The economic burden of diseases in the Nordic countries: A systematic review.

BACKGROUND: Economic burden studies can provide insights into the drivers leading to increasing healthcare costs. It can also provide a more holistic view of how diseases impact the welfare of patients and their families. Having concrete estimates of the economic burden across multiple diseases can help policymakers determine which diseases are economically more burdensome. This study aimed to review and summarise comprehensively economic burden studies across multiple diseases in the Nordic countries between 2000 and 2020. METHODS: According to the 2020 PRISMA statement, a systematic literature review was conducted in PubMed, CINAHL, Academic Search Premier and Global Health databases using key terms related to the economic burden of any disease in Denmark, Finland, Greenland, Iceland, Norway and Sweden. Grey literature was also reviewed. RESULTS: A total of 10,050 potential titles and abstracts were identified and screened, and 254 full-text papers that met the inclusion criteria were evaluated by two independent reviewers. Of these, 119 articles were included in a qualitative synthesis. Twenty-nine had clearly defined comparison groups, thus able to attribute the costs to the disease. Large variations concerning methodology and cost components were noted. Across diseases, the economic burden ranged from EUR 1668 per patient annually for chronic obstructive pulmonary disease to EUR 93,041 for multiple sclerosis. However, estimates varied widely, even within each disease. CONCLUSIONS: Our review highlights the need for more comparable economic burden studies. Future studies should focus on applying robust methodology and homogeneous cost-reporting methods to inform policymakers about which diseases are economically more burdensome.

Burden of disease due to transportation noise in the Nordic countries.

BACKGROUND: Environmental noise is of increasing concern for public health. Quantification of associated health impacts is important for regulation and preventive strategies. AIM: To estimate the burden of disease (BoD) due to road traffic and railway noise in four Nordic countries and their capitals, in terms of DALYs (Disability-Adjusted Life Years), using comparable input data across countries. METHOD: Road traffic and railway noise exposure was obtained from the noise mapping conducted according to the Environmental Noise Directive (END) as well as nationwide noise exposure assessments for Denmark and Norway. Noise annoyance, sleep disturbance and ischaemic heart disease were included as the main health outcomes, using exposure-response functions from the WHO, 2018 systematic reviews. Additional analyses included stroke and type 2 diabetes. Country-specific DALY rates from the Global Burden of Disease (GBD) study were used as health input data. RESULTS: Comparable exposure data were not available on a national level for the Nordic countries, only for capital cities. The DALY rates for the capitals ranged from 329 to 485 DALYs/100,000 for road traffic noise and 44 to 146 DALY/100,000 for railway noise. Moreover, the DALY estimates for road traffic noise increased with up to 17% upon inclusion of stroke and diabetes. DALY estimates based on nationwide noise data were 51 and 133% higher than the END-based estimates, for Norway and Denmark, respectively. CONCLUSION: Further harmonization of noise exposure data is required for between-country comparisons. Moreover, nationwide noise models indicate that DALY estimates based on END considerably underestimate national BoD due to transportation noise. The health-related burden of traffic noise was comparable to that of air pollution, an established risk factor for disease in the GBD framework. Inclusion of environmental noise as a risk factor in the GBD is strongly encouraged.

Nordic responses to covid-19 from a health promotion perspective.

On 30 January 2020, the disease covid-19 was declared by the World Health Organization to be an international threat to human health and on 11 March 2020, the outbreak was declared a pandemic. The aim of this study was to analyse policy strategies developed by the five Nordic countries during the first 3 months of the pandemic from a health promotion perspective in order to identify Nordic responses to the crisis. Although the Nordic countries have a long tradition of co-operation as well as similar social welfare policies and legislation, each country developed their own strategies towards the crisis. The strategies identified were analysed from a health promotion perspective emanating from five principles: intersectorality, sustainability, equity, empowerment and a lifecourse perspective. Denmark, Finland and Norway had lockdowns to varying degrees, whereas Sweden and Iceland had no lockdowns. Iceland implemented a test and tracking strategy from the very beginning. All countries based their recommendations and restrictions on appeals to solidarity and trust in institutions and fellow citizens. The analysis showed that the strategies in all countries could be related to health promotion principles with some differences between the countries especially regarding equity and sustainability. The Nordic governments took responsibility for protecting their citizens by developing policy strategies based on restrictions and recommendations congruent with the principles of health promotion. The findings also identified issues that will pose challenges for future pandemic strategies.

