Search

Abstract Background The Swedish Primary Health Care (PHC) system has, like in other European countries, undergone a gradual transition towards marketization and privatization, most distinctly through a 2010 choice reform. The reform led to an overall but regionally heterogenous expansion of private PHC providers in Sweden, and with evidence also pointing to possible inequities in various aspects of PHC provision. Evidence on the reform’s impact on population-level primary health care performance and equity in performance remains scarce. The present study therefore aimed to examine whether the increase in private provision after the reform impacted on population-average rates of avoidable hospitalizations, as well as on corresponding socioeconomic inequities. Methods This register-based study used a multiple-group interrupted time-series design for the study period 2001–2017, with the study population (N = 51 million observations) randomly drawn from the total Swedish population aged 18–85 years. High, medium, and low implementing comparison groups were classified by tertiles of increase in private PHC providers after the reform. PHC performance was measured by avoidable hospitalizations, and socioeconomic position by education and income. Interrupted time series analysis based on individual-level data was used to estimate the reform impact on avoidable hospitalization risk, and on inequities through the Relative Index of Inequality (RII). Results All three comparisons groups displayed decreasing risk of avoidable hospitalizations but increasing socioeconomic inequities across the study period. Compared to regions with little change in provision after the reform, regions with large increase in private provision saw a steeper decrease in avoidable hospitalizations after the reform (relative risk (95%): 1.6% (1.1; 2.1)), but at the same time steeper increase in inequities (by education: 2.0% (0.1%; 4.0); by income: 2.2% (-0.1; 4.3)). Conclusions The study suggests that the increase in private health care centers, enabled by the choice reform, contributed to a small improvement when it comes to overall PHC performance, but simultaneously to increased socioeconomic inequities in PHC performance. This duality in the impact of the Swedish reform also reflects the arguments in the European health policy debate on patient choice PHC models, with hopes of improved performance but fears of increased inequities.

Tuberculosis is recognised as a disease of the economically disadvantaged people due to its association with financial vulnerability. Mozambique still faces the challenge of the high burden of TB and associated costs. We aimed to understand the social and economic impacts of TB and the need for social support among people with TB in Mozambique. We conducted a qualitative study using a phenomenological approach focusing on the lived experiences and perceptions of people with TB. A total of 52 semi-structured one-to-one in-depth interviews were conducted and data were analysed using a reflexive thematic analysis. Three themes were drawn from the analysis: (i) TB has a social and economic impact that requires adaptation and resourcefulness amongst those affected; (ii) People with TB have different preferences and needs for social support, and (iii) People with TB have different knowledge of, and experiences with, formal social support. TB affects family and community relationships mainly due to impacts on the household’s finances. People with TB in Mozambique are not entitled to any form of social support, and they need to rely on help from family and the community which is often insufficient. Further investigation is needed on how social support schemes can be developed in Mozambique.

Purpose The COVID-19 pandemic and consequent strain on healthcare globally shed light on the concept of moral distress among healthcare workers, albeit to a smaller extent among doctors at emergency departments. This study aimed to examine moral distress as perceived by medical doctors working at emergency departments in Stockholm during the pandemic, with the purpose of investigating causes of moral distress and methods to manage moral distress. Methods Semi-structured interviews were conducted with twelve doctors working at two emergency departments. A questionnaire was developed based on previous research and the interviews were analysed qualitatively through thematic analysis. Results The themes ”The factors that precipitated moral distress”, “Experience of workplace support” and “Coping strategies” as well as seven subthemes and 15 codes were identified. The informants reported on various situations with different causes of moral distress. Common causes were resource depletion, such as hospital bed shortages, and following stricter triage criteria. Informants reported varying ways of managing moral distress. Conclusions Informants experienced moral distress when faced with challenges such as resource depletion, rules and regulations, and colleagues’ decisions. The informants who chose to seek support received it from their workplace, which helped them cope with their experiences. Some informants chose to not seek support.

Abstract Background In Norrtälje municipality, within Region Stockholm, there is a joint integrated care organisation providing health and social care, which may have facilitated a more coordinated response to the covid-19 pandemic compared to the otherwise decentralised Swedish system. This study compares the risk of covid-19 mortality among persons 70 years and older, in the municipalities of Stockholm, Södertälje, and Norrtälje, while considering area and individual risk factors. Methods A population-based study using linked register data to examine covid-19 mortality among those 70 + years (N = 127,575) within the municipalities of interest between the periods March-August 2020 and September 2020-February 2021. The effect of individual and area level variables on covid-19 mortality among inhabitants in 68 catchment areas were examined using multi-level logistic models. Results Individual factors associated with covid-19 mortality were sex, older age, primary education, country of birth and poorer health as indicated by the Charlson Co-morbidity Index. The area-level variables associated were high deprivation (OR: 1.56, CI: 1.18–2.08), population density (OR: 1.14, CI: 1.08–1.21), and usual care. Together, this explained 85.7% of the variation between catchment areas in period 1 and most variation was due to individual risk factors in period 2. Little of the residual variation was attributed to differences between catchment areas. Conclusion Integrated care in Norrtälje may have facilitated a more coordinated response during period 1, compared to municipalities with usual care. In the future, integrated care should be considered as an approach to better protect and meet the care needs of older people during emergency situations.

Abstract Background Men are more likely to have unmet need for mental healthcare than women. However, an under-investigated aspect of the gender difference is the role of mental health literacy. This study investigated how combinations of gender and mental health literacy were related to two indicators of unmet need: not perceiving a need for mental healthcare despite poor mental health, and refraining from seeking mental healthcare. Methods This cross-sectional study was based on a questionnaire sent to a general population sample, aged 16–84 years, in Stockholm County, Sweden, in 2019. Of the 1863 respondents (38%), 1563 were included (≥18 years). The sample was stratified into four groups, men and women with low or high mental health literacy, using the third quartile of the Mental Health Knowledge Schedule. The likelihood of not perceiving a need for mental healthcare and refraining from seeking mental healthcare, at any time in life, were investigated by calculating odds ratios with 95% confidence intervals. Results Men with low mental health literacy were most likely to not perceive a need for mental healthcare, also when adjusting for age, education, and poor mental health (OR 5.3, 95% CI 3.6–7.7), and to refrain from seeking mental healthcare, also when adjusting for age and education (OR 3.3, 95% CI 1.7–6.4), followed by men with high mental health literacy (OR 1.9, 95% CI 1.5–2.4, and OR 1.5, 95% CI 1.0-2.2) and women with low mental health literacy (OR 1.9, 95% CI 1.2–2.9, and OR 2.1, 95% CI 1.1–3.9). Women with high mental health literacy were least likely (reference group). Conclusion The results show differences in the likelihood of unmet need for mental healthcare based on combinations of gender and mental health literacy level, with men having low mental health literacy being most at risk, and women with high mental health literacy being least at risk. This challenges generalisations of a gender difference in unmet need by showing heterogeneity among men and women based on mental health literacy. Men with low mental health literacy may be particularly in need of targeted interventions to reduce potential individual and societal consequences of their unmet need.

Abstract Aim To examine the perceptions of managers of elder care homes on the impact of facility and staff characteristics on infection control of COVID‐19. Design Case study. Methods Six purposively sampled care home managers in the city of Stockholm were interviewed. Through content analysis, three categories and nine subcategories were identified. Results According to the interviewed care home managers, a home‐like environment that allows for isolation of residents and possibilities for staff to get changed and store personal protective equipment outside each resident's room was considered ideal. Experienced employees were reported as invaluable when facing an infectious outbreak. A mix of permanent and temporary staff was considered essential although some thought that temporary staff who work in multiple care homes might negatively influence the spread of infection. Language barriers among staff were considered an obstacle when trying to disseminate information.

