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Abstract Background Child health and development can be promoted by strengthening and supporting parents. Research on parental support programs based on positive psychology and a health-promoting approach aimed at all parents, and in particular parents of infants is limited. All Children in Focus (ACF) is a parental support program that has been evaluated in a randomized trial in parents of children 3–12 years. The ACF is based on health promotion aiming to increase parents’ confidence and child’s well-being. In the current study, we will study the effects of a revised version of the ACF called Little ACF adapted to parents with children aged 1–2 years. Methods The study includes a randomized controlled trial (RCT) taking place at several Child Health Centers (CHCs) in Sweden. The RCT will evaluate the efficacy of Little ACF (intervention) in comparison with four digital lectures about child development and parenting (active control). Parents are recruited at the 10-, 12-, or 18-month visits to CHC by CHC-nurses. Data to assess changes in parental competencies and child socio-emotional development are collected through online questionnaires completed by parents at five time points: baseline, post-intervention, after 6 and 12 months, and when the child is 3 years old. Discussion The paper describes a study protocol of a randomized controlled trial evaluating the effects of a parental support program during infancy. Several issues related to the methodology and implementation are discussed. Trial registration ClinicalTrials.gov NCT05445141. Registered on 6 July 2022.

Abstract Background To study the association of maternal age upon arrival and length of residence in Sweden with the 4-year caries increment in their children between ages 3 and 7 years in relation to the human development index (HDI) of the maternal country of origin. Method This registry-based cohort study included all children born in 2000–2003 who resided in Stockholm County, Sweden, at age 3 years and who were followed up at age 7 (n = 63,931). Negative binomial regressions were used to analyze different models adjusted for sociodemographic factors. Results Children of foreign-born mothers, regardless of the HDI of the maternal country of origin, had a higher risk of caries increment between ages 3 and 7 years than children of Swedish-born mothers. Furthermore, children of mothers who had arrived from a low or medium HDI country had a lower caries increment if their mothers arrived before age 7 compared with after age 7. Nearly half (44%) of the children whose mothers arrived in Sweden at age ≥ 20 years from a low HDI country had a caries increment compared to 22% of the children whose mothers had arrived in Sweden before 7 years of age. Furthermore, children whose mothers were born in a low HDI country and had resided in Sweden ≤ 19 years had approximately 1.5 times higher risk of caries increment compared to children of mothers who had resided in Sweden for more than 20 years. Conclusions Caries increment in the children of foreign-born mothers was associated with the age of their mother when she arrived in Sweden and was lower when the mother had arrived before age 7 years. This indicates an intergenerational effect that carries over to the children and is greater the longer the mother has participated in Swedish dental healthcare.

Abstract Background Undocumented migrants face many hardships in their everyday life such as poor living conditions, discrimination, and lack of access to healthcare. Previous studies have demonstrated considerable health care needs for psychiatric disorders as well as physical diseases. The aim of this paper was to find out the main barriers that undocumented migrants experience in accessing the Swedish healthcare system and to explore their relation with socioeconomic factors. Methods A cross-sectional study with adult undocumented migrants was performed in the three largest cities of Sweden in 2014–2016. Sampling was done via informal networks. A socioeconomic questionnaire was constructed including 22 barriers to health care. Trained field workers conducted the interviews. A principal component analysis was conducted of all barriers to reveal central components. Then, Pearson’s chi-squared test was used to explore the characteristics of undocumented migrants experiencing barriers to care. Results Two main components/barriers were extracted: “Fear of being taken by police/authorities”, which was related to fear of disclosure by or in relation to seeking health care, and “Structural and psychosocial factors” which was related to practical obstacles or shame of being ill. Lower age (74.1 % vs 56.0 %), lower level of education (75.0 % vs. 45.1 %), and having no children (70.3 % vs. 48.1 %) were significantly related to a higher likelihood of experiencing a barrier. Conclusion Fear of deportation and practical and psychosocial factors constitute hinderance of access to healthcare for undocumented migrants in Sweden. This highlights the importance of clear instructions, both to undocumented migrants and health professionals about the right to health care according to the international law on human rights as well as the law of confidentiality.

Abstract Background To analyse the impact of austerity measures taken by European governments as a response to the 2008 economic and financial crisis on social determinants on child health (SDCH), and child health outcomes (CHO). Methods A systematic literature review was carried out in Medline (Ovid), Embase, Web of Science, PsycInfo, and Sociological abstracts in the last 5 years from European countries. Studies aimed at analysing the Great Recession, governments’ responses to the crisis, and its impact on SDCH were included. A narrative synthesis of the results was carried out. The risk of bias was assessed using the STROBE and EPICURE tools. Results Fourteen studies were included, most of them with a low to intermediate risk of bias (average score 72.1%). Government responses to the crisis varied, although there was general agreement that Greece, Spain, Ireland and the United Kingdom applied higher levels of austerity. High austerity periods, compared to pre-austerity periods were associated with increased material deprivation, child poverty rates, and low birth weight. Increasing child poverty subsequent to austerity measures was associated with deterioration of child health. High austerity was also related to poorer access and quality of services provided to disabled children. An annual reduction of 1% on public health expenditure was associated to 0.5% reduction on Measles-Mumps-Rubella vaccination coverage in Italy. Conclusions Countries that applied high level of austerity showed worse trends on SDCH and CHO, demonstrating the importance that economic policy may have for equity in child health and development. European governments must act urgently and reverse these austerity policy measures that are detrimental to family benefits and child protection.