Coronavirus pandemic in the Nordic countries: Health policy and economy trade-off.

Background: Countries making up the Nordic region - Denmark, Finland, Iceland, Norway, and Sweden - have minimal socioeconomic, cultural, and geographical differences between them, allowing for a fair comparative analysis of the health policy and economy trade-off in their national approaches towards mitigating the impact of the COVID-19 pandemic. Methods: This study utilized publicly available COVID-19 data of the Nordic countries from January 2020 to January 3, 2021. COVID-19 epidemiology, public health and health policy, health system capacity, and macroeconomic data were analysed for each Nordic country. Joinpoint regression analysis was performed to identify changes in temporal trends using average monthly percent change (AMPC) and average weekly percent change (AWPC). Results: Sweden's health policy, being by far the most relaxed response to COVID-19, was found to have the largest COVID-19 incidence and mortality, and the highest AWPC increases for both indicators (13.5, 95% CI = 5.6, 22.0, P < 0.001; 6.3, 95% CI = 3.5, 9.1, P < 0.001). Denmark had the highest number of COVID-19 tests per capita, consistent with their approach of increased testing as a preventive strategy for disease transmission. Iceland had the second-highest number of tests per capita due to their mass-testing, contact tracing, quarantine and isolation response. Only Norway had a significant increase in unemployment (AMPC = 2.8%, 95% CI = 0.7-4.9, P < 0.009) while the percentage change in real Gross Domestic Product (GDP) was insignificant for all countries. Conclusions: There was no trade-off between public health policy and economy during the COVID-19 pandemic in the Nordic region. Sweden's relaxed and delayed COVID-19 health policy response did not benefit the economy in the short term, while leading to disproportionate COVID-19 hospitalizations and mortality.

"Mapping suicide prevention initiatives targeting Indigenous Sámi in Nordic countries".

BACKGROUND: Suicide is a major public health issue among Indigenous Sámi in Nordic countries, and efforts to prevent suicide in the Sámi context are increasing. However, there is no literature on suicide prevention initiatives among Sámi. The aim of the study was to map suicide prevention initiatives targeting Sámi in Norway, Sweden, and Finland during 2005-2019. METHOD: Initiatives were identified and described through utilizing networks among stakeholders in the field of suicide prevention among Sámi, acquiring documentation of initiatives and utilizing the authors first-hand experiences. The described initiatives were analyzed inspired by the "What is the problem represented to be?" (WPR)-approach. RESULTS: Seventeen initiatives targeting Sámi were identified during 2005-2019, including nine in Sweden, five in Norway, one in Finland and two international initiatives. Analysis with the WPR-approach yielded 40 problematizations regarding how to prevent suicide among Sámi, pertaining to shortcomings on individual (5), relational (15), community/cultural (3), societal (14) and health systems levels (3). All initiatives were adapted to the Sámi context, varying from tailor-made, culture-specific approaches to targeting Sámi with universal approaches. The most common approaches were the gatekeeper and mental health literacy training programs. The initiatives generally lacked thorough evaluation components. CONCLUSION: We argue that the dominant rationales for suicide prevention were addressing shortcomings on individual and relational levels, and raising awareness in the general public. This threatens obscuring other, critical, approaches, such as broadening perspectives in prevention planning, improving health systems for Sámi, and promoting cultural empowerment among Sámi. Nevertheless, the study confirms considerable efforts have been invested into suicide prevention among Sámi during the last 15 years, and future initiatives might include a broader set of prevention rationales. To improve evaluation and identify the most promising practices, increased support regarding development of plans and implementation of evaluation components is needed.

