The Swedish national public health policy report 2010.

BACKGROUND: In 2003, the Swedish Parliament adopted a cross-sectorial national public health policy based on the social determinants of health, with an overarching aim--to create societal conditions that will ensure good health, on equal terms, for the entire population--and eleven objective domains. At that time the policy was globally unique, and serves as guidance for public health practice at the national, regional and local levels. The development of the public health policy and the determinants of health are presented regularly in various reports by the Swedish National Institute of Public Health. This supplement is a condensed version of the 174-page Public Health Policy Report 2010, the second produced since the national policy was adopted in 2003. METHODS: In order to provide a holistic approach to analysing implemented measures and providing new recommendations within the eleven objective domains of the Swedish national public health policy, we have divided these in three strategic areas. These are: Good Living Conditions, Health-Promoting Living Environments and Living Habits, and Alcohol, Illicit Drugs, Doping, Tobacco and Gambling, each described in the respective introductions for Chapters 3-5. The production of the report was supported by a common analytical model that clarified the societal prerequisites for health in the eleven objective domains. These are factors that can be influenced by political actions in order to create a change. Economic analyses have also been developed to provide a priority basis for political decisions. Analyses of the development of public health determinants were based on data from the National Public Health Survey and data delivered from about 15 various national agencies. Measures that have been implemented between 2004 and 2009 are analysed in details, as the basis for new recommendations for future measures. RESULTS: The introduction describes Swedish public health policy in the new millennium and how it has developed, the role of the Swedish National Institute of Public Health and other important stakeholders. Approaches, models and methods used in carrying out the commission to produce the public health policy report are also described. In the following chapters, the trends of important determinants of public health, in relation to the overarching aim and the 11 objective domains as grouped in the three strategic areas, are analysed. The final chapter presents the proposed prioritisation for the large number of recommendations that were made, and a presentation of the annual costs of ill health in Sweden. These are compared with the costs of implementing recommended measures. The final chapter also describes how the Public Health Policy Report 2010 was received and lists the recommendations that the Swedish Government has taken action on as of September 2012. CONCLUSIONS: Public health trends have generally been stable or positive, although health inequalities persist. Economic analyses demonstrate that ill-health in Sweden costs 12 billion SEK every year, yet a large amount of this ill-health can be prevented. Sixty-eight recommendations were presented in the report. The government's response to recommendations has been very positive; approximately 60% of the recommendations in the three strategic areas have been adopted less than two years after the Public Health Policy Report 2010 was published.

Water development projects and marital violence: experiences from rural Bangladesh.

In this study, we explored the implications of a groundwater development project on women's workload and their experience of marital violence in a Bangladesh village. We believe that the project facilitated irrigation water but also that it resulted in seasonal domestic water shortages. Men used deep motorized pumps for irrigation, and women used shallow handpumps for domestic purposes. Many handpumps dried out, so women had to walk to distant wells. This increased their workload and challenged their possibilities of fulfilling household obligations, thereby increasing the risk of normative marital male violence against women as a punishment for their failure.

Economic hardships in adulthood and mental health in Sweden. The Swedish National Public Health Survey 2009.

BACKGROUND: Possible accumulative effects of a combined economic hardship's measure, including both income and non-income related economic hardships measures, on mental health has not been well investigated. The aim of this paper was to investigate; (i) independent associations between multiple measures of economic hardships and mental health problems, and (ii) associations between a combined economic hardships measure and mental health problems. METHODS: We analysed data from the 2009 Swedish National Survey of Public Health comprising a randomly selected representative national sample combined with a randomly selected supplementary sample from four county councils and three municipalities consisting of 23,153 men and 28,261 women aged 16-84 years. Mental health problems included; psychological distress (GHQ-12), severe anxiety and use of antidepressant medication. Economic hardship was measured by a combined economic hardships measure including low household income, inability to meet expenses and lacking cash reserves. RESULTS: The results from multivariate adjusted (age, country of birth, educational level, occupational status, employment status, family status and long term illness) logistic regression analysis indicate that self-reported current economic difficulties (inability to pay for ordinary bills and lack of cash reserves), were significantly associated with both women's and men's mental health problems (all indicators), while low income was not. In addition, we found a statistically significant graded association between mental health problems and levels of economic hardships. CONCLUSIONS: The findings indicate that indicators of self-reported current economic difficulties seem to be more strongly associated with poor mental health outcomes than the more conventional measure low income. Furthermore, the likelihood of mental health problems differed significantly in a graded fashion in relation to levels of economic hardships.