Abstract Background Fathers may affect expectant mothers’ daily living situations, which in turn might influence pregnancy outcomes. We investigated the association between paternal violent criminality and risk of preterm birth (≤36 weeks). Methods We conducted a register-based study with all live singleton births in the Swedish Medical Birth Register from 1992 to 2012, linked with records of paternal violent crime convictions from the National Crime Register from 1973 to 2012. Results Paternal violent criminality was associated with increased risk of preterm birth and lower gestational age. The association was especially pronounced among infants of reoffenders: men convicted of three or more violent crimes (adjusted odds ratio [aOR] 1.23 [95% CI 1.17, 1.29]). Maternal half sibling-comparisons, an analytic approach controlling for maternal factors stable across pregnancies, also suggested increased risk of preterm birth and lower gestational age when exposed to a violently reoffending father compared to a father without violent criminal convictions (aOR 1.30 [0.99, 1.72], adjusted mean difference − 1.07 [− 1.78, − 0.36]). Conclusions Persistent paternal violent criminality was associated with increased risk of preterm birth, even after controlling for maternal characteristics that did not change between pregnancies.

BackgroundDue to the circumstances of their early lives, young refugees are at risk of experiencing adverse labour market and health outcomes. The post-settlement environment is thought to play a decisive role in determining how this vulnerability plays out. This study compared trends in labour market marginalisation in young refugees and their majority peers during early adulthood in two national contexts, Denmark and Sweden, and explored the mediating role of common mental disorders and secondary school completions.MethodsUsing registry data, 13,390/45,687 refugees were included in Denmark/Sweden and 1:5 matched to majority peers. Inequalities in labour market marginalisation were investigated during 2012-2015 in each country using linear probability models and mediation analysis. Country trends were standardised to account for differences in observed population characteristics.ResultsThe risk of marginalisation was 2.1-2.3 times higher among young refugees compared with their majority peers, but the risk decreased with age in Sweden and increased in Denmark for refugees. Birth-cohort differences drove the increase in Denmark, while trends were consistent across birth-cohorts in Sweden. Differences in population characteristics did not contribute to country differences. Common mental disorders did not mediate the inequality in either country, but secondary school completions did (77-85% of associations eliminated).ConclusionsThe findings document both the vulnerability of young refugees to labour market marginalisation and the variability in this vulnerability across post-settlement contexts. While the contrast in policy climates in Denmark and Sweden sharpened over time, the risk of marginalisation appeared more similar in younger cohorts, pointing to the importance of factors other than national immigration and integration policies. Institutional efforts to assist young refugees through secondary education are likely to have long-lasting consequences for their socio-economic trajectories.

Background In the context of containment measures against the COVID-19 pandemic, the aims were to examine the impact of lockdown and school closures on childs’ and adolescents’ health and well-being and social inequalities in health.Methods Literature review by searching five databases until November 2020. We included quantitative peer-reviewed studies reporting health and well-being outcomes in children (0–18 years) related to closure measures' impact due to COVID-19. A pair of authors assessed the risk of bias of included studies. A descriptive and narrative synthesis was carried out.Findings Twenty-two studies, including high-income, middle-income and low-income countries, fulfilled our search criteria and were judged not to have an increased risk of bias. Studies from Australia, Spain and China showed an increase in depressive symptoms and decrease in life satisfaction. A decrease in physical activity and increase in unhealthy food consumption were shown in studies from two countries. There was a decrease in the number of visits to the emergency department in four countries, an increase in child mortality in Cameroon and a decrease by over 50% of immunisations administered in Pakistan. A significant drop of 39% in child protection medical examination referrals during 2020 compared with the previous years was found in the UK, a decrease in allegations of child abuse and neglect by almost one-third due to school closures in Florida, and an increase in the number of children with physical child abuse trauma was found in one centre in the USA.Interpretation From available reports, pandemic school closure and lockdown have adverse effects on child health and well-being in the short and probably long term. We urge governments to take the negative public health consequences into account before adopting restrictive measures in childhood.

Background Parental separation has been associated with adverse child mental health outcomes in the literature. For school-aged children, joint physical custody (JPC), that is, spending equal time in both parents’ homes after a divorce, has been associated with better health and well-being than single care arrangements. Preschool children’s well-being in JPC is less studied. The aim of this study was to investigate the association of living arrangements and coparenting quality with mental health in preschool children after parental separation.Methods This cross-sectional population-based study includes 12 845 three-year-old children in Sweden. Mental health was measured by parental reports of the Strength and Difficulties Questionnaire and coparenting quality with a four-item scale. The living arrangements of the 642 children in non-intact families were categorised into JPC, living mostly with one parent and living only with one parent.Results Linear regression models, adjusted for sociodemographic confounders, showed an association between increased mental health problems and living mostly and only with one parent (B=1.18; 95% CI 0.37 to 2.00, and B=1.20; 95% CI 0.40 to 2.00, respectively), while children in intact families vs JPC did not differ significantly (B=−0.11; 95% CI −0.58 to 0.36). After adjusting the analyses for coparenting quality, differences in child mental health between the post divorce living arrangements were, however, minimal while children in intact families had more mental health problems compared with JPC (B=0.70; 95% CI 0.24 to 1.15). Factorial analysis of covariance revealed that low coparenting quality was more strongly related to mental health problems for children in intact families and JPC compared with children living mostly or only with one parent.Conclusions This study suggests that coparenting quality is a key determinant of mental health in preschool children and thus should be targeted in preventive interventions.