Introduction To examine the impact of the COVID-19 pandemic on mortality, we estimated excess all-cause mortality in 24 countries for 2020 and 2021, overall and stratified by sex and age.Methods Total, age-specific and sex-specific weekly all-cause mortality was collected for 2015–2021 and excess mortality for 2020 and 2021 was calculated by comparing weekly 2020 and 2021 age-standardised mortality rates against expected mortality, estimated based on historical data (2015–2019), accounting for seasonality, and long-term and short-term trends. Age-specific weekly excess mortality was similarly calculated using crude mortality rates. The association of country and pandemic-related variables with excess mortality was investigated using simple and multilevel regression models.Results Excess cumulative mortality for both 2020 and 2021 was found in Austria, Brazil, Belgium, Cyprus, England and Wales, Estonia, France, Georgia, Greece, Israel, Italy, Kazakhstan, Mauritius, Northern Ireland, Norway, Peru, Poland, Slovenia, Spain, Sweden, Ukraine, and the USA. Australia and Denmark experienced excess mortality only in 2021. Mauritius demonstrated a statistically significant decrease in all-cause mortality during both years. Weekly incidence of COVID-19 was significantly positively associated with excess mortality for both years, but the positive association was attenuated in 2021 as percentage of the population fully vaccinated increased. Stringency index of control measures was positively and negatively associated with excess mortality in 2020 and 2021, respectively.Conclusion This study provides evidence of substantial excess mortality in most countries investigated during the first 2 years of the pandemic and suggests that COVID-19 incidence, stringency of control measures and vaccination rates interacted in determining the magnitude of excess mortality.

Abstract Background In the spring of 2020, the Covid-19 outbreak sent a shock wave through the Swedish society and placed an extraordinary pressure on the health and social care system for older people. In the initial phase there were few guidelines for care providers to follow and staff in home care organisations often had to tackle challenges posed by the pandemic as they appeared. The aim of this study was to understand how the spread of Covid-19 was managed in organisations providing home care to older adults in different municipalities in Region Stockholm, and what actions were taken to minimise the spread of the disease among clients and staff. Method A descriptive qualitative study was performed based on eight interviews with managers of home care providers for older adults in three different municipalities in Region Stockholm.Three of the eight providers operate within an integrated care system. Data were analysed using conventional content analysis. Results Three themes were identified covering actions taken to handle the spread of the virus, feelings of insecurity and anxiety, and internal and external factors influencing how the pandemic was tackled. There was no single strategy followed by all municipalities or organisations, however, there were similarities between the organisations. One such example was the introduction of cohort care and the experience of lacking personal protective equipment. Providers in the integrated care system emphasized some advantages with their system that was seen as facilitators for minimising the risk of spreading the virus, like the joint meetings with managers from both health and social care and the close contact with healthcare professionals in relation to dissemination of hygiene instructions. Conclusion Social care workers providing home care to older persons are an important group in preventing dissemination of infectious diseases like Covid-19. For better readiness and preparedness for future pandemics, municipal home care services would need larger stocks of personal protective equipment, clear guidelines and more training on how to reduce dissemination of disease. Ways to achieve closer communication between health and social care providers should also be investigated.

Abstract Background Socioeconomic inequalities in labour market participation are well established. However, we do not fully know what causes these inequalities. The present study aims to examine to what extent factors in childhood and late adolescence can explain educational differences in early labour market exit among older workers. Methods All men born in 1951–1953 who underwent conscription examination for the Swedish military in 1969–1973 (n = 145 551) were followed from 50 to 64 years of age regarding early labour market exit (disability pension, long-term sickness absence, long-term unemployment and early old-age retirement with and without income). Early life factors, such as cognitive ability, stress resilience, and parental socioeconomic position, were included. Cox proportional-hazards regressions were used to estimate the association between the level of education and each early labour market exit pathway, including adjustment for early life factors. Results The lowest educated men had a higher risk of exit through disability pension (HR: 2.72), long-term sickness absence (HR: 2.29), long-term unemployment (HR: 1.45), and early old-age retirement with (HR: 1.29) and without income (HR: 1.55) compared to the highest educated men. Factors from early life explained a large part of the educational differences in disability pension, long-term sickness absence and long-term unemployment but not for early old-age retirement. Important explanatory factors were cognitive ability and stress resilience, whilst cardiorespiratory fitness had negligible impact. Conclusions The association between education and early exit due to disability pension, long-term sickness absence and long-term unemployment was to a large part explained by factors from early life. However, this was not seen for early old-age retirement. These results indicate the importance of taking a life-course perspective when examining labour market participation in later working life.

Abstract Background Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000–2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance. Methods We acquired individual level ACSCs for those aged ≥ 45 in 2000–2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45–64, 65–75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities. Results Copenhagen had the highest IRR of ACSCs among those aged 45–64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74;

BackgroundDespite universal healthcare, socioeconomic differences in healthcare utilization (HCU) persist in modern welfare states. However, little is known of how HCU inequalities has developed over time. The aim of this study is to assess time trends of differences in utilization of primary and specialized care for the lowest (Q1) and highest (Q5) income quantiles and compare these to mortality.Methods and findingsUsing a repeated cross-sectional register-based study design, data on utilization of (i) primary; (ii) specialized outpatient; and (iii) inpatient care, as well as (iv) cause of death, were linked to family income and sociodemographic control variables (for instance, country of origin and marital status). The study sample comprised all individuals 16 years or older residing in Sweden any year during the study period and ranged from 7.1 million in year 2004 to 8.0 million year 2017. HCU and mortality for all disease as well as for the 5 disease groups causing most deaths were compared for the Q1 and Q5 using logistic regression, adjusting for sex, age, marital status, and birth country. The primary outcome measures were adjusted odds ratios (ORs), and regression coefficients of annual changes in these ORs log-transformed. Additionally, we conducted negative binominal regression to calculate adjusted rate ratios (RRs) comparing Q1 and Q5 with regard to number of disease specific healthcare encounters ≤5 years prior to death. In 2017, for all diseases combined, Q1 utilized marginally more primary and specialized outpatient care than Q5 (OR 1.07, 95% CI [1.07, 1.08]; p < 0.001, and OR 1.04, 95% CI [1.04, 1.05]; p < 0.001, respectively), and considerably more inpatient care (OR 1.44, 95% CI [1.43, 1.45]; p < 0.001). The largest relative inequality was observed for mortality (OR 1.78, 95% CI [1.74, 1.82]; p < 0.001). This pattern was broadly reproduced for each of the 5 disease groups. Time trends in HCU inequality varied by level of care. Each year, Q1 (versus Q5) used more inpatient care and suffered increasing mortality rates. However, utilization of primary and specialized outpatient care increased more among Q5 than in Q1. Finally, group differences in number of healthcare encounters ≤5 years prior to death demonstrated a similar pattern. For each disease group, primary and outpatient care encounters were fewer in Q1 than in Q5, while inpatient encounters were similar or higher in Q1. A main limitation of this study is the absence of data on self-reported need for care, which impedes quantifications of HCU inequalities each year.ConclusionsIncome-related differences in the utilization of primary and specialized outpatient care were considerably smaller than for mortality, and this discrepancy widened with time. Facilitating motivated use of primary and outpatient care among low-income groups could help mitigate the growing health inequalities.

Objective People with tuberculosis (TB) and their households face severe socioeconomic consequences, which will only be mitigated by intersectoral collaboration, especially between the health and social sectors. Evidence suggests that key factors for successful collaboration include shared goals, trust, commitment, resource allocation, efficient processes and effective communication and motivation among collaborating parties. This study aimed to understand healthcare and social support sector policymakers’ perspectives on potential solutions to mitigate financial impact among people with TB and their households in Mozambique.Design Qualitative study with primary data collection through one-to-one in-depth interviews.Setting Gaza and Inhambane provinces, Mozambique.Participants Policymakers in the health and social support sector.Results A total of 27 participants were purposefully sampled. Participants were asked about their perspectives on TB-related financial impact and potential solutions to mitigate such impact. Participants reported that people with TB are not explicitly included in existing social support policies because TB per se is not part of the eligibility criteria. People with TB and underweight or HIV were enrolled in social support schemes providing food or cash. Two themes were generated from the analysis: (1) Policymakers suggested several mitigation solutions, including food and monetary support, but perceived that their implementation would be limited by lack of resources; and (2) lack of shared views or processes related to intersectoral collaboration between health and social support sector hinders design and implementation of social support for people with TB.Conclusion Despite health and social sector policymakers reporting a willingness for intersectoral collaboration to mitigate TB-related financial impact, current approaches were perceived to be unilateral. Collaboration between health and social support sectors should focus on improving existing social support programmes.

