Eliciting a value set for the Swedish Capability-Adjusted Life Years instrument (CALY-SWE).

PURPOSE: Our aim was to elicit a value set for Capability-Adjusted Life Years Sweden (CALY-SWE); a capability-grounded quality of life instrument intended for use in economic evaluations of social interventions with broad consequences beyond health. METHODS: Building on methods commonly used in the quality-adjusted life years EQ-5D context, we collected time-trade off (TTO) and discrete choice experiment (DCE) data through an online survey from a general population sample of 1697 Swedish participants. We assessed data quality using a score based on the severity of inconsistencies. For generating the value set, we compared different model features, including hybrid modeling of DCE and TTO versus TTO data only, censoring of TTO answers, varying intercept, and accommodating for heteroskedasticity. We also assessed the models' DCE logit fidelity to measure agreement with potentially less-biased DCE data. To anchor the best capability state to 1 on the 0 to 1 scale, we included a multiplicative scaling factor. RESULTS: We excluded 20% of the TTO answers of participants with the largest inconsistencies to improve data quality. A hybrid model with an anchor scale and censoring was chosen to generate the value set; models with heteroskedasticity considerations or individually varying intercepts did not offer substantial improvement. The lowest capability weight was 0.114. Health, social relations, and finance and housing attributes contributed the largest capability gains, followed by occupation, security, and political and civil rights. CONCLUSION: We elicited a value set for CALY-SWE for use in economic evaluations of interventions with broad social consequences.

Alcohol, drug and tobacco prevention in Swedish municipalities - impact from the COVID-19 pandemic considering socio-demographic context.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and measures to prevent the spread of the virus challenged public health practice at the local level in Sweden. The objective of this study was to explore the impact of the pandemic on the prevention of alcohol, drugs and tobacco (ADT) in Sweden during 2020-21 considering socio-demographic context. METHODS: Data were collected through the Public Health Agency's survey on ADT prevention in Swedish municipalities (N = 290). This study used data from 2020 and 2021, with a response rate of 90% and 88%, respectively. Survey data were analyzed in logistic regression models (odds ratios, P < 0.05, 95% confidence intervals) against variables of education level, income level and population size from national registers. RESULTS: A majority (n = 198, 76%) of the municipalities reported a decrease in ADT prevention during the pandemic. No correlation between the decrease in ADT prevention and socio-demographic conditions was detected. A majority (2020: n = 165, 63%; 2021: n = 174, 68%) of the municipalities also reported that ADT prevention was adapted, however less common in smaller municipalities and municipalities where residents had lower levels of education and lower incomes. CONCLUSION: ADT prevention carried out by municipalities in Sweden was initially (2020) deeply affected by the preventive strategies against COVID-19. Adaptation of activities was less common in municipalities with more vulnerable socio-demographic situation. In policy, practice and research, the findings are important not only for continued progress on the national goal of equity in health but also for preparedness for future crises.

Perceived changes in capability during the COVID-19 pandemic: A Swedish cross-sectional study from June 2020.

AIMS: Measures against COVID-19 potentially impact quality of life in different ways. The capability approach by Amartya Sen with a broad and consistent framework for measuring quality of life is suited to capture the various consequences. We aimed to examine (a) whether individuals experienced change in 10 capability dimensions during the first half of 2020, (b) which dimensions were affected most, and (c) whether changes were unequally distributed in terms of gender, education, income, geography, housing, living situation and place of birth. METHODS: We assessed self-reported capability change in Sweden in 10 capability dimensions in a cross-sectional online survey among 500 participants on a five-item Likert scale. We analysed the distribution of answers by comparing the balance of positive and negative perceived changes and used mixed effects logistic regression to examine associations with background characteristics of the participants. RESULTS: Reported perceived negative changes outweighed positive changes, and a higher proportion stated negative perceived changes if they also stated having low capability in the same dimension. In the capabilities of financial situation, political resources and health, the proportions of perceived negative change were highest. Odds for perceived negative change compared to no or positive change were higher for lower incomes, living in smaller municipalities compared to living in medium-sized municipalities, being born outside Europe, living in the south of Sweden, and renting instead of owning housing. CONCLUSIONS: Self-reported negative capability change, and associated inequalities related to socioeconomic position, place of birth and regional residence should be of concern for policymakers.

