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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Does social capital protect mental health among migrants in Sweden?

Poor mental health is common among migrants. This has been explained by migration-related and socio-economic factors. Weak social capital has also been related to poor mental health. Few studies have explored factors that protect mental health of migrants in the post-migration phase. Such knowledge could be useful for health promotion purposes. Therefore, this study aimed to analyse associations between financial difficulties, housing problems and experience of discrimination and poor mental health; and to detect possible effect modification by social capital, among recently settled Iraqi migrants in Sweden. A postal questionnaire in Arabic was sent to recently settled Iraqi citizens. The response rate was 51% (n = 617). Mental health was measured by the GHQ-12 instrument and social capital was defined as social participation and trust in others. Data were analysed by means of logistic regression. Poor mental health was associated with experience of discrimination (OR 2.88, 95% CI 1.73-4.79), housing problems (OR 2.79, 95% CI 1.84-4.22), and financial difficulties (OR 2.14, 95% CI 1.44-3.19), after adjustments. Trust in others seemed to have a protective effect for mental health when exposed to these factors. Social participation had a protective effect when exposed to experience of discrimination. Social determinants and social capital in the host country play important roles in the mental health of migrants. Social capital modifies the effect of risk factors and might be a fruitful way to promote resilience to factors harmful to mental health among migrants, but must be combined with policy efforts to reduce social inequities.

Health and wellbeing in informal caregivers and non-caregivers: a comparative cross-sectional study of the Swedish general population.

BACKGROUND: Informal caregiving by relatives is a great resource for individuals as well as for society, but the caregiving role is associated with health problems for the caregiver. This study aimed to compare caregivers' self-rated health, number of recent days with poor health and psychological wellbeing with that of non-caregivers in a general Swedish population. METHODS: From 2004 to 2013, 90,845 Swedish people completed a postal questionnaire about their health, number of recent days with poor health during last month, psychological wellbeing and if they were performing caregiving or not. Descriptive statistics, chi-square analysis, ANOVA, logistic regressions and negative binomial regression models were used to investigate associations between being a caregiver or not and health and wellbeing. Negative binomial regression was used to assess the relation between caregiver status and recent days with poor health or functioning. RESULTS: Eleven percent reported having a caregiving role. Caregivers reported poorer self-rated health compared to non-caregivers, also in adjusted models; odds ratio (OR): 1.07 with a 95% confidence interval (CI): 1.01-1.13. Caregivers also reported lower psychological wellbeing compared to non-caregivers; OR: 1.22, CI: 1.15-1.30. Caregiving status was associated with more recent days with poor physical health and more recent days with poor mental health. CONCLUSIONS: This study suggests that caregivers have worse perceptions in self-rated health and psychological wellbeing compared with non-caregivers, indicating that the role of caregiver is adversely associated with health. This association also appears in terms of reporting days of poor health in the last month. The underlying mechanism of these associations, including the potential detrimental health effects of being a caregiver, needs to be investigated in longitudinal studies.

Immigrant women's experiences and views on the prevention of cervical cancer: a qualitative study.

BACKGROUND: Many Western countries have cervical cancer screening programmes and have implemented nation-wide human papillomavirus (HPV) vaccination programmes for preventing cervical cancer. OBJECTIVE: To explore immigrant women's experiences and views on the prevention of cervical cancer, screening, HPV vaccination and condom use. DESIGN: An exploratory qualitative study. The Health Belief Model (HBM) was used as a theoretical framework. SETTING AND PARTICIPANTS: Eight focus group interviews, 5-8 women in each group (average number 6,5), were conducted with 50 women aged 18-54, who studied Swedish for immigrants. Data were analysed by latent content analysis. RESULTS: Four themes emerged: (i) deprioritization of women's health in home countries, (ii) positive attitude towards the availability of women's health care in Sweden, (iii) positive and negative attitudes towards HPV vaccination, and (iv) communication barriers limit health care access. Even though the women were positive to the prevention of cervical cancer, several barriers were identified: difficulties in contacting health care due to language problems, limited knowledge regarding the relation between sexual transmission of HPV and cervical cancer, culturally determined gender roles and the fact that many of the women were not used to regular health check-ups. CONCLUSION: The women wanted to participate in cervical cancer prevention programmes and would accept HPV vaccination for their daughters, but expressed difficulties in understanding information from health-care providers. Therefore, information needs to be in different languages and provided through different sources. Health-care professionals should also consider immigrant women's difficulties concerning cultural norms and pay attention to their experiences.

