Non-employment and low educational level as risk factors for inequitable treatment and mortality in heart failure: a population-based cohort study of register data.

BACKGROUND: The risk of heart failure is disproportionately high among the socioeconomically disadvantaged. Furthermore, socioeconomically deprived patients are at risk of inequitable access to heart failure treatment and poor outcomes. Non-employment as a risk factor in this respect has not previously been studied at the level of the individual. The aim of this register-based cohort study was to analyse equity in access to renin-angiotensin system blockers and mortality, by employment status and educational level. METHODS: The study population consisted of Swedish patients aged 20-64 years hospitalised for heart failure in July 2006-December 2010, without a heart failure hospitalisation within one year or more before index hospitalisation and without renin-angiotensin system blocker dispensation in the 6 months preceding index hospitalisation. Non-access to renin-angiotensin system blockers, measured as drug dispensations, was investigated by employment status and educational level through logistic regression. Cox regression models were used to obtain hazard ratios for all-cause death by educational level and employment status. Interaction analysis was used to test whether associations between access to treatment and mortality differed by employment status. RESULTS: Among the 3874 patients, 1239 (32%) were women. The median age was 57 years. Fifty-three percent were employed. The non-employed patients had more comorbidity and lower access (68%) to renin-angiotensin system blockers compared with the employed (82%). The adjusted odds ratio for non-access to renin-angiotensin system blockers among the non-employed was 1.76. Non-employment was associated with an adjusted hazard ratio of 1.76 for death. Low educational level was associated with a higher death risk. Mortality was highest among the non-employed without access to renin-angiotensin system blockers and the association between access to renin-angiotensin system blockers and survival was slightly weaker in this group. CONCLUSIONS: Non-employment and low educational level were associated with elevated mortality in heart failure. Non-employment was a risk factor for lower access to evidence-based treatment, and among the non-employed access to treatment was associated with a slightly smaller risk reduction than among the employed. The results underscore that clinicians need to be aware of the importance of socioeconomic factors in heart failure care.

Understanding the needs and use of sexual and reproductive health services among Thai women: a descriptive cross-sectional study in Sweden.

Background Immigrants are at increased risk of HIV infection in Europe and at risk of delayed diagnosis. In Sweden, Thailand belongs to one of the three most common countries of origin among immigrants diagnosed with HIV. This study investigated the need and use of sexual and reproductive health (SRH) services among Thai women residing in Sweden. Use of contraceptives and HIV testing in Thailand was also investigated to understand if this influences utilisation of SRH services in Sweden. METHODS: A cross-sectional study using postal questionnaire to all Thai-born women (age 23-60) in Stockholm, residing in Sweden since 2014. The response rate was 52.3% (n= 266). Bivariate and multivariate logistic regression analyses were used. RESULTS: The majority reported a significant need for information related to SRH services. Most of the women using contraception (70%) bought their contraceptives in Thailand. In total, 60% of the women had been HIV-tested at some point in their lives; the majority were tested in Thailand. Women who had been HIV-tested in Thailand were more likely to also have been tested in Sweden. Significant differences in contraception use, participation in contraceptive counselling and having had an HIV test were found between groups of younger and older women. CONCLUSIONS: Our findings imply that age is an important factor to understand women's need and use of SRH services in Sweden versus Thailand. Furthermore, women's lack of knowledge and reported need for SRH information needs to be considered when making policies and strategies to increase access to SRH services.

Lower socioeconomic status predicts higher mortality and morbidity in patients with heart failure.