Reducing or reproducing inequalities in health? An intersectional policy analysis of how health inequalities are represented in a Swedish bill on alcohol, drugs, tobacco and gambling.

BACKGROUND: According to post-structural policy analyses, policies and interventions aiming at reducing social inequalities have been found to be part in producing and reifying such inequalities themselves. Given the central role of health inequalities on the public health policy agenda globally it seems important to examine the way policy on health inequalities may potentially counteract the goal of health equity. The aim of this intersectional policy analysis, was to critically analyze the representation of health inequalities in a government bill proposing a national strategy on alcohol, drugs, tobacco and gambling, to examine its performative power, and to outline alternative representations. METHOD: A post-structural approach to policy analysis was combined with an intersectional framework. The material was analyzed through an interrogating process guided by the six questions of the "What's the problem represented to be?" (WPR) approach. Thus, the underlying assumptions of the problem representation, its potential implications and historical background were explored. In a final step of the analysis we examined our own problem representations. RESULTS: The recommendations found in the gender and equity perspective of the bill represented the problem of health inequalities as a lack of knowledge, with an emphasis on quantitative knowledge about differences in health between population groups. Three underlying assumptions supporting this representation were found: quantification and objectivity, inequalities as unidimensional, and categorization and labelling. The analysis showed how the bill, by opting into these partly overlapping assumptions, is part of enacting a discourse on health inequalities that directs attention to specific subjects (e.g., vulnerable) with special needs (e.g., health care), in certain places (e.g., disadvantaged neighborhoods). It also showed how underlying processes of marginalization are largely neglected in the bill due to its focus on describing differences rather than solutions. Finally, we showed how different intersectional approaches could be used to complement and challenge this, potentially counteractive, problem representation. CONCLUSIONS: The problem representation of health inequalities and its underlying assumptions may have counteractive effects on health equity, and even though some of its strengths are raised, it seems to be profoundly entangled with a system resisting the kind of change that the bill itself advocates for. If carefully used, intersectionality has the potential to support a more comprehensive and inclusive equality-promoting public health policy and practice.

Languishing in the crossroad? A scoping review of intersectional inequalities in mental health.

The concept of intersectionality has gradually been introduced to health inequality research, adding depth and breadth to the way inequalities in health are approached. We conducted a scoping review with the purpose to systematically map, describe and analyze the literature about intersectional inequalities in mental health. For eligibility, the study had to analyze and report inequality defined by combinations of socioeconomic position, gender, race/ethnicity, sexual orientation or religion. The mental health outcome had to be measured as self-reported symptoms assessed through validated scales, or disorders assessed through diagnostic interviews. The search strategy was applied in two databases and the screening process yielded 20 studies. The interaction of intersectional positions showed no consistent patterns in mental health across studies, but both synergistic and antagonistic effects were observed. In most studies an absolute measure of inequality was used and few studies analyzed factors potentially explaining the intersectional inequalities. Taken together, the findings of this review highlight the value of assessing intersectional inequalities across population groups for priority setting and action on mental health inequalities.

Societal costs of illegal drug use in Sweden.

