Alcohol, drug and tobacco prevention in Swedish municipalities - impact from the COVID-19 pandemic considering socio-demographic context.

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.

Cross-sectoral cooperation at the ministerial level in three Nordic countries - With a focus on health inequalities.

To reduce health inequalities requires interventions that address the social determinants of health. The responsibilities, at the ministerial level, for these determinants are mainly situated outside the ministry of health. Accordingly, interventions to reduce health inequalities require coordination between the ministry of health and other ministries. Yet, a large literature in public administration has demonstrated that cross-sectoral cooperation is hard to achieve. The goal of this paper was to examine whether inter-ministerial cooperation relating to the reduction of health inequalities is occurring in practice. Semi-structured interviews were performed with senior officials at 26 ministries in Finland, Norway, and Sweden. The interviews were analyzed both qualitatively and quantitatively. The point of departure was a question if the ministries had initiated substantial measures, such as reforms, regulations, funding, or fiscal strategies, aiming to promote health equity in the population and, if so, if this was done in cooperation with other ministries. The informants reported 80 measures intended to promote health equity and stated inter-ministerial cooperation for 65 of these measures. Many informants described that cooperation between the ministries was routine and well-functioning. Thus, there was no recorded lack of inter-ministerial cooperation. However, the measures that were reported, seemed to be insufficient to reduce health inequalities, both due to lack of extent and lack of effectiveness. This might be due to insufficient political commitment to tackle health inequalities. If so, the WHO Health in All Policies approach might not be effective.

Effects of Local Alcohol Prevention Initiatives in Swedish Municipalities, 2006-2014.

Background: Several components of the Swedish alcohol policy, e.g., pricing and availability, weakened when Sweden joined the EU in 1995. To counteract the possible negative effects of this, emphasis was placed on the local level as an important arena of alcohol prevention. Thus, considerable efforts were made to strengthen alcohol prevention in Swedish municipalities. Objectives: The aim of this study was to examine whether local alcohol prevention reduced consumption and alcohol-related harm in Swedish municipalities. Methods: Alcohol prevention was monitored using a composite measure called the Alcohol Prevention Magnitude Measure (APMM), with subcategories of staff and budget, inspections and licenses, policy, activities, and cooperation. APMM and its categories were analysed in relation to alcohol consumption and harm over time, 2006-2014. A fixed effects model was used with 63% (N=182, consumption) and 71% (N=207, harm) of 290 Swedish municipalities, respectively, included in the analyses. Results: The main results suggest that when APMM increases with 1 percent, the alcohol-related mortality decreases with 0.26 percent, controlled for changes in population size, median income, unemployment, and post-secondary education. In light of this result, the estimated effect of APMM on alcohol consumption (sales) is small (0.02 percent decrease); possible explanations for this are discussed in the article. Conclusion: The overall results indicate that local alcohol prevention initiatives in Sweden have reduced some forms of alcohol-related harm, not least alcohol-related mortality, during the period 2006-2014. Further studies are needed to assess the generalizability of the present study.

Unemployment among young people and mental health: A systematic review.

Aim: The aim of this systematic review is to obtain a better understanding of the association between unemployment among young people and mental health. Methods: After screening the title and abstract of 794 articles drawn from four electronic databases, 52 articles remained for full-text reading. Of these, 20 studies met the inclusion criteria and were assessed on methodological quality. All steps were performed independently by two reviewers. Finally, a total of 17 articles were included in the systematic review. Results: Analysis of cross-sectional studies (N = 5) showed an association between unemployment among young people and mental health. An effect of unemployment on mental health was found when considering cohort studies (N = 12) that did not control for confounders (7/7). When controlling for confounders except mental health at baseline, this effect decreased in most studies leading to mixed results, although the majority (6/8) still found an effect. However, when taking mental health at baseline into account as one of the confounders, only a minority of studies (3/8) found a significant effect of unemployment on mental health. Conclusions: This systematic review showed an association between unemployment among young people and mental health. However, whether there is a causal relationship is less clear. More evidence from, for example, natural experiments and longitudinal studies that control for confounding variables, especially mental health at baseline, is required to better understand the association and potential causation between unemployment among young people and mental health.

