Yearly incidence of mental disorders in economically inactive young adults.

Increasing rates of mental health problems in youth and an extended period of school-to-work transition is a major concern in Sweden and many other European countries. In this study, being out of the workforce and not in education was associated with severe mental disorders. The risk of being admitted in hospital due to depression was more than doubled in economically inactive young adults. Similarly, the risk of being admitted to hospital due to self-harm and alcohol-related disorder was tripled. Drug abuse was seven times more prevalent among inactive young adults. Processes leading to economic inactivity and to deteriorating mental health are inextricably intertwined. Even if it is not possible to clarify if the association is caused by selection or if it is being outside of labour force that causes mental disorders, it is still urgent to prevent young persons from ending up in long-term economic inactivity.

The association of early IQ and education with mortality: 65 year longitudinal study in Malmö, Sweden.

OBJECTIVES: To establish whether differences in early IQ explain why people with longer education live longer, or whether differences in father's or own educational attainment explain why people with higher early IQ live longer. DESIGN: Population based longitudinal study. Mortality risks were estimated with Cox proportional hazards regressions. SETTING: Malmö, Sweden. PARTICIPANTS: 1530 children who took IQ tests at age 10 and were followed up until age 75. RESULTS: Own educational attainment was negatively associated with all cause mortality in both sexes, even when early IQ and father's education were adjusted for (hazard ratio (HR) for each additional year in school 0.91 (95% CI 0.85 to 0.97) for men and HR 0.88 (95 % CI 0.78 to 0.98) for women). Higher early IQ was linked with a reduced mortality risk in men, even when own educational attainment and father's education were adjusted for (HR for one standard deviation increase in IQ 0.85 (95 % CI 0.75 to 0.96)). In contrast, there was no crude effect of early IQ for women, and women with above average IQ had an increased mortality risk when own educational attainment was adjusted for, but only after the age of 60 (HR 1.60 (95 % CI 1.06 to 2.42)). Adding measures of social career over and above educational attainment to the model (for example, occupational status at age 36 and number of children) only marginally affected the hazard ratio for women with above average IQ (<5%). CONCLUSIONS: Mortality differences by own educational attainment were not explained by early IQ. Childhood IQ was independently linked, albeit differently, to male adult mortality and to female adult mortality even when father's education and own educational attainment was adjusted for, thus social background and own social career seem unlikely to be responsible for mortality differences by childhood IQ. The clear difference in the effect of IQ between men and women suggests that the link between IQ and mortality involves the social and physical environment rather than simply being a marker of a healthy body to begin with. Cognitive skills should, therefore, be addressed in our efforts to create childhood environments that promote health.

Is there a "school effect" on pupil outcomes? A review of multilevel studies.

STUDY OBJECTIVE: The school environment is of importance for child outcomes. Multilevel analyses can separate determinants operating at an individual level from those operating at a contextual level. This paper aims to systematically review multilevel studies of school contextual effects on pupil outcomes. DESIGN: Key word searching of five databases yielded 17 cross sectional or longitudinal studies meeting the inclusion criteria. Results are summarised with reference to type of school contextual determinant. MAIN RESULTS: Four main school effects on pupil outcomes were identified. Having a health policy or antismoking policy, a good school climate, high average socioeconomic status, and urban location had a positive effect on pupil outcomes. Outcomes under study were smoking habits, wellbeing, problem behaviour, and school achievement. CONCLUSIONS: Despite the different pupil outcomes and the variety of determinants used in the included papers, a school effect was evident. However, to improve our understanding of school effects, presentations of results from multilevel studies need to be standardised. Intraclass correlation and explained between school variance give relevant information on factors in the school environment influencing pupil outcomes, and should be included in all multilevel studies. Inclusion of pupil level predictors in the multilevel models should be based on theoretical considerations of how schools and communities are interconnected and how pupils and their families are influenced by school contextual factors.

Validity of self reports in a cohort of Swedish adolescent smokers and smokeless tobacco (snus) users.