BACKGROUND: Illegal drug use is a public health concern with far-reaching consequences for people who use them and for society. In Sweden, the reported use of illegal drugs has been growing and the number of drug-induced deaths is among the highest in Europe. The aim of this study was to provide a comprehensive and up-to-date estimation of the societal costs of illegal drug use in Sweden, relying as much as possible on registry and administrative data. METHODS: A prevalence-based cost-of-illness study of illegal drug use in Sweden in 2020 was conducted. A societal approach was chosen and included direct costs (such as costs of health care, social services, and the criminal justice system), indirect costs (such as lost productivity due to unemployment and drug-induced death), and intangible costs (such as reduced quality of life among people who use drugs and their family members). Costs were estimated by combining registry, administrative, and survey data with unit cost data. RESULTS: The estimated societal costs of illegal drug use were 3.7 billion euros in 2020. This corresponded to 355 euros per capita and 0.78 % of the gross domestic product. The direct and intangible costs were of similar sizes, each contributing to approximately 40 % of total costs, whereas indirect costs contributed to approximately 20 %. The largest individual cost components were reduced quality of life among people who use drugs and costs of the criminal justice system. CONCLUSION: Illegal drug use has a negative impact on the societal aim to create good and equitable health in Sweden. The findings call for evidence-based prevention of drug use and treatment for those addicted. It is important to address the co-morbidity of mental ill-health and drug dependence, to develop low-threshold services and measures for early prevention among children and young adults, as well as to evaluate laws and regulations connected to illegal drug use.

The effects and costs of the universal parent group program - all children in focus: a study protocol for a randomized wait-list controlled trial.

BACKGROUND: In recent decades, parents have been involved in programs that aim to improve parenting style and reduce child behavior problems. Research of preventive parenting programs has shown that these interventions generally have a positive influence on both parents and children. However, to our knowledge there is a gap in the scientific literature when it comes to randomized controlled trials of brief, manual-based structured programs which address general parenting among the population, and focus on promoting health. A four-session universal health promotion parent group program named All Children in Focus was developed. It aims at promoting parental competence and children's positive development with the parent-child relationship as the target. There is currently no randomized controlled trial existing of the program. METHODS/DESIGN: A prospective multicenter randomized wait-list controlled trial is being conducted. Approximately 600 parents with children ranging in age from 3-12 years have been recruited in eleven municipalities and city districts in the County of Stockholm, Sweden. Parents are randomized at baseline to an intervention group, which receives the program directly, or to a waiting-list control group, which participates in the program six months later. Changes in parenting and child health and development are assessed with measures immediately post-intervention and six months after the baseline. Observations of a minor group of parents and children are conducted to explore possible relations between parental reports and observed behaviors, as well as changes in the interaction between parent and child. Further, data collected within the evaluation will also be applied to evaluate the possible cost-effectiveness of the program. DISCUSSION: This paper describes a study protocol of a randomized controlled trial. Except for the quantitative outcome measures to evaluate the effectiveness of All Children in Focus, this protocol also describes health economic and qualitative analyses to deepen the knowledge of the program. We further discuss some issues regarding the implementation of the program in municipalities and city districts. TRIAL REGISTRATION: Current Controlled Trials ISRCTN70202532.

Could gender equality in parental leave harm off-springs' mental health? A registry study of the Swedish parental/child cohort of 1988/89.

INTRODUCTION: Mental ill-health among children and young adults is a growing public health problem and research into causes involves consideration of family life and gender practice. This study aimed at exploring the association between parents' degree of gender equality in childcare and children's mental ill-health. METHODS: The population consisted of Swedish parents and their firstborn child in 1988-1989 (N = 118 595 family units) and the statistical method was multiple logistic regression. Gender equality of childcare was indicated by the division of parental leave (1988-1990), and child mental ill-health was indicated by outpatient mental care (2001-2006) and drug prescription (2005-2008), for anxiety and depression. RESULTS: The overall finding was that boys with gender traditional parents (mother dominance in childcare) have lower risk of depression measured by outpatient mental care than boys with gender-equal parents, while girls with gender traditional and gender untraditional parents (father dominance in childcare) have lower risk of anxiety measured by drug prescription than girls with gender-equal parents. CONCLUSIONS: This study suggests that unequal parenting regarding early childcare, whether traditional or untraditional, is more beneficial for offspring's mental health than equal parenting. However, further research is required to confirm our findings and to explore the pathways through which increased gender equality may influence child health.