COVID-19: A Comprehensive Review of Epidemiology and Public Health System Response in Nordic Region.

This paper investigates the epidemiology and public health response of novel coronavirus infection (COVID-19) in the Nordic region. The data on cases and deaths due to COVID-19 were drawn from the European Centre for Disease Prevention and Control. The data on age- and sex-wise cases, deaths and intensive care unit (ICU) admissions, and public health interventions in the Nordic region through November 10, 2020, were obtained from respective countries' health ministries. Sweden accounted for 60.59% of cases (162 240 of 267 768 cases) and 81% of deaths (6057 of 7477 cases) in the Nordic region. The incidence rate for the Nordic region was 989.59 per 100 000, varying from 327.30 per 100 000 in Finland to 1616.51 per 100 000 in Sweden, and the mortality rate for the region was 27.63 per 100 000, ranging from 5.3 per 100 000 in Norway to 60.35 per 100 000 in Sweden. The case-fatality ratio of the Nordic region was 2.79%. Females were more susceptible to COVID-19 infection than males (52.30% vs 47.66%), while males had a greater proportion of deaths (54.7%) and ICU need (71.99%) than females. It is imperative to continue with social distancing, mandatory masks, testing, prohibition of mass gatherings, isolation of confirmed cases, and preventing the importation of cases from other countries to avoid the further resurgence of cases.

Immunisation of healthcare workers in the Nordic countries: Variation in recommendations and practices and a lack of assessment.

Healthcare workers (HCWs) are at increased risk of both exposure and transmission of infectious disease. Two European Union (EU) directives state that health services are responsible for assessing their employees' potential exposure to infectious diseases and offering immunisation free of charge. We assessed current policy for immunisation of HCWs and the availability of vaccine coverage data in the Nordic countries by surveying national vaccination experts in Denmark, Finland, Iceland, Norway and Sweden, as well as Swedish county medical officers (CMOs). All national experts and 17 of 21 Swedish CMOs responded. All EU countries had transposed the European directives into national law, while Norway and Iceland had similar national legislation. Recommendations or guidelines were issued in Denmark, Finland, Iceland, Norway and 15 of 17 responding Swedish counties. The range of diseases covered differed by countries and Swedish counties. HCW vaccine coverage data were not systematically collected; incomplete estimates were only available for Finland and two Swedish counties. In conclusion, recommendations or guidelines exist in the Nordic countries, but their impact cannot be assessed, as vaccine uptake among HCWs is not currently measured. Systematic collection of data is a necessary step towards improving HCW immunisation policy and practice in the Nordic countries.

Smoking During Pregnancy Among Immigrant Women With Same-Origin and Swedish-Born Partners.

INTRODUCTION: Although ethnically mixed couples are on the rise in industrialized countries, their health behaviors are poorly understood. We examined the associations between partner's birthplace, age at immigration, and smoking during pregnancy among foreign-born women. METHODS: Population-based register study including all pregnancies resulting in a livebirth or stillbirth in Sweden (1991-2012) with complete information on smoking and parental country of birth. We compared the prevalence of smoking during pregnancy between women in dual same-origin foreign-born unions (n = 213 111) and in mixed couples (immigrant women with a Swedish-born partner) (n = 111 866) using logistic regression. Swedish-born couples were used as a benchmark. RESULTS: The crude smoking rate among Swedish women whose partners were Swedish was 11%. Smoking rates of women in dual same-origin foreign-born unions varied substantially by birthplace, from 1.3% among women from Asian countries to 23.2% among those from other Nordic countries. Among immigrant groups with prevalences of pregnancy smoking higher than that of women in dual Swedish-born unions, having a Swedish-born partner was associated with lower odds of smoking (adjusted odds ratios: 0.72-0.87) but with higher odds among immigrant groups with lower prevalence (adjusted odds ratios: 1.17-5.88). These associations were stronger among women immigrating in adulthood, whose smoking rates were the lowest. CONCLUSIONS: Swedish-born partners "pull" smoking rates of immigrant women toward the level of smoking of Swedish-born women, particularly among women arrived during adulthood. Consideration of a woman's and her partner's ethnic background and life stage at migration may help understand smoking patterns of immigrant women. IMPLICATIONS: We found that having a Swedish-born partner is associated with higher rates of smoking during pregnancy among immigrants from regions where women smoke less than Swedish women, but with lower smoking rates among immigrants from regions where women smoke more. This implies that prevention efforts should concentrate on newly arrived single women from low prevalence regions, such as Africa and Asia, whereas cessation efforts may target women from high prevalence regions, such as other European countries. These findings suggest that pregnancy smoking prevention or cessation interventions may benefit from including partners and approaches culturally tailored to mixed unions.