Introduction Sweden has long been praised for a generous parental leave policy oriented towards facilitating a gender-equitable approach to work and parenting. Yet certain aspects of Swedish parental leave could also be responsible for the maintenance of (or even the increase in) health inequalities. Using a ‘Health in All Policies’ lens, this research project aims to assess the unintended health consequences of various components of Sweden’s parental leave policy, including eligibility for and uptake of earnings based benefits.Methods and analysis We will use individual-level data from multiple Swedish registers. Sociodemographic information, including parental leave use, will be retrieved from the total population register, Longitudinal Integration Database for Health Insurance and Labour Market Studies and Social Insurance Agency registers. Health information for parents and children will be retrieved from the patient, prescribed drug, cause of death, medical birth and children’s health registers. We will evaluate parents’ mental, mothers’ reproductive and children’s general health outcomes in relation to several policy reforms aiming to protect parental leave benefits in short birth spacing (the speed premium) and to promote father’s uptake (the father’s quota) and sharing of parental leave days (the double days reform). We will also examine effects of increases in basic parental leave benefit levels. Using quasi-experimental designs, we will compare health outcomes across these reforms and eligibility thresholds with interrupted time series, difference-in-difference and regression discontinuity approaches to reduce the risk of health selection and assess causality in the link between parental leave use and health.Ethics and dissemination This project has been granted all necessary ethical permissions from the Stockholm Regional Ethical Review Board (Dnr 2019-04913) for accessing and analysing deidentified data. The final outputs will primarily be disseminated as scientific articles published in open-access, high-impact peer-reviewed international journals, as well as press releases and policy briefs.

Abstract Background Herd immunity levels of vaccine uptake are still not reached in some high-income countries, usually in countries with persisting social inequities in uptake. Previous studies have focused on factors within one health care system. This study takes a broader health care systems approach by reviewing the socioeconomic distribution of vaccination coverage on the national level in light of structural and organizational differences of primary care for children. Methods A systematic literature review of socio-economic patterns of uptake of Measles-Mumps-Rubella (MMR) and/or Diphteria-Tetanus-Pertusis (DTP) in population based studies of children 0–5 years of age living in the 30 European Economic Area (EEA) or European Free Trade Association (EFTA) countries and Australia, was carried out using the PRISMA guidelines. The health care system in the countries in the study were categorized by degree of freedom of the primary care provider (hierarchical or non-hierarchical) and whether preventive services were provided in a separate organization (well-baby clinics). Results The review identified 15 studies from 10 European countries and Australia that fulfilled the criteria. Although the heterogeneity of the socio-economic indicators did not allow for a conclusive meta-analysis, the study pointed towards lower levels of inequities in primary care models with well-baby clinics. In non-hierarchical primary care organizations that also lacked well-baby clinics, socioeconomic gaps in uptake were often found to be large. Conclusion This review indicates that structural and organizational aspects of health care systems for young children are important for equity in vaccine uptake.

Abstract Background Undocumented migrants (UMs) in Europe constitute a heterogeneous group. They are typically in a vulnerable and marginalised situation, since most of them have exhausted their options for gaining asylum and protection from war and persecution, many are traumatised and fear disclosure and deportation, and they typically lack basic social security. The present study investigates living conditions, access to human rights and mental health of UMs living in Sweden. Methods A cross-sectional study with adult UMs was performed in the three largest cities in Sweden in 2014–2016. Sampling was done via informal networks. A socioeconomic questionnaire was constructed, and psychiatric symptoms were screened for using Beck’s Depression Inventory II, Beck’s Anxiety Inventory and the PTSD Checklist (PCL) for civilians. Trained field workers conducted the interviews. Descriptive statistics, chi-square tests and logistic regression models were used. Results A total number of 104 individuals participated. Preliminary findings show that 68% of respondents were suffering from either moderate or severe anxiety, 71% from either moderate or severe depression and 58% from PTSD. No statistically significant gender differences occurred, but age was statistically significant in relation to anxiety and depression. The majority feared returning to their country of origin, for political reasons, due to war in progress there and/or because they belonged to a minority and feared harassment. Almost all had an unstable housing situation and were often forced to move. Fifty-seven percent experienced food insecurity. Conclusion The psychosocial situation among UMs in Sweden, in addition to insecure living conditions without a guarantee of basic needs being met is stressful, and many UMs live in constant fear of disclosure and deportation, all of which has a detrimental effect of the mental health. It is important to understand both associated risk factors for ill-health and coping strategies in this vulnerable population in order try to reduce ongoing stress.

This study aims to examine whether disparities in gestational age outcomes between foreign and Swedish-born mothers are contingent on the measure used to estimate gestational age and, if so, to identify which maternal factors are associated with the discrepancy. Using population register data, we studied all singleton live births in Sweden from 1992-2012 (n = 1,317,265). Multinomial logistic regression was performed to compare gestational age outcomes classified into very (

Background: Non-European international adoptees in Sweden were shown to have a three-to fourfold higher risk of suicidal behaviour in youth during 1986–1995 compared with the general population. The aim of this study was to investigate whether this high risk persists beyond youth and in later cohorts. Methods: A register study of Swedish national cohorts born 1972–86 including 20 625 non-European international adoptees, and comparison populations of 10 915 non-European immigrants and 1 435 167 Swedish born was performed. The study population was followed from age 18 between 1991 and 2016, with suicide and hospital admissions due to suicide attempt as outcomes. Poisson regression models of person time in the study, adjusted for gender and household income at age 17, were fitted to calculate relative risks (RR). Findings: Adjusted RR for suicide in non-European international adoptees was high at age 18–22, 2·74 (95% C.I. 1·95–3·86), but decreased gradually to age 33–43 when the risk was similar to Swedish-born. Adjusted RR for suicide attempts in international adoptees was 2·33 (2·15–2·52) at age 18–22, decreased slightly with older age, but remained higher than Swedish born in all age-classes. Risks for both outcomes were greatest, around three times higher compared with the Swedish-born in the oldest birth cohorts of non-European international adoptees, born 1972–76. Risks for both suicidal outcomes increased with higher age at adoption. Interpretation: The risk of suicidal behaviour in non-European international adoptees in Sweden decreases with age and is lower in later birth cohorts and in infant adoptions.

