Professional's Views on the 'Nordic Paradox' in a Low Intimate Partner Violence Prevalence Country.

The apparently contradictory co-existence of high levels of gender equality and intimate partner violence against women (IPVAW) found in Nordic countries has been termed the Nordic Paradox. The aim of this study was to examine how the Nordic Paradox is discussed and explained by Spanish professionals working in the IPVAW field. Five focus groups (n = 19) and interviews with key informants (n = 10) were conducted. Four main categories of possible explanations for the Nordic Paradox were identified: Macro-micro disconnect (i.e., discordance between individual beliefs and behaviors and macro-social norms of gender equality), IPVAW as multicausal (i.e., IPVAW defined as a multicausal phenomenon that does not necessarily have to be associated with gender equality), cultural patterns of social relationships (i.e., the role of social relationships and the way people relate to each other in the Nordic countries), and backlash effect (i.e., men's reaction to greater equality for women). Although this study does not provide a final explanation for the Nordic paradox, its results provide us with a better understanding of the phenomenon and can help to advance research in this field.

Claims in the clinic: A qualitative group interview study on healthcare communication about unestablished side effects of the copper IUD.

BACKGROUND: Lay online communication about health-related issues has in recent years largely been associated with the spread of misinformation and decreased trust in healthcare. Such communication has included claims about systemic side effects of the copper IUD. In Sweden, a social media group centered on this issue now gathers around 8,700 members. This study aimed to use the case of reported yet unestablished side effects of the copper IUD to investigate experiences of and reasoning about healthcare encounters between caregivers and patients contesting established medical knowledge. METHODS: We conducted qualitative, semi-structured, digital group interviews with members of the social media group (seven groups, n = 23) and with midwives and gynecologists (six groups, n = 15). We also gathered essays written by social media group members (n = 23). The material was analyzed thematically. RESULTS: The participant accounts pointed towards tensions related to principles of evidence-based medicine, i.e., perceived insufficiency of research on the safety of the copper IUD and lack of clarity in routines for reporting and following up suspected side effects, and of patient-centered care, i.e., listening respectfully to patients. Tension between caregivers' obligation to adhere to evidence-based medicine while also providing patient-centered care was noted. CONCLUSION: Healthcare providers' efforts to assess and address patient claims contesting established medical knowledge should include ensuring and communicating sufficient research, clarifying procedures for reporting suspected side effects, and improving person-centered care. This can increase the quality of care while contributing to the mitigation of distrust in healthcare and the spreading of health-related misinformation.

The different facets of 'experiential knowledge' in Swedish women's claims about systemic side effects of the copper intrauterine device.

'Experiential knowledge' has been identified as a key epistemic resource used by lay people to contest medical authorities and build new knowledge related to health. The Internet has created unprecedented opportunities for such experience-based epistemic projects. This article contributes to understandings of the as yet under-theorised concept of experiential knowledge by analysing accounts of a group of Swedish women who claim that their use of contraceptive copper IUDs has led to systemic side effects not recognised by health care providers. Based on digital group interviews and written essays, we distinguish between three components or stages of experiential knowledge at work in the women's use of experience as an epistemic resource: somatic knowing, collective validation and self-experimentation. Drawing on a critical realist framework, we defend a notion of experiential knowledge as crucially, while only partially, based on a bodily and practical access to aspects of reality organised by extra-discursive principles. By providing theoretical complexity to the notion of experiential knowledge, we contribute resources for discriminating between and evaluating various experience-based claims, something that is particularly needed in the current 'post-truth' era where experience-based knowledge claims pointing in divergent directions flourish.

Assessing the use of clinical guidelines against domestic violence in southern Sweden: A mixed-methods study.

BACKGROUND AND AIM: Domestic violence is a prevalent public health issue. While clinical guidelines and care programs for its identification and handling have been formulated in all administrative regions of Sweden, their degree of implementation is largely unknown. This study aims to assess the implementation of one administrative region's care program, including how it is seen to align with and function in clinical practice, and any perceived barriers to or facilitators of its use. METHODS: A survey was distributed to first-line managers for healthcare units with patient contact in the region (n = 807). The responses were analysed using descriptive statistics. Open responses were analysed thematically. Group interviews (n = 5) were held with caregivers (n = 15) working primarily with young patients and analysed thematically. RESULTS: 73% of the survey respondents reported previous awareness of the care program, and 27% reported knowledge of its content. The extent to which their staff knew about and followed the care program was assessed to be relatively low. The survey response rate was 19%. Among interview participants, knowledge of the care program was generally quite low. Survey responses and interview discussions pointed to the importance of developing routines, of collegial and managerial support and of training on domestic violence and the care program. CONCLUSION: This study indicates that the knowledge and use of the regional care program is limited among healthcare staff, including among those working with young patients. This underscores the importance of information and training for furthering the implementation of clinical guidelines on domestic violence.

