The Swedish intersectoral national public health policy: effects on child and adolescent health.

BACKGROUND: To improve health, intersectoral cooperation is often advocated. However, only few studies have reported health effects of this approach. Sweden has adopted a national public health policy (NPHP), which focuses on intersectoral primary prevention of disorders and injuries. AIM: To investigate the effects of the NPHP, on child and adolescent health in Sweden during the period 2000-19. METHODS: In the first step, the most important improvements in disorders and injuries, assessed as DALYs and incidences, were identified using the GBD Compare database. In the second step, primary prevention methods for these disorders and injuries were identified. In the third step, the relative importance of various government agents for these preventive measures was assessed using Google searches. RESULTS: Out of 24 groups of causes of disease or injury, only two groups demonstrated an incidence decrease: neoplasms and transport injuries. Leukaemia neoplasms might be prevented by reducing parental smoking, reducing outdoor air pollution and having the mother take folate supplements before getting pregnant. Transport injuries might be prevented by speed restrictions, and physically separating pedestrians from vehicle transport. Most of the primary prevention work was done by government agencies, like the Swedish Transport Agency, which worked independently of the National Institute of Public Health. CONCLUSION: Governmental agencies outside the health carried out most of the effective primary preventive efforts, almost independently of the NPHP.

Mortality trends for young adults in Sweden in the years 2000-2017.

AIM: Mental health problems in young people seem to be on the rise and more so in Sweden than in other locations. The aim was to compare the development of mortality rates for young adults in Sweden with Western Europe in total. METHODS: Young adults were defined as individuals aged 20-34 years and the study period was 2000-2017. Mortality data were derived from the Institute of Health Metrics and Evaluation. RESULTS: During the period 2000-2017, the mortality rate in young adults in Sweden stayed about the same, while in Western Europe as a whole the mortality rate decreased by 42%. The leading explanation for the unfavourable Swedish development was deaths due to drug use, mainly opioids, which increased by 60% during this period. The other major causes of death decreased both in Sweden and Western Europe, but decreased more slowly in Sweden. The differences in the rate of decrease between Sweden and Western Europe were for self-harm (27%), transport injuries (12%), unintentional injuries (31%) and for neoplasms (23%). The unfavourable development in Sweden resembled the development in the USA. CONCLUSIONS: The risks of four of the five leading causes of death in this age group were affected by the individuals' social conditions. The unfavourable mortality development in young adults in Sweden was mainly due to substance use. A contributing cause might be the change in the Swedish healthcare system that introduced competition between providers, which might have encouraged providers to prescribe opioids.

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.

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

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

Antidepressant medication might increase the risk of self-harm injuries: findings in 17 OECD countries.

Clinical trials suggest that antidepressants increase the risk of self-harm injuries (SHI). The aim was to investigate associations between antidepressants' use and the rate of change of SHI in 17 countries over the period 2000-16, with initial levels of SHI taken into account. The rate of change of SHI seems mainly (81%) determined by initial rates. The rate of SHI decreased in most countries. The decrease was slower in countries with a high level of antidepressants' use and in countries with an increase of depressive disorders. The study indicates that the use of antidepressants might increase the risk of SHI.

Mortality rates in OECD countries converged during the period 1990-2010.

AIMS: Since the scientific revolution of the 18th century, human health has gradually improved, but there is no unifying theory that explains this improvement in health. Studies of macrodeterminants have produced conflicting results. Most studies have analysed health at a given point in time as the outcome; however, the rate of improvement in health might be a more appropriate outcome. METHODS: Twenty-eight OECD member countries were selected for analysis in the period 1990-2010. The main outcomes studied, in six age groups, were the national rates of decrease in mortality in the period 1990-2010. The effects of seven potential determinants on the rates of decrease in mortality were analysed in linear multiple regression models using least squares, controlling for country-specific history constants, which represent the mortality rate in 1990. RESULTS: The multiple regression analyses started with models that only included mortality rates in 1990 as determinants. These models explained 87% of the intercountry variation in the children aged 1-4 years and 51% in adults aged 55-74 years. When added to the regression equations, the seven determinants did not seem to significantly increase the explanatory power of the equations. CONCLUSIONS: The analyses indicated a decrease in mortality in all nations and in all age groups. The development of mortality rates in the different nations demonstrated significant catch-up effects. Therefore an important objective of the national public health sector seems to be to reduce the delay between international research findings and the universal implementation of relevant innovations.

Suicide rates in European OECD nations converged during the period 1990-2010.