OBJECTIVE: It is not fully understood whether and how socioeconomic status (SES) has a prognostic impact in patients with heart failure (HF). We assessed SES and its association with patient characteristics and outcomes in a contemporary and well-characterised HF cohort. METHODS: Socioeconomic risk factors (SERF) were defined in the Swedish HF Registry based on income (low vs high according to the annual median value), education level (no degree/compulsory school vs university/secondary school) and living arrangement (living alone vs cohabitating). RESULTS: Of 44 631 patients, 21% had no, 33% one, 30% two and 16% three SERF. Patient characteristics strongly and independently associated with lower SES were female sex and no specialist referral. Additional independent associations were older age, more severe HF, heavier comorbidity burden, use of diuretics and less use of HF devices. Lower SES was associated with higher risk of HF hospitalisation/mortality, and overall cardiovascular and non-cardiovascular events. These associations persisted after extensive adjustment for patient characteristics, treatments and care. The magnitude of the association increased linearly with the increasing number of coexistent SERF: HR (95% CI) 1.09 (1.05 to 1.13) for one, 1.16 (1.12 to 1.20) for two and 1.22 (1.18 to 1.28) for three SERF (p<0.01). CONCLUSIONS: In a contemporary and well-characterised HF cohort and after comprehensive adjustment for confounders, lower SES was linked with multiple factors such as less use of HF devices and age, but most strongly with female sex and lack of specialist referral; and associated with greater risk of morbidity/mortality.

Effectiveness by gender and age of renin-angiotensin system blockade in heart failure-A national register-based cohort study.

PURPOSE: Investigate effectiveness by gender and age and equity implications of treatment with renin-angiotensin system blockade (RASb) in heart failure (HF) patients. METHODS: In this population-based register study, we used inpatient data from 2006 to 2010 for patients age 20 years or older with no HF hospitalisation for minimum of 1 year before an index hospitalisation. A wash-out period for RASb of 6 months preceding admission was used. Hospital data were linked with drug dispensation data and cause of death data. The associations between time-dependent RASb exposure and all-cause death and HF death, respectively, were examined by Cox regression models. Interactions by gender and age were also investigated on the multiplicative and additive scales. RESULTS: Thirty thousand seven hundred twenty-one patients were analysed. Fifty-one percent were women. Median age was 83. Fifty-three percent of women and 64% of men received RASb after the index hospitalisation. Younger patients were more likely to receive RASb than older ones. One-year mortality was 28%. RASb was associated with an overall hazard ratio (HR) for all-cause death of 0.72 (95% confidence interval 0.69-0.75), and an HR of 0.85 (0.77-0.93) for HF death. Interaction analyses showed HRs for all-cause death associated with RASb between 0.12 (0.10-0.13) in the youngest, and 0.80 (0.76-0.84) in the oldest patients. CONCLUSIONS: RASb appeared effective for women and men and for patients of all ages in this hospitalised HF cohort. No gender difference in effectiveness was found. RASb exposure was low overall, indicating a need for improved adherence to treatment guidelines. Treatment with RASb may be inequitable for women and older patients.

[Rational Use of Antibiotics Among Turkish Migrants In Germany: Knowledge, Attitudes and Interaction With Physicians and Pharmacists]. / Antibiotikanutzung bei Menschen mit türkischem Migrationshintergrund ­ Wissen, Einstellungen und Interaktion mit ÄrztInnen und ApothekerInnen.

OBJECTIVES: Due to strong transnational ties, the use of and demand for antibiotics among Turkish migrants in Germany may be influenced by cultural aspects of antibiotic use in Turkey. Research on the use of antibiotics among Turkish migrants in Germany, however, is scarce. The aim of this study was to find out how Turkish migrants in Germany use antibiotics, whether and how knowledge, underlying motives and attitudes influence demand and how Turkish migrants interact with medical professionals. MATERIALS AND METHODS: Using a qualitative approach, behavioural patterns and logic of action of adult Turkish migrants were identified. We carried out semi-structured focus group interviews with adults of Turkish origin residing in Germany and expert interviews with family physicians and pharmacists. The interviews were analysed by means of content analysis. RESULTS: While younger migrants had a generally positive, but cautious attitude towards the use of antibiotics, older migrants often showed exaggerated, unrealistic expectations resulting from a lack of factual knowledge. Overall, participants adopted a passive role in the patient-provider relationship. This led to a perpetuation of significant knowledge gaps. CONCLUSIONS: Older Turkish migrants who have less factual knowledge show exaggerated expectations concerning the effectiveness of antibiotics. In conjunction with a passive patient role, resulting in information needs not being satisfied, this can affect the patient-provider relationship. A more active communication by physicians and information materials sensitive to the needs of migrants can positively influence the interaction between migrant patients and medical professionals.