Mapping sociodemographic and geographical differences in human papillomavirus non-vaccination among young girls in Sweden.

AIMS: Human papillomavirus (HPV) vaccination plays a key role in the prevention of cervical cancer. Yet, disparities in HPV vaccination in Sweden have persisted. Previous research on such disparities has typically focused on singular sociodemographic variables and measures of average risk. Using a multi-categorical approach and drawing on intersectionality theory, this study aimed to provide a more precise mapping of HPV non-vaccination among girls in different sociodemographic groups and geographical areas in Sweden during 2013-2020. METHODS: Using nationwide register data, we conducted a multi-categorical analysis of individual heterogeneity and discriminatory accuracy complemented by a multilevel geographical analysis. We mapped HPV non-vaccination prevalence across 54 strata defined by parental income, education and country of birth, and urban versus rural place of residence. We also disentangled municipal and regional influences on HPV non-vaccination. RESULTS: HPV non-vaccination was more common in groups with a low income, a low education and an immigration background, whereas among those with an immigration background, the association between income, education and HPV non-vaccination was more complex. Geographical differences were found between municipalities. However, the discriminatory accuracy of the sociodemographic and geographical groups was weak, and 50% of the non-vaccination cases were observed in eight strata, of which some are among those with low risk. CONCLUSIONS: Our findings underscore the importance of universal yet tailored approaches, including providing adequate information about HPV vaccination in Swedish and other languages, and of health-care professionals displaying sensitivity to patients' and parents' questions or needs.

Stories of Backlash in Interviews With Survivors of Intimate Partner Violence Against Women in Sweden.

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

On the verge between the scientific and the alternative: Swedish women's claims about systemic side effects of the copper intrauterine device.

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

Revisiting socio-economic inequalities in sedentary leisure time in Sweden: An intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA).

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

Attitudes Toward the Copper IUD in Sweden: A Survey Study.

Background: While the efficacy and safety of the contraceptive copper intrauterine device (IUD) have been affirmed, alongside its importance for the prevention of unintended pregnancies, some studies have pointed to negative attitudes toward the device. In recent years, social media communication about it has included claims about systemic side effects, unsubstantiated by medical authorities. Research from the Swedish context is sparse. This study investigates attitudes toward the copper IUD and any correlations between negative attitudes toward or experiences of the device, and (1) sociodemographic characteristics, (2) the evaluation of the reliability of different sources of information, and (3) trust in healthcare and other societal institutions. Methods: A survey was distributed online to adult women in Sweden (n = 2,000). Aside from descriptive statistics, associations between negative attitudes toward or experiences of the copper IUD and sociodemographic and other variables were calculated using logistic regressions and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). Open survey responses (n = 650) were analyzed thematically. Results: While many reported positive attitudes toward and experiences of the IUD, 34.7% of all respondents reported negative attitudes and 45.4% of users reported negative experiences. Negative attitudes were strongly correlated with negative experiences. Negative attitudes and experiences were associated with low income, but no conclusive associations were identified with other socioeconomic variables. Negative attitudes and experiences were associated with lower levels of confidence in and satisfaction with healthcare, as well as lower self-assessed access and ability to assess the origin and reliability of information about the IUD. In open responses, negative comments were prevalent and included references to both common and unestablished perceived side-effects. Respondents pointed to problematic aspects of information and knowledge about the copper IUD and called for improved healthcare communication and updated research. Conclusion: Healthcare provider communication about the copper IUD should promote reproductive autonomy and trust by providing clear information about potential side effects and being open to discuss women's experiences and concerns. Further research on copper IUD dissatisfaction and ways in which health professionals do and may best respond to it is needed.

Attitudes Toward HPV Vaccination in Sweden: A Survey Study.

Background: While HPV vaccination uptake in Sweden is quite high, at around 80%, vaccine hesitancy remains an issue in countries throughout Europe. The latter can be related to a contemporary context of increased contestation of expert knowledge and of a large share of information on health-related issues including vaccination today being sought via the internet. Still, there is a paucity of recent research on attitudes toward the HPV vaccine in a larger sample of the population in Sweden. This survey study assesses such attitudes and any correlations between vaccine hesitancy and sociodemographic characteristics, trust in healthcare and other societal institutions, and evaluation of the reliability of different sources of information. Methods: The validated survey questionnaire was distributed to adult women in Sweden (n = 2,000), via a nationally representative web panel. The response rate was 37%. Aside from descriptive statistics, associations between vaccine hesitancy and sociodemographic and other variables were computed using logistic regressions and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). Results: Our results show a positive attitude toward HPV vaccination overall. Still, some degree of HPV vaccine hesitancy was indicated by 33.8% of the respondents, and more pronounced hesitancy by 7.6%. Regarding vaccination in general, a very positive attitude was indicated by 55%. HPV vaccine hesitancy was associated with low education and low income and strongly associated with a lack of confidence in healthcare and other societal institutions. It was also correlated with a self-assessed lack of access to, and ability to assess the origin, quality and reliability of, information about the HPV vaccine. Conclusion: Efforts to provide transparent information about HPV vaccination should be combined with healthcare providers being open to discuss vaccine concerns with patients and avoiding practices that do not promote trust.