OBJECTIVE: To validate self reports of cigarette and smokeless tobacco (snus) use in a prospective cohort of adolescents. DESIGN: A cross sectional analysis of a cohort sub-sample. SETTING: County of Stockholm, Sweden. SUBJECTS: 520 adolescents in the final grade of junior high school (mean age 15.0 years). MAIN OUTCOME MEASURE: Concordance between self reported tobacco use and saliva cotinine concentration. RESULTS: Using a cut point of 5 ng/ml saliva cotinine to discriminate active tobacco use, there was a 98% concordance between self reported non-use in the past month and cotinine concentration. The sensitivity of the questionnaire compared to the saliva cotinine test, used as the gold standard, was 90% and the specificity 93%. One hundred and fifteen out of 520 subjects (22%) reported monthly tobacco use. Among these, 67% (46/69) of the exclusive cigarette smokers, 82% (23/28) of exclusive snus users, and 94% (15/16) of mixed users (cigarettes + snus) had cotinine concentrations above 5 ng/ml. Among subjects reporting daily use 96% (64/67) had saliva cotinine concentrations above the cut point. Exclusive current cigarette users were more likely to be classified discordantly by questionnaire and cotinine test compared to snus users (odds ratio 3.2, 95% confidence interval 1.2 to 8.6). CONCLUSION: This study confirms the reliability of adolescents' self reported tobacco use. In a context of low exposure to environmental tobacco smoke a cut off for saliva cotinine of 5 ng/ml reliably discriminated tobacco users from non-users. Irregular use of tobacco in this age group probably explains the discrepancy between self reported use and cotinine concentrations.

Socially unbiased parenting support on the Internet: a cross-sectional study of users of a large Swedish parenting website.

BACKGROUND: The Internet is becoming increasingly recognized as a source of social support. Parents of children with cancer and autism have been shown to find social support online, and many parents of healthy infants and children seek information about parenting online. However, access and use of the Internet is greater among socio-economically advantaged groups, a phenomenon known as the 'digital divide'. Our aim was to investigate whether users of a Swedish general parenting website perceived support in the parenting role and, if so, whether this support was socially biased because of the digital divide phenomenon. METHODS: Users of the largest Swedish parenting website were asked to participate in the study. A total of 2221 users completed the anonymous survey posted on the website during a one-week period. RESULTS: Most respondents (95%) were female (mean age 30.6 years). Respondents' educational level was slightly, but not significantly, higher than that in the general population, whereas 68% had income levels at or under the national average, contradicting the intuitive hypothesis that users would be socio-economically privileged. Perceived social support, measured by the Interpersonal Support Evaluation List (ISEL) appraisal subscale, indicated high perceived support. Living without a partner and having lower levels of income and education increased perceived support. The perception that other parents' opinions are more valuable than the advice of experts was influential in the regression equation for ISEL scores, indicating that peer help is important in online social support. CONCLUSIONS: Internet use for general parenting issues in Sweden, mainly by women, does not seem to follow the digital divide phenomenon. Therefore, the internet provides an exciting opportunity for future infant and child public health work. The lack of fathers, however, was a surprising finding and introduces a gender bias into this seemingly socially unbiased medium.

Evaluation of a counseling method for the prevention of child exposure to tobacco smoke: an example of client-centered communication.

BACKGROUND: Environmental tobacco smoke (ETS) is an important risk factor. The aim of this study is to evaluate effects of the counseling method "Smoke-free children" that focuses on protection of infants. METHODS: The counseling method, "Smoke-free children", has been developed and implemented at Swedish child health centers. The counseling method's point of departure is based upon a client-centered approach. Saliva cotinine samples from the mothers were collected when the child was 1-4 weeks and 3 months of age. Interviews regarding mothers' smoking habits and self-reported maternal smoking were also carried out. RESULTS: Forty-one mothers participated in the study, 26 in the intervention group and 15 in the control group. Cotinine was collected from 22 subjects in the intervention and 8 in the control group. Before the intervention, the mean cotinine level was 185 ng/mL in the intervention group and 245 ng/mL in the control group. After the intervention, cotinine levels were reduced in the intervention group (165 ng/mL) and increased in the control group (346 ng/mL). Yet, after the intervention, the mothers themselves reported more smoking in the intervention group than in the control group. Only weak correlations were found between self-reported smoking and cotinine. CONCLUSIONS: The statistical analysis supports the view that a client-centered intervention, aimed at increasing self-efficacy, exerts a positive effect on maternal smoking in the prevention of infant exposure to ETS, when applied in a routine clinical setting.

Association between childhood community safety interventions and hospital injury records: a multilevel study.