Living life with cerebral palsy? A description of the social safety nets for individuals with cerebral palsy in the Nordic countries.

AIMS: This report reviews major laws, acts and regulations of social benefits and services for individuals with disabilities, focusing on cerebral palsy in the five Nordic countries. It summarizes the available benefits and services and the re-application process and provides comparative analyses among the countries. METHODS: Published reports, articles and relevant government and municipal websites were reviewed for each respective country and used to compile an overview and comparison between the countries. RESULTS: In the Nordic countries, there are a number of laws and regulations in place to support individuals with cerebral palsy and their families. In addition, there are numerous social benefits available for which individuals with disabilities can apply. Although there are national differences, the similarities across the five countries regarding laws, social benefits offered for individuals with cerebral palsy and the application processes are clear. However, the application processes seem cumbersome and, at times, redundant. Physicians and other healthcare specialists repeatedly need to write 'medical certificates' describing the diagnosis and its consequences for a disability that is chronic and lifelong. CONCLUSIONS: Participation in society for individuals with cerebral palsy disabilities can be enabled by social benefits. By extension, social benefits may indirectly have implications for public health in individuals with disabilities. Although the lives of individuals with cerebral palsy - as with others - can improve in certain areas, the need for social benefits will generally increase, not decrease, over time. Although it is clearly important to have checks and balances that prevent system misuse, it might be worthwhile from a cost-benefit perspective to investigate whether the current systems could be improved to better manage time and resources and avoid emotional distress by streamlining the application process.

Compensation claims after knee cartilage surgery is rare. A registry-based study from Scandinavia from 2010 to 2015.

BACKGROUND: Focal cartilage defects (FCDs) in the knee joint has a high prevalence. A broad range of treatment options exists for symptomatic patients. Knowledge of patient compensation claims following surgical treatment of FCDs is missing. The purpose of this study is to evaluate compensation claims filed to the Scandinavian registries for patient compensation following treatment of FCDs in the knee joint from 2010 to 2015 and identify possible areas of improvement. METHODS: A cross-sectional study design was used to obtain all complaints following surgical treatment of FCDs from the Scandinavian registries from 2010 to 2015. Data such as age, gender, type of treatment, type of complaint, reason of verdict and amount of compensation were collected and systematically analyzed. RESULTS: 103 patients filed a compensation claim. 43 had received debridement (41.7%), 54 microfracture (MF) (52.4%), 3 mosaicplasty (2.9%) and 3 autologous chondrocyte implantation (ACI) (2.9%). Of the 103 claims, 36 were granted (35%). 21 following debridement (58.3%), 13 after MF (36.1%), 1 following mosaicplasty (2.8%) and 1 after ACI (2.8%). The most common reason for complaint was infection (22.1%), of which 89% were granted. The average compensation was €24.457 (range €209 - €458.943). CONCLUSION: Compensation claims following surgical treatment of knee cartilage injuries in Scandinavia are rare. Establishing nationwide cartilage registries can add further knowledge on this troublesome disease.

Rural-urban mortality inequalities in four Nordic welfare states.