Health literacy and refugees' experiences of the health examination for asylum seekers - a Swedish cross-sectional study.

BACKGROUND: The purpose of the health examination for asylum seekers in most countries is to identify poor health in order to secure the well-being of seekers of asylum and to guarantee the safety of the population in the host country. Functional health literacy is an individual's ability to read information and instructions about health and to function effectively as a patient in the health system, and comprehensive health literacy is an individual's competence in accessing, understanding, appraising and applying health information. Little is known about refugees' health literacy and their experiences of the health examination for asylum seekers. The purposes of the study were to investigate refugees' experiences of communication during their health examination for asylum seekers and the usefulness of that examination, and whether health literacy is associated with those experiences. METHODS: A cross-sectional study was made among 360 adult refugees speaking Arabic, Dari, Somali or English. Health literacy was measured using the Swedish Functional Health Literacy Scale and the short European Health Literacy Questionnaire. Experiences of communication and the usefulness of the health examination were measured in several questions. Associations were sought using univariate and multivariate statistical models. RESULTS: In the health examination for asylum seekers, a poor quality of communication was experienced by 36 %, receiving little information about health care by 55 %, and receiving little new knowledge by 41 % and/or help by 26 %. Having inadequate as compared to sufficient comprehensive health literacy was associated with the experience of a poorer quality of communication (OR: 9.64, CI 95 %: 3.25-28.58) and the experience of receiving little valuable health care information (OR: 6.54, CI 95 %: 2.45-17.47). Furthermore, having inadequate as compared to sufficient comprehensive health literacy was associated with the experience of not receiving new knowledge (OR: 7.94, CI 95 %: 3.00-21.06) or receiving help with health problems (OR: 8.07, 95 % CI: 2.50-26.07. Functional healthy literacy was not associated with experiences of HEA. CONCLUSION: Refugees' experiences indicate that a low level of comprehensive health literacy can act as a barrier to fulfilling the purposes of the health examination for asylum seekers. Comprehensive health literacy seems to be of greater importance in that context than functional health literacy.

The influence of locus of control on self-rated health in context of chronic disease: a structural equation modeling approach in a cross sectional study.

BACKGROUND: Self-rated health is a robust predictor of several health outcomes, such as functional ability, health care utilization, morbidity and mortality. The purpose of this study is to investigate and explore how health locus of control and disease burden relate to self-rated health among patients at risk for cardiovascular disease. METHODS: In 2009, 414 Swedish patients who were using statins completed a questionnaire about their health, diseases and their views on the three-dimensional health locus of control scale. The scale determines which category of health locus of control - internal, chance or powerful others - a patient most identifies with. The data was analyzed using logistic regression and a structural equation modeling approach. RESULTS: The analyses showed positive associations between internal health locus of control and self-rated health, and a negative association between health locus of control in chance and powerful others and self-rated health. High internal health locus of control was negatively associated with the cumulative burden of diseases, while health locus of control in chance and powerful others were positively associated with burden of diseases. In addition, age and education level had indirect associations with self-rated health through health locus of control. CONCLUSIONS: This study suggests that self-rated health is positively correlated with internal locus of control and negatively associated with high locus of control in chance and powerful others in patients at high risk for cardiovascular disease. Furthermore, disease burden seems to be negatively associated with self-rated health.

Health literacy among refugees in Sweden - a cross-sectional study.

BACKGROUND: Refugees have poorer health compared to indigenous populations, which may be explained by lower health literacy, i.e. not being able to access, understand, appraise or apply health information. This study aims to determine levels of functional and comprehensive health literacy, and factors associated with inadequate health literacy, in refugees coming to Sweden. METHOD: A cross-sectional study was performed among 455 adult refugees speaking Arabic, Dari, Somali or English. Participants in 16 strategically selected language schools for immigrants responded to a questionnaire. Health literacy was measured using the Swedish Functional Health Literacy Scale and the HLS-EU-Q16 questionnaire. Uni- and multivariate statistical methods were used to investigate group differences. RESULTS: The majority of the participating refugees had inadequate or limited functional health literacy and comprehensive health literacy. About 60% of them had inadequate functional health literacy and 27% had inadequate comprehensive health literacy. Low education and/or being born in Somalia were factors associated with an increased risk of having inadequate functional health literacy. Having inadequate functional health literacy was associated with an increased risk of having inadequate comprehensive health literacy. CONCLUSIONS: The majority of refugees in the language schools had limited or poor health literacy. Health literacy should be taken into consideration in contexts and in activities addressing migrants. More research is needed to better understand health literacy among refugees and to develop strategies and methods to increase health literacy and make life easier for those with low health literacy.

Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination.

AIM: To explore why parents refused to allow their 10- to 12-year-old daughters to receive the human papillomavirus (HPV) vaccination from the Swedish school-based vaccination programme. METHODS: Individual interviews with 25 parents who had been offered, but not consented to, their daughters receiving the HPV vaccination. RESULTS: Five themes emerged through the interviews: 1) she is just a little girl, 2) inadequate information, 3) not compatible with our way of life, 4) scepticism about the vaccination and 5) who can you trust? The parents made their decisions with their child's best interests in mind. This was not considered the right time, and the vaccine was perceived as unnecessary and different from other vaccines. Mistrust in Government recommendations and a lack of evidence or information were other reasons to decline. CONCLUSION: The decision-making process was complex. These parents preferred to wait until their daughter was older and believed the information they received from the school health system was insufficient. The results indicate that a more flexible HPV vaccination schedule may improve vaccine uptake. This includes more transparent information about the virus and the vaccine and information about who to contact to get the daughter vaccinated at a later date.

Innovations in medical care and mortality trends from four circulatory diseases between 1970 and 2005.

BACKGROUND: Governments have identified innovation in pharmaceuticals and medical technology as a priority for health policy. Although the contribution of medical care to health has been studied extensively in clinical settings, much less is known about its contribution to population health. We examine how innovations in the management of four circulatory disorders have influenced trends in cause-specific mortality at the population level. METHODS: Based on literature reviews, we selected six medical innovations with proven effectiveness against hypertension, ischaemic heart disease, heart failure and cerebrovascular disease. We combined data on the timing of these innovations and cause-specific mortality trends (1970-2005) from seven European countries. We sought to identify associations between the introduction of innovations and favourable changes in mortality, using Joinpoint-models based on linear spline regression. RESULTS: For both ischaemic heart disease and cerebrovascular disease, the timing of medical innovations was associated with improved mortality in four out of five countries and five out of seven countries, respectively, depending on the innovation. This suggests that innovation has impacted positively on mortality at the population level. For hypertension and heart failure, such associations could not be identified. CONCLUSION: Although improvements in cause-specific mortality coincide with the introduction of some innovations, this is not invariably true. This is likely to reflect the incremental effects of many interventions, the time taken for them to be adopted fully and the presence of contemporaneous changes in disease incidence. Research on the impact of medical innovations on population health is limited by unreliable data on their introduction.

Health-related and social factors predicting non-reemployment amongst newly unemployed.

BACKGROUND: Many researchers have examined the effect that mental health has on reemployment opportunities amongst the unemployed, but the results are inconclusive. Our aim in this study is to investigate the effects that different aspects of mental and physical health, as well as socio-demographic, social, and economic factors, have on reemployment. METHODS: A questionnaire was administered to 1,000 and answered by 502 newly registered unemployed Swedes, who were followed for one year using data from the Swedish National Labour Market Board. The differences between those reemployed and those not reemployed was analysed using stepwise logistic regression. RESULTS: General mental ill health amongst unemployed individuals measured by the General Health Questionnaire scale was associated with lower levels of reemployment after one year. This effect could not be explained by any of the scales measuring specific aspects of mental disease such as health-related level of function, rate of depression, burnout, or alcohol misuse. Instead being above 45, low control over one's financial situation, being an immigrant, and visiting a physician during the last three months were better predictors of failure to be reemployed. CONCLUSION: There are theoretical reasons to assume that psychological distress leads to a decreased reemployment rate amongst the unemployed. The results of this study partly endorse this hypothesis empirically, showing that general subjective mental distress decreases the rate of reemployment amongst newly unemployed individuals, although this effect was mediated by social and economic factors. Indicators of psychiatric disease had no significant effect on reemployment. The results of this study lead us to suggest the early introduction of financial counselling, psychological support, and other interventions for groups with lower reemployment rates.