STUDY OBJECTIVE: To study municipal variations in children's injury risk and to assess the impact of safety promotion measures in general municipal, preschool, school, and leisure activity settings, on injury outcome. DESIGN: A cohort study based on individual data on children's consumption of hospital care as a result of injury, the age and sex of each child, and socioeconomic data on each child's mother. Municipal characteristics-that is, population density and municipal safety measures-were also used. Connections between individual and community level determinants were analysed with multilevel logistic regression. SETTING: Twenty five municipalities in Stockholm County in Sweden were studied. PARTICIPANTS: Children between 1 and 15 years old in 25 municipalities in Stockholm County, identified in the Total Population Register in Sweden. The study base included 1 055 179 person years. MAIN RESULTS: Municipality injury rates varied between 3.84-7.69 per 1000 person years among 1-6 year olds and, between 0.86-6.18 among 7-15 year olds. Implementation of multiple safety measures in a municipality had a significant effect on the risk of injury for preschool children. In municipalities that implemented few safety measures, the risk of injury was 33% higher than in municipalities that implemented many. A similar effect, though insignificant, was observed in the school aged children. CONCLUSIONS: This study shows that how municipalities organise their safety activities affect injury rates. Sweden has a comparatively low injury rate and thus, in a European perspective, there is an obvious potential for municipal safety efforts.

Does an increase of low income families affect child health inequalities? A Swedish case study.

STUDY OBJECTIVE: Reduction of health inequalities is a primary public health target in many countries. A change of proportion of low income families might affect child health inequalities. Yet, the importance of family incomes in high income welfare states is not well established. The aim of this study was to investigate the effect of increased percentage of low income families on child health inequalities during an economic recession in Sweden, 1991-1996. DESIGN: Health inequalities for six health indicators were assessed during the period 1991-1996 and during adjacent periods. Relative inequality indices were estimated according to Pamuk and Mackenback. Appraisal of a child's socioeconomic situation was based on social data for the child's residency area. SETTING: The total population of children and adolescents 0-<19 years old living in Stockholm County, Sweden, was studied. Each one year cohort comprised 20 470-25 420 people. MAIN OUTCOME MEASURES: Mortality; rate of low birth weight; days of hospital care for infections, asthma/allergic disorders, and unintentional injuries; and rate of abortions. MAIN RESULTS: Mortality decreased annually by 6.9%. The average relative inequality index for mortality before the recession was 1.40 and was lower during the recession, 1.14. The remaining five health indicators, and the relative inequality index for these indicators, did not differ significantly between the recession years (1991-1996) and adjacent periods. CONCLUSIONS: Relative health inequalities did not change, or decreased, during the recession years. The findings indicate that the connection was weak between child health inequalities and family incomes, within the frame of time and the range of income changes that occurred during the study period.

Social aetiology of violent deaths in Swedish children and youth.

STUDY OBJECTIVE: To describe the contribution of social conditions for the main causes of injury deaths in Swedish children and youth aged 5-25 years. DESIGN: Cohort study. All children below 15 years of age that resided in Sweden 1985 were followed up during 1991-1995. Injury deaths were recorded from The National Cause of Death Register. Information on parental social determinants were collected from various national registers. Connections between the social determinants and an injury death outcome were analysed in multivariate Cox regression models. MAIN RESULTS: In total 1474 injury deaths were recorded during approximately 8 million person years. In a regression model, with control for sex, year of birth, and residency (urban/rural), the aetiological fraction for parental SES, maternal country of birth, family situation, parental risk factors, and all these factors combined were 13%, 6%, 1.4%, 1.3%, and 19%, respectively. Similar regression models were studied separately for each of the main causes of injury death. The parental social determinants explained 58% of all homicides, 47% of all motor traffic injuries, and 30% of all other traffic injuries while the suicide rate was not affected by these determinants. Parental socioeconomic status was the single most important parental determinant for all major causes of injury. CONCLUSIONS: There was a wide variation of the aetiological fractions of parental social determinants for different causes of injury death. This variation might be used to further investigate the social aetiology of injuries.

Child health-centre-based promotion of a tobacco-free environment--a Swedish case study.

