face-to-face and group interviews with children and adolescents aged 6–17 years. Results: The first modification of the adult language was to change single words into words intelligible to and used by children [e.g. changing ‘depression’ (depression) into ‘ledsen’ (sad)]. The second related to whole expressions (using verb-form in the headings of dimensions). Conclusion: The advantage of being able to collect much the same data from children and adolescents, for example in population surveys covering all ages and in chronic childhood diseases, as for adults might outweigh possible disadvantages of modifying existing HRQoL instruments. The Swedish child-friendly EQ-5D pilot version resulting from this development process is further tested for feasibility and construct validity in a clinical interview study; initial results are reported in a subsequent paper. [ABSTRACT FROM AUTHOR]

Background: The incidence of skin cancer has had a rapid increase in Sweden during the last 20 years. Sun exposure is an important preventable risk factor for skin cancer. It is essential to develop interventions to change people's exposure to the sun. The perception of own susceptibility to harm is essential in theories about self-protective behaviour. The aim of the present paper was to examine the associations between different risk perceptions, sun-related behaviour, readiness to change, and optimism bias. Method: A total of 722 visitors of a mobile skin cancer screening unit answered a questionnaire in the summer of 2001. The campaign was conducted at five different locations in Sweden. Results: The participants in this study seemed to have realistic believes about the contribution of solar radiation to the risk of developing skin cancer, however, they seriously underestimated skin cancer incidence in the population and the impact of skin cancer on general health. Conclusion: People concerned about skin cancer seem to be aware of the fact that sun exposure is an important risk factor for skin cancer, but they fail to use this information in a consistent way to formulate a judgment of their own vulnerability to harm. People need to be informed about the high incidence of skin cancer, the personal risk factors of skin cancer, and the fact that unintentional as well as intentional sun exposure increases the risk of developing skin cancer. [ABSTRACT FROM AUTHOR]

This paper describes how the Östergötland County Council health policy and targets were developed and implemented in collaboration with municipalities as well as other sectors of regional and local society. Community participation and intersectoral action is described. The strategy for implementation talks about the local community as the basis for activities supported by education, training and information. Building alliances and collaborating with both official and voluntary organisations as well as with the general public has been the county council strategy all the way from policy formulation to implementation of local health activities. [ABSTRACT FROM AUTHOR]

Background The income gradient in mortality is generated through an interplay between socio-economic processes and health over the life course. International migration entails the displacement of an individual from one context to another and may disrupt these processes. Furthermore, migrants are a selected group that may adopt distinct strategies and face discrimination in the labour market. These factors may have implications for the income gradient in mortality. We investigate whether the income gradient in mortality differs by migrant status and by individual-level factors surrounding the migration event. Methods We use administrative register data comprising the total resident population in Sweden aged between 30 and 79 in 2015 (n  = 5.7 million) and follow them for mortality during 2015–17. We estimate the income gradient in mortality by migrant status, region of origin, age at migration and country of education using locally estimated scatterplot smoothing and Poisson regression. Results The income gradient in mortality is less steep among migrants compared with natives. This pattern is driven by lower mortality among migrants at lower levels of income. The gradient is less steep among distant migrants than among close migrants, migrants that arrived as adults compared with children and migrants that received their education in Sweden as opposed to abroad. Conclusions Our results are consistent with the notion that income inequalities in mortality are generated through life-course processes that may be disrupted by migration. Data restrictions prevent us from disentangling life-course disruption from selection into migration, discrimination and labour market strategies. [ABSTRACT FROM AUTHOR]

Background The Sámi are an ethnic minority and the only Indigenous people in the European Union. Population-based health studies among Sámi in Sweden are scarce and outdated. The aim of this study was to analyse the ethnic, Sámi vs. non-Sámi, health differences among men and women living in Sweden. Methods This study combined two data sources: the national Health on Equal Terms (HET) survey and a similar study conducted among the Sámi population, the SámiHET study, both carried out during spring 2021. Twelve outcomes were used to capture different aspects of the population's health organized along four dimensions: general health, physical health, mental health and lifestyle behaviours. Prevalence ratios, adjusted for age, civil status, education and income, were used as the measure of effect with 95% confidence intervals to provide inference. Analyses were disaggregated by sex. Results The prevalence of poor self-rated dental health (and chronically ill health among men), asthma and overweight were higher among the Sámi; however, the mental health outcomes were similar or lower among the Sámi participants. The Sámi ate less vegetables and fruits, but they were smoking and drinking alcohol less than the national Swedish population. These patterns were similar among both men and women. Conclusion Poor self-rated dental health, asthma, overweight and a low consumption of vegetables and fruits were a concern among the Sámi population in both men and women. These areas therefore require specific targeted interventions to decrease the observed ethnic health inequalities in Sweden. The design of this study opens the possibility for continuous monitoring of the health of the Sámi but also offers the best possible comparison with Swedish population health data. [ABSTRACT FROM AUTHOR]

Background Differences in pre-existing health conditions are hypothesized to explain immigrants' excess COVID-19 mortality compared to natives. In this study, we evaluate whether immigrants residing in Sweden before the outbreak were more likely to be hospitalized for conditions associated with severe COVID-19 disease. Methods A cohort study using population-register data was conducted with follow-up between 1 January 1997 and 31 December 2017. Poisson regression was fitted to estimate incidence rate ratio (RR) and 95% confident intervals (95% CI) for 10 causes of hospitalization. Results Compared to Swedish-born individuals, most immigrant groups showed a decreased risk of hospitalization for respiratory chronic conditions, CVD, cancer, chronic liver conditions and neurological problems. All immigrant groups had increased risk of hospitalization for tuberculosis [RR between 88.49 (95% CI 77.21; 101.40) for the Horn of Africa and 1.69 (95% CI 1.11; 2.58) for North America], HIV [RR between 33.23 (95% CI 25.17; 43.88) for the rest of Africa and 1.31 (95% CI 0.93; 1.83) for the Middle East] and, with a few exceptions, also for chronic kidney conditions, diabetes and thalassemia. Conclusions Foreign-born individuals—including origins with excess COVID-19 mortality in Sweden—did not show increased risk of hospitalizations for most causes associated with severe COVID-19 disease. However, all groups showed increased risks of hospitalization for tuberculosis and HIV and, with exceptions, for chronic kidney conditions, diabetes and thalassemia. Although studies should determine whether these health conditions explain the observed excess COVID-19 mortality, our study alerts to an increased risk of hospitalization that can be avoidable via treatment or preventive measures. [ABSTRACT FROM AUTHOR]