Abstract Background Understanding the mechanisms of implementation of public health interventions in community settings is a key aspect of programme assessments. To determine core components and establish a programme theory are important tools to improve functioning and support dissemination of programme models to new locations. An extended early childhood home visiting intervention has been developed on-site in a socioeconomically disadvantaged area of Sweden since 2013 with the aim of reducing persisting health inequities in the population. This study aimed at investigating the core programme components and how the intervention was perceived to contribute towards health equity from early childhood. Methods Qualitative framework method was applied in a document analysis and subsequent semi-structured interviews with 15 key actors involved in the programme. Results The intervention was found to be constituted of five core components centred around the situation-based, parental strengthening work method delivered by a qualified team of child health care nurse and social worker. The programme theory foresaw positive effects on child and parental health, responsive parenting practices, families’ use of welfare services according to need and increased integration and participation in society. The principles of Proportionate Universalism were recognised in the programme theory and the intervention was perceived as an important contribution to creating conditions for improved health equity for the families. Still, barriers to health equity were identified on the structural level which limit the potential impact of the programme. Conclusions The core components of the Extended home visiting programme in Rinkeby correspond well to those of similar evidence-based home visiting interventions. Combining focus on early childhood development and responsive parenting with promoting access to the universal welfare services and integration into society are considered important steppingstones towards health equity. However, a favourable macro-political environment is required in the endeavour to balance the structural determinants’ influence on health inequities. Improved availability and accessibility to welfare services that respond to the needs of the families regarding housing, education and employment are priorities. Trial registration The study was retrospectively registered on 11/08/2016 in the ISRCTN registry ( ISRCTN11832097 ).

Abstract Background Health literacy (HL) is important for individuals in terms of knowledge and competence to make decisions about healthcare, health promotion and disease prevention. Migrants generally demonstrate lower HL levels compared to the majority populations. HL interventions among migrants are rarely studied. Thus, there is a need to find useful HL measurements for multicultural settings. The importance of understanding parents’ HL is related to their key role in providing and promoting the health of their children. This study aimed to add knowledge about the psychometric properties of the HLS-EU-Q16 instrument (Swedish version) among parents in Swedish multicultural settings. Methods A cross sectional design was used. Totally 193 first-time parents (N = 193) were recruited through two child healthcare centres in Stockholm. Parents were interviewed when their infants were

Abstract Background Understanding the impact of the burden of COVID-19 is key to successfully navigating the COVID-19 pandemic. As part of a larger investigation on COVID-19 mortality impact, this study aims to estimate the Potential Years of Life Lost (PYLL) in 17 countries and territories across the world (Australia, Brazil, Cape Verde, Colombia, Cyprus, France, Georgia, Israel, Kazakhstan, Peru, Norway, England & Wales, Scotland, Slovenia, Sweden, Ukraine, and the United States [USA]). Methods Age- and sex-specific COVID-19 death numbers from primary national sources were collected by an international research consortium. The study period was established based on the availability of data from the inception of the pandemic to the end of August 2020. The PYLL for each country were computed using 80 years as the maximum life expectancy. Results As of August 2020, 442,677 (range: 18–185,083) deaths attributed to COVID-19 were recorded in 17 countries which translated to 4,210,654 (range: 112–1,554,225) PYLL. The average PYLL per death was 8.7 years, with substantial variation ranging from 2.7 years in Australia to 19.3 PYLL in Ukraine. North and South American countries as well as England & Wales, Scotland and Sweden experienced the highest PYLL per 100,000 population; whereas Australia, Slovenia and Georgia experienced the lowest. Overall, males experienced higher PYLL rate and higher PYLL per death than females. In most countries, most of the PYLL were observed for people aged over 60 or 65 years, irrespective of sex. Yet, Brazil, Cape Verde, Colombia, Israel, Peru, Scotland, Ukraine, and the USA concentrated most PYLL in younger age groups. Conclusions Our results highlight the role of PYLL as a tool to understand the impact of COVID-19 on demographic groups within and across countries, guiding preventive measures to protect these groups under the ongoing pandemic. Continuous monitoring of PYLL is therefore needed to better understand the burden of COVID-19 in terms of premature mortality.

Introduction: Potentially inappropriate drug use (PID) is common among older adults. Cross-sectional data suggest that there are marked regional variations in PID in Sweden. There is, however, a lack of knowledge about how the regional variations have changed over time.Objectives: This study aimed to investigate the regional differences in the prevalence of PID in Sweden, 2006–2020.Methods: In this repeated cross-sectional study, we included all older adults (≥75 years) registered in Sweden, yearly from 2006 to 2020. We used nationwide data from the Swedish Prescribed Drug Register linked at the individual level to the Swedish Total Population Register. We selected three indicators of PID according to the Swedish national “Quality indicators for good drug therapy in the elderly”: 1) Excessive polypharmacy (use of ≥10 drugs); 2) Concurrent use of three or more psychotropic drugs; 3) Use of “drugs that should be avoided in older adults unless specific reasons exist.” The prevalence of these indicators was calculated for each of Sweden’s 21 regions, yearly from 2006 to 2020. The annual coefficient of variation (CV) was calculated for each indicator by dividing the standard deviation of the regions by the national average, to measure relative variability.Results: In the population of about 800,000 older adults per year, the national prevalence of “drugs that should be avoided in older adults,” was reduced by 59% from 2006 to 2020. There was a slight decline in the use of three or more psychotropics, while the prevalence of excessive polypharmacy increased. The CV for excessive polypharmacy was 14% in 2006 and 9% in 2020 compared to 18% and 14% for “use of three or more psychotropics”, and stable at around 10% for ‘drugs that should be avoided in older adults.’Conclusions: The regional variation in potentially inappropriate drug use decreased or were stable from 2006 to 2020. The regional differences were largest for the use of three or more psychotropics. We found a general tendency that regions with a good performance at the start of the period performed well across the entire period. Future studies should investigate the reasons for regional variation and explore strategies to reduce unwarranted differences.

Lack of skilled human resources in primary care remains a major concern for policymakers in low- and middle-income countries. There is little evidence supporting the impact of residency training in family medicine in the quality of care, and it perpetuates misconceptions among policymakers that the provision of primary care can be easily done by any physician without special training. This article compares the risk of patients being hospitalized due to Ambulatory care sensitive conditions and the odds of having follow-up visits in primary care after hospital discharge, according to the type of their medical provider: (1) Generalists (reference), (2) Family physicians; and, (3) patients with no consultations prior to the event. Multilevel multivariate binomial regression models estimated the relative risks of a patient being hospitalized in a given month and the relative risks for the occurrence of a follow-up visit in primary care in a retrospective cohort of 636.640 patients between January 2013 and July 2018 in Rio de Janeiro. For all 14 conditions, there was a higher risk of hospitalization when patients had no consultation in primary care prior to the event. Except for Ear, Nose and Throat infections, patients seen by family physicians had a lower risk of being hospitalized, compared to patients seen by Generalists. Follow-up visits were more likely to happen among patients treated by family physicians for almost every condition analyzed. With two years of training in family medicine, Family physicians can reduce the risk of their patients being hospitalized and increase the likelihood of those patients having a follow-up consultation in primary care. Investments in residency training in family medicine should be made to fix the shortage of skilled physicians in primary care, reduce hospitalizations and improve quality and continuity of care.