The importance of childhood and adulthood aspects of gendered life for adult mental ill-health symptoms--a 27-year follow-up of the Northern Swedish Cohort.

BACKGROUND: The increasing gender equality during the 20th century, mainly in the Nordic countries, represents a major social change. A well-established theory is that this may affect the mental health patterns of women and men. This study aimed at examining associations between childhood and adulthood gendered life on mental ill-health symptoms. METHODS: A follow-up study of a cohort of all school leavers in a medium-sized industrial town in northern Sweden was performed from age 16 to age 42. Of those still alive of the original cohort, 94% (n = 1007) participated during the whole period. Gendered life was divided into three stages according to whether they were traditional or non-traditional (the latter includes equal): childhood (mother's paid work position), adulthood at age 30 (ideology and childcare), and adulthood at age 42 (partnership and childcare). Mental ill-health was measured by self-reported anxious symptoms ("frequent nervousness") and depressive symptoms ("frequent sadness") at age 42. The statistical method was logistic regression analysis, finally adjusted for earlier mental ill-health symptoms and social confounding factors. RESULTS: Generally, parents' gendered life was not decisive for a person's own gendered life, and adulthood gender position ruled out the impact of childhood gender experience on self-reported mental ill-health. For women, non-traditional gender ideology at age 30 was associated with decreased risk of anxious symptoms (76% for traditional childhood, 78% for non-traditional childhood). For men, non-traditional childcare at age 42 was associated with decreased risk of depressive symptoms (84% for traditional childhood, 78% for non-traditional childhood). A contradictory indication was that non-traditional women in childcare at age 30 had a threefold increased risk of anxious symptoms at age 42, but only when having experienced a traditional childhood. CONCLUSION: Adulthood gender equality is generally good for self-reported mental health regardless of whether one opposes or continues one's gendered history. However, the childcare findings indicate a differentiated picture; men seem to benefit in depressive symptoms from embracing this traditionally female duty, while women suffer anxious symptoms from departing from it, if their mother did not.

Risk of self-reported Chlamydia trachomatis infection by social and lifestyle factors: a study based on survey data from young adults in Stockholm, Sweden.

OBJECTIVE: To analyse the associations between demographic, socio-economic and lifestyle factors, and the risk of self-reported chlamydial infection among young adults (20-29 years old) in Stockholm, Sweden. METHODS: This study was based on the Stockholm Public Health Survey of 2006 (N = 4278). Demographic factors (gender, age, and country of birth), socio-economic factors (individual and parental educational levels, individual income level, and employment status), and lifestyle factors (body mass index, mental health, alcohol consumption, and partnership status) were taken into account. Possible associations were analysed by logistic regression. RESULTS: The risk of self-reported chlamydial infection decreases with age, is higher among individuals both who personally, and whose parents, were educated to high school level compared to university level education, and is higher among those employed, unemployed or on sick-leave/pre-retired compared to students. The risk of chlamydial infection is also higher among subjects who report greater alcohol consumption, and those who live without a partner. After considering demographic, socio-economic and lifestyle factors, the associations with age, educational level, employment status and alcohol consumption are strong and statistically significant. CONCLUSION: Indicators of risk-taking behaviours, especially in settings with generally little educational ambition or options, should be incorporated in the design of STI prevention strategies.

An initiative to develop capability-adjusted life years in Sweden (CALY-SWE): Selecting capabilities with a Delphi panel and developing the questionnaire.