How 15- to 16-year-old Swedish adolescents experience social relationships and health-related behaviours: A qualitative study.

Aims: Health-related behaviours are associated with social relationships. Adolescence is a time when healthy and unhealthy behaviours are established. There is a need to investigate adolescents' views on how social relationships are related to health-related behaviours of adolescents in the Scandinavian welfare system. This study aimed to explore Swedish adolescents' experiences and thoughts of how social relationships in different social environments are related to health-related behaviours. Methods: A total of 36 adolescents aged 15-16 years were interviewed in seven focus-group sessions. Qualitative content analysis was used for analysis of the transcribed interviews. Results: Two themes - social context and personal management - emerged. Swedish adolescents describe that their health-related behaviours as being partly shaped by their own personal management but mainly by the social contexts that surround them. Social contexts were expressed as playing a role in the adolescents' health-related behaviours, as they provide fellowship, pressure, dependability and engagement. Fellowship with friends and family was expressed as providing healthy behaviours and high levels of well-being. Fellowship with friends was particularly important for physical activity. Close relationships were stated to influence health-related behaviours. Pressure from friends, teachers and social media were described as mainly influencing unhealthy behaviours and, to some extent, low levels of well-being. However, adolescents' personal ability illustrated how adolescents shaped their own health-related behaviours. Conclusions: The study results contribute to the understanding of Swedish adolescents' views on how social relationships can shape their health-related behaviours. The findings may be useful to school professionals in supporting adolescents to improve well-being and healthy behaviours.

Perspectives on health examination for asylum seekers in relation to health literacy - focus group discussions with Arabic and Somali speaking participants.

BACKGROUND: Asylum seekers coming to most countries are offered a specific health examination. A previous study concluded that a considerable proportion of those taking part of it in Sweden had poor experiences of the communication in and the usefulness of this examination and had poor health literacy. The aim of this study was to explore in greater depth the experiences of the health examination for asylum seekers among Arabic- and Somali-speaking participants in Sweden. A secondary aim was to examine experiences and discuss findings using a health literacy framework. METHODS: Seven focus group discussions were conducted with 28 Arabic and Somali speaking men and women that participated in a health examination for asylum seekers. Data were analyzed by latent content analysis. RESULTS: One overarching theme - beneficial and detrimental - was found to represent the participants' experiences of the health examination for asylum seekers. Three categories were identified that deal with those experiences. The category of "gives some good" describes the examination as something that "gives support and relief" and "cares on a personal level." The category of "causes feelings of insecurity" describes the examination as something that "lacks clarity" and that "does not give protection." The category "causes feelings of disappointment" views the examination as something that "does not fulfil the image of a health examination" and "does not focus on the individual level." CONCLUSION: The health examination for asylum seekers was experienced as beneficial and detrimental at the same time. The feelings were influenced by the experiences of information and communication before, during and after the examination and on how health literate the organizations providing the HEA are. To achieve more satisfied participants, it is crucial that all organizations providing the HEA become health literate and person-centered.

A missed opportunity? Lack of knowledge about sexual and reproductive health services among immigrant women in Sweden.