Review article: Globalisation and women's health in Sub-Saharan Africa: would paying attention to women's occupational roles improve nutritional outcomes?

AIM: This paper explores, through a review of literature, the link between globalisation and nutritional outcomes in Sub-Saharan Africa, focusing on the pathways of women's occupational roles on the food produced, consumed, and secured for households. METHODS: Following a framework linking globalisation and health, we drew evidence from peer reviewed, cross-national or large scale studies, official sources, reviews, online scientific databases, and case studies, published between 1990 and 2009. RESULTS: Publications cite improved technology, information, know how, normative commitments to and resources for human development, returns from access to investment in agriculture for low-income women producers, and urban employment opportunities reducing social discrimination and improving opportunities for household food security, particularly if access to these benefits is reinforced by national policy. However, many more publications cite negative consequences, including in falling national and local food self-sufficiency, livelihood and nutritional losses, widening inequalities, and in declining or insecure access to production inputs, markets, incomes, local foods, and healthcare. These effects are documented to increase time and resource burdens for women, with negative consequences for their own and their families' health and nutrition. CONCLUSIONS: The evidence suggests that globalisation-related economic and trade policies have, on balance, been associated with shifts in women's occupational roles and resources that contribute to documented poor nutritional outcomes in Africa. These trends call for public policies that address such positive and negative effects for women and for improved monitoring of such gender and socio-economic trends, especially at the household and community level, in the tracking of the Millennium Development Goals.

Can the Millennium Development Goals database be used to measure the effects of globalisation on women's health in Sub-Saharan Africa? A critical analysis.

BACKGROUND: Africa has had poor returns from integration with world markets in globalisation, has experienced worsening poverty and malnutrition and has high burdens of HIV and communicable disease, with particular burdens on women. It is therefore essential to describe the impact of globalisation on women's health. Indicators such as the Millennium Development Goals (MDGs) are presented as having a major role in measuring this impact, but an assessment of the adequacy of aggregate national indicators used in monitoring the MDGs for this purpose is lacking. METHODS: The Millennium Development Goals' panel database 2000 to 2006 was used to investigate the association between globalisation and women's health in Sub-Saharan Africa based on various determinants of heath. Out of the 148 countries classified as developing countries, 48 were in Sub-Saharan Africa. RESULTS: Results suggest that developing countries are becoming more integrated with world markets through some lowering of trade barriers. At the same time, women's occupational roles are changing, which could affect their health status. However, it is difficult to measure the impact of globalisation on women's health from the MDG database. First, data on trade liberalization is aggregated at the regional level and does not hold any information on individual countries. Second, too few indicators in the MDG database are disaggregated by sex, making it difficult to separate the effects on women from those on men. CONCLUSIONS: The MDG database is not adequate to assess the effects of globalisation on women's health in Sub-Saharan Africa. We recommend that researchers aim to address this research question to find other data sources or turn to case studies. We hope that results from this study will stimulate research on globalisation and health using reliable sources.

A cost-effectiveness analysis of the Chlamydia Monday--a community-based intervention to decrease the prevalence of chlamydia in Sweden.

AIMS: The study was undertaken to assess the cost-effectiveness of the Chlamydia Monday, 2007. This is a community-based intervention aimed at reducing the prevalence of chlamydia by information and increased availability of testing, treatment and contact tracing in Stockholm. The aim was to analyze the cost-effectiveness by estimating costs, savings and effects on health associated with the intervention, and to determine if cost-effectiveness varies between men and women. METHODS: A societal perspective was adopted, meaning all significant costs and consequences were taken into consideration, regardless of who experienced them. A cost-effectiveness model was constructed including costs of the intervention, savings due to avoiding potential costs associated with medical sequels of chlamydia infection, and health gains measured as quality adjusted life years (QALY). Sensitivity analyses were done to explore model and result uncertainty. RESULTS: Total costs were calculated to be 66,787.21; total savings to 30,370.14; and total health gains to 9.852324 QALYs (undiscounted figures). The discounted cost per QALY was 8,346.05 (10,810.77/QALY for women and 6,085.35/QALY for men). Sensitivity analyses included changes in effectiveness, variation of prevalence, reduced risk of sequel progression, inclusion of prevented future production loss and shortened duration for chronic conditions. The cost per QALY was consistently less than 50,000, which is often regarded as cost-effective in a Swedish context. CONCLUSIONS: The Chlamydia Monday has been demonstrated by this study to be a cost-effective intervention and should be considered a wise use of society's resources.