Professionals' Views on the Comparatively Low Prevalence of Intimate Partner Violence Against Women in Spain.

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

Socio-economic disparities in the dispensation of antibiotics in Sweden 2016-2017: An intersectional analysis of individual heterogeneity and discriminatory accuracy.

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

Antidepressant use in Sweden: an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).

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

An intersectional analysis providing more precise information on inequities in self-rated health.

BACKGROUND: Intersectionality theory combined with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can facilitate our understanding of health disparities. This enables the application of proportionate universalism for resource allocation in public health. Analyzing self-rated health (SRH) in Sweden, we show how an intersectional perspective allows for a detailed mapping of health inequalities while avoiding simplification and stigmatization based on indiscriminate interpretations of differences between group averages. METHODS: We analyzed participants (n=133,244) in 14 consecutive National Public Health Surveys conducted in Sweden in 2004-2016 and 2018. Applying AIHDA, we investigated the risk of bad SRH across 12 intersectional strata defined by gender, income and migration status, adjusted by age and survey year. We calculated odds ratios (with 95% confidence intervals) to evaluate between-strata differences, using native-born men with high income as the comparison reference. We calculated the area under the receiver operating characteristic curve (AU-ROC) to evaluate the discriminatory accuracy of the intersectional strata for identifying individuals according to their SRH status. RESULTS: The analysis of intersectional strata showed clear average differences in the risk of bad SRH. For instance, the risk was seven times higher for immigrated women with low income (OR 7.00 [95% CI 6.14-7.97]) than for native men with high income. However, the discriminatory accuracy of the intersectional strata was small (AU-ROC=0.67). CONCLUSIONS: The intersectional AIHDA approach provides more precise information on the existence (or the absence) of health inequalities, and can guide public health interventions according to the principle of proportionate universalism. The low discriminatory accuracy of the intersectional strata found in this study warrants universal interventions rather than interventions exclusively focused on strata with a higher average risk of bad SRH.

Representation of Intimate Partner Violence Against Women in Swedish News Media: A Discourse Analysis.

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

The Use of Complementary and Alternative Medicine (CAM) in Psychiatric Units in Sweden.

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

Does country-level gender equality explain individual risk of intimate partner violence against women? A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) in the European Union.

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

Understanding the complexity of socioeconomic disparities in type 2 diabetes risk: a study of 4.3 million people in Sweden.

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

Correction: Precision public health: Mapping socioeconomic disparities in opioid dispensations at Swedish pharmacies by Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA).

[This corrects the article DOI: 10.1371/journal.pone.0220322.].

Precision public health: Mapping socioeconomic disparities in opioid dispensations at Swedish pharmacies by Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA).

BACKGROUND: In light of the opioid epidemic in the United States, there is growing concern about the use of opioids in Sweden as it may lead to misuse and overuse and, in turn, severe public health problems. However, little is known about the distribution of opioid use across different demographic and socioeconomic dimensions in the Swedish general population. Therefore, we applied an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA), to obtain an improved mapping of the risk heterogeneity of and socioeconomic inequalities in opioid prescription receipt. METHODS AND FINDINGS: Using data from 6,846,106 residents in Sweden aged 18 and above, we constructed 72 intersectional strata from combinations of gender, age, income, cohabitation status, and presence or absence of psychological distress. We modelled the absolute risk (AR) of opioid prescription receipt in a series of multilevel logistic regression models distinguishing between additive and interaction effects. By means of the Variance Partitioning Coefficient (VPC) and the area under the receiver operating characteristic curve (AUC), we quantified the discriminatory accuracy (DA) of the intersectional strata for discerning those who received opioid prescriptions from those who did not. The AR of opioid prescription receipt ranged from 2.77% (95% CI 2.69-2.86) among low-income men aged 18-34, living alone, without psychological distress, to 28.25% (95% CI 27.95-28.56) among medium-income women aged 65 and older, living alone, with psychological distress. In a model that conflated both additive and interaction effects, the intersectional strata had a fair DA for discerning opioid users from non-users (VPC = 13.2%, AUC = 0.68). However, in the model that decomposed total effects into additive and interaction effects, the VPC was very low (0.42%) indicating the existence of small interaction effects for a number of the intersectional strata. CONCLUSIONS: The intersectional MAIHDA approach aligns with the aims of precision public health, through improving the evidence base for health policy by increasing understanding of both health inequalities and individual heterogeneity. This approach is particularly relevant for socioeconomically conditioned outcomes such as opioid prescription receipt. We have identified intersections of social position within the Swedish population at greater risk for opioid prescription receipt.