Abstract Background Child psychiatric treatment facilities vary greatly worldwide and are virtually non-existent in many low-income countries. One of the most common psychiatric disorders in childhood is ADHD, with an estimated prevalence of 3–5% in Sweden. Previous studies have shown a similar prevalence of ADHD in minority and majority children in Sweden and the UK. However, clinical studies demonstrated that children from immigrant families living in Sweden received less psychiatric care than those of native-born parents. We tested the hypothesis that the consumption of child psychiatric care in immigrant families would be determined by the availability of such treatment in the parents’ country of origin. Patterns of medication for attention-deficit hyperactivity disorder (ADHD) were studied as a proxy for child psychiatric care. Methods This was a register study of dispensed stimulant medication during 2013–2014 in Swedish national birth cohorts from 1995–2009. The study population, consisting of nearly 1.4 million children, was divided by national income of the parental country of origin and whether the parents were native Swedes, European immigrants, non-European immigrants or a mixture. Logistic regression was used to calculate the odds ratios of having been dispensed at least one ADHD drug during 2013, with adjustments for gender, family status indicating whether the child is living with both parents, household income and area of residence. Results Having parents born in low-income (OR [95% confidence interval] 0.27 [0.24–0.29]) or middle-income (European: OR 0.23 [0.20–0.26], non-European: OR 0.39 [0.34–0.41]) countries was associated with lower ADHD treatment levels than having parents born in high-income countries (European: OR 0.60 [0.54–0.66], non-European: OR 0.68 [0.59–0.79]), when compared to children of parents born in Sweden. In families with a background in low or middle income countries, there was no significant association between household income and ADHD medication, while in children with Swedish and mixed backgrounds high level of disposable income was associated with lower levels of ADHD medication. Conclusion The use of child psychiatric care by immigrant families in Sweden was largely associated with the income level of the country of origin.

Abstract Background Fetal alcohol spectrum disorders (FASD) is an umbrella term covering several conditions for which alcohol consumption during pregnancy is taken to play a causal role. The benefit of individuals being identified with a condition within FASD remains controversial. The objective of the present study was to identify ethical aspects and consequences of diagnostics, interventions, and family support in relation to FASD. Methods Ethical aspects relating to diagnostics, interventions, and family support regarding FASD were compiled and discussed, drawing on a series of discussions with experts in the field, published literature, and medical ethicists. Results Several advantages and disadvantages in regards of obtaining a diagnosis or description of the condition were identified. For instance, it provides an explanation and potential preparedness for not yet encountered difficulties, which may play an essential role in acquiring much needed help and support from health care, school, and the social services. There are no interventions specifically evaluated for FASD conditions, but training programs and family support for conditions with symptoms overlapping with FASD, e.g. ADHD, autism, and intellectual disability, are likely to be relevant. Stigmatization, blame, and guilt are potential downsides. There might also be unfortunate prioritization if individuals with equal needs are treated differently depending on whether or not they meet the criteria for a specific condition. Conclusions The value for the concerned individuals of obtaining a FASD-related description of their condition – for instance, in terms of wellbeing – is not established. Nor is it established that allocating resources based on whether individuals fulfil FASD-related criteria is justified, compared to allocations directed to the most prominent specific needs.

Abstract Background Infant mortality rates are commonly used to compare the health of populations. Observed differences are often attributed to variation in child health care quality. However, any differences are at least partly explained by variation in the prevalence of risk factors at birth, such as low birth weight. This distinction is important for designing interventions to reduce infant mortality. We suggest a simple method for decomposing inter-country differences in crude infant mortality rates into two metrics representing risk factors operating before and after birth. Methods We used data from 7 European countries participating in the EURO-PERISTAT project in 2010. We calculated crude and birth weight-standardised stillbirth and infant mortality rates using Norway as the standard population. We decomposed between-country differences in crude stillbirth and infant mortality rates into the within-country difference in crude and birth weight-standardised stillbirth and infant mortality rates (metric 1), reflecting prenatal risk factors, and the between-country difference in birth weight-standardised stillbirth and infant mortality rates (metric 2), reflecting risk factors operating after birth. We also calculated birth weight-specific mortality. Results Using our metrics, we showed that for England, Wales and Scotland risk factors before and after birth contributed equally to the differences in crude stillbirth and infant mortality rates relative to Norway. In Austria, Czech Republic and Switzerland the differences were driven primarily by metric 1, reflecting high rate of low birth weight. The highest values of metric 2 observed in Poland partially reflected high rates of congenital anomalies. Conclusions Our suggested metrics can be used to guide policy decisions on preventing infant deaths through reducing risk factors at birth or improving the care of babies after birth. Aggregate data tabulated by birth weight/gestational age should be routinely collected and published in high-income countries where birth weight is reported on birth certificates.