PURPOSE AND METHODS: The aim of this study was to investigate, with multiple regression analyses, the effect of selected characteristics on the rate of decrease of suicide rates in 21 OECD (Organisation for Economic Co-operation and Development) nations over the period 1990-2010, with initial levels of suicide rates taken into account. RESULTS: The rate of decrease seems mainly (83%) to be determined by the initial suicide rates in 1990. In nations with relatively high initial rates, the rates decreased faster. The suicide rates also converged. CONCLUSION: The study indicates that beta convergence alone explained most of the cross-national variations.

The rate of country-level improvements of the infant mortality rate is mainly determined by previous history.

BACKGROUND: Studies of country-level determinants of health have produced conflicting results even when the analyses have been restricted to high-income counties. Yet, most of these studies have not taken historical, country-specific developments into account. Thus, it is appropriate to separate the influence of current exposures from historical aspects. METHODS: Determinants of the infant mortality rate (IMR) were studied in 28 OECD countries over the period 1990-2012. Twelve determinants were selected. They refer to the level of general resources, resources that specifically address child health and characteristics that affect knowledge dissemination, including level of trust, and a health related behaviour: the rate of female smoking. RESULTS: Bivariate analyses with the IMR in year 2000 as outcome and the 12 determinants produced six statistically significant models. In multivariate analyses, the rate of decrease in the IMR was investigated as outcome and a history variable (IMR in 1990) was included in the models. The history variable alone explained 95% of the variation. None of the multivariate models, with the 12 determinants included, explained significantly more variation. CONCLUSION: Taking into account the historical development of the IMR will critically affect correlations between country-level determinants and the IMR.

Might extended education decrease inequalities in health?-a meta-analysis.

BACKGROUND: Health is substantially worse in less educated people, and extended education might potentially improve their health. A prerequisite for a beneficial health effect of education is that the effect is absolute. An absolute effect of education means that the health effect comes about independently of any effect on other persons. A relative effect, on the other hand, only contributes to individual competitiveness in relation to others. Studies of natural experiments of extended compulsory education, and other educational-policy changes, provide an option for the analysis of absolute effects of education. Published studies, however, present conflicting results. METHODS: A meta-analysis was performed of European studies where the health effects of extended compulsory or secondary level education on low-educated individuals were investigated. RESULTS: Twenty-two relevant publications were identified. The meta-analysis indicated statistically significant favourable effects of educational reforms on rates of mortality, self-reported poor health and obesity. The effects were, however, small, 1-4%. CONCLUSIONS: An educational reform that typically added one educational year in the least educated group was associated with a mean 2.1% reduction in mortality in men before age 40. This effect might be compared with the total educational gradients of mortality rates in Swedish men at ages 30-64. One extra year of education after compulsory education corresponds to a 41% reduction in mortality, which is 20 times more than the absolute effect of education found in this meta-analysis. Thus, it unlikely that extended compulsory education will substantially improve the health of the least educated individuals.

Mental health problems are rising more in Swedish adolescents than in other Nordic countries and the Netherlands.

UNLABELLED: Mental health problems increased in adolescents and young adults in Europe between 1950 and 1990, and the cause is largely unknown. Denmark, Finland, the Netherlands, Norway and Sweden form a relatively homogenous group of countries with favourable conditions for children. Our review examined the time trends for mental health problems in these countries between 1990 and 2010. CONCLUSION: In general, there were only small changes in mental health problems in the countries studied. However, we did note a marked rising trend in mental health problems among adolescents in Sweden, which also has more issues with school achievement and unemployment rates.

[Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior]. / Revisión sistemática del efecto de las advertencias gráficas impresas en los paquetes de cigarrillos sobre el comportamiento de los fumadores.

We used a structured approach to assess whether active smokers presented with pictorial warnings on cigarette packages (PWCP) had a higher probability of quitting, reducing, and attempting to quit smoking than did unexposed smokers. We identified 21 articles from among nearly 2500 published between 1993 and 2013, prioritizing coverage over relevance or quality because we expected to find only a few studies with behavioral outcomes. We found very large heterogeneity across studies, poor or very poor methodological quality, and generally null or conflicting findings for any explored outcome. The evidence for or against the use of PWCP is insufficient, suggesting that any effect of PWCP on behavior would be modest. Determining the single impact of PWCP on behavior requires studies with strong methodological designs and longer follow-up periods.

Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior.