Abstract Background Depression and anxiety disorder contribute to a significant part of the disease burden among men, yet many men refrain from seeking care or receive insufficient care when they do seek it. This is plausibly associated with poorer mental well-being, but there is a lack of population-based research. This study investigated 1) if men who had refrained from seeking mental healthcare at any time in life had poorer mental well-being than those who sought care, 2) if those who had sought care but perceived it as insufficient had poorer mental well-being than those who had perceived care as sufficient, and 3) if these differences persisted after 1 year. Methods This longitudinal study used questionnaire data from a population-based sample of 1240 men, aged 19–64 years, in Sweden. Having refrained from seeking mental healthcare, or perceiving the care as insufficient, at any time in life, was assessed in a questionnaire, 2008. Current mental well-being was assessed in 2008 and 2009 using mean scores on the WHO (Ten) Well-being Index. Lower scores indicate poorer mental well-being. Group differences were calculated using t-tests and multivariable linear regression analysis. Results Of the men who had perceived a need for mental healthcare, 37% had refrained from seeking such care. They had lower mental well-being scores in 2008, compared to those who sought care. Of those seeking care, 29% had perceived it as insufficient. They had lower mental well-being scores in 2008, compared to those who perceived the care as sufficient, but this was not statistically significant when controlling for potential confounders. There were no differences in mental well-being scores based on care-seeking or perceived care-sufficiency in 2009. Conclusions This population-based study indicates that men who have previously refrained from seeking mental healthcare, or perceived the care as insufficient, have poorer mental well-being. However, the lack of differences at the one-year follow-up contradicts these results. The results highlight the need for larger longitudinal studies, measuring care-seeking within a more specified time frame. This should be combined with efforts to increase men’s mental healthcare-seeking and to provide mental healthcare that is perceived as sufficient.

Abstract Background There is a need for evidence that residency training in family medicine can benefit the care of patients in primary care in low- and middle-income countries. We tested the hypothesis that two years of residency training in family medicine enables doctors to better detect chronic health conditions while requesting fewer laboratory tests and providing more follow-up visits. Methods We performed a retrospective longitudinal observational analysis of medical consultations from 2013 to 2018 in primary care in Rio de Janeiro, comparing doctors without residency training in family medicine (Generalists) versus family physicians (FPs). Multivariate multilevel binomial regression models estimated the risks of patients being diagnosed for a list of 31 chronic health conditions, having a follow-up visit for these conditions, and having laboratory tests ordered from a list of 30 exams. Results 569.289 patients had 2.908.864 medical consultations performed by 734 generalists and 231 FPs. Patients seen by FPs were at a higher risk of being detected for most of the chronic health conditions, at a lower risk of having any of the 30 laboratory tests requested, and at a higher risk of having a follow-up visit in primary care. Conclusions Residency training in family medicine can make physicians more skilled to work in primary care. Policymakers must prioritize investments in capacity building of healthcare workforce to make primary care truly comprehensive.

OBJECTIVE: High-quality longitudinal evidence exploring the mental health risk associated with low-quality employment trajectories is scarce. We therefore aimed to investigate the risk of being diagnosed with common mental disorders, substance use disorders, or suicide attempt according to low-quality employment trajectories. METHODS: A longitudinal register-study based on the working population of Sweden (N=2 743 764). Employment trajectories (2005–2009) characterized by employment quality and pattern (constancy, fluctuation, mobility) were created. Hazard ratios (HR) were estimated using Cox proportional hazards regression models for first incidence (2010–2017) diagnosis of common mental disorders, substance use disorders and suicide attempt as dependent on employment trajectories. RESULTS: We identified 21 employment trajectories, 10 of which were low quality (21%). With the exception of constant solo self-employment, there was an increased risk of common mental disorders (HR 1.07–1.62) and substance use disorders (HR 1.05–2.19) for all low-quality trajectories. Constant solo self-employment increased the risk for substance use disorders among women, while it reduced the risk of both disorders for men. Half of the low-quality trajectories were associated with a risk increase of suicide attempt (HR 1.08–1.76). CONCLUSIONS: Low-quality employment trajectories represent risk factors for mental disorders and suicide attempt in Sweden, and there might be differential effects according to sex – especially in terms of self-employment. Policies ensuring and maintaining high-quality employment characteristics over time are imperative. Similar prospective studies are needed, also in other contexts, which cover the effects of the Covid-19 pandemic as well as the mechanisms linking employment trajectories with mental health.

This commentary refers to the article by Fisher et al on lessons from Australian primary healthcare (PHC), which highlights the role of PHC to reduce non-communicable diseases (NCDs) and promote health equity. This commentary discusses important elements and features when aiming for health equity, including going beyond the healthcare system and focusing on the social determinants of health in public health policies, in PHC and in the healthcare system as a whole, to reduce NCDs. A wider biopsychosocial view on health is needed, recognizing the importance of social determinants of health, and inequalities in health. Public funding and universal access to care are important prerequisites, but regulation is needed to ensure equitable access in practice. An example of a PHC reform in Sweden indicates that introducing market solutions in a publicly funded PHC system may not benefit those with greater needs and may reduce the impact of PHC on population health.

Abstract Background Lack of control over life situations is an important social determinant that may negatively affect parental and child health. This study took place in an area of Stockholm, Sweden with high indications of socioeconomic disadvantage, a large part of the population with foreign background, as well as higher levels of poor health than the county average. It investigated staff perceptions of pathways from situations of low control, potentially leading to health inequities, affecting families enrolled in an early childhood home visiting programme during the Covid-19 pandemic. Methods Semi-structured interviews were carried out with 23 child health care nurses and parental advisors working in a home visiting programme. The data was analysed using Reflexive Thematic Analysis. Results The analysis resulted in five pathways on two explanatory levels, affecting parents’ health and parenting capacity and children’s health and well-being, potentially damaging health and leading to health inequities. The first four pathways related to control at the personal explanatory level: Families facing instability and insecurity; Caring for children in crowded and poor housing conditions; Experiencing restricted access to resources; and Parenting with limited social support. The fifth pathway, Living in a segregated society, covered the collective experience of lack of control on community level. The Covid-19 pandemic was observed to negatively affect all pathways and thus potentially aggravate health inequities for this population. The pandemic has also limited the delivery of home visits to the families which creates further barriers in families’ access to resources and increases isolation for parents with already limited social support. Conclusions The diversity of pathways connected to health inequities presented in this study highlights the importance of considering this variety of influences when designing interventions for socioeconomically disadvantaged areas. The additional negative consequences of Covid-19 indicate the need for sustainable preventive early childhood interventions for families in such areas. The study also emphasizes the need for further research as well as policy action on possible long-term effects of changing behaviours during the Covid-19 period on child health and health equity. Trial registration The study was retrospectively registered (11 August 2016) in the ISRCTN registry ( ISRCTN11832097 ).

Objectives To investigate the association between inpatient care expenditure (ICE) and income group and the effect of demographic factors, health status, healthcare and social care utilisation on ICE in the last year of life.Design Retrospective population-based study.Setting Stockholm County.Participants Decedents ≥65 years in 2015 (N=13 538).Outcome ICE was calculated individually for the month of, and 12 months preceding death using healthcare register data from 2014 and 2015. ICE included the costs of admission and treatment in inpatient care adjusted for the price level in 2018.Results There were difference between income groups and ICE incurred at the 75th percentile, while a social gradient was found at the 95th percentile where the highest income group incurred higher ICE (SEK45 307, 95% CI SEK12 055 to SEK79 559) compared with the lowest income groups. Incurring higher ICE at the 95th percentile was driven by greater morbidity (SEK20 333, 95% CI SEK12 673 to SEK29 993) and emergency department care visits (SEK77 995, 95% CI SEK64 442 to SEK79 549), while lower ICE across the distribution was associated with older age and residing in institutional care.Conclusion Gaining insight into patterns of healthcare expenditure in the last year of life has important implications for policy, particularly as socioeconomic differences were visible in ICE at a time of greater care need for all. Future policies should focus on engaging in advanced care planning and strengthening the coordination of care for older people.