This study investigated mental health in schoolchildren in different living arrangements after parental separation. The study population included 31,519 children from the Danish National Birth Cohort, followed-up at age 11 in 2010–2014. Child mental health was measured with a maternal report of the Strength and Difficulties Questionnaire (SDQ). Associations between living arrangements and mental health were analyzed using logistic and linear regression models, taking into account early childhood indicators of the parents’ relations, income, education and psychiatric care. At age 11, children living in a nuclear family had the lowest rate of total SDQ score, 8.9%. Of the children who had experienced parental separation, children in joint physical custody had the lowest adjusted odds ratio (OR)1.25 (95%-CI 1.09–1.44), for a high SDQ score relative to children living in a nuclear family, with adjusted ORs of 1.63 (1.42–1.86) and OR 1.72 (1.52–1.95) for sole physical custody arrangements with and without a new partner. An analysis of change in SDQ scores between ages 7 and 11 in children showed a similar pattern. This study indicates that joint physical custody is associated with slightly more favorable mental health in schoolchildren after parental separation than sole physical custody arrangements.

Abstract Background Psychological distress and lack of family support may explain the mental health problems that are consistently found in young unaccompanied refugees in Western countries. Given the strong relationship between poor mental health and alcohol misuse, this study investigated hospital admissions due to alcohol related disorders among accompanied and unaccompanied young refugees who settled in Sweden as teenagers. Methods The dataset used in this study was derived from a combination of different registers. Cox regression models were used to estimate the risks of hospital care due to alcohol related disorders in 15,834 accompanied and 4376 unaccompanied young refugees (2005–2012), aged 13 to 19 years old when settling in Sweden and 19 to 32 years old in December 2004. These young refugees were divided into regions with largely similar attitudes toward alcohol: the former Yugoslavian republics, Somalia, and the Middle East. The findings were compared with one million peers in the native Swedish population. Results Compared to native Swedes, hospital admissions due to alcohol related disorders were less common in young refugees, with a hazard ratio (HR) of 0.65 and 95% confidence interval (CI) between 0.56 and 0.77. These risks were particularly lower among young female refugees. However, there were some differences across the refugee population. For example, the risks were higher in unaccompanied (male) refugees than accompanied ones (HR = 1.49, 95% CI = 1.00–2.19), also when adjusted for age, domicile and income. While the risks were lower in young refugees from Former Yugoslavia and the Middle East relative to native Swedes, independent of their length of residence in Sweden, refugees from Somalia who had lived in Sweden for more than ten years showed increased risks (HR = 2.54, 95% CI = 1.71–3.76), after adjustments of age and domicile. These risks decreased considerably when income was adjusted for. Conclusion Young refugees have lower risks of alcohol disorders compared with native Swedes. The risks were higher in unaccompanied young (male) refugees compared to the accompanied ones. Moreover, Somalian refugees who had lived in Sweden for more than ten years seems to be particularly vulnerable to alcohol related disorders.

A growing corpus of evidence reveals that smoking patterns of migrant women tend to converge with that of the host population over time (‘acculturation paradox’). In this paper we aim to adopt a health equity perspective by studying the extent to which this pattern reflects a convergence with the group of natives who are more socioeconomically disadvantaged. Using population-based registers, we study 1,194,296 women who gave birth in Sweden between 1991 and 2012. Using logistic regression, we estimated odds ratios to assess the effect of duration of residence on the association between smoking during pregnancy and women's origin (classified according to inequality-adjusted Human Development Index (iHDI) of the country of birth). Sibling information and multilevel models were used to assess the extent to which our results might be affected by the cross-sectional nature of the data. Smoking during pregnancy increases with duration of residence among migrants from all levels of iHDI to such an extent that they tend to converge or increase in relation to the levels of the Swedish population with low education and low income, leaving behind the native population with high education and income. The results are robust to possible selection bias related to the cross-sectional nature of the data. Our findings indicate the need of a health equity perspective and suggest the use of ‘unequal assimilation’ rather than ‘acculturation paradox’ as a more suitable framework to interpret these findings. Keywords: Assimilation paradox, Acculturation paradox, Tobacco, Migration, Social determinants, Unequal assimilation

Joint physical custody (JPC) refers to a practice where children with separated parents share their time between the parents' respective homes. Studies on parents' views of JPC for young children are scarce. The aim of this interview study was to explore parents' perceptions on how they experience and practice equally shared JPC for their 1-4 year-olds in Sweden. Forty-six parents (18 fathers and 28 mothers) of 50 children (31 boys and 19 girls) under 5 years of age were interviewed. Parents were recruited through information in the media and represented a broad range of socioeconomic backgrounds, as well as both voluntary and court-ordered custody arrangements. The interviews were semi-structured and analyzed using systematic text condensation. Two themes emerged regarding the research question. In the first theme, Always free, never free, parents described their striving to coparent without a love relationship. While they appreciated the freedom of being a "half-time parent", doing things one's own way, they felt constrained by the long-term commitment to live close to and keep discussing child rearing issues with the ex-partner. Good communication was key and lessened parent's feelings of being cut-off from half of the child's life. When JPC was ordered by court or conflicts were intense, parents tried to have less contact and worried when the children were in the other home. The second theme, Is it right, is it good?, included descriptions of how the parents monitored the child's responses to the living arrangement and made changes to optimize their adjustment. Adaptations included visits for the child with the other parent mid-week, shared meals or adapting schedules. In conclusion, these parents worked hard to make JPC work and cause minimal damage to their children. Most parents were pleased with the arrangements with the notable exception of couples experiencing ongoing conflict.