OBJECTIVE: Poor sexual and reproductive health (SRH) among immigrant women is often related to limited access, or suboptimal use of healthcare services. This study investigates the knowledge about and use of sexual and reproductive healthcare services among immigrant women in Sweden. METHOD: A cross-sectional study of 288 immigrant women. A structured questionnaire was distributed among immigrants speaking Arabic, Dari, Somali or English registered at Swedish language schools for immigrants. Data collection took place in 19 strategically selected schools in Sweden. Descriptive statistics, chi-square tests, and logistic regressions were used for the analysis. RESULTS: About one-third of the immigrant women reported lack of knowledge of where to go for contraceptive counselling. Experiencing lack of emotional social support and not having had children was associated with this lack of knowledge. An even higher proportion (56%) lacked knowledge of where to go to be HIV tested, and this was associated with not having participated in a health examination. Almost 25% stated that their culture kept them back from using contraception. CONCLUSION: Lack of knowledge of where to turn for contraceptive counselling and HIV testing among immigrant women participating in Swedish language schools for immigrants could be considered as a missed opportunity, as all citizens in Sweden have free access to these services. New health policies and strategies should aim to increase knowledge of SRH services among immigrants. Swedish language schools could play an important role in increasing knowledge of SRH-related information as many new immigrants become students during their first years in Sweden.

Living environment, social support, and informal caregiving are associated with healthcare seeking behaviour and adherence to medication treatment: A cross-sectional population study.

Despite the well-known associations between local environment and health, few studies have focused on environment and healthcare utilisation, for instance healthcare seeking behaviour or adherence. This study was aimed at analysing housing type, behaviour based on perceived local outdoor safety, social support, informal caregiving, demographics, socioeconomics, and long-term illness, and associations with health-seeking and adherence behaviours at a population level. This study used data from the Swedish National Public Health Survey 2004-2014, an annually repeated, large sample, cross-sectional, population-based survey study. In all, questionnaires from 100,433 individuals were returned by post, making the response rate 52.9% (100,433/190,000). Descriptive statistics and multiple logistic regressions were used to investigate associations between explanatory variables and the outcomes of refraining from seeking care and non-adherence behaviour. Living in rented apartment, lodger, a dorm or other was associated with reporting refraining from seeking care (adjusted OR 1.16, 95% CI 1.00-1.22), and non-adherence (adjusted OR 1.22; 95% CI 1.13-1.31). Refraining from going out due to a perceived unsafe neighbourhood was associated with refraining from seeking care (adjusted OR 1.59, 95% CI 1.51-1.67) and non-adherence (adjusted OR 1.26, 95% CI 1.17-1.36). Social support and status as an informal caregiver was associated with higher odds of refraining from seeking medical care and non-adherence. This study suggests that living in rental housing, refraining from going out due to neighbourhood safety concerns, lack of social support or informal caregiver status are associated with lower health-seeking behaviour and non-adherence to prescribed medication.

Length of time periods in treatment effect descriptions and willingness to initiate preventive therapy: a randomised survey experiment.

BACKGROUND: Common measures used to describe preventive treatment effects today are proportional, i.e. they compare the proportions of events in relative or absolute terms, however they are not easily interpreted from the patient's perspective and different magnitudes do not seem to clearly discriminate between levels of effect presented to people. METHODS: In this randomised cross-sectional survey experiment, performed in a Swedish population-based sample (n = 1041, response rate 58.6%), the respondents, aged between 40 and 75 years were given information on a hypothetical preventive cardiovascular treatment. Respondents were randomised into groups in which the treatment was described as having the effect of delaying a heart attack for different periods of time (Delay of Event, DoE): 1 month, 6 months or 18 months. Respondents were thereafter asked about their willingness to initiate such therapy, as well as questions about how they valued the proposed therapy. RESULTS: Longer DoE:s were associated with comparatively greater willingness to initiate treatment. The proportions accepting treatment were 81, 71 and 46% when postponement was 18 months, 6 months and 1 month respectively. In adjusted binary logistic regression models the odds ratio for being willing to take therapy was 4.45 (95% CI 2.72-7.30) for a DoE of 6 months, and 6.08 (95% CI 3.61-10.23) for a DoE of 18 months compared with a DoE of 1 month. Greater belief in the necessity of medical treatment increased the odds of being willing to initiate therapy. CONCLUSIONS: Lay people's willingness to initiate preventive therapy was sensitive to the magnitude of the effect presented as DoE. The results indicate that DoE is a comprehensible effect measure, of potential value in shared clinical decision-making.