Environmental tobacco smoke exposure is an important health risk for small children. The development, spread and evaluation of a national child health-centre-based counselling method targeting environmental tobacco smoke is described. The work progressed in six steps. In a first step, accomplished in 1994, it was found that child health nurses used a limited repertoire of techniques and were dissatisfied with their discussion on tobacco smoke. In a second step, routine recording of parental smoking status was introduced at all child health centres. In a third step, a counselling method based on Bandura's self-efficacy concept was developed, 'smoke-free children'. In a fourth step, smoke-free children was tested by 28 nurses in 128 families. At follow-up discussions, all parents said that they now smoked outdoors and that they had cut down on their smoking. In a fifth step, the national dissemination of smoke-free children was studied. A manual and a videotape were launched in 1995, supported by a newsletter and 10 regional conferences in the following years. In January 1997, 36% of the child health nurses in Sweden (three counties excluded) stated that they used the method. Training of county instructors did not seem to have improved dissemination. In a sixth step, routinely collected information on parental smoking in Stockholm county on infants born 1995-1997 was used to study the effect. Little change in smoking rates between two consecutive years was found before the introduction of smoke-free children. Yet, after training of the child health nurses, the annual decrease was 1.7% in a pilot area and later, in remaining parts of the county, 2.7%. Thus, answers to two crucial questions were given: first, that the method seemed to affect parental behaviour; and secondly, that the training of county instructors might not have affected the dissemination of smoke-free children.

Risk of childhood injury: predictors of mothers' perceptions.

BACKGROUND AND OBJECTIVES: Safety education often targets parental risk perception. Predictors of risk perception, however, are not well known, thus limiting the feasibility of effective safety education. Accordingly, in this study, a range of predictors of maternal risk perception were examined. METHODS: A random sample of 870 mothers in northern Sweden was included in the study. Three different questionnaires, with scenarios of a burn injury, a bicycle injury in the home environment, and a bicycle injury in traffic, were completed by the subjects. Multiple linear regression models tested the possible influence of causal attributions, normative beliefs, and sociodemographic and behaviour-related variables on mothers' risk perception. RESULTS: Only 14-23% of the variance in mothers' risk perception could be explained by the multivariate models. Causal attribution to the child was found to be the most important predictor of maternal risk perception. CONCLUSION: Present theoretical models give few clues about how to design educational models that might influence risk perception. To make safety education more effective, other modifiable factors that influence parental safety behaviour, such as subjective norms and self-efficacy, might be better targets.

Quality of evidence for the present Swedish child health surveillance programme.

The present Swedish health surveillance programme includes 15 examinations by a nurse, 5 examinations by a physician, 7 assessments of development, 2 assessments of hearing and 1 assessment of visual acuity. The WHO criteria for evaluation of screening programmes can be applied to the Swedish health surveillance programme. These criteria state that the health problem must be important, that there should be an early phase during which the condition is only detectable by medical professionals and that treatment at an early phase should favourably affect the prognosis. The quality of evidence for fulfilment of these criteria has been graded I-III. Grade II-2 refers to evidence obtained from well-designed cohort or case-control analytical studies. The following disorders might be affected by health surveillance at child health centres: amblyopia, ADHD/DAMP, failure to thrive, cerebral palsy, congenital heart failure, congenital luxation of hip, hearing impairment (severe or moderate), mental retardation, retentio testis and hydrocephalus. None of these conditions fulfils the WHO criteria with quality of evidence grade II-2 or better. Thus the evidence for the present Swedish health surveillance programmed is problematic.

Health promotion at Swedish Child Health Centres.

Effective health promotion intervention is understood to modify appropriate risk and protective factors. The relevance of such interventions for the Child Health Service (CHS) was examined in three steps. In the first step, the six most important public health problems in the target group that might be affected by CHS interventions were identified. The health problems include sudden infant death syndrome (SIDS), mental health problems, injuries, infections, asthma and allergic and nutritional disorders. In the second step, three groups of modifiable determinants were identified: risk and protective factors for (i) SIDS, asthma and allergic disorders and airway tract infections (determinants: breastfeeding, environmental tobacco smoke, sleeping non-prone and lacking indoor ventilation). (ii) injuries and (iii) mental health problems. In the third step, evidence for the preventive measure's ability to alleviate the effects of these risk factors was scrutinized. Evidence was found for effectiveness of CHS interventions aiming at decrease of environmental tobacco smoke. Evidence was also found for injury prevention provided that the intervention is a part of a wider community effort, and possibly also if it is very focused. Requirements for mental health promotion are also at hand. Thus, effective health promotion via CHS interventions is feasible.

Education of staff--a key factor for a safe environment in day care.

In order to create a safe environment in day-care settings, an understanding of factors within the organization of day care, factors which influence safety, is essential. Day-care directors in 83 daycare centres completed a mail-in survey that contained questions about professional experience, the day-care centre's organization of child safety measures and a battery of questions designed to evaluate the directors' perceptions and beliefs about child safety. The day-care directors also carried out a safety inspection at their centre. The results were analysed using the multivariate logistic regression technique. The existence of a continuing plan for continued staff education in child safety was shown to be the strongest predictor of few safety hazards in day-care centres. The day-care directors' perceptions and beliefs about injury prevention were of less importance. This study indicates that in order to promote safety in day-care settings, an on-going plan for continued staff education in child safety should be a matter of routine. The introduction of such a plan should be the concern of the individual day-care directors, policy-makers and managers at the local and national level, and health professionals working in this field.