Background Migrants' socioeconomic adversity has been linked to schizophrenia. Aims To investigate whether the more favourable socioeconomic situation of adoptees prevents them from the high risk of schizophrenia found in other migrants. Method Register study in a cohort of refugees and inter-country adoptees aged 16–40 years, born in East Africa (n=8389), Latin America (n=11 572) and 1.2 million native Swedes. Cox-regression models estimated hazard ratios (HRs) of schizophrenia in data from psychiatric care. Results Despite diverse income levels, HRs for schizophrenia were similar for refugees and adoptees, with East Africans having the highest HRs: 5.83 (3.30–10.27) and 5.80 (5.03–6.70), followed by Latin Americans: HRs 3.09 (2.49–3.83) and 2.31 (1.79–2.97), compared with native Swedes. Adjustment for income decreased these risks slightly for refugees, but not for adoptees. Conclusions This study suggests that risk factors associated with origin are more important determinants of schizophrenia than socioeconomic adversity in the country of settlement.

Objective Our aim was to investigate whether the risk of depression in adulthood in children raised by substitute parents from an early age differ by care arrangements.Methods Register study in Swedish national cohorts born 1972–1981, with three study groups of children raised in adoptive or foster homes with care starting before the age of 2 years and a comparison majority population group. Cox regression estimated HRs of prescribed antidepressive medication and specialised psychiatric care with a diagnosis of depression in adulthood during 2006–2012.Results Compared with the general population, long-term foster care carried the highest age-adjusted and sex-adjusted HR for both antidepressive medication, 2.07 (95% CI 1.87 to 2.28), and psychiatric care for depression, 2.85 (95% CI 2.42 to 3.35), in adulthood. Adults raised by adoptive parents were far more similar to the general population with HR of 1.19 (95% CI 1.00 to 1.43) for domestic and 1.13 (95% CI 1.08 to 1.18) for international adoption for antidepressive medication. Adjusting the analysis for school marks and income attenuated these risks more in the long-term foster care group.Conclusion The study demonstrates the benefits of early adoption when substitute parents are provided for young children, and underlines the importance of improved educational support for children in foster care.

Introduction Child mortality is nearly twice as high in England as in Sweden. A comparison of mortality from potentially preventable causes could inform health system responses. This study focused on respiratory tract infection (RTI)-related deaths, amenable to healthcare interventions, and sudden unexpected deaths in infancy (SUDI), amenable to public health interventions. Objectives and Approach We developed nationally-representative birth cohorts of singleton live births in 2003-2012 using a hospital admissions database in England and the Medical Birth Register in Sweden. Children were followed-up from 31st day of life until their fifth birthday via linkage to hospital admission and mortality records. We compared child mortality using Cox proportional hazards models to estimate hazard ratios (HR) for England versus Sweden for RTI-related mortality at 31-364 days and 1-4 years, and for SUDI mortality at 31-364 days. Models were adjusted for birth characteristics (gestational age, birthweight, sex, congenital anomalies), and socio-economic factors (maternal age and socio-economic status). Results Of 3,928,483 children in England, there were 807 RTI-related deaths at 31-364 days (17% of all deaths in the age range), 691 deaths at 1-4 years (31%), and 1,166 SUDIs (24%) in England. Corresponding figures for 1,012,682 children in Sweden were 136 (18%), 118 (25%) and 189 (24%). Unadjusted HRs for RTI-related deaths in England versus Sweden were 1.50 (95% confidence interval: 1.25-1.80) at 31-364 days. Adjustment for birth characteristics reduced the HR to 1.16 (0.97-1.39), and for socio-economic factors to 1.11 (0.92-1.33). Corresponding figures for RTI-related mortality at 1-4 years were 1.58 (1.30-1.92), 1.32 (1.09-1.61) and 1.30 (1.07-1.59), respectively. Unadjusted HRs for SUDIs reduced from 1.59 (1.36-1.85) to 1.40 (1.20-1.63) after adjusting for birth characteristics, and to 1.19 (1.02-1.39) after adjusting for socio-economic factors. Conclusion/Implications Higher prevalence of adverse birth characteristics (such as prematurity, low birthweight, congenital anomalies) contributed to increased risks of RTI-related and SUDI mortality in England relative to Sweden. Therefore, preventive strategies should focus on maternal health and socio-economic circumstances before and during pregnancy to reduce RTI-related and SUDI mortality in England.

Introduction Separation from one’s child can have significant consequences for parental health and well-being. Objectives and Approach We aimed to investigate whether parents whose children were placed in care had higher rates of avoidable (amenable and preventable) mortality. Data were obtained from the Swedish national registers. Mortality rates among parents whose children were placed in care between 1990 and 2012 (17 505 mothers, 18 286 fathers) were compared with a 5:1 matched cohort of parents whose children were not placed. We computed rate differences and hazard ratios of all-cause and avoidable mortality. Results When compared with parents who did not have a child placed in care, there were an additional 21 avoidable deaths per 10 000-person years among mothers and an additional 27 avoidable deaths per 10 000-person years among fathers whose children were placed in care. Among mothers, death due to preventable causes were 3·83 times greater (95% CI 2·82-5·21) and deaths due to amenable causes were 3·12 times greater (95% CI 2·07-4·69) for those whose children were placed in care. Among fathers, death due to preventable causes was 1·75 times greater (95% CI 1·41-2·16) and deaths due to amenable causes were 1·52 times greater (95% CI 1·08- 2·13) for those whose children were placed in care. Avoidable mortality rates were higher among mothers whose children were young when placed in care and parents whose children were all placed in care. Conclusion/Implications Mothers who had a young child placed and parents whose children were all placed in care are at much higher risk of avoidable mortality than parents whose children were not placed in care. Targeted public health interventions and more attentive health care could reduce risk of avoidable mortality in this group of parents.