Background The present study examined the independent and combined effects of childhood adversity (CA) and occupational class on the risk of future labor market marginalization (LMM) in young employees in Sweden. Occupational class (non-manual/manual workers) was also explored as a potential mediator. Methods This population-based longitudinal cohort study included 556 793 employees, 19–29 years, residing in Sweden in 2009. CAs included parental death, parental mental and somatic disorders, parental separation, household public assistance, single-parent household and residential instability. Measures of LMM included long-term unemployment (LTU), long-term sickness absence (LTSA) and disability pension. Estimates of risk of each LMM measure, between 2010 and 2016 were calculated as hazard ratios (HRs) with 95% confidence intervals (CIs), using a Cox regression analysis. Results Those exposed to CA had an elevated risk for all measures of LMM. Manual workers with a history of household public assistance had the highest risk estimates compared to non-manual workers with no CAs [adjusted HR spanning from 1.59 (LTSA) to 2.50 (LTU)]. Regardless of occupational class, the risk of LMM grew higher with increasing number of CAs (e.g. adjusted HR of LMM in manual workers with 3+ CAs: 1.87, 95% CI: 1.81–1.94). These patterns persisted after adjustments for a range of confounders, including psychiatric and somatic morbidity. Last, we found a small but significant mediating effect of occupational class in the association between CA and LMM. Conclusions Information on CAs are important determinants of LMM in young adults, and especially in manual workers. [ABSTRACT FROM AUTHOR]

Background The COVID-19 pandemic has had wide effects on child health globally. Increased prevalence of childhood obesity has been observed by a number of countries during the pandemic. The absence of a formal societal lockdown during the pandemic, made Sweden stand out compared to other countries. This study aims to examine changes in BMI among preschool children in Sweden before and during COVID-19 pandemic. Methods Retrospective population-based cross-sectional study, with longitudinal follow-up for a portion of the children. The study included 25 049 children from three Swedish regions, with growth measures at 3- (n  = 16 237), 4- (n  = 14 437) and 5-years of age (n  = 11 711). Care Need Index was used as a socioeconomic parameter at health centre level. Results There was an increase in BMI in children aged three (P  = 0.028) and four (P <0.001) during the COVID-19 pandemic. Obesity in 3-year-old girls increased from 2.8% to 3.9%. Four-year-olds increased in obesity, and overweight (girls) and the prevalence of underweight decreased in boys. No change in BMI was observed in 5-year-olds. Children in areas of low socioeconomic status had higher risk of obesity. Conclusions Overweight and obesity increased among 3- and 4-year-old children in Sweden, findings that were accentuated in children attending child health centres in areas with lower socioeconomic status. The COVID-19 pandemic is likely to have affected health behaviours negatively in Swedish preschool children. Our results expose the need for extended efforts directed to prevent childhood obesity, especially targeting lower socioeconomic areas. [ABSTRACT FROM AUTHOR]

Background A growing literature finds that adult mental health worsens during economic downturns. Current insights on the relationship between macroeconomic fluctuations and psychotropic medication are based on self-reported information or aggregate measures on prescriptions. This study assesses the relationship between local macroeconomic conditions and individual use of psychotropic medication as reported in administrative registers. Methods We use local information on unemployment linked to individual-level longitudinal data on detailed psychotropic drug consumption from administrative registers, for individuals in working age (20–65) in Sweden 2006–13. Any psychotropic medication uptake and the related number of redeemed prescriptions are the primary outcomes. Mortality is considered a secondary outcome. Results Among young men (aged 20–44) and older women (aged 45–65), we find reduced use of psychotropic medication (2–4% compared to the mean) when the local labor market conditions deteriorate. The relationship is driven by reduced use of antidepressants. The same age-gender groups experience a significantly higher risk of mortality in bad times. Conclusions This study shows that economic downturns may not only put strain on individuals' mental health but also on their access to psychopharmaceutic treatments. [ABSTRACT FROM AUTHOR]

Background Changes in Swedish national insurance policies over time and/or migration-related health inequalities may influence the risk for labour market marginalization (LMM) in refugees as compared to the Swedish-born host population. This study aimed to investigate potential period effects in the association between refugee status and the risk of LMM and explore any differences by country of birth, age and duration of residence. Methods Using national registers, three cohorts including all Swedish residents during 1999, 2004 and 2009 were followed for 4 years (cohort 2000, 2005 and 2010). Cox regression models were used to examine associations between refugee status and LMM defined as long-term unemployment (>180 days annually) and disability pension. The analyses were adjusted for socio-demographic factors, morbidities and labour market-related factors. Stratified analyses were run for age, country of birth and duration of residence. Results Across the cohorts, hazard ratios (HRs) were higher for long-term unemployment [2000: HR = 1.98; 95% confidence interval (CI): 1.96–2.01; 2005: HR = 2.30; 95% CI: 2.27–2.33; 2010: HR = 2.78; 95% CI: 2.75–2.81] for refugees compared to Swedish-born but not for disability pension. HRs for long-term unemployment were highest among refugees aged 25–34 and 35–44 years, from Somalia, Afghanistan and Iraq and refugees with a shorter duration of residence. Conclusions The risk of long-term unemployment appears to have increased for refugees over time. Particularly some refugee subgroups experienced more difficulties. These findings highlight ongoing disparities for refugees and implicate on a broader scale that changes in policies such as stricter regulations in the insurance or healthcare system might adversely affect them. [ABSTRACT FROM AUTHOR]