We used a structured approach to assess whether active smokers presented with pictorial warnings on cigarette packages (PWCP) had a higher probability of quitting, reducing, and attempting to quit smoking than did unexposed smokers. We identified 21 articles from among nearly 2500 published between 1993 and 2013, prioritizing coverage over relevance or quality because we expected to find only a few studies with behavioral outcomes. We found very large heterogeneity across studies, poor or very poor methodological quality, and generally null or conflicting findings for any explored outcome. The evidence for or against the use of PWCP is insufficient, suggesting that any effect of PWCP on behavior would be modest. Determining the single impact of PWCP on behavior requires studies with strong methodological designs and longer follow-up periods.

Anti-tobacco policy in schools: upcoming preventive strategy or prevention myth? A review of 31 studies.

OBJECTIVE: To summarise the evidence on effectiveness of school anti-tobacco policies (exposure) in preventing tobacco use (outcome) among high school students. DATA SOURCES: The search was conducted between 1 September and 30 November 2011 on six electronic databases with keywords: 'policy', 'ban', 'restriction' and 'environment' in combination with 'adolescent' or 'student', 'school' and 'smoking' in titles, abstracts or keywords. Restrictions were made to articles published in English. STUDY SELECTION: Studies were included if they targeted the relevant grades/age; reported at least one outcome measure of students' ever or current tobacco use; reported on the effects of exposure to policy separately from other interventions. Inclusion criteria were assessed independently by two of the coauthors. Of 2723 articles initially identified, 31 articles met the inclusion criteria (1.1%). DATA EXTRACTION: Independent multiple observers extracted the data following the GRADE system guidelines to classify the level of evidence in relation to the review objective. DATA SYNTHESIS: Studies were very heterogeneous in the definitions of exposure to school anti-tobacco policy and of tobacco use, adjustment for potential confounders and reporting of results, therefore summary quantitative measures of effect were not calculated. Qualitative summary statements were derived by reviewing the results reported in text and tables for distinct policy constructs. Evidence could be classified as low or very low, resting on cross-sectional studies with high risk of bias. Studies were rather consistent in indicating that comprehensive smoking bans, clear rules, strict policy enforcement, availability of education and prevention were associated with decreased smoking prevalence. Formally adopted and written policies, surveillance of students' behaviour and presence/severity of sanctions were not consistently associated to students' tobacco use. CONCLUSIONS: The evidence concerning the effectiveness of a school policy alone in preventing youth tobacco use is weak and inconclusive. Experimental studies or observational studies with longitudinal design are warranted, employing clear definitions of policy components and careful control for confounding.

School policies for preventing smoking among young people.

BACKGROUND: School tobacco policies (STPs) might prove to be a promising strategy to prevent smoking initiation among adolescents, as there is evidence that the school environment can influence young people to smoke. STPs are cheap, relatively easy to implement and have a wide reach, but it is not clear whether this approach is effective in preventing smoking uptake. OBJECTIVES: To assess the effectiveness of policies aiming to prevent smoking initiation among students by regulating smoking in schools. SEARCH METHODS: We searched seven electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO and ERIC. We also searched the grey literature and ongoing trials resources. The most recent search was performed in May 2014. SELECTION CRITERIA: We included cluster-randomised controlled trials (c-RCTs) in which primary and secondary schools were randomised to receive different levels of smoking policy or no intervention. Non-randomised controlled trials, interrupted time series and controlled before-after studies would also have been eligible. Cross-sectional studies were not formally included but we describe their findings and use them to generate hypotheses to inform future research. DATA COLLECTION AND ANALYSIS: We independently assessed studies for inclusion in the review, and present a narrative synthesis, as the studies are too limited in quality to undertake a formal meta-analysis. MAIN RESULTS: We found only one study which was eligible for inclusion in the review. It was judged to be at high risk of bias. The study compared two 'middle schools' from two different regions in China. The experimental conditions included the introduction of a tobacco policy, environmental changes, and communication activities, while the control condition was no intervention. After a year's follow-up the study found no differences in smoking prevalence between intervention and control schools. We also described 24 observational studies, the results of which we considered for hypothesis generation. In these, policy exposure was mainly described using face-to-face interviews with school staff members, and the outcome evaluation was performed using self-administered questionnaires. Most studies reported no differences in students' smoking prevalence between schools with formal STPs when compared with schools without policies. In the majority of studies in schools with highly enforced policies, smoking bans extended to outdoor spaces, involving teachers and including sanctions for transgressions, with assistance to quit for smokers plus support by prevention programmes, there was no significant difference in smoking prevalence when compared to schools adopting weaker or no policies. AUTHORS' CONCLUSIONS: Despite a comprehensive literature search, and rigorous evaluation of studies, we found no evidence to support STPs. The absence of reliable evidence for the effectiveness of STPs is a concern in public health. We need well-designed randomised controlled trials or quasi-experimental studies to evaluate the effectiveness of school tobacco policies.