INTRODUCTION: Capability-adjusted life years Sweden (CALY-SWE) are a new Swedish questionnaire-based measure for quality of life based on the capability approach. CALY-SWE are targeted towards use in cost-effectiveness evaluations of social welfare consequences. Here, we first motivate the measure both from a theoretical and from a Swedish policy-making perspective. Then, we outline the core principles of the measure, namely the relation to the capability approach, embedded equity considerations inspired by the fair-innings approach, and the bases for which capabilities should be considered. The aims were to 1) the most vital capabilities for individuals in Sweden, 2) to define a sufficient level of each identified capability to lead a flourishing life, and to 3) develop a complete questionnaire for the measurement of the identified capabilities. MATERIAL AND METHODS: For the selection of capabilities, we used a Delphi process with Swedish civil society representants. To inform the questionnaire development, we conducted a web survey in three versions, with each Swedish 500 participants, to assess the distribution of capabilities that resulted from the Delphi process in the Swedish population. Each version was formulated with different strictness so that less strict wordings of a capability level would apply to a larger share of participants. All versions also included questions on inequality aversion regarding financial, educational, and health capabilities. RESULTS: The Delphi process resulted in the following six capabilities: Financial situation & housing, health, social relations, occupations, security, and political & civil rights. We formulated the final phrasing for the questionnaire based on normative reasons and the distribution of capabilities in the population while taking into account inequality aversion. CONCLUSION: We developed a capability-based model for cost effectiveness economic evaluations of broader social consequences, specific to the Swedish context.

Intersectional inequalities in mental health across multiple dimensions of inequality in the Swedish adult population.

Intersectionality has recently gained traction in health inequality research emphasizing multiple intersecting dimensions of inequality as opposed to the traditional unidimensional approaches. In this study inequalities in mental health were estimated across intersections of gender, income, education, occupation, country of birth, and sexual orientation. The outcomes and inequalities of intersectional strata were disentangled analogously to the possibilities described by intersectionality theory; as a result of either of the two inequality dimensions, as a result of the sum the dimensions, or as a unique outcome not equaling the sum. Furthermore the study examined the discriminatory accuracy of the six inequality dimensions as well as the intersectional space comprising 64 strata. The study population (N = 52,743) consists of a yearly random sample of the Swedish population 26-84 years between 2010 and 2015, from The Health on Equal Terms survey. Mental health was measured through a self-administered General Health Questionnaire (GHQ)-12, and sociodemographics through survey and linked register data. Intersectional inequalities in mental health were estimated for all pairwise combinations of inequality dimensions by joint inequalities, excess intersectional inequalities and referent inequalities. The findings of the study found that the sum of dimensions contributed to the overall (joint) inequality in mental health rather than a reinforced adverse effect of multiple disadvantages or the contribution by a single dimension. Nevertheless, the dimension of income was found to be the most important in terms of relative contribution. The discriminatory accuracy was low indicating that policy action targeting mental health should be universal rather than focusing on particular groups. The results highlight the unpredictable inequality patterns revealed by an intersectional approach, even for a single health outcome and within one country, and illustrate the need for empirical investigations into the actual population patterns in health that appear in the intersections of multiple disadvantages.

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.

Towards capability-adjusted life years in public health and social welfare: Results from a Swedish survey on ranking capabilities.

INTRODUCTION: The aim of this study was to rank capabilities and suggest a relevant set of capabilities for the Swedish context to inform the development of capability-adjusted life years (CALYs). CALYs is a quality of life measure for policy making based on the capability approach by Amartya Sen. MATERIALS AND METHODS: A Swedish governmental review proposed the following 10 relevant capabilities: time, financial situation, mental/physical health, political resources, knowledge, living environment, occupation, social relations, security, and housing. Researchers in health-related disciplines from 5 universities ranked these capabilities from 1 to 10 (most to least important) in a web-based cross-sectional survey; 115 of 171 responses were eligible. RESULTS: Health, social relations, and financial situation were deemed most important. Stratification by gender, research field, and age group revealed few differences. We found that it was possible to rank capabilities and that health, social relations, and financial situation were ranked highest by a non-representative sample of researchers and doctoral students from health-related disciplines at five Swedish universities. CONCLUSIONS: The revealed ranking is dependent on the metric and must be further explored. The findings support continued development of CALYs for monitoring and evaluating outcomes in public health and social-welfare interventions.