Background The aim of the present study was to compare the cross-sectional association between smoking and depressive symptoms among adolescents between Sweden and Italy, two countries historically characterized by different norms about tobacco use and different tobacco control efforts. Methods A cross-sectional study including 3283 adolescents 15–16 years of age participating in the Swedish KUPOL study and 1947 same-age adolescents from the Italian BE-TEEN study. Current smoking was defined as any smoking in the past 30 days. Depressive symptoms were assessed using the Centre for Epidemiological Studies Depression Scale for Children (CES-DC) and the internalizing score of the Strengths and Difficulties Questionnaire (SDQ). Country differences were explored in stratified and interaction analyses. Results Current smoking was associated with a 2- to 3-fold increased odds of depressive symptoms among Swedish adolescents using both CES-DC and SDQ internalizing scale. Among Italian adolescents, slightly lower increased odds of 1.5–2.5 for depressive symptoms with smoking were found using the CES-DC but not the SDQ scale. Both multiplicative and additive interactions for country were significant. The association between smoking and depressive symptoms was weaker among Italian compared with Swedish adolescents for both scores. Conclusions Countries with different tobacco norms and control show different associations between smoking and depressive symptoms in adolescence, probably due to different psychosocial profiles of smokers. These findings need to be considered when planning tobacco prevention programmes, e.g. by focusing on early detection of mental health distress among adolescents in settings with declining smoking prevalence and restrictive tobacco control environments. [ABSTRACT FROM AUTHOR]

The article offers information on health policy research. One study focused on the use of public opinion surveys in decision-making involved in public health policies for water fluoridation programs. Another paper explored the regional differences of the Swedish welfare system. In another study, the organization of an avian flu task force by the Norwegian Institute of Public Health as a response to public concerns regarding the disease is discussed.

We aimed to identify common elements in work sickness absence (SA) in Spain, Sweden and The Netherlands. We estimated basic statistics on benefits eligibility, SA incidence and duration and distribution by major diagnostics. The three countries offer SA benefits for at least 12 months and wage replacement, differing in who and when the payer assumes responsibility; the national health systems provide health care with participation from occupational health services. Episodes per 1000 salaried workers and episode duration varied by country; their distribution by diagnostic was similar. Basic and useful SA indicators can be constructed to facilitate cross-country comparisons. [ABSTRACT FROM AUTHOR]

Background Acceptability of the recommended screening procedure represents a crucial determinant of the impact of colorectal cancer (CRC) screening programmes. This study aims to explore how individuals in CRC screening experience the screening procedure. Methods Study participants (n  =   44), aged 60–62 years, screened by faecal immunochemical test (FIT) and/or colonoscopy, were recruited from the Screening of Swedish Colons (SCREESCO) study. Data were collected through six focus group discussions and 20 individual telephone interviews and analyzed using qualitative content analysis. Results The analysis resulted in 30 subcategories together forming four categories describing individuals' experiences of the CRC screening procedure: From no worries to bothering emotions; Varying logistical concerns; Being well treated, but inconsistently informed and involved and Expectations not matching reality. Some subcategories only applied to either FIT or colonoscopy screening, while others applied to both screening procedures. Conclusions Undergoing CRC screening by FIT or colonoscopy is an individual experience. Strategies to improve patient experiences may include using one-sample FITs and optimizing bowel preparation and scheduling of colonoscopies according to individual preferences. Ensuring that needs for emotional support are acknowledged, together with clear and adequate information delivered at right time are further important aspects to consider. [ABSTRACT FROM AUTHOR]

Reports on the interviews with Swedish physicians, politicians and health economists seven years after the introduction of the Stockholm model of internal market reforms in delivering health care. Information on the Stockholm model; Privatization of family doctors; Role of primary care physicians.

Background Most refugees and other forced migrants have experienced potentially traumatic events (PTEs). Torture and other traumatic experiences, as well as various daily stressors, impact the mental health and psychosocial well-being of war-affected populations. Methods The study includes two population-based samples of Iranian and Iraqi men living in Finland and Sweden. The Finnish Migrant Health and Well-being Study (Maamu) was conducted in 2010–2012. The Linköping study was conducted in Sweden in 2005. In both samples, health and well-being measures, social and economic outcomes as well as health service utilization were reported. Results The final sample for analysis consisted of two groups of males of Iranian or Iraqi origin: 278 residents in Finland and 267 residents in Sweden. Both groups were subdivided according to the reported PTEs: Torture survivors; Other PTEs; No PTEs. Migrants that reported PTEs, torture survivors in particular, had significantly poorer social and health outcomes. Torture survivors also reported lower trust and confidence in authorities and public service providers, as well as more loneliness, social isolation and experiences of discrimination. Conclusions Torture and other PTEs prevalent in refugee and migrant populations create a wide-ranging and long-term impact in terms of increased risk of various types of adverse social and health conditions. Early identification through systematic and effective screening should be the first step in guiding migrants and refugees suffering from experiences of torture and other PTEs to flexible, multidisciplinary services. [ABSTRACT FROM AUTHOR]

Background In responding to Covid-19, governments have tried to balance protecting health while minimizing gross domestic product (GDP) losses. We compare health-related net benefit (HRNB) and GDP losses associated with government responses of the UK, Ireland, Germany, Spain and Sweden from UK healthcare payer perspective. Methods We compared observed cases, hospitalizations and deaths under 'mitigation' to modelled events under 'no mitigation' to 20 July 2020. We thus calculated healthcare costs, quality adjusted life years (QALYs), and HRNB at £20,000/QALY saved by each country. On per population (i.e. per capita) basis, we compared HRNB with forecast reductions in 2020 GDP growth (overall or compared with Sweden as minimal mitigation country) and qualitatively and quantitatively described government responses. Results The UK saved 3.17 (0.32–3.65) million QALYs, £33 (8–38) billion healthcare costs and £1416 (220–1637) HRNB per capita at £20,000/QALY. Per capita, this is comparable to £1455 GDP loss using Sweden as comparator and offsets 46.1 (7.1–53.2)% of total £3075 GDP loss. Germany, Spain, and Sweden had greater HRNB per capita. These also offset a greater percentage of total GDP losses per capita. Ireland fared worst on both measures. Countries with more mask wearing, testing, and population susceptibility had better outcomes. Highest stringency responses did not appear to have best outcomes. Conclusions Our exploratory analysis indicates the benefit of government Covid-19 responses may outweigh their economic costs. The extent that HRNB offset economic losses appears to relate to population characteristics, testing levels, and mask wearing, rather than response stringency. [ABSTRACT FROM AUTHOR]