Effects of mental health interventions for students in higher education are sustainable over time: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Symptoms of depression, anxiety, and distress are more common in undergraduates compared to age-matched peers. Mental ill health among students is associated with impaired academic achievement, worse occupational preparedness, and lower future occupational performance. Research on mental health promoting and mental ill health preventing interventions has shown promising short-term effects, though the sustainability of intervention benefits deserve closer attention. We aimed to identify, appraise and summarize existing data from randomized control trials (RCTs) reporting on whether the effects of mental health promoting and mental ill health preventing interventions were sustained at least three months post-intervention, and to analyze how the effects vary for different outcomes in relation to follow-up length. Further, we aimed to assess whether the effect sustainability varied by intervention type, study-level determinants and of participant characteristics. MATERIAL AND METHODS: A systematic search in MEDLINE, PsycInfo, ERIC, and Scopus was performed for RCTs published in 1995-2015 reporting an assessment of mental ill health and positive mental health outcomes for, at least, three months of post-intervention follow-up. Random-effect modeling was utilized for quantitative synthesis of the existing evidence with standardized mean difference (Hedges' g) used to estimate an aggregated effect size. Sustainability of the effects of interventions was analyzed separately for 3-6 months, 7-12 months, and 13-18 months of post-intervention follow-up. RESULTS: About 26 studies were eligible after reviewing 6,571 citations. The pooled effects were mainly small, but significant for several categories of outcomes. Thus, for the combined mental ill health outcomes, symptom-reduction sustained up to 7-12 months post-intervention (standardized mean difference (Hedges' g) effect size (ES) = -0.28 (95% CI [-0.49, -0.08])). Further, sustainability of symptom-reductions were evident for depression with intervention effect lasting up to 13-18 months (ES = -0.30 (95% CI [-0.51, -0.08])), for anxiety up to 7-12 months (ES = -0.27 (95% CI [-0.54, -0.01])), and for stress up to 3-6 months (ES = -0.30 (95% CI [-0.58, -0.03])). The effects of interventions to enhance positive mental health were sustained up to 3-6 months for the combined positive mental health outcomes (ES = 0.32 (95% CI [0.05, 0.59])). For enhanced active coping, sustainability up to 3-6 months was observed with a medium and significant effect (ES = 0.75 (95% CI [0.19, 1.30])). DISCUSSION: The evidence suggests long-term effect sustainability for mental ill health preventive interventions, especially for interventions to reduce the symptoms of depression and symptoms of anxiety. Interventions to promote positive mental health offer promising, but shorter-lasting effects. Future research should focus on mental health organizational interventions to examine their potential for students in tertiary education.

Effects on Alcohol Consumption and Alcohol Related Harm of a Community-Based Prevention Intervention With National Support in Sweden.

BACKGROUND: In order to strengthen local alcohol prevention work in Sweden the Swedish government has for the past almost 15 years commissioned the Public Health Agency of Sweden to initiate a series of community-based alcohol prevention projects. The latest of these, labeled local development with ambitions (LUMA), included 25 municipalities in Sweden. OBJECTIVES: Aim of this study is to examine if LUMA municipalities that received financial support, with requirements, increased local alcohol prevention and if alcohol consumption and harm declined. METHODS: Twenty-five Swedish municipalities that received financial support aiming to strengthen local alcohol preventing activities (intervention group) were compared to municipalities that did not receive such support (control group, N = 224), before, during, and after the intervention period. Two composite measures of policy and activity were created and used. The composite activity measure includes seven activity indicators and the composite policy measure includes six policy indicators. Harm measures have been selected based on several recommended indicators for monitoring alcohol, tobacco, and other drugs in Sweden. A fixed effects model was used to analyze data. RESULTS: The results reveal that prevention activities increased and several alcohol-related harm indicators were reduced in intervention municipalities (LUMA) compared with in control municipalities. CONCLUSIONS: It seems as if financial support, combined with specific requirements and support from the regional and national level, can stimulate local alcohol prevention activities and have a significant effect on alcohol consumption and alcohol-related harm. Similar evaluations in other countries would be of great value for assessing the generalizability of findings.

The DECIDE evidence to recommendation framework adapted to the public health field in Sweden.