A comparative analysis of early child health and development services and outcomes in countries with different redistributive policies.

BACKGROUND: The social environment is a fundamental determinant of early child development and, in turn, early child development is a determinant of health, well-being, and learning skills across the life course. Redistributive policies aimed at reducing social inequalities, such as a welfare state and labour market policies, have shown a positive association with selected health indicators. In this study, we investigated the influence of redistributive policies specifically on the social environment of early child development in five countries with different political traditions. The objective of this analysis was to highlight similarities and differences in social and health services between the countries and their associations with other health outcomes that can inform better global early child development policies and improve early child health and development. METHODS: Four social determinants of early child development were selected to provide a cross-section of key time periods in a child's life from prenatal to kindergarten. They included: 1) prenatal care, 2) maternal leave, 3) child health care, and 4) child care and early childhood education. We searched international databases and reports (e.g. Organization for Economic Cooperation and Development, World Bank, and UNICEF) to obtain information about early child development policies, services and outcomes. RESULTS: Although a comparative analysis cannot claim causation, our analysis suggests that redistributive policies aimed at reducing social inequalities are associated with a positive influence on the social determinants of early child development. Generous redistributive policies are associated with a higher maternal leave allowance and pay and more preventive child healthcare visits. A decreasing trend in infant mortality, low birth weight rate, and under five mortality rate were observed with an increase in redistributive policies. No clear influence of redistributive policies was observed on breastfeeding and immunization rates. In the analysis of child care and early education, the lack of uniform measures of early child development outcomes was apparent. CONCLUSIONS: This paper provides further support for an association between redistributive policies and early child health and development outcomes, along with the organization of early child health and development services.

[¼Death of despair« among young adults is most common in the sparsely populated regions in the north of Sweden]. / ¼Död av förtvivlan« är vanligare bland unga vuxna i skogslänen.

Case and Deaton have introduced the term ¼Death of Despair« to describe the increased mortality in the United States in young adults and middle-aged persons due to suicide and alcohol and drug use. A corresponding development is found in Sweden among young adults, in contrast to other parts of Western Europe. In Sweden, the disadvantageous development has been particularly evident in the sparsely populated regions in the north of Sweden. The explanation for the adverse development, both in the US and Sweden, might be the ongoing de-industrialization which especially affects young, low-educated men in sparsely populated areas.

The missing middle of childhood.

Middle childhood, between six and twelve years, is a critical bridge between earlier childhood and adolescence with rapid physical and psychological transitions. Most of the world's 2.6 billion young people, of which the middle childhood age group is a significant portion, live in low- and middle-income countries. Many live in environments that place them at high and growing risk for mental ill-health, injuries, and adoption of risky behaviours that often lead to non-communicable diseases in later years. Still, middle childhood, the 'missing middle,' is omitted from global health information systems, targeted policies, and strategies. The dearth of internationally comparable and standardised indicators on middle childhood in major international development agency databases hampers age-appropriate policy and programme development. Better understanding of the needs of this increasingly vulnerable population is critical. Middle childhood needs to be an explicit focus within child-focused research and implementation. Standardised, comprehensive, and relevant indicators are required to quantify the contribution of middle childhood to the global burden of disease and to facilitate interventions, monitoring, and evaluation, to ensure that all children flourish and thrive.

Psychosocial determinants of attrition in a longitudinal study of tobacco use in youth.

To gain knowledge on psychosocial characteristics that predict the propensity of participation in longitudinal studies, attrition was analysed in a cohort of 3020 adolescents participating in the baseline survey of a longitudinal study with repeated followup focusing on adolescents' tobacco use. During the followup surveys, the proportion of responders was constantly at or above 90%. There were 941 adolescents (31.2%) who failed to participate in at least one of the six followup surveys. Boys had a fifty percent increased risk of nonparticipation compared with girls. Adolescents in families with experience of divorce, unemployment, and change of residence had a higher risk of nonparticipation. An increasing number of stressful life events during the previous year, uptake of tobacco use, number of friends, perceived performance at school, truancy, and alcohol use during the last term also independently associated with nonparticipation. Diverse psychosocial characteristics are independently associated with nonparticipation of youths in longitudinal studies.