Background Health 2020 is the regional health policy framework of the World Health Organization (WHO) Regional Office for Europe. The goals of Health 2020 are to improve health and well-being, reduce health inequalities and strengthen public health. To gain insight into the Health 2020 targets needing extra attention in coming years, we assessed progress under Health 2020 in the WHO European Region. Methods Quantitative methods were used to assess progress in 50 out of 53 Member States of the WHO European Region in 2005, 2010 and 2015. The 16 quantitative Health 2020 indicators were rescaled from 1 to 100, with 1 indicating poor performance and 100 indicating good performance. The geometric mean of all 16 rescaled indicators was taken by Health 2020 target to compose a Health 2020 index. Results The Health 2020 index (2015) ranged from 82.8 in Sweden to 30.0 in Turkmenistan. A clear east-west gradient was observed in the WHO European Region, with countries in western parts performing relatively better than countries in eastern parts. Indicators with the largest increase between 2005 and 2015 were premature mortality, mortality external causes, life expectancy and infant mortality. However, all quintiles showed a decline on overweight. Conclusions The Health 2020 index gives a relative overview regarding the past and present performance on the Health 2020 policy framework of countries in the WHO European Region. Although improvements have been observed between 2005 and 2015, challenges remain to improve health for all in the context of the United Nations 2030 Agenda for Sustainable Development. [ABSTRACT FROM AUTHOR]

The article discusses public health research on social and environmental inequalities in health. One study explored the impact of segregation on social class inequalities in incidences of myocardial infarction in the metropolitan area of Stockholm, Sweden. Another paper presented a review of studies on the health impacts of housing improvement from around the world.

Background Little is known about adolescent mental health problems, including social phobia, as risk factors for future work incapacity. The aim of this study was to investigate the association between social phobia in adolescence and unemployment and sickness absence (SA) in early adulthood, also evaluating the role of familial factors (genetics and shared environment). Methods A sample of 2845 Swedish twins born in 1985–86 in Sweden was followed longitudinally in the population-based and prospective Twin study of CHild and Adolescent Development. Information on twins' social phobia was collected at ages 13–4, 16–7 and 19–20 years. Logistic regression providing odds ratios (OR) with 95% confidence intervals (95% CI) was used to analyze the associations between social phobia, unemployment and SA during the follow-up 2006–12. The influence of familial factors was evaluated by conditional logistic regression. Results Presence of social phobia during adolescence was associated with increased odds for unemployment and SA in young adulthood. For unemployment, the highest OR was at the age of 13–4 years (1.58 [95% CI: 1.22–2.06]), and the associations became null after adjusting for familial factors. For SA, the highest OR was at the age of 19–20 years (1.73 [95% CI: 1.13–2.65]), and the estimates changed slightly after adjusting for familial factors. Conclusions : Results suggest that social phobia experienced in adolescence contribute to early adulthood unemployment and SA. Familial factors seemed to explain the association between social phobia and unemployment. [ABSTRACT FROM AUTHOR]

The author discusses public reaction to a terrorist attack on April 7, 2017 in Stockholm, Sweden where the editorial office of the European Public Health Association is based.

Background Mental health in adolescents has become a major public health issue. This study examined school experiences in relation to mental health (emotional problems and conduct problems) from early to middle adolescence. Methods This longitudinal 3-year follow up study used data from the Swedish Study of Health in School Children in Umeå. Analyses were conducted in 1379 participants that were attending grade six in 2003 or 2006 (age 12 years). KIDSCREEN-52 was used to assess school experiences and the Strengths and Difficulties Questionnaire for emotional and conduct problems. Statistical analyses included repeated measures ANOVA and multiple linear regressions. Results Positive school experiences decreased while emotional and conduct problem scores increased from grades six to nine. Positive school experiences were negatively associated with emotional and conduct problem scores and contributed to the explanation of mental health scores in middle adolescence after controlling for background factors. When baseline mental health problem scores were taken into account the association with early school experiences disappeared (except for conduct problems in boys). However, incorporating concurrent school experiences in the analysis increased the levels of explanation for emotional and conduct problem scores further. Conclusions The results of this study confirm that school experiences are linked to emotional and conduct problems. That link may be stronger for conduct problems. In addition, the association of school experiences in early adolescence with later mental health may be overridden by concurrent school experiences in middle adolescence. [ABSTRACT FROM AUTHOR]

Background Most research on parental bereavement and health have analysed health consequences of parental loss in childhood, while collateral health in adulthood has been less studied. Methods Using register-based population data from Finland, we analyse adult offspring aged 18–50 years with discrete-time hazard models that adjust for offspring and parental socioeconomic and demographic characteristics. In focus are adult children whose parents were alive and lived together at the beginning of the observation period. We compare two culturally distinct but otherwise similar ethno-linguistic groups, Finnish speakers and Swedish speakers. Results The results suggest that bereaved men have an approximately 30% higher death risk than non-bereaved men, while there is practically no difference in women. Associations between parental and child deaths are, as expected, stronger for concordant causes of death than for discordant causes of death. However, some associations for discordant causes of death remain, which may indicate causality. Among Swedish speakers, who have notably higher family stability than Finnish speakers, the death of one or both parents shows a stronger association with own mortality. Conclusions The estimated associations found are generally larger than in the neighbouring country Sweden, which may be due to a stronger obedience to traditional family values and patriarchal family roles in Finland. These findings suggest that the association between parental death and mortality in adult offspring may depend on the societal context as well as on cultural practices. These factors should be increasingly acknowledged in future studies on collateral health. [ABSTRACT FROM AUTHOR]