Organizations worldwide compile results from scientific studies, and grade the evidence of interventions, in order to assist policy makers. However, quality of evidence alone is seldom sufficient to make a recommendation. The Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence (DECIDE) framework aims to facilitate decision making and to improve dissemination and implementation of recommendations in the healthcare and public health sector. The aim of this study was to investigate whether the DECIDE framework is applicable in the public health field in Sweden. The DECIDE framework was presented and discussed in interviews with stakeholders and governmental organizations and tested in panels. Content analyses were performed. In general, the informants were positive to the DECIDE framework. However, two questions, the first regarding individual autonomy and the second regarding method sustainability, were by the stakeholders felt to be missing in the framework. The importance of the composition of the DECIDE stakeholder panel was lifted by the informants, as was the significant role of the chair. Further, the informants raised concerns about the general lack of research evidence based on RCT design regarding universal methods in the public health sector. Finally, the local, regional and national levels' responsibility for dissemination and implementation of recommendations were lifted by the informants. The DECIDE framework might be useful as a tool for dissemination and implementation of recommendations in the public health field in Sweden. Important questions for further research are whether these findings are suitable for other public health topics and in other public health settings.

Implementation of a school-wide prevention programme-teachers' and headmasters' perceptions of organizational capacity.

This study focuses on schools' organizational capacity to implement a Swedish school-wide programme, Prevention in School (PS). It is based on semi-structured interviews with seven headmasters and 13 teachers from seven Swedish schools. The interviews were analyzed by the use of qualitative content analysis. The findings show that the adoption of a comprehensive intervention like PS challenges the school organization as the staff encountered a variety of organizational barriers when implementing the programme. Factors connected to lack of consensus, collaboration and insufficient programme management were the main barriers that were identified. Teachers wanted a more extensive support from their headmasters in terms of participation in different programme activities. It was emphasized that peer coaches need to be prepared for their task, although the headmasters found it difficult to be able to choose those teachers who they perceived as the most suitable. It is concluded that leadership, coaching and staff selection need particular attention when implementing a programme like PS, since those factors have been defined as important implementation drivers, both in this study and previously.

Factors associated with implementation of a multicomponent responsible beverage service program--results from two surveys in 290 Swedish municipalities.

BACKGROUND: The purpose of this study was to investigate which factors affected the implementation of a multicomponent Responsible Beverage Service (RBS) program in 290 Swedish municipalities and whether the amount of such factors influenced the level of implementation of the program. METHODS: This study used variation in the presence of implementation-promoting factors to predict the level of implementation of the RBS program in municipalities throughout Sweden. The presence of such factors and the level of implementation of the program were studied by means of two surveys in all Swedish municipalities (N=290). Logistic regression and Spearman's correlation analyses were used to analyze the relationship between implementation-promoting factors and the level of implementation of the RBS program. RESULTS: The response rates of the two surveys were 96% and 98%, respectively. One main finding was that program fidelity was low. Only 13% of the municipalities surveyed had implemented the RBS program as a whole, as stated in the specification of requirements. In municipalities reporting a higher amount of implementation-promoting factors, a significantly higher level of implementation of the program was shown. Evaluation and feedback was the only factor that correlated significantly with the level of implementation of the RBS program as a whole. CONCLUSION: Evaluation and feedback constitutes an important implementation-promoting factor also in complex programs like the RBS program. Program fidelity is significant for the outcome of an intervention and must be a major focus of the implementation processes.

Identification of potential opinion leaders in child health promotion in Sweden using network analysis.

BACKGROUND: Opinion leaders are often local individuals with high credibility who can influence other people. Robust effects using opinion leaders in diffusing innovations have been shown in several randomized controlled trials, for example regarding sexually transmitted infections (STI), human immunodeficiency virus (HIV) prevention, mammography rates and caesarean birth delivery rates. In a Cochrane review 2010 it was concluded that the use of opinion leaders can successfully promote evidence-based practice. Thus, using opinion leaders within the public health sector might be one means to speed up the dissemination of health promoting and disease preventing innovations. Social network analysis has been used to trace and map networks, with focus on relationships and positions, in widely spread arenas and topics. The purpose of this study was to use social network analysis in order to identify potential opinion leaders at the arena of child health promotion in Sweden. RESULTS: By using snowball technique a short e-mail question was spread in up to five links, starting from seven initially invited persons. This inquiry resulted in a network consisting of 153 individuals. The most often mentioned actors were researchers, public health officials and paediatricians, or a combination of these professions. Four single individuals were mentioned by five to seven other persons in the network. These individuals obviously possess qualities that make other professionals within the public health sector listen to and trust them. CONCLUSIONS: Social network analysis seemed to be a useful method to identify influential persons with high credibility, i.e. potential opinion leaders, at the arena of child health promotion in Sweden. If genuine opinion leaders could be identified directed measures can be carried out in order to spread new and relevant knowledge. This may facilitate for public health actors at the local, regional and national level to more rapidly progress innovations into everyday practice. However, effectiveness studies of opinion leaders in the public health sector still have to be performed.