What has trust in the health-care system got to do with psychological distress? Analyses from the national Swedish survey of public health.

OBJECTIVE: Mental health disorders are a rapidly growing public health problem. Despite the fact that lack of trust in the health-care system is considered to be an important determinant of health, there is scarcity of empirical evidence demonstrating its associations with health outcomes. This is the first study which aims to evaluate the association between trust in the health-care system and psychological distress. DESIGN: Cross-sectional study. The association between trust in the health-care system and psychological distress was analysed with multiple logistic regression analysis adjusting for other factors. SETTING: A randomly selected representative sample of women and men aged 16-84 years from the Swedish population who responded to the 2006 Swedish National Survey of Public Health. PARTICIPANTS: A total of 26 305 men and 30 584 women participated in the study. INTERVENTION: None. MAIN OUTCOME MEASURE: The main outcome measure was psychological distress measured by the General Health Questionnaire. RESULTS: Very low trust in health-care services was associated with an increased risk for psychological distress among men (odds ratio = 1.59, 95% confidence intervals 1.25-2.02) and among women (odds ratio = 1.83, 95% confidence intervals 1.47-2.27) after controlling for age, country of birth, socioeconomic circumstances, long-term illness and interpersonal trust. CONCLUSIONS: Our results suggest that health-care system mistrust is associated with an increased likelihood of psychological distress. Although causal relationships cannot be established, patient mistrust of health-care providers may have detrimental implications on health. Public health policies should include strategies aimed at increasing access to health-care services, where trust plays a substantial role.

Community perceptions and factors influencing utilization of health services in Uganda.

BACKGROUND: Healthcare utilization has particular relevance as a public health and development issue. Unlike material and human capital, there is little empirical evidence on the utility of social resources in overcoming barriers to healthcare utilization in a developing country context. We sought to assess the relevance of social resources in overcoming barriers to healthcare utilization. STUDY OBJECTIVE: To explore community perceptions among three different wealth categories on factors influencing healthcare utilization in Eastern Uganda. METHODS: We used a qualitative study design using Focus Group Discussions (FGD) to conduct the study. Community meetings were initially held to identify FGD participants in the different wealth categories, ('least poor', 'medium' and 'poorest') using poverty ranking based on ownership of assets and income sources. Nine FGDs from three homogenous wealth categories were conducted. Data from the FGDs was analyzed using content analysis revealing common barriers as well as facilitating factors for healthcare service utilization by wealth categories. The Health Access Livelihood Framework was used to examine and interpret the findings. RESULTS: Barriers to healthcare utilization exist for all the wealth categories along three different axes including: the health seeking process; health services delivery; and the ownership of livelihood assets. Income source, transport ownership, and health literacy were reported as centrally useful in overcoming some barriers to healthcare utilization for the 'least poor' and 'poor' wealth categories. The 'poorest' wealth category was keen to utilize free public health services. Conversely, there are perceptions that public health facilities were perceived to offer low quality care with chronic gaps such as shortages of essential supplies. In addition to individual material resources and the availability of free public healthcare services, social resources are perceived as important in overcoming utilization barriers. However, there are indications that having access to social resources may compensate for the lack of material resources in relation to use of health care services mainly for the least poor wealth category. CONCLUSION: The differential patterning of social resources may explain or contribute to the persisting inequities in health care utilization. Additional research using quantitative analytical methods is needed to test the robustness of the contribution of social resources to the utilization of and access to healthcare services.

Institutional trust and alcohol consumption in Sweden: the Swedish National Public Health Survey 2006.