Background Empirical research suggests that household debt and payment difficulties are detrimental to mental health. Despite well-known measurement problems that may contaminate analyses using subjective self-reported health measures, our knowledge is very limited concerning the effect of payment difficulties on 'objective' measures of mental health. Moreover, few studies use longitudinal data to examine the relationship. This study combines rich survey data and longitudinal data from administrative registers on a representative sample of the Swedish population to examine the relationship between payment difficulties and subjective and objective measures of mental health. Methods We use data from a large survey of Swedish inhabitants (The Swedish Living Conditions Surveys) combined with data from administrative registers. We investigate both directions of the relationship between mental ill health and payment difficulties, controlling for previous mental health status and previous experiences of payment difficulties. We compare the association between payment difficulties and a self-reported measure of anxiety with the associations between payment difficulties and objective measures of mental ill health from a register of psychopharmaceutical drug consumption. Results Payment difficulties associate with subjectively reported mental ill health, but less to psychopharmaca use. For objective measures, we find stronger evidence of a link running from mental ill health to later payment difficulties. Conclusions Self-reported and objective measures of mental problems may convey different messages regarding the impact of payment difficulties on mental health. Policy measures depend on whether the primary target group is individuals with severe mental problems or individuals with mild anxiety. [ABSTRACT FROM AUTHOR]

Background Cardiometabolic diseases (CMDs) are the number one cause of death. Selective prevention of CMDs by general practitioners (GPs) could help reduce the burden of CMDs. This measure would entail the identification of individuals at high risk of CMDs—but currently asymptomatic—followed by interventions to reduce their risk. No data were available on the attitude and the extent to which European GPs have incorporated selective CMD prevention into daily practice. Methods A survey among 575 GPs from the Czech Republic, Denmark, Greece, the Netherlands and Sweden was conducted between September 2016 and January 2017, within the framework of the SPIMEU-project. Results On average, 71% of GPs invited their patients to attend for CMD risk assessment. Some used an active approach (47%) while others used an opportunistic approach (53%), but these values differed between countries. Most GPs considered selective CMD prevention as useful (82%) and saw it as part of their normal duties (84%). GPs who did find selective prevention useful were more likely to actively invite individuals compared with their counterparts who did not find prevention useful. Most GPs had a disease management programme for individuals with risk factor(s) for cardiovascular disease (71%) or diabetes (86%). Conclusions Although most GPs considered selective CMD prevention as useful, it was not universally implemented. The biggest challenge was the process of inviting individuals for risk assessment. It is important to tailor the implementation of selective CMD prevention in primary care to the national context, involving stakeholders at different levels. [ABSTRACT FROM AUTHOR]

Background Recently, an increased trend toward non-drinking among adolescents has been observed in several countries. The aim of the present study is to evaluate a common suggestion in literature, that adolescents do not drink alcohol because they spend more time on the internet, monitored at home, by examining associations between internet activities (social media/chatting and computer gaming) and non-drinking. Methods A health questionnaire was distributed to all 9th graders (15–16 years) in a mid-sized Swedish county in 2008, 2010 and 2012. In total, 7089 students returned the questionnaire. Results In contrast to the suggestion, no association was found between total time spent on computers and non-drinking. Social media/chatting was robustly associated with a decreased probability of non-drinking across the three survey years. On the other hand, computer gaming during weekends only (OR = 1.74, CI = 1.13–2.69) or both on weekdays and weekends increased the probability of non-drinking (OR = 1.82, CI = 1.31–2.54) in 2012 only. However, neither social media/chatting nor computer gaming was associated with the increased trend of non-drinking from 2008 to 2012. Conclusions Internet activities were in general not associated with non-drinking among adolescents aged 15–16 years in Sweden. Although, a weak positive association between computer gaming and non-drinking was found in 2012, this effect benefited the vast majority of the boys. The larger alcohol use among those with extensive social media use/chatting may indicate that these online platforms are arenas where adolescents are exposed for positive alcohol preferences and alcohol advertising without parental supervision. [ABSTRACT FROM AUTHOR]

Background Prior studies have reported substantial differences in caesarean rates between migrant and non-migrant women. In this study we investigate whether the association between maternal country of birth and caesarean section is modified by length of residence in Sweden. Methods Population-based register study. A total of 106 760 migrant and 473 881 Swedish-born women having singleton, first births were studied using multinomial multiple regression models to estimate odds ratios (OR) and 95% confidence intervals for mode of birth. Random effect meta-analyses were conducted to assess true heterogeneity between categories of length of residence. Results Longer duration of residence was associated with an increased overall risk of both unplanned and planned caesarean section among migrant women. This pattern was more pronounced among countries grouped as having higher prevalence (compared to Swedes) of unplanned: OR≤1=1.41 (1.32–1.50); OR>1–<6=1.49 (1.42–1.57); OR6–<10=1.61 (1.50–1.72); OR≥10=1.71 (1.64–1.79) and planned caesarean section [OR≤1=1.14 (0.95–1.36); OR>1–<6=1.30 (1.13–1.51); OR6–<10=1.97 (1.64–2.37]; OR≥10=1.82 (1.67–1.98)]. The results were robust to social, obstetric and health adjustments. There were some country-of-origin-specific findings. Conclusions The fact that the risk of unplanned and planned caesarean section tended to increase with length of residence, even with adjustment for social, obstetric and health factors, suggests that receiving country-specific factors are playing an important role in caesarean section. [ABSTRACT FROM AUTHOR]