An exploration of the theoretical concepts policy windows and policy entrepreneurs at the Swedish public health arena.

In John Kingdon's Policy Streams Approach policy formation is described as the result of the flow of three 'streams', the problem stream, the policy stream and the politics stream. When these streams couple, a policy window opens which facilitate policy change. Actors who promote specific solutions are labelled policy entrepreneurs. The aim of this study was to test the applicability of the Policy Streams Approach by verifying whether the theoretical concepts 'policy windows' and 'policy entrepreneurs' could be discernable in nine specified cases. Content analyses of interviews and documents related to child health promoting measures in three Swedish municipalities were performed and nine case studies were written. The policy processes preceding the municipal measures and described in the case studies were scrutinized in order to find statements related to the concepts policy windows and policy entrepreneurs. All conditions required to open a policy window were reported to be present in eight of the nine case studies, as was the most important resource of a policy entrepreneur, sheer persistence. This study shows that empirical examples of policy windows and policy entrepreneurs could be identified in child health promoting measures in Swedish municipalities. If policy makers could learn to predict the opening of policy windows, the planning of public health measures might be more straightforward. This also applies to policy makers' ability to detect actors possessing policy entrepreneur resources.

Municipal policies and plans of action aiming to promote physical activity and healthy eating habits among schoolchildren in Stockholm, Sweden: a cross-sectional study.

BACKGROUND: Promoting physical activity and healthy eating habits by structural measures that reach most children in a society is presumably the most sustainable way of preventing development of overweight and obesity in childhood. The main purpose of the present study was to analyse whether policies and plans of action at the central level in municipalities increased the number of measures that aim to promote physical activity and healthy eating habits among schoolchildren aged six to 16. Another purpose was to analyse whether demographic and socio-economic characteristics were associated with the level of such measures. METHODS: Questionnaires were used to collect data from 25 municipalities and 18 town districts in Stockholm County, Sweden. The questions were developed to capture municipal structural work and factors facilitating physical activity and the development of healthy eating habits for children. Local policy documents and plans of action were gathered. Information regarding municipal demographic and socio-economic characteristics was collected from public statistics. RESULTS: Policy documents and plans of action in municipalities and town districts did not seem to influence the number of measures aiming to promote physical activity and healthy eating habits among schoolchildren in Stockholm County. Municipal demographic and socio-economic characteristics were, however, shown to influence the number of measures. In town districts with a high total population size, and in municipalities and town districts with a high proportion of adults with more than 12 years of education, a higher level of health-promoting measures was found. In municipalities with a high annual population growth, the number of measures was lower than in municipalities with a lower annual population growth. Another key finding was the lack of agreement between what was reported in the questionnaires regarding existence and contents of local policies and plans of action and what was actually found when these documents were scrutinized. CONCLUSION: Policy documents and plans of action aiming to promote physical activity and healthy eating habits among schoolchildren aged six to 16 in municipalities and town districts in Stockholm County did not seem to have an impact on the local level of measures. Demographic and socio-economic characteristics of the municipalities and town districts were on the other hand associated with local health-promoting measures.

Implementation of a computerized alcohol advice concept in routine emergency care.

BACKGROUND: There is a growing body of evidence for computer-generated advice for many health behaviours. This study evaluated the implementation of a computerized concept to provide tailored advice on alcohol in a Swedish emergency department (ED). AIM: The aim was to evaluate the usage of the concept over 12 months: participation rate among the ED population; representativeness of the participants; and participation development over time. METHODS: The target population was defined as all patients aged 18-69 years given a card from ED triage staff with a request to conduct a computerized test about their alcohol use. After completing the 5-10-min programme, the patient received a printout, containing personalised alcohol habit feedback, as calculated by the computer from the patient's answers. Data for this study were primarily obtained from the computer programme and ED logs. RESULTS: Forty-one percent of the target population completed the computerized test and received tailored alcohol advice. The number of patients who used the concept showed a slight decreasing trend during the first half of the year, leveling off for the second half of the year. CONCLUSION: A computerized concept for provision of alcohol advice can be implemented in an ED without unrealistic demands on staff and with limited external support to attain sustainability.