In the Nordic countries, there are ambitious welfare policies that might reduce rural-urban health disparities. AIM: To investigate the effect of population density on health in four Nordic countries. METHODS: The health outcomes analysed were life expectancy and potential years of life lost. The effect of population density was appraised as the difference in life expectancy/ potential years of life lost by a 10-fold increase of population density. RESULTS: In Finland, Norway and Sweden, mortality rates were consistently higher in less densely populated municipalities. These disparities increased over time. Conclusions: The welfare efforts to offset rural-urban disparities have mostly not been sufficient.

Global, regional, and national burden of neck pain in the general population, 1990-2017: systematic analysis of the Global Burden of Disease Study 2017.

OBJECTIVE: To use data from the Global Burden of Disease Study between 1990 and 2017 to report the rates and trends of point prevalence, annual incidence, and years lived with disability for neck pain in the general population of 195 countries. DESIGN: Systematic analysis. DATA SOURCE: Global Burden of Diseases, Injuries, and Risk Factors Study 2017. MAIN OUTCOME MEASURES: Numbers and age standardised rates per 100 000 population of neck pain point prevalence, annual incidence, and years lived with disability were compared across regions and countries by age, sex, and sociodemographic index. Estimates were reported with uncertainty intervals. RESULTS: Globally in 2017 the age standardised rates for point prevalence of neck pain per 100 000 population was 3551.1 (95% uncertainty interval 3139.5 to 3977.9), for incidence of neck pain per 100 000 population was 806.6 (713.7 to 912.5), and for years lived with disability from neck pain per 100 000 population was 352.0 (245.6 to 493.3). These estimates did not change significantly between 1990 and 2017. The global point prevalence of neck pain in 2017 was higher in females compared with males, although this was not significant at the 0.05 level. Prevalence increased with age up to 70-74 years and then decreased. Norway (6151.2 (95% uncertainty interval 5382.3 to 6959.8)), Finland (5750.3 (5058.4 to 6518.3)), and Denmark (5316 (4674 to 6030.1)) had the three highest age standardised point prevalence estimates in 2017. The largest increases in age standardised point prevalence estimates from 1990 to 2017 were in the United Kingdom (14.6% (10.6% to 18.8%)), Sweden (10.4% (6.0% to 15.4%)), and Kuwait (2.6% (2.0% to 3.2%)). In general, positive associations, but with fluctuations, were found between age standardised years lived with disability for neck pain and sociodemographic index at the global level and for all Global Burden of Disease regions, suggesting the burden is higher at higher sociodemographic indices. CONCLUSIONS: Neck pain is a serious public health problem in the general population, with the highest burden in Norway, Finland, and Denmark. Increasing population awareness about risk factors and preventive strategies for neck pain is warranted to reduce the future burden of this condition.

Comparison of psychotropic medication use in the Baltic countries.

Purpose: While the pivotal role of pharmacotherapy in psychiatry is universal, significant regional differences exist in drug use patterns. Herewith we compare the use of ATC psychotropic drugs (N05, psycholeptics and N06A, antidepressants) in 2010-2015 in the three Baltic Countries with reference to the Nordic Countries.Methods: Data were obtained from the national authorities on medicines as expressed in DDD per 1000 inhabitants per day. A semi-structured questionnaire was used for expert statements on the rationale of current use of medicines.Results: During the observation period the use of antipsychotics, anxiolytics, hypnotics and sedatives, and antidepressants steadily increased, while the growth in use of anxiolytics stagnated in the more recent years. Antipsychotic use was the largest in Lithuania and the lowest in Estonia. The use on anxiolytics in Lithuania was more than twice of that in Estonia and Latvia. Conversely, the use of hypnotics and sedatives was about three times higher in Estonia than in Latvia or Lithuania. Antidepressant use was dominated by the selective serotonin reuptake inhibitors in all three countries, but overall was much lower in Latvia as compared to Lithuania and Estonia. As compared to the Nordic Countries in 2015, antidepressants are used at much lower level throughout Baltics, probably reflecting underdiagnostics of depression and anxiety disorders.Conclusion: While the health-care expenditures in Estonia, Latvia and Lithuania are largely similar, as is the cultural and recent political background of these EU member countries, the extent and the pattern of psychotropic drug use is remarkably variable.