OBJECTIVES: This study aimed to explore multidimensional operationalizations of precarious employment (PE) in Swedish register data using two approaches: (i) a typological approach and (ii) a dimensional, summative scale approach. It also examined the distribution of sociodemographic and occupational characteristics of precarious employees in Sweden. METHOD: Register data was retrieved on individuals and their employers in the Swedish workforce. Five items corresponding to three dimensions of PE were operationalized: contractual relationship insecurity, contractual temporariness, multiple jobs/sectors, income level, and lack of unionization. First, latent class analysis was applied and a typology of six employment types emerged. Second, a summative scale was constructed by scoring all PE-items. RESULTS: Three types of PE were found using the typological approach, which were characterized by direct employment, solo self-employment and multiple job holding, respectively. The summative scale score ranged between -10 and +2 (average: -1.8). Particularly poor scores were seen for solo self-employed, multiple job holders/multiple sectors, and low income. Female gender, young age, low education and foreign origin were prone to precariousness. PE was more frequent among certain economic sectors and occupations. CONCLUSIONS: Using an existing register of labor market data, two operationalizations of PE were constructed and rendered promising for exposure assessment. Hence, the operationalizations could be of interest for countries with similar data structure. Both approaches highlighted precarious combinations of employment conditions and pointed towards the existence of a wide continuum of precariousness on the labor market. Etiological studies and research assessing trends over time are needed to validate these findings.

Abstract Background The purpose of this study is to increase understanding of physicians’ attitudes towards disability pension applicants, and the impact of diagnosis. We hypothesize that physicians are more likely to think that patients with physical illnesses should get a disability pension than those with mental illness or alcohol dependence. Disability pension is an important source of income for those unable to work because of a disability and type of diagnosis should not impact accessing these benefits. Methods We conducted an experiment with a 2 by 3 factorial structure in Sweden. Each physician was randomly assigned one of six patient vignettes, with the same background description but with a different diagnosis. Each vignette had a diagnosis of either depression, alcohol dependence or low back pain, and was about a man or a woman. Logistic regression was used to examine the odds of a physician reporting that a patient should get a disability pension. Effects are reported in terms of odds ratios (ORs). Results 1414 Swedish registered physicians in psychiatry or general practice (24% response rate) completed the survey. Physicians assigned the alcohol dependent vignette had OR 0.45 (95% CI: 0.34 to 0.60) for perceiving that a patient should get a disability pension compared to physicians assigned the low back pain vignette. Physicians assigned the depression vignette had OR 1.89 (95% CI: 1.42 to 2.50) for perceiving that a patient should get a disability pension compared to physicians assigned the low back pain vignette. Conclusion The patient diagnosis was associated with the physicians’ response regarding if the patient should get a disability pension. A physician’s perception is likely to impact a patient’s access to disability pension.

Abstract Background This study aimed to culturally translate the Attribution Questionnaire (AQ) to the Swedish language and examine the reliability and validity of the new Swedish version to measure stigma towards disability pension applicants in the Swedish context among psychiatrists and general practitioners. Methods The AQ was translated from the original English version into Swedish using the recommended guidelines for cultural translation of questionnaires. Steps included forward/back-translation, use of expert committee and pretesting. Cronbach’s alpha was used to determine internal consistency and structural equation modelling (SEM) was used to test the responsibility model of stigma compared to the original English version. Results 1,414 physicians completed the questionnaire (23.6%). Cultural translation resulted in many modifications to the original questionnaire to increase the external validity. Internal reliability of the AQ Swedish version (AQ-S) was 0.733 and is considered acceptable. Pity and Segregation-coercion sub-scales showed limited consistency. SEM findings show that the responsibility model of stigma is an acceptable fit for the Swedish setting. Conclusion Findings show that the AQ-S is comparable to the other versions of the AQ and is a reliable measure to assess and monitor stigma among physicians in the Swedish setting. Our study shows that cultural translation does not significantly impact the validity of the questionnaire.

Abstract Background A psychometrically validated instrument to measure patient experience in Chinese public hospitals would be useful and is currently lacking. Our research team developed the Patient-Reported Experience Measure for Care in Chinese Hospitals (PREM-CCH). We aimed to validate this PREM-CCH in the present study. Methods Data were drawn from a cross-sectional patient survey in 2016. Complete responses from 2293 outpatients and 1510 inpatients were included. Separate psychometric evaluation was carried out on outpatient and inpatient PREM-CCHs in terms of exploratory factor analysis, internal consistency, construct validity and criterion validity. Results The validated outpatient PREM-CCH contained 22 items and five Factors, i.e. Communication and information, Professional competence, Medical costs, Efficiency, and Hospital recommendation. The validated inpatient PREM-CCH contained 19 items and six Factors, i.e. Communication and information, Professional competence, Medical costs, Efficiency, Health outcomes, and Hospital recommendation. The PREM-CCH showed satisfactory internal consistency, construct validity and criterion validity. Conclusions The PREM-CCH is one of the first validated instruments capturing patient experience of care in the context of Chinese public hospitals. It performed well in the psychometric evaluation. It consists of a basic set of items important to patients that could be applicable to public hospitals in China and actionable to inform quality improvement initiatives.

OBJECTIVES: The lack of a common definition for precarious employment (PE) severely hampers the comparison of studies within and between countries, consequently reducing the applicability of research findings. We carried out a systematic review to summarize how PE has been conceptualized and implemented in research and identify the construct’s dimensions in order to facilitate guidance on its operationalization. METHODS: According to PRISMA guidelines, we searched Web of Science and Scopus for publications with variations of PE in the title or abstract. The search returned 1225 unique entries, which were screened for eligibility. Exclusion criteria were (i) language other than English, (ii) lack of a definition for PE, and (iii) non-original research. A total of 63 full-text articles were included and qualitative thematic-analysis was performed in order to identify dimensions of PE. RESULTS: We identified several theory-based definitions of PE developed by previous researchers. Most definitions and operationalizations were either an accommodation to available data or the direct result of qualitative studies identifying themes of PE. The thematic-analysis of the selected articles resulted in a multidimensional construct including the following three dimensions: employment insecurity, income inadequacy, and lack of rights and protection. CONCLUSIONS: Despite a growing number of studies on PE, most fail to clearly define the concept, severely restricting the advancement of the research of PE as a social determinant of health. Our combined theoretical and empirical review suggests that a common multidimensional definition could be developed and deployed in different labor market contexts using a variety of methodological approaches.

Objective: To analyse socioeconomic inequalities in all-cause mortality among men and women in nine European urban areas during the recent economic crisis, and to compare the results to those from two periods before the crisis. Method: This is an ecological study of trends based on three time periods (2000-2003, 2004-2008 and 2009-2014). The units of analysis were the small areas of nine European urban areas. We used a composite deprivation index as a socioeconomic indicator, along with other single indicators. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyse the evolution of socioeconomic inequalities, we fitted an ecological regression model that included the socioeconomic indicator, the period of time, and the interaction between these terms. Results: We observed significant inequalities in mortality among men for almost all the socioeconomic indicators, periods, and urban areas studied. However, no significant changes occurred during the period of the economic crisis. While inequalities among women were less common, there was a statistically significant increase in inequality during the crisis period in terms of unemployment and the deprivation index in Prague and Stockholm, respectively. Conclusions: Future analyses should also consider time-lag in the effect of crises on mortality and specific causes of death, and differential effects between genders. Resumen: Objetivo: Analizar las desigualdades socioeconómicas en la mortalidad por todas las causas en hombres y mujeres de nueve áreas urbanas europeas durante la reciente crisis económica, y comparar los resultados con dos periodos previos a la crisis. Método: Estudio ecológico de tendencias basado en tres periodos (2000-2003, 2004-2008 y 2009-2014). Las unidades de análisis fueron las áreas pequeñas de nueve zonas urbanas europeas. Se utilizaron un índice compuesto de privación socioeconómica como indicador socioeconómico y otros indicadores simples. Como indicador de mortalidad se usó la razón de mortalidad estandarizada suavizada, calculada utilizando el modelo jerárquico bayesiano propuesto por Besag, York y Mollié. Para analizar la evolución de las desigualdades socioeconómicas se utilizó un modelo de regresión ecológico que incluía el indicador socioeconómico, el periodo y la interacción de ambos. Resultados: Se observaron desigualdades significativas en la mortalidad en los hombres para casi todos los indicadores socioeconómicos, periodos y áreas urbanas. Sin embargo, no hubo cambios significativos en las desigualdades en el periodo de crisis. Aunque las desigualdades entre las mujeres fueron menos comunes, hubo un incremento significativo en las desigualdades en mortalidad en el periodo de crisis en términos de desempleo y del índice de privación en Praga y Estocolmo, respectivamente. Conclusiones: Futuros análisis deberán tener en cuenta el tiempo transcurrido entre la crisis y su efecto en la mortalidad, así como diferentes causas de mortalidad y el efecto diferencial entre géneros.