The significance of policy documents in municipal child health promotion.

AIMS: To investigate municipal utilization of policy documents in child health-promoting activities with reference to document types, substance in the documents and timing in the policy process. METHODS: Fifty semi-structured interviews were performed using the snowball method, and content analyses of written documentation were made. Data were categorized by means of a policy process matrix, and nine case studies were written. Triangulation was used as a validating method, and the coding reliability was assessed. Statements related to various policy documents were categorized according to document types, substance in the documents, and timing in the policy process. RESULTS: Various policy documents were spontaneously mentioned by 33 of 50 interviewees, in eight of nine case studies, and in all stages of the policy process. Well-defined statements concerning which content in the policy documents that actually impacted on the policy process development were uncommon. CONCLUSIONS: This study shows that policy documents are present in policy processes related to child health-promoting activities in Swedish municipalities. As Swedish municipalities are autonomous and not forced to pursue governmental recommendations, this probably demonstrates that policy documents are significant in the development of such processes.

The chance of Sweden's public health targets making a difference.

BACKGROUND: There is a trend in health policy towards more focus on determinants and societal interventions and less on individuals. The Swedish public health targets are in line with this trend. The value of public health targets lies in their ability to function as a tool in governing with targets. This paper examines the possibility of the Swedish targets functioning as such a tool. METHOD: Document analyses were performed to examine three prerequisites of governing with targets: (1) the influence of the administration in the target setting process, (2) the explicitness of targets and (3) the follow-up system. The material consisted of the documents from the committee drafting the targets, the written opinions on the drafts, and the governmental bill with the adopted public health targets. RESULTS: The administration influenced the target setting process. Further, the government invests in a follow-up system that makes indicators on health determinants visible. However, although there existed explicit targets earlier in the process, the final targets in the bill are not explicit enough. CONCLUSION: The Swedish public health targets are not explicit enough to function in governing with targets. The reasons for this were political rather than technical. This suggests that policy makers focusing health determinants should not put time and resources in technical target formulating. Instead they could make indicators visible, thereby drawing attention to trends that are political by nature.

Two approaches to school health promotion--a focus on health-related behaviours and general competencies. An ecological study of 25 Swedish municipalities.

The school is an important potential health-promoting setting for children and adolescents. Two main perspectives on school health promotion have been identified, one addressing health-related behaviours, the other stressing the development of general competencies. From a policy perspective, it is important to establish whether these two approaches are complementary or competing. This question was analysed by examining school administrations in 25 municipalities in Stockholm County, Sweden. An attempt was made to relate level of activity in line with each approach to general adolescent health outcomes. Data related to the two approaches were collected through the administration of a questionnaire. Outcome variables, measured as fraction of students qualified for upper secondary school, fraction of students with high alcohol intake, and fraction of 15-18 year olds suspected of crime, were measured on the basis of registry data. To control for structural patterns, socio-economic, demographic and system characteristics were gathered from public statistics. Spearman rank correlation coefficients were computed. Clusters of determinants assignable to each of the two approaches--promotion of health-related behaviours and supporting the development of student competencies--were identified. The two approaches were found to be negatively correlated. Thus, the perspective focusing on promotion of student health-related behaviours and the one emphasizing general development of student competencies seem to be competing rather than complementary. If this result is confirmed by other studies, it will have important policy implications.

A model for cost-effectiveness analyses of smoking cessation interventions applied to a Quit-and-Win contest for mothers of small children.

AIMS: The first aim of this study was to develop a model that predicts health and economic consequences of smoking cessation in Sweden, striving to follow the methodological recommendations to reflect the societal perspective and to use the health measure quality-adjusted life-years (QALYs). The second aim was to apply the model estimates to a smoking cessation intervention. METHODS: A Markov cost-effectiveness model was developed on smoking-related lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease. Swedish primary data on medical treatment costs and quality-of-life weights were used, supplemented with secondary data on other societal effects and the disease and death risks. The model simulations were applied to a "Quit-and-Win" contest for mothers of pre-school children. In total, 238 women participated, with 34 sustained tobacco-free at 12-month follow-up. RESULTS: The cost-effectiveness model estimates a gain of 0.34 to 0.55 QALYs (discounted 3%), and cost savings of SEK 20-35,000 per female quitter in the age range 15 to 49 years. The cost-effectiveness analyses of the intervention showed intervention costs per quitter of SEK 7,850, and intervention costs per life-years saved (YLS) (discounted 3%) of SEK 13,200. The cost-utility analysis demonstrated cost savings and a gain of 16 QALYs. CONCLUSIONS: The cost-utility analysis estimated health gains and cost savings resulting from the "Quit-and-Win" contest. As the model estimates on the differences in societal cost between smokers and quitters are considerable, many tobacco control programmes would result in cost savings. The construction of an optimal mix of tobacco control policies, however, demands incremental calculations on a range of programmes.