BACKGROUND: Trust as a measure of social capital has been documented to be associated with health. Mediating factors for this association are not well investigated. Harmful alcohol consumption is believed to be one of the mediating factors. We hypothesized that low social capital defined as low institutional trust is associated with harmful alcohol consumption. METHODS: Data from the 2006 Swedish National Survey of Public Health were used for analyses. The total study population comprised a randomly selected representative sample of 26.305 men and 30.584 women aged 16-84 years. Harmful alcohol consumption was measured using a short version the Alcohol Use Disorders Identification Test (AUDIT), developed and recommended by the World Health Organisation. Low institutional trust was defined based on trust in ten main welfare institutions in Sweden. RESULTS: Independent of age, country of birth and socioeconomic circumstances, low institutional trust was associated with increased likelihood of harmful alcohol consumption (OR (men) = 1.52, 95% CI 1.34-1.70) and (OR (women) = 1.50, 95% CI 1.35-1.66). This association was marginally altered after adjustment for interpersonal trust. CONCLUSION: Findings of the present study show that lack of trust in institutions is associated with increased likelihood of harmful alcohol consumption. We hope that findings in the present study will inspire similar studies in other contexts and contribute to more knowledge on the association between institutional trust and lifestyle patterns. This evidence may contribute to policies and strategies related to alcohol consumption.

Men's Perceptions of Women's Participation in Development Initiatives in Rural Bangladesh.

Without taking masculine issues into account, women's participation in development initiatives does not always guarantee their empowerment, health, and welfare in a male-dominated society. This study aimed to explore men's perceptions of women's participation in development (WPD) in rural Bangladesh. In adopting a qualitative approach, the study examined 48 purposively selected married and unmarried men aged 20-76 years in three northwest villages. Data collection was accomplished through four focus group discussions (FGDs) with 43 men clustered into four groups and through individual interviews with five other men. A qualitative content analysis of the data revealed an overall theme of "feeling challenged by fears and hopes," indicating variations in men's views on women's participation in development initiatives as represented by three main categories: (a) fearing the loss of male authority, (b) recognizing women's roles in enhancing family welfare, and (c) valuing women's independence. In the context of dominant patriarchal traditions in Bangladesh, these findings provide new insight into dynamics and variations of men's views, suggesting a need to better engage men during different stages of women-focused development initiatives.

Is cumulative exposure to economic hardships more hazardous to women's health than men's? A 16-year follow-up study of the Swedish Survey of Living Conditions.

BACKGROUND: Previous research has shown an association between cumulative economic hardships and various health outcomes. However, the cumulative effects of economic hardships in regard to gender differences have not been given enough attention. METHODS: 1981 women and 1799 men were followed up over a period of 16 years (1981-1997), using data from the Swedish Survey of Living Conditions panel study. The temporal association between economic hardships and self-rated health, psychological distress and musculoskeletal disorders was analysed. RESULTS: A dose-response effect on women's health was observed with increasing scores of cumulative exposure to financial stress but not with low income. Women exposed to financial stress at both T(1) and T(2) had an increased risk of 1.4-1.6 for all health measures compared with those who were not exposed. A similar consistent dose-response effect was not observed among men. CONCLUSIONS: There is a temporal relationship between cumulative economic hardships and health outcomes, and health effects differ by gender. Financial stress seems to be a stronger predictor of poor health outcomes than low income, particularly among women. Policies geared towards reducing health inequalities should recognise that long-term exposure to economic hardships damages health, and actions need to be taken with a gender perspective.

Perceived discrimination, socioeconomic disadvantage and refraining from seeking medical treatment in Sweden.

STUDY OBJECTIVE: To analyse the association between perceived discrimination and refraining from seeking required medical treatment and the contribution of socioeconomic disadvantage. DESIGN AND SETTING: Data from the Swedish National Survey of Public Health 2004 were used for analysis. Respondents were asked whether they had refrained from seeking required medical treatment during the past 3 months. Perceived discrimination was based on whether respondents reported that they had been treated in a way that made them feel humiliated (due to ethnicity/race, religion, gender, sexual orientation, age or disability). The Socioeconomic Disadvantage Index (SDI) was developed to measure economic deprivation (social welfare beneficiary, being unemployed, financial crisis and lack of cash reserves). PARTICIPANTS: Swedish population-based survey of 14,736 men and 17,115 women. MAIN RESULTS: Both perceived discrimination and socioeconomic disadvantage were independently associated with refraining from seeking medical treatment. Experiences of frequent discrimination even without any socioeconomic disadvantage were associated with three to nine-fold increased odds for refraining from seeking medical treatment. A combination of both frequent discrimination and severe SDI was associated with a multiplicative effect on refraining from seeking medical treatment, but this effect was statistically more conclusive among women (OR = 11.6, 95% CI 8.1 to 16.6; Synergy Index (SI) = 2.0 (95% CI 1.2 to 3.2)) than among men (OR = 12, 95% CI 7.7 to 18.7; SI = 1.6 (95% CI 1.3 to 2.1)). CONCLUSIONS: The goal of equitable access to healthcare services cannot be achieved without public health strategies that confront and tackle discrimination in society and specifically in the healthcare setting.