Background Previous studies showed that disability pensioners have a higher risk of premature death than others, but residual confounding has been suggested. The aim was to assess the degree of residual confounding of the association between disability pension (DP) and risk of premature death. Methods Prospective cohort study of everyone aged 19–64 years, living in Sweden 31 December 2004 (n = 5 406 469), followed up through 2010. Mortality hazard rates over time were estimated for three groups; incident disability pensioners during 2005 from start of DP (February–December 2005), prevalent disability pensioners (January 2005 or since before), and individuals not on DP in January 2005, after standardizing populations to characteristics of the incident disability pensioners, stratified by previous hospitalization or not. If DP has no immediate effect on mortality, incident disability pensioners and those not on DP should initially have similar hazard rates, thereby, allowing assessment of the degree of residual confounding. Results For those not previously hospitalized, the mortality hazard rate on the first DP day was: 3.07 (95% CI 2.21, 4.36), 2.09 (1.78, 2.48) and 0.78 (0.73, 0.84) per thousand person-years for incident, prevalent, and non DP, respectively. Among previously hospitalized these figures were: 21.67 (17.73, 26.24), 17.00 (15.76, 18.51) and 18.88 (18.14, 19.64) respectively. Hazard ratios were 1.15 (0.94, 1.40) in the strata with and 3.94 (2.78, 5.57) in the strata without, previous hospitalization comparing incident DP with non-DP. Conclusions Substantial residual confounding was found in the association between DP and premature death among those not previously hospitalized. [ABSTRACT FROM AUTHOR]

Background Worldwide, about 5.8 million people die each year due to injuries. In Sweden, the corresponding number amounts to 3000. There are large differences among injury types regarding the age-profile of the fatalities and as most of them occur in older age groups, counting the absolute number of injury fatalities does not fully reflect the size of the burden of injury. Methods Using age- and sex-specific life expectancy tables in combination with data on external causes of injury, the number of injury fatalities in Sweden for the time period 1972–2014 is converted to a sum of potential years of life lost (PYLL). We then fit cause and group-specific spline regression models to the data to estimate temporal trends in both fatality counts and PYLL. Results There has been a steady reduction in the number of injury fatalities and in the sum of PYLL from the early 1970s to around the year 2000. Since then, there has been an increase in the number of injury fatalities and in the sum of PYLL. The upward trend is mainly explained by an increasing number of deaths due to poisonings and suicide, specifically among younger men. Conclusions The increases in suicide and poisoning mortality offset the reductions in downward trending causes of injury mortality during the last decades. The share of PYLL is larger than the share of fatalities for both suicides and poisonings implying that an aging population does not cause the increase. [ABSTRACT FROM AUTHOR]

Background The article examines gender differences in happy life expectancy at age 50 (LE50) and computes the age-specific contributions of mortality and happiness effects to gender differences in happy LE50 in 16 European countries. Methods Abridged life tables and happy LE50 were calculated using conventional life tables and Sullivan's method. Age-specific death rates were calculated from deaths and population exposures in the Human Mortality Database. Happiness prevalence was estimated using the 2010–11 Survey of Health, Ageing and Retirement in Europe. Happiness was defined using a single question about life satisfaction on a scale of 0–10. A decomposition algorithm was applied to estimate the exact contributions of the differences in mortality and happiness to the overall gender gap in happy LE50. Results Gender differences in happy LE50 favour women in all countries except Portugal (0.43 years in Italy and 3.55 years in Slovenia). Generally, the contribution of the gender gap in happiness prevalence is smaller than the one in mortality. The male advantage in the prevalence of happiness partially offsets the effects of the female advantage in mortality on the total gender gap in happy LE50. Gender differences in unhappy life years make up the greatest share of the gender gap in total LE50 in all countries except Denmark, Germany, Netherlands, Slovenia and Sweden. Conclusion Countries with the largest gender gap in LE are not necessarily the countries with larger differences in happy LE50. The remaining years of life of women are expected to be spent not only in unhealthy but also in unhappy state. [ABSTRACT FROM AUTHOR]

Background: There is limited knowledge regarding psychiatric healthcare utilization around the time of granting disability pension (DP) due to common mental disorders (CMD) among immigrants and if this is related to social insurance regulations. The aim was to evaluate patterns of psychiatric healthcare utilization before and after DP due to CMD among immigrants and natives. A second aim was to evaluate if such patterns differed before and after changes in social insurance regulations in Sweden in 2008. Methods: All 28 354 individuals living in Sweden with incident DP due to CMD, before (2005-06; n = 24 298) or after (2009-10; n = 4056) changes in regulations of granting DP, were included. Patterns of psychiatric in- and specialized outpatient healthcare utilization during a 7- year window around DP granting were assessed by Generalized Estimating Equations estimating multivariate adjusted odds ratios (OR) and 95% confidence intervals (CI). Results: Prevalence rates of psychiatric inpatient care were comparable among immigrants and natives, lower in non-Western immigrants (Africa, Asia and South-America). Three years after DP, non-Western immigrants in comparison to natives and Western immigrants had a stronger decrease in inpatient psychiatric healthcare: OR 0.48 (CI 0.38-0.62), 0.76 (0.70-0.83) and 1.01 (0.76-1.34), respectively. After 2008, a strong reduction in outpatient psychiatric healthcare after DP granting was observed, similarly in immigrants and natives. Conclusions: Non-Western immigrants showed a different pattern of inpatient specialized healthcare after DP granting in comparison to natives. After changes in social insurance regulations, the decline in outpatient psychiatric healthcare following DP granting was comparable in immigrants and natives. [ABSTRACT FROM AUTHOR]