Life expectancy and disease burden in the Nordic countries: results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017.

BACKGROUND: The Nordic countries have commonalities in gender equality, economy, welfare, and health care, but differ in culture and lifestyle, which might create country-wise health differences. This study compared life expectancy, disease burden, and risk factors in the Nordic region. METHODS: Life expectancy in years and age-standardised rates of overall, cause-specific, and risk factor-specific estimates of disability-adjusted life-years (DALYs) were analysed in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. Data were extracted for Denmark, Finland, Iceland, Norway, and Sweden (ie, the Nordic countries), and Greenland, an autonomous area of Denmark. Estimates were compared with global, high-income region, and Nordic regional estimates, including Greenland. FINDINGS: All Nordic countries exceeded the global life expectancy; in 2017, the highest life expectancy was in Iceland among females (85·9 years [95% uncertainty interval [UI] 85·5-86·4] vs 75·6 years [75·3-75·9] globally) and Sweden among males (80·8 years [80·2-81·4] vs 70·5 years [70·1-70·8] globally). Females (82·7 years [81·9-83·4]) and males (78·8 years [78·1-79·5]) in Denmark and males in Finland (78·6 years [77·8-79·2]) had lower life expectancy than in the other Nordic countries. The lowest life expectancy in the Nordic region was in Greenland (females 77·2 years [76·2-78·0], males 70·8 years [70·3-71·4]). Overall disease burden was lower in the Nordic countries than globally, with the lowest age-standardised DALY rates among Swedish males (18 555·7 DALYs [95% UI 15 968·6-21 426·8] per 100 000 population vs 35 834·3 DALYs [33 218·2-38 740·7] globally) and Icelandic females (16 074·1 DALYs [13 216·4-19 240·8] vs 29 934·6 DALYs [26 981·9-33 211·2] globally). Greenland had substantially higher DALY rates (26 666·6 DALYs [23 478·4-30 218·8] among females, 33 101·3 DALYs [30 182·3-36 218·6] among males) than the Nordic countries. Country variation was primarily due to differences in causes that largely contributed to DALYs through mortality, such as ischaemic heart disease. These causes dominated male disease burden, whereas non-fatal causes such as low back pain were important for female disease burden. Smoking and metabolic risk factors were high-ranking risk factors across all countries. DALYs attributable to alcohol use and smoking were particularly high among the Danes, as was alcohol use among Finnish males. INTERPRETATION: Risk factor differences might drive differences in life expectancy and disease burden that merit attention also in high-income settings such as the Nordic countries. Special attention should be given to the high disease burden in Greenland. FUNDING: Bill & Melinda Gates Foundation. The work on this paper was supported by the Research Council of Norway through FRIPRO (project number 262030) and by the Norwegian Institute of Public Health.

CP-North: living life in the Nordic countries? A retrospective register research protocol on individuals with cerebral palsy and their parents living in Sweden, Norway, Denmark, Finland and Iceland.

INTRODUCTION: Cerebral palsy (CP) is one of the most common neurodevelopmental disabilities. Yet, most individuals with CP are adults. How individuals with CP fare in terms of health, quality of life (QoL), education, employment and income is largely unknown. Further, little is known about the effects of having a child with CP on the parents. The Nordic countries are known for their strong welfare systems, yet it is unknown to what extent the added burden related to disability is actually compensated for. We will explore how living with CP affects health, QoL, healthcare utilisation, education, labour market outcomes, socioeconomic status and mortality throughout the lifespan of individuals with CP and their parents. We will also investigate if these effects differ between subgroups, within and across the Nordic countries. METHODS AND ANALYSES: CP-North is a multidisciplinary 4-year (1 August 2017 to 31 July 2021) register research project. The research consortium comprises researchers and users from Sweden, Norway, Denmark, Iceland and Finland. Data from CP registries and follow-up programmes, or cohorts of individuals with CP, will be merged with general national registries. All individual studies are structured under three themes: medical outcomes, social and public health outcomes, and health economics. Both case-control and cohort designs will be included depending on the particular research question. Data will be analysed in the individual countries and later merged across nations. ETHICS AND DISSEMINATION: The ethics approval processes in each individual country are followed. Findings will be published (open access) in international peer-reviewed journals in related fields. Updates on CP-North will be published online at http://rdi.arcada.fi/cpnorth/en/.