Work-related health factors for female immigrants in Sweden.

Work-related health has been a focus of research since the rate of sickness-related absences began to increase in Sweden. The incidence of sickness-related absences and early retirement is higher among female immigrants than among others in the total population. This study is based on a questionnaire survey which was conducted in a municipality in Sweden. The study population consisted of 2 429 native and immigrant female employees. The aim was to study work-related health factors for female immigrants. The results of this study show that about 20% of female immigrants who participate in the survey have temporary employment while the proportion is 8% for native women. The perception of ethnic discrimination among female immigrants was three times as much as among native females. The results also show that 69% of female immigrants report having received no opportunity to discuss their wages with managers, in comparison to 63% of native females. About 40% of female immigrants and 35% of native women report that they do not get opportunities to upgrade their skills. Female immigrants over the age of 50 experience gender and ethnic discrimination and lack of access to skills training programs more often than younger immigrants. They also participate in health-care activities more often.

Inequity in access to dental care services explains current socioeconomic disparities in oral health: the Swedish National Surveys of Public Health 2004-2005.

OBJECTIVE: To analyse the effects of socioeconomic disadvantage on access to dental care services and on oral health. Design, setting and outcomes: Cross-sectional data from the Swedish National Surveys of Public Health 2004 and 2005. Outcomes were poor oral health (self-rated oral health and symptoms of periodontal disease) and lack of access to dental care services. A socioeconomic disadvantage index (SDI) was developed, consisting of social welfare beneficiary, being unemployed, financial crisis and lack of cash reserves. PARTICIPANTS: Swedish population-based sample of 17 362 men and 20 037 women. RESULTS: Every instance of increasing levels of socioeconomic disadvantage was associated with worsened oral health but, simultaneously, with decreased utilisation of dental care services. After adjusting for age, men with a mild SDI compared with those with no SDI had 2.7 (95% confidence interval (CI) 2.5 to 3.0) times the odds for self-rated poor oral health, whereas odds related to severe SDI were 6.8 (95% CI 6.2 to 7.5). The corresponding values among women were 2.3 (95% CI 2.1 to 2.5) and 6.8 (95% CI 6.3 to 7.5). Nevertheless, people with severe socioeconomic disparities were 7-9 times as likely to refrain from seeking the required dental treatment. These associations persisted even after controlling for living alone, education, occupational status and lifestyle factors. Lifestyle factors explained only 29% of the socioeconomic differences in poor oral health among men and women, whereas lack of access to dental care services explained about 60%. The results of the multilevel regression analysis indicated no additional effect of the administrative boundaries of counties or of municipalities in Sweden. CONCLUSIONS: Results call for urgent public health interventions to increase equitable access to dental care services.

Trends in absolute socioeconomic inequalities in mortality in Sweden and New Zealand. A 20-year gender perspective.