Poor health and refraining from seeking healthcare are associated with comprehensive health literacy among refugees: a Swedish cross-sectional study.

OBJECTIVES: The objectives of the study were to explore the distributions of comprehensive health literacy (CHL), general health, psychological well-being, and having refrained from seeking healthcare among refugees in Sweden. Further objectives were to examine associations between CHL and the above-mentioned factors. METHODS: A cross-sectional study was conducted among 513 refugees speaking Arabic, Dari, and Somali. Participants in the civic orientation course in Sweden responded to a questionnaire. CHL was measured using the HLS-EU-Q16 questionnaire. Uni- and multivariate logistic regression was used to investigate potential associations. RESULTS: The majority of the respondents had limited CHL, and about four of ten had reported poor health and/or having refrained from seeking healthcare. Limited CHL was associated with having reported poor health and having refrained from seeking healthcare. CONCLUSIONS: A considerable proportion of the refugees in Sweden have limited CHL, and report less than good health and impaired well-being, or that they have refrained from seeking healthcare. Furthermore, CHL is associated with the above-mentioned factors. Efforts are needed to promote refugees' CHL, optimal health-seeking behavior, and health.

Psychosocial vulnerability underlying four common unhealthy behaviours in 15-16-year-old Swedish adolescents: a cross-sectional study.

BACKGROUND: Factors that influence unhealthy behaviours in adolescents may have different impacts in different sociocultural settings. There is lack of research on the association between psychosocial vulnerability and unhealthy behaviours in adolescents, particularly outside the United States. The aim was to investigate both direct and indirect relationships between psychosocial conditions (subjective well-being, social relationships and self-esteem) and four health-related behaviours (smoking, alcohol consumption, meal frequency and physical activity) in Swedish adolescents aged 15-16 years. Socio-demographic variables (socio-economic status, gender and age) were also investigated. METHODS: To study these associations, a hypothesised model was tested using structural equation modelling. In the hypothesised model, interrelated psychosocial conditions (low well-being, poor social relationships and low self-esteem) and socio-demographic factors (low self-perceived socio-economic status, being female and higher age) together represented a vulnerability underlying smoking, alcohol consumption, irregular meal frequency and low level of physical activity. In this cross-sectional study, self-report questionnaires were used to collect data from 492 adolescents. RESULTS: Hypothesised pathways between psychosocial conditions, socio-demographic factors and the four unhealthy behaviours were confirmed. Low well-being was strongly associated with unhealthy behaviours, and poor social relationships showed a strong indirect association with the unhealthy behaviours. Low self-esteem, low self-perceived socio-economic status and female gender were also vulnerability factors for the unhealthy behaviours. CONCLUSIONS: Vulnerability for four common unhealthy behaviours was found in Swedish adolescents. This study presents the interrelationships of psychosocial and socio-demographic factors and how they were related with unhealthy behaviours. The results bring new insight into how psychosocial factors are related to unhealthy behaviours in adolescents living in northern Europe.

Catch-up HPV vaccination status of adolescents in relation to socioeconomic factors, individual beliefs and sexual behaviour.