What makes things happen? An analysis of the development of nine health-promoting measures aimed at children and adolescents in three Swedish municipalities.

The Swedish municipalities offer important environments for health promotion. However, national actors need increased knowledge on how to support the development of public health measures in the municipalities. The aims of this study were to describe the development of municipal health-promoting measures directed at children and adolescents and to identify factors that might explain the development of such measures. Fifty semi-structured interviews and written documentation gathered from three municipalities in Stockholm County resulted in nine case studies. A policy process matrix, based on the actor-structural approach, was constructed to categorise the data. Five aspects contributing to the trajectory of municipal health-promoting measures aimed at children and adolescents were often mentioned in the data set. These are financial problems, perceived local needs, access to external funding, statements in national and international policy documents and the presence of a local public health sector. Politicians, public officials, and non-governmental organisations were the most mentioned actors, with heavy commitment, professional skills, and powerful position referred to as prevalent characteristics. Public health core concepts such as epidemiological statistics and evidence-based measures were rarely mentioned. The health care sector did not seem to have had any direct influence on municipal health-promoting measures. The dissemination of knowledge about public health related international and national policy documents and support for the institutionalisation of a local public health sector might be useful ways to support municipal public health measures.

Implementation of a Health Impact Assessment (HIA) tool in a regional health organization in Sweden--a feasibility study.

During the last decade, Health Impact Assessment (HIA) has been discussed worldwide as being an important tool for the development of healthy public policy. In Sweden, the Swedish Federation of County Councils and the Swedish Association of Local Authorities have taken the initiative to and are responsible for the development of an HIA tool concerning proposed policy decisions at local and regional levels. The HIA tool was developed as three different templates to be adapted to local conditions and needs: the Health Question, the Health Matrix and the Health Impact Analysis. In this paper we present a feasibility study of the experiences of implementing this HIA tool at regional level in a Health Care District (SWHCD) of Stockholm County Council, based on an inductive approach and on principles of data triangulation. The main findings include the need for continuous revision of the HIA templates during the pilot period. The following factors were instrumental in successfully using the HIA tool in local policy making and management: political consensus, agreement between politicians and public officials on political intentions, a clear- cut decision from management, and offering an opportunity for training. Respondents felt that all public officials should use the HIA as part of their normal work routines. In conclusion, the HIA tool has to be locally adapted and the implementation process has to include close collaboration between politicians and public officials and be followed by continuing education, providing possibilities for a dialogue around the HIA tool, in order to ensure the quality of the instrument. Implications of the study are that the process of developing the tool has worked well but that the possible impacts of its use in this case remain an open question. However, this was not the focus of our study.

A study of safety-promoting activities for children and adolescents in 25 Swedish municipalities.

The purpose of this study was to investigate two elements of the community approach to safety promotion for children and adolescents. The first concerns whether there is any correlation between safety-promoting activities in different municipal settings, and the second whether socio-economic and demographic characteristics affect the level of safety-promoting activities. A cross-sectional study was performed comprising 25 municipalities in Stockholm County. The extent of safety-promoting activities was studied in four settings: the municipal setting in general, the traffic setting, the pre-school setting, and the school and leisure activity setting. Data on nine demographic and socio-economic characteristics of the municipalities were collected from public statistics. There were three main findings. First, safety-promoting activities in the municipal setting in general, the pre-school setting, and the school and leisure activity setting, but not in the traffic setting, were apparently associated with total municipal safety-promoting activities. Secondly, socio-economic characteristics, measured as the proportion of adults with >12 years of education, did not predict the extent of safety-promoting activities. Finally, growing municipalities with a large proportion of children reported fewer safety-promoting activities than non-growing municipalities. This study demonstrated weak correlations between safety-promoting activities in different municipal settings. The finding that growing municipalities have fewer safety-promoting activities provides pertinent lessons for future action and research. The study offers a method by which it may be possible to better assess the complex components of the community approach to safety promotion.