BACKGROUND: Both trends in socioeconomic inequalities in mortality, and cross-country comparisons, may give more information about the causes of health inequalities. We analysed trends in socioeconomic differentials by mortality from early 1980s to late 1990s, comparing Sweden with New Zealand. METHODS: The New Zealand Census Mortality Study (NZCMS) consisting of over 2 million individuals and the Swedish Survey of Living Conditions (ULF) comprising over 100, 000 individuals were used for analyses. Education and household income were used as measures of socioeconomic position (SEP). The slope index of inequality (SII) was calculated to estimate absolute inequalities in mortality. Analyses were based on 3-5 year follow-up and limited to individuals aged 25-77 years. Age standardised mortality rates were calculated using the European population standard. RESULTS: Absolute inequalities in mortality on average over the 1980s and 1990s for both men and women by education were similar in Sweden and New Zealand, but by income were greater in Sweden. Comparing trends in absolute inequalities over the 1980s and 1990s, men's absolute inequalities by education decreased by 66% in Sweden and by 17% in New Zealand (p for trend <0.01 in both countries). Women's absolute inequalities by education decreased by 19% in Sweden (p = 0.03) and by 8% in New Zealand (p = 0.53). Men's absolute inequalities by income decreased by 51% in Sweden (p for trend = 0.06), but increased by 16% in New Zealand (p = 0.13). Women's absolute inequalities by income increased in both countries: 12% in Sweden (p = 0.03) and 21% in New Zealand (p = 0.04). CONCLUSION: Trends in socioeconomic inequalities in mortality were clearly most favourable for men in Sweden. Trends also seemed to be more favourable for men than women in New Zealand. Assuming the trends in male inequalities in Sweden were not a statistical chance finding, it is not clear what the substantive reason(s) was for the pronounced decrease. Further gender comparisons are required.

Gender and Women Development Initiatives in Bangladesh: A Study of Rural Mother Center.

Women-focused development initiatives have become a controversial issue connected with women's health and welfare. Previous studies indicated that development initiatives might increase women's workload, family conflict, and marital violence. This study explored the gendered characteristics of a development initiative Rural Mother Center in Bangladesh. Data incorporated policy document and interviews of social workers working with the mother centers in two northwest subdistricts. The qualitative content analysis of data emerged a general theme of expanding women's responsibility while maintaining male privilege explaining gendered design and practice of the development initiative. The theme was supported by two gendered categories related to the design: (a) essentializing women's participation; (b) maintaining traditional gender, and four categories related to the practice; (c) inadequate gender knowledge and skills; (d) reinforcing traditional gender; (e) using women for improving office performance; and (f) upholding male privilege. The study suggests that though women-focused development initiatives need to be embraced with gender-redistributive policies, the social workers should be trained for attaining gender-transformative motivation and competencies.

Swedish public health policy: Impact on regional and local public health practice and priorities.

We evaluated the Swedish National Public Health Policy to determine its impact on public health priorities and practice at regional and local levels between 2004 and 2013. We conducted a survey by questionnaire in February 2013 among Swedish county councils/regions (n=19/21), and municipalities (n=219/290). The National Public Health Policy facilitated systematic public health practice, particularly for planning, for high priority concerns, including conditions during childhood and adolescence, physical activity, and tobacco prevention. Respondents expressed need for a comprehensive monitoring system with comparable indicators nationwide and explicit measurable objectives. To ensure effective monitoring and follow-up, the measurable outcomes need direct relevance to decision making and high-priority public health issues addressing Sweden's "overarching public health goal" - to create societal conditions for good health on equal terms for the entire population.

Depressive symptoms in relation to marital and work stress in women with and without coronary heart disease. The Stockholm Female Coronary Risk Study.

OBJECTIVE: The aim of this study was to investigate the effect of marital and job stress on depressive symptoms in middle aged women with coronary heart disease (CHD) and healthy women who were cohabiting and currently working. METHOD: Data were obtained from the Stockholm Female Coronary Risk (FemCorRisk) Study, a population-based case-control study, comprising all women aged 65 years or younger who were admitted for an acute event of CHD between 1991 and 1994. For each patient, an age-matched healthy control was recruited. Marital stress was assessed by a structured interview developed in our research laboratory and work stress by the Karasek demand-control questionnaire. Depressive symptoms were measured by a questionnaire derived from Pearlin et al. [J. Health Soc. Behav. 22 (1981) 337], which was validated by the Beck Depression Inventory. RESULTS: Depressive symptoms were twice as common in women with as in women without coronary disease: Marital stress was statistically significantly associated with depressive symptoms, even after controlling for age, educational level, menopausal status, body mass index (BMI), sedentary lifestyle, cigarette smoking and severity of heart failure symptoms. In both groups, depressive symptoms increased with increasing exposure to marital stress in a graded fashion. Work stress was not associated with depressive symptoms after multivariate adjustment. CONCLUSIONS: Marital stress but not work stress is independently related to depressive symptoms in women. Women with coronary disease react similarly to marital stress as healthy women, but depart from a higher level of depression, which may be explained by their poorer health status.