Background: Homeless people are a socially excluded group whose health reflects exposures to intersecting social determinants of health. The aim of this study was to describe and compare the demographic composition, certain social determinants of health, and self-reported health among homeless people in Stockholm, Sweden, in 2006 and 2018.Methods: Analysis of data from face-to-face interviews with homeless people in Stockholm 2006 (n = 155) and 2018 (n = 148), based on a public health survey questionnaire adapted to the group, including the EQ-5D-3L instrument. The chi-squared test was employed to test for statistical significance between groups and the independent t-test for comparison of mean scores and values. Ordinary Least Squares (OLS) regression, with Robust Standard Errors (RSE) was performed on merged 2006 and 2018 data with mean observed EQ VAS score as outcome variable.Results: In 2018 more homeless people originated from countries outside Europe, had temporary social assistance than long-term social insurance, compared to in 2006. In 2018 more respondents reported lack of social support, exposure to violence, and refrained from seeking health care because of economic reasons. Daily smoking, binge drinking, and use of narcotic drugs was lower 2018 than 2006. In 2018 a higher proportion reported problems in the EQ-5D-3L dimensions, the mean TTO index value and the VAS index value was significantly lower than in 2006. In the regression analysis of merged data there was no significant difference between the years.Conclusions: Homeless people are an extremely disadvantaged group, have high rates of illness and disease and report poor health in all EQ-5D-3L dimensions. The EQ VAS score among the homeless people in 2018 is comparable to the score among persons aged 95–104 years in the general Swedish population 2017. The EQ-5D-3L instrument was easily administered to this group, its use allows comparison with larger population groups. Efforts are needed regarding housing, but also intensified collaboration by public authorities with responsibilities for homeless people's health and social welfare. Further studies should evaluate the impact of such efforts by health and social care services on the health and well-being of homeless people.

Abstract Background In Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use. Methods A population-based study analysing the utilisation of ED care by (N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services. Results Those 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12–44% for those in the lowest income groups. However, age and gender differences were observed with men 65–79 years (OR 1.75 CI: 1.51–2.03) and women 80+ years (OR 1.50, CI 1.19–1.87) in the lowest income groups having a higher odds of frequent ED use. Conclusion This study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care.

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 In most developed countries, governments are implementing policies encouraging older persons to work past 65 years to reduce the burden on societies related to disability benefits and pension payments. Despite this push to extend working lives, we know little about who already works past this age and any inequalities that may exist. Our study investigates the employment rates of those aged 65–75 years of age by educational level, health status and sex in Canada (CAN), Denmark (DK), Sweden (SE) and the United Kingdom (UK). Secondly, we aim to relate findings on employment rates to prevailing policies in the different countries, to increase the understanding on how to further extend working lives. Methods We used nationally representative cross-sectional survey data from the 2012–2013 Canadian Community Health Survey, 2013/14 Survey of Health, Ageing and Retirement in Europe for Denmark and Sweden and the 2013 English Longitudinal Study of Ageing to examine employment rates for those aged 65–75 years by sex, educational level and health status (having limiting longstanding illness (LLI) or not). Results Employment rates decline by age, but we see a linear decline in CAN and the UK compared to an initial decline then a plateau of employment rates from 66 to 68 years in DK and SE. Employment rates among persons aged 65–75 years were lower in the UK than in CAN, DK and SE. Among women, employment rates were highest in SE. Women with low education and a LLI had considerably lower employment rates than men with low education and a LLI (employment rates for men ranged from 27% to 12% compared with employment rates for women which ranged from 12% to 0%). Conclusions Our results suggest that educational level, sex and health all play a role in extending working lives. The variation in employment rates between the four countries implies that policies do matter, but that social differentials show that policies cannot be ‘one size fits all’. Policy-makers must consider different groups (i.e. low-educated women with a LLI) when designing policies to extend working lives.

Abstract Background This study aimed to measure outpatients’ general satisfaction with and experiences of different aspects of health care in Chinese public hospitals and to investigate to what extent general satisfaction could be explained by patients’ experiences in public hospitals located at urban and rural areas. Methods Data on 4782 outpatients were derived from a patient survey in 9 city-level (urban) and 16 county-level (rural) public hospitals across China in 2016. According to Donabedian’s model, questions on patients’ experiences were categorized into six aspects under “structure” and “process”, with general satisfaction representing “outcome”. The Chi-square tests were used to test the differences in patients’ experiences and general satisfaction between urban and rural areas. The Partial Least Squares Structural Equation Modeling (PLS-SEM) was used to estimate effects of patients’ experiences on general satisfaction. Results Compared with respondents in rural areas, there were significantly higher percentages of respondents in urban areas reporting satisfaction and positive experiences in most aspects. As manifested by the path coefficients in PLS models, the positive effect of professional competence (0.197) on general satisfaction was the most significant in respondents at urban areas, followed by communication and information (0.183), and caring attitudes and emotional support (0.174). Among respondents at rural areas, the positive effect of environment facilities (0.199) was the most significant, followed by caring attitudes and emotional support (0.188), and professional competence (0.179). The PLS models explained 44.9 and 46.0% of variations in patient satisfaction at urban and rural areas, respectively. Conclusions Levels of patient satisfaction and experiences at Chinese public hospitals were higher in urban than in rural areas. Outpatients’ experiences of professional competence, caring attitudes and emotional support were strongly related to their satisfaction in both settings. However, among respondents in urban areas, experiences of communication and information were more strongly related to satisfaction, whereas among respondents in rural areas, experiences of environment and facilities were more strongly related to satisfaction.

Abstract Background To improve prerequisites for better health development among children growing up in multicultural suburbs in Stockholm County, where poorer health is displayed in several aspects including child health, early support was initiated for first-time parents in one of the suburbs. An extended postnatal home visiting program during the child’s first 15 months was offered to families with first-time mothers during 2013–2014 and consisted of six home visits by a child health care nurse and a parental advisor from social services. Almost all invited families (94%) participated in the program and the program evaluation. Fathers’ participation in two or more home visits within the program was 53%. The aim of this study was to explore the experiences of fathers participating in the program, with respect to their role as a first-time parent from a resilience perspective. Methods In-depth interviews were conducted with nine fathers. Constructivist grounded theory (GT) was applied in the analysis. Results The fathers’ experiences formed the core category of the study, ‘striving for stability in living conditions’, as well as three categories: ‘everyday life conditions’, ‘adjustment to fatherhood in Sweden’ and ‘channels of support’. The fathers perceived that the home visiting program strengthened their parental confidence and increased their knowledge of societal services and local resources for their family. Conclusions In terms of resilience, the extended postnatal home visiting program benefitted the interviewed migrant fathers on an individual level by meeting part of their need for support regarding knowledge and parental confidence; on a structural level the program helped fathers gain information about available societal services and resources in their local area. Trial registration The study was retrospectively registered (11 August 2016) in the ISRCTN registry (ISRCTN11832097 DOI: https://doi.org/10.1186/ISRCTN11832097).