Introduction Children born to teenage mothers have greater healthcare needs than those born to mothers in their 20s and older, including higher rates of childhood hospitalisations. We performed a direct cross-country comparison of maternal age-related inequalities in infant outcomes in England, Scotland, Sweden, New South Wales (NSW; Australia) and Ontario (Canada). Objectives and Approach We used administrative hospital data capturing 3,002,749 singleton births surviving to discharge between 2010-2014 (2008-2012 for Sweden). We derived risk ratios and risk differences to compare rates of preterm birth (24-37 weeks of gestation), unplanned hospital admissions, emergency department (ED) visits, and mortality within 12 months of postnatal discharge, for infants born to mothers aged 15-19, 20-24, 25-29 and 30-34 years. Results Infants born to teenage mothers experienced higher rates of preterm birth, unplanned admissions, ED visits, and mortality compared with older mothers in all countries. Despite variation in the distribution of maternal characteristics between countries, inequalities according to maternal age were similar. Infants of teenage mothers were between 1.37 (95% CI for risk ratio 1.28-1.47, Sweden) and 1.56 (95% CI 1.49-1.64, NSW) times more likely to have ≥1 unplanned hospital admission and between 2.25 (95% CI 1.92-2.64, England) and 3.87 (95% CI 2.07-7.36, Sweden) times more likely to die, compared with those born to mothers aged 30-34. Conclusion/Implications A similar excess of adverse outcomes was observed for teenage mothers in all five countries, despite different prevalence rates and support for young families. Public health strategies are needed to address these inequalities, which may be due to social risk factors associated with both young motherhood and adverse infant outcomes.

Linkage of population-based administrative data is a valuable tool for combining detailed individual-level information from different sources for research. While not a substitute for classical studies based on primary data collection, analyses of linked administrative data can answer questions that require large sample sizes or detailed data on hard-to-reach populations, and generate evidence with a high level of external validity and applicability for policy making. There are unique challenges in the appropriate research use of linked administrative data, for example with respect to bias from linkage errors where records cannot be linked or are linked together incorrectly. For confidentiality and other reasons, the separation of data linkage processes and analysis of linked data is generally regarded as best practice. However, the ‘black box’ of data linkage can make it difficult for researchers to judge the reliability of the resulting linked data for their required purposes. This article aims to provide an overview of challenges in linking administrative data for research. We aim to increase understanding of the implications of (i) the data linkage environment and privacy preservation; (ii) the linkage process itself (including data preparation, and deterministic and probabilistic linkage methods) and (iii) linkage quality and potential bias in linked data. We draw on examples from a number of countries to illustrate a range of approaches for data linkage in different contexts.

ABSTRACT Objectives England has one of the highest child mortality rates in Western Europe, while Sweden has one of the lowest. These differences suggest that improvements in early life mortality should be achievable in England. However, policy makers need to know when in the life course to target interventions to prevent the largest number of deaths in early life, e.g. by addressing the prevalence of risk factors at birth (such as preterm birth or low birthweight), or improving the care of babies after birth. This study aims to compare child mortality in England and in Sweden using whole country birth cohorts based on linked administrative health databases in order to determine whether the disparities are driven by risk factors operating before or after birth. Approach We created birth cohorts from a national birth register (Sweden) and a hospital admission database (England). These were linked to longitudinal hospital data and death registration data. All singleton live births for 2003-2012 were included and followed from birth up to five years. We compared mortality in England and in Sweden using Cox proportional hazard model with characteristics at birth (gestation, birthweight, gender, maternal age, congenital malformations), socio-economic status and country as covariates. Results The study cohort comprised 1,047,192 children in Sweden and 6,117,693 children in England. 2,820 of cohort children died in Sweden (0.3%) and 28,434 in England (0.5%). Preliminary results showed that under-5 mortality was almost twice as high in England as in Sweden (5.1 deaths per 1000 live births, 95% confidence interval (CI): 5.0/1000-5.2/1000 vs 3.0/1000, 95% CI: 2.9/1000-3.2/1000). Mortality rates were 45% higher in England during infancy, but only 15% higher in early-childhood (1-4 years). Children with congenital malformations were at similar risk of death in England (33.9/1000, 95% CI: 32.9/1000-34.8/1000) as in Sweden (32.7/1000, 95% CI: 29.5/1000-35.8/1000). The prevalence of congenital malformations, however, was twice as high in England (5.1% vs 2.6%). Conclusions Our preliminary results suggest that the disparities in early-childhood mortality were partly driven by increased prevalence of congenital malformations in England relative to Sweden, as mortality rates within this group were comparable. Individual-level data from birth cohorts constructed using linked administrative health databases enable comparing mortality among children with the same combinations of risk factors at birth. Such analyses can inform policy makers whether resources to prevent early-life mortality are most effectively targeted at improving the health of pregnant women, neonatal care, or supporting families with young children.

The aim of this paper is to estimate the cumulative effect of childhood household dysfunction (CHD) on alcohol related illness and death later in life and to test the interaction between CHD and socioeconomic background. The study utilised Swedish national registers including data of a Swedish national cohort born 1973-82 (n = 872,912), which was followed from age 18 to 29-40 years. Cox regression analyses were used to calculate hazard ratios (HR) for alcohol related illness or death in young adulthood. The CHD measure consisted of seven indicators: parental alcohol/drug misuse, mental health problems, criminality, death, divorce, social assistance, and child welfare interventions. Childhood socioeconomic position (SEP) was indicated by parental occupational status. Outcomes were alcohol related inpatient hospital care, specialised outpatient care or deaths. Using the highest socioeconomic group without CHD experience as a reference, those in the same socioeconomic group with one indicator of CHD had HRs of 2.1 [95% CI: 1.7-2.5], two CHD indicators 5.6 [4.4-7.1], three or more indicators 9.4 [7.1-12.4] for retrieving inpatient care. Socioeconomic disadvantage further increased the risks-those with low socioeconomic background and three CHD indicators or more had a HR of 12.5 [10.9-14.3]. Testing for interaction suggests that the combined HRs deviates from additivity [Synergy index: 1.6, 95% CI: 1.4-1.9]. The results for outpatient care were similar, but not as pronounced. In conclusion, this Swedish national cohort study shows that childhood household dysfunction is strongly and cumulatively associated to alcohol related illness later in life and that it interacts with socioeconomic disadvantage.