Background: Exposure to psychological stress can elicit a physiological response that may influence characteristics of the gastrointestinal mucosa, including increased intestinal permeability, in turn possibly increasing susceptibility to gastrointestinal infections. We investigated whether low stress resilience in adolescence is associated with an 'increased' risk of gastrointestinal infections in subsequent adulthood. Methods: Data were provided by Swedish registers for a cohort of 237 577 men who underwent military conscription assessment in late adolescence (196976). As part of the assessment procedure, certified psychologists evaluated stress resilience through semistructured interviews. The cohort was followed from conscription assessment until 31 December 2009 (up to age 57years). Cox regression assessed the association of stress resilience with gastrointestinal infections (n = 5532), with adjustment for family background measures in childhood and characteristics in adolescence. Peptic ulcer disease (PUD) in adulthood was modelled as a time-dependent covariate. Results: Compared with high stress resilience, lower stress resilience was associated with a 'reduced' risk of gastrointestinal infections after adjustment for family background in childhood, characteristics in adolescence and PUD in adulthood, with hazard ratios (and 95% confidence intervals) of 0.88 (0.81-0.97) and 0.83 (0.77-0.88) for low and moderate stress resilience, respectively. Conclusion: Lower stress resilience in adolescence is associated with reduced risk of gastrointestinal infections in adulthood, rather than the hypothesized increased risk. [ABSTRACT FROM AUTHOR]

Background: Comparisons of outcomes of health care in different systems can be used to inform health policy. The EuroHOPE (European Healthcare Outcomes, Performance and Efficiency) project investigated the feasibility of comparing routine data on selected conditions including breast cancer across participating European countries. Methods: Routine data on incidence, treatment and mortality by age and clinical characteristics for breast cancer in women over 24years of age were obtained (for a calendar year) from linked hospital discharge records, cancer and death registers from Finland, the Turin metropolitan area, Scotland and Sweden (all 2005), Hungary (2006) and Norway (2009). Age-adjusted breast cancer incidence and 1-year survival were estimated for each country/region. Results: In total, 24576 invasive breast cancer cases were identified from cancer registries from over 13 million women. Age-adjusted incidence ranged from 151.1 (95%CI 147.2-155.0) in Hungary to 234.7 (95%CI 227.4-242.0)/100 000 in Scotland. One-year survival ranged from 94.1% (95%CI 93.5-94.7%) in Scotland to 97.1% (95%CI 96.298.1%) in Italy. Scotland had the highest proportions of poor prognostic factors in terms of tumour size, nodal status and metastases. Significant variations in data completeness for prognostic factors prevented adjustment for case mix. Conclusion: Incidence of and survival from breast cancer showed large differences between countries. Substantial improvements in the use of internationally recognised common terminology, standardised data coding and data completeness for prognostic indicators are required before international comparisons of routine data can be used to inform health policy. [ABSTRACT FROM AUTHOR]

Background: Cancer survival in the UK and Denmark are lower when compared with similar countries with late diagnosis a possible cause. We aimed to study the relationship between barriers to attending a primary care physician (GP) and anticipated time to help seeking (ATHS) with four cancer symptoms in six countries. Methods: A population-based survey measuring cancer awareness and beliefs conducted within the International Cancer Benchmarking Partnership in Australia, Canada, Denmark, Norway, Sweden and UK. Data were collected on perceived barriers to GP consultation (including embarrassment, worry about wasting the doctors' time, fear about what the doctor might find and being too busy) and ATHS for persistent cough, abdominal swelling, rectal bleeding and breast changes. Relationships between perceived barriers and ATHS were investigated using multivariable analysis. Results: Among 19079 respondents, higher perceived barrier scores were associated with longer ATHS intervals for all symptoms studied (P<0.01) responders with the highest barrier scores (>10.84) had between two and three times the odds of longer ATHS. ATHS was low in Australia for all symptoms and highest in Denmark for abdominal bloating. Conclusions: Perceived barriers to help-seeking have a role in delaying GP presentation. Early diagnosis campaigns should address emotional and practical barriers that reduce early presentation with potential cancer symptoms. [ABSTRACT FROM AUTHOR]

Background: Mass unemployment in Europe is endemic, especially among the young. Does it cause mortality? Methods: We analyzed long-term effects of unemployment occurring during the deep Swedish recession 1992-96. Mortality from all and selected causes was examined in the 6-year period after the recession among those employed in 1990 (3.4 million). Direct health selection was analyzed as risk of unemployment by prior medical history based on all hospitalizations 1981-91. Unemployment effects on mortality were estimated with and without adjustment for prior social characteristics and for prior medical history. Results: A prior circulatory disease history did not predict unemployment; a history of alcohol-related disease or suicide attempts did, in men and women. Unemployment predicted excess male, but not female, mortality from circulatory disease, both ischemic heart disease and stroke, and from all causes combined, after full adjustment. Adjustment for prior social characteristics reduced estimates considerably; additional adjustment for prior medical history did not. Mortality from external and alcohol-related causes was raised in men and women experiencing unemployment, after adjustment for social characteristics and medical history. For the youngest birth cohorts fully adjusted alcohol mortality HRs were substantial (male HR = 4.44; female HR = 5.73). The effect of unemployment on mortality was not uniform across the population; men, those with a low education, low income, unmarried or in urban employment were more vulnerable. Conclusions: Direct selection by medical history explains a modest fraction of any increased mortality risk following unemployment. Mass unemployment imposes long-term mortality risk on a sizeable segment of the population. [ABSTRACT FROM AUTHOR]

Objective: Fall-related injuries among the elderly, specifically hip fractures, cause significant morbidity and mortality as well as imposing a substantial financial cost on the health care system. Impact-absorbing flooring has been advocated as an effective method for preventing hip fractures resulting from falls. This study identifies the cost-effectiveness of impact-absorbing flooring compared to standard flooring in residential care facilities for the elderly in a Swedish setting. Method: An incremental cost-effectiveness analysis was performed comparing impact-absorbing flooring to standard flooring using a Markov decision model. A societal perspective was adopted and incremental costs were compared to incremental gains in quality-adjusted life years (QALYs). Data on costs, probability transitions and health-related quality of life measures were retrieved from the published literature and from Swedish register data. Probabilistic sensitivity analysis was performed through a Monte Carlo simulation. Results: The base-case analysis indicates that the impact-absorbing flooring reduces costs and increases QALYs. When allowing for uncertainty we find that 60% of the simulations indicate that impact-absorbing flooring is cost-saving compared to standard flooring and an additional 20% that it has a cost per QALY below a commonly used threshold value Conclusions: Using a modelling approach, we find that impact-absorbing flooring is a dominant strategy at the societal level considering that it can save resources and improve health in a vulnerable population. [ABSTRACT FROM AUTHOR]