Pioneers and laggards - is the effect of gender equality on health dependent on context?

This study combines data at individual and area level to examine interactions between equality within couples and gender equality in the municipality in which individuals live. The research question is whether the context impacts on the association between gender equality and health. The material consists of data on 37,423 men and 37,616 women in 279 Swedish municipalities, who had their first child in 1978. The couples were classified according to indicators of their level of gender equality in 1980 in the public sphere (occupation and income) and private sphere (child care leave and parental leave) compared to that of their municipality. The health outcome is compensated days from sickness insurance during 1986-1999 with a cut-off at the 85% percentile. Data were analysed using logistic regression with the overall odds as reference. The results concerning gender equality in the private sphere show that among fathers, those who are equal in an equal municipality have lower levels of sick leave than the average while laggards (less equal than their municipality) and modest laggards have higher levels. In the public sphere, pioneers (more equal t han their municipality) fare better than the average while laggards fare worse. For mothers, those who are traditional in their roles in the public sphere are protected from high levels of sick leave, while the reverse is true for those who are equal. Traditional mothers in a traditional municipality have the lowest level of sick leave and pioneers the highest. These results show that there are distinct benefits as well as disadvantages to being a gender pioneer and/or a laggard in comparison to your municipality. The associations are markedly different for men and women.

The relationship between a less gender-stereotypical parenthood and alcohol-related care and death: a registry study of Swedish mothers and fathers.

BACKGROUND: In general men tend to drink more alcohol and experience more alcohol-related sickness, injuries and mortality than women. In this paper, the overall hypothesis was that increased gender similarity in the division of parental duties would lead to convergence in alcohol-related harm. The aim was to analyse whether the risk of alcohol harm differs between parents who fit a gender-stereotypical versus those with a less gender-stereotypical division of childcare and paid work. METHODS: The study sample was a retrospective registry-based cohort study of all Swedish couples who had their first child together in 1978 (N = 49,120). A less gender-stereotypical parenthood was indicated by paternity leave for fathers (1978-1979) and full-time work for mothers (1980). The outcome was inpatient care and/or death caused by alcohol psychosis, alcoholism, liver disease, or alcohol intoxication in the two decades following (1981-2001). Our main statistical method was multivariate logistic regression with odds ratios used to estimate relative risks. RESULTS: The main results show that fathers who took paternity leave had 18% lower risk of alcohol-related care and/or death than other fathers. Mothers who worked full-time about two years after having a child had 71% higher risk than mothers who were unemployed or worked part-time. CONCLUSION: A less gender-stereotypical division of duties between parents in early parenthood may contribute to a long-term decreased gender disparity regarding risky alcohol consumption and alcohol-related harm. In order to know more about the causal direction however, future research has to consider subjects' drinking patterns in the years prior to parenthood.

Screening fathers for postpartum depression can be cost-effective: An example from Sweden.

BACKGROUND: Postpartum depression negatively affects the whole family and its prevalence in Sweden ranges between 6-10% for fathers and 13-16% for mothers. However, only mothers in Sweden are currently routinely screened. AIM: The aim of this study was to determine if a postpartum depression screening for fathers in Stockholm County could be cost-effective. METHODS: National Swedish databases were used to find registry data and a literature review was undertaken to identify the model data inputs associated with postpartum depression in Sweden. The generated evidence was used to build a Markov model in TreeAge. One-way and probabilistic sensitivity analyses were performed to account for parameter uncertainties. Alternative scenario analyses were further undertaken to test the assumptions in the base case analysis. RESULTS: A postpartum screening for depression in fathers is cost-effective in base case and alternative scenarios. The results indicate that the screening program is associated with lower costs and higher health effects. The results were sensitive to variables of quality adjusted life years for the depressed fathers, probabilities of remission in treatment and no treatment groups and start age and productivity losses. The probabilistic sensitivity analysis resulted in a 70% probability of the postnatal depression screening intervention being cost-effective. LIMITATIONS: The current study only uses secondary data; therefore future research should assess the cost-effectiveness of screening fathers for depression. CONCLUSION: The postpartum screening intervention for fathers could be cost-effective compared to no screening. Future research should replicate the potential cost-effectiveness for screening fathers for postpartum depression.