Introduction: Reducing avoidable hospital admissions is often viewed as a possible positive consequence of introducing integrated care (IC). The aim of this study was to investigate the impact of implementing IC in Norrtälje on the rate of admissions for ambulatory care sensitive conditions (ACSC). Method: Using interrupted time series analyses we investigated the effect of implementing IC in Norrtälje municipality in the northern part of Stockholm county, Sweden. The time period included 48 time points, from year 2000 to year 2011 with measurements before and after introducing IC in Norrtälje in 2006. In order to control for other extraneous events that could affect the outcome measure, but not related to the introduction of IC, we included a control population from Stockholm municipality. Results: After introducing IC in Norrtälje the rate of admissions for ACSC decreased. This decrease was greater in Norrtälje than in the matched control population, however the difference between the two areas was not statistically significant (p = 0.08). Conclusion: Introducing IC in Norrtälje may have had positive impact on admissions for ACSC for older people living in Norrtälje; however, the interpretation of the impact of IC on admissions for ACSC is complicated by intervening policy changes in health and social care during the study period.

Background: In 2010, Sweden opened up for establishment of privately owned primary health care providers, as part of a national Free Choice in Primary Health Care reform. The reform has been highly debated, and evidence on its effects is scarce. The present study therefore sought to evaluate whether the reform have impacted on primary health care service performance.Methods: This ecological register-based study used a natural experimental approach through an interrupted time series design. Data comprised the total adult population of the 21 counties of Sweden 2001–2009 (pre-intervention period) and 2010–2016 (post-intervention period). Hospitalizations and emergency department visits for ambulatory care sensitive conditions (ACSC) were used as indicators of primary health care performance. Segmented regression analysis was used to assess the effects of the reform, in Sweden as a whole, as well as compared between counties grouped by (i) change in private provision pre- to post reform; (ii) the timing of the implementation; and (iii) sustained presence of private providers both pre- and post-reform.Results: The results suggest that, following the introduction of the reform in Sweden as a whole, the trends in total hospitalizations rates were slowed down by 1.0% albeit acute emergency visits increased 1.1% more rapidly after the introduction of the reform. However, we found no evidence of more beneficial effects in counties where the reform had been implemented more ambitiously, specifically those with a larger increase in private primary care providers, or where the reform was introduced early and thus had longer time effects to emerge. Lastly, counties with a sustained high presence of private primary care providers displayed the least favorable development when it comes to ACSC.Conclusion: Taken together, the present study does not support that the Swedish Free Choice reform has improved performance of the primary care delivery system in Sweden, and suggests that high degree of private provision may involve worse performance and higher care burden for specialized health care. Further evaluations of the consequences of the reform are dire needed to provide a comprehensive picture of its intended and unintended impact on health care provision, delivery and results.

Background: Type 2 diabetes mellitus is increasing in rural China and should be managed in primary health care, but knowledge is lacking. Educational interventions have been implemented but not followed up long-term. Objective: The study aimed to assess the long-term impact of an educational intervention on patients’ diabetes knowledge and fasting blood glucose (FBG) level, and whether these outcomes differed between two rural counties. Methods: The study was nested in an educational intervention project in primary health care in Jiangsu province. Patients with type 2 diabetes mellitus from Huaiyin county and Gaochun county were randomly divided into an intervention group receiving an educational intervention and follow-up visits, and a control group with standard care. Questionnaires and medical records, including FBG level and diabetes knowledge score, were compared, at baseline in 2015 and two follow-ups, in 2016, and 2017, respectively. A paired t-test and two mixed-effects linear regression models were used. Results: The diabetes knowledge score increased in the intervention group in 2016 and in 2017, compared with 2015. The FBG level decreased in 2016 compared with 2015 in the intervention and control groups. Comparing data in 2015 and 2017, there was no significant change in FBG level in the intervention or control group, but the diabetes knowledge score increased in the intervention group both in 2016 and 2017. A significant association between FBG level and the interaction of time and group, suggesting a long-term effect, was only found in Gaochun county in 2017. Conclusion: The educational intervention improved the diabetes knowledge score in the intervention group, while no significant improvement was found in the control group in both year 2016 and 2017. Meanwhile, the intervention had a positive impact on FBG level in the intervention group in 2017. Patients in Gaochun county had better improvement in both diabetes knowledge and controlling FBG level, compared with Huaiyin county.

OBJECTIVES:Comorbidity is prevalent in older working ages and might affect employment exits. This study aimed to 1) assess the associations between comorbidity and different employment exit routes, and 2) examine such associations by gender. METHODS:We used data from employed adults aged 50-62 in the Stockholm Public Health Survey 2002 and 2006, linked to longitudinal administrative income records (N = 10,416). The morbidity measure combined Limiting Longstanding Illness and Common Mental Disorder-captured by the General Health Questionnaire-12 (≥4)-into a categorical variable: 1) No Limiting Longstanding Illness, no Common Mental Disorder, 2) Limiting Longstanding Illness only, 3) Common Mental Disorder only, and 4) comorbid Limiting Longstanding Illness+Common Mental Disorder. Employment status was followed up until 2010, treating early retirement, disability pension and unemployment as employment exits. Competing risk regression analysed the associations between morbidity and employment exit routes, stratifying by gender. RESULTS:Compared to No Limiting Longstanding Illness, no Common Mental Disorder, comorbid Limiting Longstanding Illness+Common Mental Disorder was associated with early retirement in men (subdistribution hazard ratio = 1.73, 95% confidence intervals: 1.08-2.76), but not in women. For men and women, strong associations for disability pension were observed with Limiting Longstanding Illness only (subdistribution hazard ratio = 11.43, 95% confidence intervals: 9.40-13.89) and Limiting Longstanding Illness+Common Mental Disorder (subdistribution hazard ratio = 14.25, 95% confidence intervals: 10.91-18.61), and to a lesser extent Common Mental Disorder only (subdistribution hazard ratio = 2.00, 95% confidence intervals: 1.31-3.05). Women were more likely to exit through disability pension than men (subdistribution hazard ratio = 1.96, 95% confidence intervals: 1.60-2.39). Common Mental Disorder only was the only morbidity category associated with unemployment (subdistribution hazard ratio = 1.70, 95% confidence intervals: 1.36-2.15). CONCLUSIONS:Strong associations were observed between specific morbidity categories with different employment exit routes, which differed by gender. Initiatives to extend working lives should consider older workers' varied health needs to prevent inequalities in older age.

BACKGROUND:Keeping older workers in employment is critical for societies facing the challenge of an ageing population. This study examined the association between types of health conditions and differentials in the probability of employment by level of education among men and women between 60-69 years of age in Canada, Denmark, Sweden and England. METHODS:Data were drawn from the Canadian Community Health Survey, Survey of Health, Ageing and Retirement in Europe and English Longitudinal Study of Ageing. We combined country data, applied logistic regression, adjusted for educational level, and stratified the analysis by sex to calculate the odds ratio (OR) of employment (>15 hours work per week) for persons with physical health conditions, mental health conditions (depression) and physical-mental health comorbidity. RESULTS:The odds of employment among men and women with physical-mental health comorbidity were lower compared to those with no/other conditions (men: OR 0.32, 95% CI: 0.25-0.42, women: OR 0.38 95% CI: 0.30-0.48). Women with low education had lower odds of employment compared to their counterparts with high education (OR 0.66, 95% CI: 0.57-0.76). The odds of employment at older ages was lower in Canada, Denmark and England compared with Sweden (e.g. English men: OR 0.48 95% CI 0.40-0.58; English women OR 0.33 95% CI 0.27-0.41). CONCLUSIONS:The odds of employment beyond age 60 is lower for groups with low education, particularly women, and those with physical-mental health co-morbidities. As such, policies to extend working lives should not be 'one size fits all' but instead consider subgroups, in particular, these groups that we have shown to be most vulnerable on the labour market.