Patients' autonomy and medical benefit: ethical reasoning among GPs.

BACKGROUND: During the last decades, the traditional role of GPs as decision-makers for their patients has been questioned. OBJECTIVES: The aim of this study was to identify and discuss how GPs deal with and how they reason in situations where there is a possible tension between the obligation to respect the patients' right to self-determination and the obligation to promote their health. METHODS: One hundred and twenty randomly selected Swedish GPs received a mailed questionnaire with two vignettes, one describing a patient reluctant to have a medically motivated intervention, the other describing a patient requesting a medically doubtful intervention. Forty seven of these GPs subsequently were interviewed by telephone. RESULTS: With regard to the first vignette, approximately two-thirds of respondents to the questionnaire (n = 82) answered that they would not accept the patient's reluctance. Older GPs were somewhat more inclined to try to persuade the patient to come to their surgery than were younger colleagues. In the interview, most respondents answered that the right to self-determination ought to be given priority, but the obligation to promote health had a greater influence on their behaviour. Regarding the second vignette, two-thirds of respondents to the questionnaire answered that they would not give way to the patient's request for intervention. Younger GPs said "No" more often than did their older colleagues. In the interviews, justifications for their response referred to medical benefit, uneasy patients, self-protection and justice. CONCLUSION: When facing such conflicts in everyday practice, the ethical codes of medicine are often too categorical to give any guidance. The situational ideal of covenant would be more helpful, and ought to be emphasized by medical teachers as well as tutoring older colleagues.

Lower respiratory tract infections in an ethnic and social context.

Family size and smoking during pregnancy were studied as mediating factors for social and ethnic variation of lower respiratory tract infection (LRI) in hospital discharge data. The study population consisted of all children aged 0-4 years in the three largest metropolitan areas of Sweden during 1990-94. Maternal smoking during pregnancy increased the risk of children being admitted to hospital for LRI during their first 3 years of life, with an adjusted odds ratio (OR) of 1.3 for the age-group 0-1 years. The risk attributed to smoking during pregnancy was the same in children of mothers in ethnic groups in which smoking during pregnancy was related to social adversity as in those in which it was not. Having at least one sibling increased the risk of being admitted to hospital for LRI in the age group 0-1 years (adjusted OR 2.2). This risk was lower in children in families in which the mother was born in southern Europe, Africa, Asia or Latin America, suggesting a contextual relation to ethnicity for this risk factor. It is concluded that family size and smoking during pregnancy are important mediators of the risk for LRI related to social adversity and ethnicity in Swedish children below 2 years of age.

Social adversity, migration and hospital admissions for childhood asthma in Sweden.

The number of children admitted to hospitals because of asthma has been reported to decrease in Sweden in recent decades despite an increasing prevalence of childhood asthma. This decrease has been explained by improved maintenance therapy of children with severe asthma. In this study we used data on hospital admissions for asthma from the Swedish National Patient Discharge Registers in Stockholm, Malmö and Gothenburg 1990-1994 to identify social and ethnic characteristics of children 2-18-y-old in need of improvement in disease management. Children in families on social welfare (adjusted odds ratios (OR): 1.3 and 1.5) and children in single-parent households (adjusted OR: 1.3 and 1.4) were more often admitted to hospital because of asthma at least once during a calendar year in the 2-6- and 7-18-y-old groups. Children in families on social welfare had a particularly high risk of being admitted more than once during a calendar year (adjusted OR: 1.6 in the younger age group and 2.9 in the older group). Exposure to smoking during pregnancy was more common in socially disadvantaged families and increased the risk of hospital admission in children below 3 y of age. Children born outside Western Europe, the USA and Australia were less commonly admitted to hospital because of asthma than other children in the population (adjusted OR: 0.1-0.5). Swedish-born children with mothers who were born in Eastern and Southern Europe were also at lower risk for admission to hospital with a diagnosis of asthma (adjusted OR: 0.2-0.6). This probably indicates a lower prevalence of asthma in these ethnic groups. Further studies are needed to identify factors that can explain these ethnic differences in childhood asthma.