Does increased gender equality lead to a convergence of health outcomes for men and women? A study of Swedish municipalities.

This study examines associations between indicators of gender equality and public health. We compare Swedish municipalities on nine indicators in both the private and public sphere, and an additive index, and study the correlations with indicators of morbidity and mortality. The hypothesis that a higher level of gender equality is associated with a convergence of health outcomes (life expectancy, sickness absence) between men and women was supported for equality of part-time employment, managerial positions and economic resources for morbidity, and for temporary parental leave for mortality. Our main finding is that gender equality was generally correlated with poorer health for both men and women. Our conclusions are tentative due to the methodological uncertainties. However, the results suggest an unfortunate trade-off between gender equality as we know it and public health. Sweden may have reached a critical point where further one-sided expansion by women into traditionally male roles, spheres and activities will not lead to positive health effects unless men also significantly alter their behaviour. Negative effects of this unfinished equality might be found both for women, who have become more burdened, and men, who as a group have lost many of their old privileges. We propose that this contention be confronted and discussed by policymakers, researchers and others. Further studies are also needed to corroborate or dispute these findings.

Paternity leave in Sweden: costs, savings and health gains.

OBJECTIVES: The initial objective is to examine the relationship between paternity leave in 1978-1979 and male mortality during 1981-2001, and the second objective is to calculate the cost-effectiveness of the 1974 parental insurance reform in Sweden. METHODS: Based on a population of all Swedish couples who had their first child together in 1978 (45,801 males), the risk of death for men who took paternity leave, compared with men who did not, was estimated by odds ratios. The cost-effectiveness analysis considered costs for information, administration and production losses, minus savings due to decreased sickness leave and inpatient care, compared to health gains in life-years and quality-adjusted life-years (QALYs). RESULTS: It is demonstrated that fathers who took paternity leave have a statistically significant decreased death risk of 16%. Costs minus savings (discounted values) stretch from a net cost of EUR 19 million to a net saving of EUR 11 million, and the base case cost-effectiveness is EUR 8000 per QALY. CONCLUSIONS: The study indicates that that the right to paternity leave is a desirable reform based on commonly stated public health, economic, and feminist goals. The critical issue in future research should be to examine impact from health-related selection.

Parental share in public and domestic spheres: a population study on gender equality, death, and sickness.

STUDY OBJECTIVE: Examine the relation between aspects of gender equality and population health based on the premise that sex differences in health are mainly caused by the gender system. SETTING/ PARTICIPANTS: All Swedish couples (98 240 people) who had their first child together in 1978. DESIGN: The exposure of gender equality is shown by the parents' division of income and occupational position (public sphere), and parental leave and temporary child care (domestic sphere). People were classified by these indicators during 1978-1980 into different categories; those on an equal footing with their partner and those who were traditionally or untraditionally unequal. Health is measured by the outcomes of death during 1981-2001 and sickness absence during 1986-2000. Data are obtained by linking individual information from various national sources. The statistical method used is multiple logistic regressions with odds ratios as estimates of relative risks. MAIN RESULTS: From the public sphere is shown that traditionally unequal women have decreased health risks compared with equal women, while traditionally unequal men tend to have increased health risks compared with equal men. From the domestic sphere is indicated that both women and men run higher risks of death and sickness when being traditionally unequal compared with equal. CONCLUSIONS: Understanding the relation between gender equality and health, which was found to depend on sex, life sphere, and inequality type, seems to require a combination of the hypotheses of convergence, stress and expansion.