Background: Annually, 100 people die as a result of residential fires in Sweden and almost a third of the fatal fires are known to be caused by smoking. In an attempt to reduce the occurrence of these events, reduced ignition propensity (RIP) cigarettes have been developed. They are designed to reduce the risk of fire by preventing the cigarette from burning through the full length when left unattended. In November 2011, a ban was introduced, forbidding the production and sale of all non-RIP cigarettes in all member states of the European Union, including Sweden. Methods: Monthly data on all recorded residential fires and associated fatalities in Sweden from January 2000 to December 2013 were analyzed using an interrupted time series design. The effect of the intervention [in relative risk (RR)] was quantified using generalised additive models for location, shape and scale. Results: There were no statistically significant intervention effects on residential fires (RR 0.95 [95% CI: 0.89-1.01]), fatal residential fires (RR 0.99 [95% CI: 0.80-1.23]), residential fires where smoking was a known cause (RR 1.10 [95% CI: 0.95-1.28]) or fatal residential fires where smoking was a known cause (RR 0.92 [95% CI: 0.63-1.35]). Conclusion: No evidence of an effect of the ban on all non-RIP cigarettes on the risk of residential fires in Sweden was found. The results may not be generalisable to other countries. [ABSTRACT FROM AUTHOR]

Background: Sickness absence with cash benefits from the sickness insurance gives an opportunity to be relieved from work without losing financial security. There are, however, downsides to taking sickness absence. Periods of sickness absence, even short ones, can increase the risk for future spells of sickness absence and unemployment. The sickness period may in itself have a detrimental effect on health. The aim of the study was to investigate if there is an association between exposure to sickness absence at a young age and later sickness absence, disability pension, death, unemployment and income from work. Methods: Our cohort consisted of all immigrants aged 21-25 years in Sweden in 1993 (N = 38 207) and a control group of native Swedes in the same age group (N = 225 977). We measured exposure to sickness absence in 1993 with a follow-up period of 15 years. We conducted separate analyses for men and women, and for immigrants and native Swedes. Results: Exposure to ≥60 days of sickness absence in 1993 increased the risk of sickness absence [hazard ratio (HR) 1.6-11.4], unemployment (HR 1.1-1.2), disability pension (HR 1.2-5.3) and death (HR 1.2-3.5). The income from work, during the follow-up period, among individuals with spells of sick leave for ≥60 days in 1993 was around two-thirds of that of the working population who did not take sick leave. Conclusions: Individuals on sickness absence had an increased risk for work absence, death and lower future income. [ABSTRACT FROM AUTHOR]

Background: Sweden provides a free school lunch to every child in the compulsory (9-year) school system. It consists of a hot meal, a salad buffet, bread and a beverage. The Education Act states it must be free of charge (since 1997) and ‘nutritious' (since 2011). No standards/limits are specified but voluntary guidelines for serving of the school meal exist. We describe how school meal quality has changed since 2011. Methods: A random sample of schools were contacted in spring 2011 and invited to use a novel web-based instrument to evaluate school meal quality. In spring 2013, the participating schools (N= 191) were encouraged to use it again and 97 did. The outcomes were measures of quality including food provision/choice, adherence to serving guidelines and, using validated food-based criteria, nutritional quality. Results: No change was seen in the proportion offering alternative options daily, but a vegetarian option was significantly more widely available in 2013. Adherence to all but one of the studied serving guidelines improved, although this reached significance for only a small number. Adherence to two of the four nutrient criteria improved significantly. Conclusion: Two years after the introduction of new legislation, school meal quality in Sweden has improved modestly. The effect of the law itself is difficult to separate from other influences, including the effect of monitoring. Extended follow-up of schools will allow us to evaluate the longer-term changes and effects on health, learning and equality in health. [ABSTRACT FROM AUTHOR]

Background: Little is known about how disease co-occurrences with common mental disorders (CMD) associate with social integration in young refugees. We identify diagnostic groups associated with labor market marginalization (LMM) in refugees and Swedish-born with CMD and determine whether multimorbidity is associated with LMM in young refugees and Swedish-born with CMD. Methods: This longitudinal registry-based study included adults aged 20- 25 years followed from 2011-2016 in Sweden. LMM was defined as > 180 days unemployment or being granted disability pension. A multimorbidity score was derived from a network of disease co-occurrences observed in 2009-2011. Relative risks for LMM in refugees with CMD compared to Swedish-born with CMD in 114 diagnostic groups were calculated. Multivariate logistic regression was applied to estimate the odds of LMM by CMD. Results: Among 249,245 young adults, 2,841 (1.1%) were granted disability pension and 16,323 (6.5%) individuals experienced unemployment, 20,679 (8.3%) suffered from CMD. Most comorbid diagnostic groups were positively associated with unemployment in young refugees with CMD. Inflammatory bowel disease and acute upper respiratory disease showed the highest relative risks of unemployment for young refugees with CMD, compared to Swedish-born with CMD: RRs 6.4[3.2, 12.8], 4.0[2.6, 6.1], respectively. The multimorbidity score was associated with elevated odds for unemployment and granted disability pension in refugees with/without CMD and Swedish born with/without CMD (OR range: 1.1-1.8; highest for young refugees without CMD). Conclusions: Specific diagnostic group had differential risks for unemployment for refugees and Swedish-born. Early culturally sensitive public health measures are warranted to target the detrimental consequences of multimorbidity on LMM in young adults. Key messages: The importance of diagnostic groups for LMM differs for young refugees and Swedish-born with CMD. Multimorbidity increases the risk for LMM, particularly disability pension. [ABSTRACT FROM AUTHOR]