In 2012, human papillomavirus (HPV) vaccination was introduced free of charge in the Swedish national school-based vaccination programme for 10-12-year-old girls, and as catch-up vaccination for young women. In Sweden, there is an ongoing discussion about including boys in the national vaccination programme. Few studies are undertaken about adolescents' knowledge, beliefs and HPV vaccination status in relation to socioeconomic status and sexual experience. Thus, the aim was to examine HPV catch-up vaccination status in adolescents in relation to 1) socioeconomic factors, 2) beliefs and knowledge about HPV prevention, and 3) sexual behaviour. The Health Belief Model was used as a theoretical framework. Upper secondary school students (n = 832) aged 16, randomly chosen from a larger sample, were invited to participate in conjunction with the general health interview with the school nurse. A total of 751/832 (90.3%), girls (n = 391, 52%) and boys (n = 360, 48%) completed the questionnaire. HPV vaccination was associated with ethnicity and the mothers' education level; i.e. girls with a non-European background and girls with a less educated mother were less likely to have received the vaccine (p<0.01 and p = 0.04 respectively). Vaccinated girls perceived HPV infection as more severe (p = 0.01), had more insight into women's susceptibility to the infection (p = 0.02), perceived more benefits of the vaccine as protection against cervical cancer (p<0.01) and had a higher intention to engage in HPV-preventive behaviour (p = 0.01). Furthermore, boys and girls were almost equally sexually experienced, although fewer girls had used condom during first intercourse with their latest partner (p = 0.03). Finally, HPV vaccinated girls were less likely to have unprotected sex (p<0.01). In summary, catch-up HPV vaccination among young girls was associated with a European background and high maternal education level, as well as more favourable beliefs towards HPV prevention and less sexual risk-taking. Further preventive measures should therefore be directed at the migrant population.

Condom use among Swedes while traveling internationally: A qualitative descriptive study.

This study explores factors influencing condom use among Swedish women and men who visited a sexual health clinic after unprotected sex during international travel. Semi-structured interviews were conducted with 25 women and 25 men. The data were analyzed using conventional content analysis. The informants' narratives were categorized as strategies and barriers. Strategies found were: risk assessment, testing, and treatment for sexually transmitted infections. The barriers were characterized as technical and personal or emotional. The findings indicate that sexual behavior may be different while traveling internationally, and that a release of social constraints and increased alcohol consumption were risk factors for practicing unprotected sex. Some of the strategies may be appropriate for the prevention of sexually transmitted infections, but several strategies and most barriers were used to explain why unprotected sex was practiced. Thus, people need the opportunity to reconsider strategies and strengthen confidence in their ability to use condoms. An individual-based approach employed within routine health care may support the practice of safer sex and prevent further transmission of sexually transmitted infections.

Findings from a prospective cohort study evaluating the effects of International Health Advisors' work on recently settled migrants' health.

BACKGROUND: Several interventions have been carried out to tackle health inequalities between migrant groups, especially refugees, and native-born European populations. These initiatives are often address language or cultural barriers. One of them is the International Health Advisors (IHA) in Sweden; a peer education intervention aimed at providing health information for recently settled migrants. It is known that social determinants, such as educational level and access to social capital, affect health. Social determinants may also affect how health information is received and transformed into practice. The aims of this study was to a) assess the impact of the IHA on recently settled migrants' self-reported health status, and received health information; b) determine the moderating role of educational level and social capital; and c) critically discuss the outcomes and suggest implications for health promotion practice. METHODS: The study was designed as a prospective cohort study. A postal questionnaire translated to Arabic was sent to recently settled Iraqi migrants in eight counties in Sweden, in May 2008 and May 2010. Two of the counties were exposed to the intervention, and six were used as references. RESULTS: The proportion of individuals who reported that they had received information on healthy diet and physical exercise was higher in the intervention group than in the non-intervention group (OR 2.31, 95% CI 1.02-5.22), after adjustments. Low social participation was negatively associated with deteriorated or unchanged health needs (OR 0.47, 95% CI 0.24-0.92). No other statistically significant differences in health outcomes could be observed between the groups. No signs of effect modification on this association by social capital or educational level could be found. CONCLUSIONS: Health information provided by the IHA increased self-reported level of knowledge on healthy diet and physical exercise. The interpretation of the observed negative association between low social participation and deteriorated or unchanged health needs is that participation was limited to one's own social group, and therefore had limited positive influence on health seeking behaviour. The lack of measurable improvements in health status could be explained by limitations in the study, in the theoretical assumptions underlying the intervention, and in the implementation of the intervention. Further research is needed to understand success factors in health promoting interventions among recently settled migrants better.