Modelling the Effect of Compliance with Nordic Nutrition Recommendations on Cardiovascular Disease and Cancer Mortality in the Nordic Countries.

The objective of this study is to estimate the number of deaths attributable to cardiovascular diseases and diet-related cancers that could be prevented or delayed in the Nordic countries, i.e., Sweden, Denmark, Finland, Norway, and Iceland, if adults adhere to the Nordic Nutrition Recommendations (NNR). A sex- and age-group specific epidemiological macro-simulation model was used to estimate the preventable deaths due to the differences between country specific actual intake and recommended intake of changes in food components. Data included in the model are a baseline scenario (actual dietary intake), a counterfactual scenario (recommended intake), and age-and sex-specific mortality for cardiovascular and diet-related cancer diseases, together with the total population risk of a specific year. Monte Carlo analyses with 5000 iterations were performed to produce the 95% uncertainty intervals. The model predicts that Iceland would benefit the most by adhering to the NNR, followed by Finland. In all the Nordic countries, the highest benefit would be achieved by adhering to the fruits and vegetable intakes, except Denmark, where a lower recommended intake of salt would provide the highest benefit. For men, fruits and vegetables could have saved more lives compared to other dietary components for all the Nordic countries, while for women, dietary fiber was the most prominent factor, except in Iceland. The Nordic Council should consider policies for promoting healthy eating according to the needs of each country.

Cross-country comparisons of trends in adolescent psychosomatic symptoms - a Rasch analysis of HBSC data from four Nordic countries.

BACKGROUND: To analyse the psychometric properties of the HBSC Symptom Checklist (HBSC-SCL) on psychosomatic symptoms with a focus on the operating characteristics of the items, and on the impacts of measurement distortions on the comparisons of person measures across time and between countries. METHODS: Data were collected in 1993/94, 1997/98, 2001/02, 2005/06, 2008/09, 2013/14 in Denmark, Finland, Norway and Sweden as part of the Health Behaviour in School-aged Children (HBSC) study. Data comprised 116,531 students 11, 13 and 15 years old. Rasch analysis was conducted of the HBSC-SCL consisting of eight items with a focus on Differential Item Functioning (DIF) and item threshold ordering. The impacts of DIF and threshold disordering on trend analyses were analysed in a subsample consisting of 15 years old students. RESULTS: One item shows evidence of severe DIF and the categorisation of some items does not seem to work as intended. Analyses of changes based on proportions of psychosomatic symptoms show that bad item functioning affects some comparisons between countries across time: A four percentage point difference between 15 years old girls in Finland and Sweden concerning the rate of increase of psychosomatic symptoms from 1994 to 2014 disappears when the problems with DIF and disordered item thresholds are taken into account. Although the proportions of students with psychosomatic symptoms are clearly higher 2014 than 1994 in all four countries the shape of most trends is nonlinear. CONCLUSIONS: Some of the cross-country comparisons were distorted because of DIF and problems related to disordering of the item thresholds. The comparisons among girls between Finland and Sweden were affected by the problems pertaining to the original measure of psychosomatic symptoms, while the trend patterns among boys were not much affected. In addition to confirming increasing rates of adolescent mental health problems in the Nordic countries, the substantive analyses in the current study show that Finland is joining Sweden in having the sharpest increase among older adolescents, in particular among girls. To improve the functioning of the scale the DIF item could be removed or replaced and response categories collapsed in post hoc analyses.