BackgroundRestrictions in the eligibility requirements for disability benefits have been introduced in many countries, on the assumption that this will increase work incentives for people with chronic illness and disabilities. Evidence to support this assumption is unclear, but there is a danger that removal of social protection without increased employment would increase the risk of poverty among disabled people. This paper presents a systematic review of the evidence on the employment effects of changes to eligibility criteria across OECD countries.MethodsSystematic review of all empirical studies from OECD countries from 1990 to June 2018 investigating the effect of changes in eligibility requirements and income replacement level of disability benefits on the employment of disabled people. Studies were narratively synthesised, and meta-analysis was performed using meta-regression on all separate results. The systematic review protocol was registered with the Prospective Register for Systematic Reviews (Registration code: PROSPERO 2018 CRD42018103930).ResultsSeventeen studies met inclusion criteria from seven countries. Eight investigated an expansion of eligibility criteria and nine a restriction. There were 36 separate results included from the 17 studies. Fourteen examined an expansion of eligibility; six found significantly reduced employment, eight no significant effect and one increased employment. Twenty-two results examined a restriction in eligibility for benefits; three found significantly increased employment, 18 no significant effect and one reduced employment. Meta-regression of all studies produced a relative risk of employment of 1.06 (95% CI 0.999 to 1.014; I2 77%).ConclusionsThere was no firm evidence that changes in eligibility affected employment of disabled people. Restricting eligibility therefore has the potential to lead to a growing number of people out of employment with health problems who are not eligible for adequate social protection, increasing their risk of poverty. Policymakers and researchers need to address the lack of robust evidence for assessing the employment impact of these types of welfare reforms as well as the potential wider poverty impacts.

Abstract Background Chronic diseases are becoming a huge threat to the Chinese health system. Although the New Round of Medical Reform aims to improve this, the chronic disease management in rural China is still worrying as it relies highly on hospital care instead of primary care. The vertical integrated care model has proven to be effective for chronic disease patients in many high-income countries, while few studies have been conducted in China. In this project, vertical integrated care will be applied to optimize the care of patients with type 2 diabetes mellitus (T2DM) and primary hypertension in rural China, and to shift the care from hospital to primary care. Methods An educational intervention was conducted in three pilot counties in Jiangsu province, a high-income province in southeast China. The intervention was based on the model of vertical integrated care between the three-levels of healthcare institutions. In the pilot counties, 22 townships were included (11 in the intervention and control groups, respectively). Service teams assembled by the local health bureaus implemented the intervention which provides services for both patients and healthcare professionals. Questionnaire interviews (n = 4259) and medical records were used to collect patient data (physiological measures, health-related quality of life, satisfaction with care). Data from healthcare professionals (n = 282) was gathered through questionnaires and in-depth interviews (knowledge about chronic diseases, general procedure of diagnosing and registering, chronic disease management situation, perceptions of chronic disease treatment and prevention). Baseline data were collected before the start of the intervention in Nov 2015, follow-up data in Oct-Nov 2016, and final data completed in Jul-Aug 2017. Discussion The intervention has been conducted smoothly and gotten support from patients, healthcare institutions and local health authorities. The research team anticipates that the vertical integrated model will improve patients’ health, satisfaction with care, and their understanding of their chronic disease. We also anticipate that healthcare professionals can acquire more information about chronic diseases and improve their strategy for providing good quality care for patients. Trial registration ISRCTN13319989 Registration date: 4th April, 2017.

Abstract Background Health inequities among children in Sweden persist despite the country’s well-developed welfare system and near universal access to the national child health care programme. A multisectoral extended home visiting intervention, based on the principles of proportionate universalism, has been carried out in a disadvantaged area since 2013. The present study investigates the content of the meetings between families and professionals during the home visits to gain a deeper understanding of how it relates to a health equity perspective on early childhood development. Methods Three child health care nurses documented 501 visits to the families of 98 children between 2013 and 2016. A qualitative data-driven conventional content analysis was performed on all data from the cycle of six visits per child, and a general content model was developed. Additional content analysis was carried out on the data from visits to families who experienced adverse situations or greater needs. Results The analysis revealed that the home visits covered three main categories of content related to the health, care and development of the child; the strengthening of roles and relations within the new family unit; and the influence and support located in the broader external context around the family. The model of categories and sub-categories proved stable over all six visits. Families with extra needs received continuous attention to their additional issues during the visits, as well as the standard content described in the content model. Conclusions This study on home visiting implementation indicates that the participating families received programme content which covered all the domains of nurturing care as recommended by the WHO Commission on Social Determinants of Health and recent research. The content of the home visits can be understood to create enabling conditions for health equity effects. The intervention can be seen to represent a practical example of proportionate universalism.

Abstract Background Evaluations on different aspects of the performance of public hospitals in China have been conducted, usually based on indicators developed by literature review and expert suggestions. The patient perspective was not always considered. This study aims to identify what patients care most about in China’s public hospitals exclusively from a patient perspective. Methods A mix of stratified sampling and typical sampling was used to select 15 public hospitals in Jiangsu Province of China. In each sampled hospital, a convenient sample of six outpatients and six inpatients was selected to conduct face-to-face individual interviews. An interview guide consisting of six open-ended questions was designed. Donabedian’s quality of care framework was applied to categorize themes and subthemes, which were generated from patients’ interviews by using the conventional content analysis approach. Frequencies of themes and subthemes were counted. Results Nine key themes were identified regarding patients’ concerns about hospital care, which were environment and facilities, professional competence, hospital reputation, and morals of medical staff in the “structure” category of Donabedian’s framework, caring attitudes and emotional support, medical costs, communication and information, and efficiency and coordination of care in the “process” category, and health outcomes in the “outcome” category. Conclusions This study has identified and prioritized the aspects that patients care most about in China’s public hospitals in Jiangsu Province exclusively from a patient perspective. A measurement tool of patient-reported experiences in public hospitals could be built based on this study. Efforts should be made to represent the patient perspective to further improve the reform of public hospitals in China.

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 The association between social capital and health-related quality of life (HRQoL) has not been thoroughly studied among older persons in rural China, especially among those who were left behind or not. This study investigates the association between social capital and HRQoL and examines possible differences of this association between being left behind or not in rural China. Methods A cross-sectional survey of 825 people aged 60 years and older, residing in three rural counties in Jiangsu Province in China, was conducted in 2013. Factor analysis was performed to measure social capital. EQ-5D was used to measure HRQoL. Tobit regression analysis with upper censoring was conducted to explore the association between social capital and EQ-5D index. Results After controlling for individual characteristics, low social capital and being left behind were significantly associated with low HRQoL. Old people with low social capital had 0.055 lower EQ-5D index compared to those with high social capital. Old people being left behind had 0.040 lower EQ-5D index compared to those who were not left behind. For different dimensions of social capital, the main effects came from the domain of trust and reciprocity. There was a significant interaction between low social capital and being left behind on HRQoL, suggesting that low social capital was associated with low HRQoL among persons left behind. Conclusions Our findings indicate that the left behind old people with low social capital were a potentially vulnerable group in rural China. Formulating and implementing initiatives and strategies which increase social capital may foster better HRQoL, especially for old people who were left behind.

Introduction: The growing number of older adults with multiple needs increases the pressure to reform existing healthcare systems. Integrated care may be part of such reforms. The aim of this systematic review was to identify important patient-related outcomes of integrated care provided to older adults. Methods: A systematic search of 5 databases to identify studies comprising older adults assessing hospital admission, length of hospital stay, hospital readmission, patient satisfaction and mortality in integrated care settings. Retrieved literature was analysed employing a narrative synthesis. Results: Twelve studies were included (2 randomised controlled trials, 7 quasi-experimental design, 2 comparison studies, 1 survey evaluation). Five studies investigated patient satisfaction, 9 hospital admission, 7 length of stay, 3 readmission and 5 mortality. Findings show that integrated care tends to have a positive impact on hospital admission rates, some positive impact on length of stay and possibly also on readmission and patient satisfaction but not on mortality. Conclusions: Integrated care may reduce hospital admission rates and lengths of hospital stay. However due to lack of robust findings, the effectiveness of integrated care on patient-related outcomes in later life remain largely unknown. Further research is needed to establish the effect of integrated care on these patient-related outcomes. Prospero registration number: CRD42018110491.