Social and health-related factors associated with refraining from seeking dental care: A cross-sectional population study.

BACKGROUND: Social inequities are considered to affect healthcare utilization, whereas less is known about the factors associated with refraining from seeking dental care. This study aimed to investigate whether people with no social support, long-term illness, caregiver burden and low socioeconomic status (SES) refrained from seeking dental care in higher proportion than the general Swedish population. METHODS: This study used cross-sectional questionnaire data from repeated nationwide health surveys during 2004-2013 of a total of 90 845 people. The questionnaire included questions on demographic characteristics, social support, long-term illness, caregiving burden, SES and dental care-seeking behaviour. Descriptive statistics, chi-square tests, correlation analyses and logistic regressions were used to investigate associations between independent variables and dental care-seeking behaviour. RESULTS: In the total sample, 15.1% of respondents reported refraining from seeking dental care. Having no emotional social support or having no instrumental social support was separately associated with reporting refraining from seeking dental care in adjusted multivariate models (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.18-1.34 and OR: 1.89, 95% CI: 1.67-2.13, respectively). Having a long-term illness was associated with refraining from seeking dental care in adjusted models (adjusted OR: 1.43, 95% CI: 1.35-1.51). Furthermore, being an informal caregiver was associated with refraining from seeking dental care (adjusted OR: 1.15, 95% CI: 1.07-1.23). Low SES was associated with higher refraining from seeking dental care; the strongest association was with having financial problems (adjusted OR: 3.57, 95% CI: 3.19-4.00). Interaction effects were found between education level and SES, and between social support and long-term illness, and the outcome. CONCLUSIONS: The findings in this study imply that having no social support, having long-term illness, being informal caregiver or having financial problems are factors associated with reporting refraining from seeking dental care, on a population basis.

Healthcare-seeking behaviour in relation to sexual and reproductive health among Thai-born women in Sweden: a qualitative study.

Thailand is one of the most common countries of origin among immigrants in Sweden and Thai immigrants comprise the immigrant group most frequently diagnosed with HIV. Little is known about their healthcare-seeking behaviour and views on HIV prevention. This study explored Thai women's healthcare-seeking behaviour in relation to sexual and reproductive health and their views on HIV prevention. Nineteen in-depth interviews were conducted with Thai-born women in the Stockholm area. Three themes were identified: (1) poor access to healthcare in Sweden, preferring to seek care in Thailand; (2) partners playing a key role in women's access to healthcare; (3) no perceived risk of HIV, but a positive attitude towards prevention. Despite expressing sexual and reproductive healthcare needs, most women had not sought this type of care, except for the cervical cancer screening programme to which they had been invited. Identified barriers for poor access to healthcare were lack of knowledge about the healthcare system and language difficulties. To achieve 'healthcare on equal terms', programmes and interventions must meet Thai women's healthcare needs and consider what factors influence their care-seeking behaviour. Integrating HIV prevention and contraceptive counselling into the cervical screening programme might be one way to improve access.

To Consent or Decline HPV Vaccination: A Pilot Study at the Start of the National School-Based Vaccination Program in Sweden.

BACKGROUND: Parents' beliefs about human papillomavirus (HPV) vaccination influence whether they allow their daughters to be vaccinated. We examined the association between parents' refusal and sociodemographic background, knowledge and beliefs about HPV, and the HPV vaccination in relation to the Health Belief Model. METHODS: The sample consisted of 200 (55%) parents of children aged 11-12 years in the Swedish national vaccination program. Data were collected using a self-reported questionnaire. Most parents (N = 186) agreed to the vaccination. Pearson's chi-square, Fisher's exact test, and the Mann-Whitney U test were used to analyze data. RESULTS: Declining parents saw more risks and fewer benefits of HPV vaccination but no differences in beliefs regarding the severity or young girls' susceptibility to HPV were found. There was an association between refusing the HPV vaccine and lower acceptance of previous childhood vaccinations, and their main source of information was the Internet. Parents who declined the vaccine believed it could adversely affect condom use, the age of their daughter's sexual debut, and the number of sexual partners. CONCLUSION: Parents should have the possibility to discuss HPV and HPV vaccine with a school nurse or other health care professionals, and should have access to evidence-based information on the Internet.