High rates of mental health problems have been described in young refugees, but few studies have been conducted on substance misuse. This study aimed to investigate the patterns of hospital care and criminality associated with substance misuse in refugees who settled in Sweden as teenagers.Gender stratified Cox regression models were used to estimate the risks of criminal convictions and hospital care associated with substance misuse from national Swedish data for 2005-2012. We focused on 22,992 accompanied and 5,686 unaccompanied refugees who were aged 13-19 years when they settled in Sweden and compared them with 1 million native Swedish youths from the same birth cohort.The risks of criminal conviction associated with substance misuse increased with the length of residency in male refugees, after adjustment for age and domicile. The hazard ratios (HRs) were 5.21 (4.39-6.19) for unaccompanied and 3.85 (3.42-4.18) for accompanied refugees after more than 10 years of residency, compared with the native population. The risks were slightly lower for hospital care, at 2.88 (2.18-3.79) and 2.52(2.01-3.01) respectively. Risks were particularly pronounced for male refugees from the Horn of Africa and Iran. The risks for all male refugees decreased substantially when income was adjusted for. Young female refugees had similar risks to the general population.The risks of criminality and hospital care associated with substance misuse in young male refugees increased with time of residency in Sweden and were associated with a low level of income compared with the native Swedish population. Risks were similar in accompanied and unaccompanied refugees.

Higher risks of psychiatric disorders and lower-than-average subjective health in adulthood have been demonstrated in offspring of immigrants in Sweden compared with offspring of native Swedes, and linked to relative socioeconomic disadvantage. The present study investigated mortality rates in relation to this inequity from a gender perspective.We used data from national registers covering the entire Swedish population aged 18-65 years. Offspring of foreign-born parents who were either Swedish born or had received residency in Sweden before school age (

PURPOSE: Stressful childhood experiences have negative long-term health consequences. The present study examines the association between adverse childhood experiences, socioeconomic position, and risk of psychotropic medication in young adulthood. METHODS: This register-based cohort study comprises the birth cohorts between 1985 and 1988 in Sweden. We followed 362 663 individuals for use of psychotropic medication from January 2006 until December 2008. Adverse childhood experiences were severe criminality among parents, parental alcohol or drug abuse, social assistance recipiency, parental separation or single household, child welfare intervention before the age of 12, mentally ill or suicidal parents, familial death, and number of changes in place of residency. Estimates of risk of psychotropic medication were calculated as odds ratio (OR) with 95% confidence intervals (CIs) using logistic regression analysis. RESULTS: Adverse childhood experiences were associated with increased risks of psychotropic medication. The OR for more than three adverse childhood experiences and risk of psychotropic medication was for women 2.4 (95% CI 2.3-2.5) and for men 3.1 (95% CI 2.9-3.2). The risk of psychotropic medication increased with a higher rate of adverse childhood experiences, a relationship similar in all socioeconomic groups. CONCLUSIONS: Accumulation of adverse childhood experiences increases the risk of psychotropic medication in young adults. Parental educational level is of less importance when adjusting for adverse childhood experiences. The higher risk for future mental health problems among children from lower socioeconomic groups, compared to peers from more advantaged backgrounds, seems to be linked to a higher rate of exposure to adverse childhood experiences.

BACKGROUND: It has been proposed that maternal obesity during pregnancy may increase the risk that the child develops allergic disease and asthma, although the mechanisms underpinning this relationship are currently unclear. We sought to assess if this association may be due to confounding by genetic or environmental risk factors that are common to maternal obesity and childhood asthma, using a sibling pair analysis. METHODS: The study population comprised a Swedish national cohort of term children born between 1992 and 2008 to native Swedish parents. Maternal body mass index (BMI) was measured at 8-10 weeks gestation. Unconditional logistic regression models were used to determine if maternal obesity was associated with increased risk of inhaled corticosteroid (ICS) in 431,718 first-born children, while adjusting for potential confounders. An age-matched discordant sib-pair analysis was performed, taking into account shared genetic and environmental risk factors. RESULTS: Maternal over-weight and obesity were associated with increased risk that the child would require ICS (for BMI≥35 kg/m(2), aOR = 1.30, 95%CI = 1.10-1.52 compared with normal weight mothers) in children aged 6-12 years. Similar effects were seen in younger children, but in children aged 13-16 years, maternal obesity (BMI≥30) was related to increased risk of ICS use in girls (aOR = 1.28, 95%CI = 1.07-1.53) but not boys (OR = 1.05, 95%CI = 0.87-1.26). The sib-pair analysis, which included 2,034 sib-pairs older than six years who were discordant for both ICS use and maternal BMI category, failed to find any evidence that increasing maternal weight was related to increased risk of ICS use. CONCLUSION: Maternal obesity is associated with increased risk of childhood ICS use up to approximately 12 years of age, but only in girls after this age. These effects could not be confirmed in a sib pair analysis, suggesting either limited statistical power, or the effects of maternal BMI may be due to shared genetic or environmental risk factors.