Knowledge and utilization of sexual and reproductive healthcare services among Thai immigrant women in Sweden.

BACKGROUND: Migration from Thailand to Sweden has increased threefold over the last 10 years. Today Thailand is one of the most common countries of origin among immigrants in Sweden. Since the year 2000, new HIV cases are also more prevalent among Thai immigrants compared to other immigrant nationalities in Sweden. The purpose of this study was to investigate the association between knowledge and utilization of sexual and reproductive healthcare services, contraceptive knowledge and socio-demographic characteristics and social capital among Thai immigrant women in Sweden. METHODS: This is a cross-sectional study using a postal questionnaire to all Thai women (18-64) in two Swedish regions, who immigrated to the country between 2006 and 2011. The questionnaire was answered by 804 women (response rate 62.3 %). Bivariate and multivariate logistic regression analyses were used. RESULTS: The majority (52.1 %) of Thai women had poor knowledge of where they should turn when they need sexual and reproductive healthcare services. After controlling for potential confounders, living without a partner (OR = 2.02, CI: 1.16-3.54), having low trust in others (OR = 1.61, CI: 1.10-2.35), having predominantly bonding social capital (OR = 1.50, CI: 1.02-2.23) and belonging to the oldest age group (OR = 2.65, CI: 1.32-5.29) were identified as risk factors for having poor knowledge. The majority (56.7 %) had never been in contact with healthcare services to get advice on contraception, and about 75 % had never been HIV/STI tested in Sweden. Low utilization of healthcare was associated with poor knowledge about healthcare services (OR = 6.07, CI: 3.94-9.34) and living without a partner (OR = 2.53, CI: 1.30-4.90). Most Thai women had knowledge of how to prevent an unwanted pregnancy (91.6 %) and infection with HIV/STI (91.1 %). CONCLUSIONS: The findings indicate that social capital factors such as high trust in others and predominantly bridging social capital promote access to knowledge about healthcare services. However, only one-fourth of the women had been HIV/STI tested, and due to the HIV prevalence among Thai immigrants in Sweden, policy makers and health professionals need to include Thai immigrants in planning health promotion efforts and healthcare interventions.

Treatment effect expressed as the novel Delay of Event measure is associated with high willingness to initiate preventive treatment - A randomized survey experiment comparing effect measures.

OBJECTIVES: This study aimed to investigate patients' willingness to initiate a preventive treatment and compared two established effect measures to the newly developed Delay of Events (DoE) measure that expresses treatment effect as a gain in event-free time. METHODS: In this cross-sectional, randomized survey experiment in the general Swedish population,1079 respondents (response rate 60.9%) were asked to consider a preventive cardiovascular treatment. Respondents were randomly allocated to one of three effect descriptions: DoE, relative risk reduction (RRR), or absolute risk reduction (ARR). Univariate and multivariate analyses were performed investigating willingness to initiate treatment, views on treatment benefit, motivation and importance to adhere and willingness to pay for treatment. RESULTS: Eighty-one percent were willing to take the medication when the effect was described as DoE, 83.0% when it was described as RRR and 62.8% when it was described as ARR. DoE and RRR was further associated with positive views on treatment benefit, motivation, importance to adhere and WTP. CONCLUSIONS: Presenting treatment effect as DoE or RRR was associated with a high willingness to initiate treatment. PRACTICE IMPLICATIONS: An approach based on the novel time-based measure DoE may be of value in clinical communication and shared decision making.