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A better understanding of population distributions of capability and inequalities is relevant for public health and social welfare. We surveyed 3639 representatively sampled individuals on background characteristics and on self-reported capability using the capability-adjusted life years Sweden (CALY-SWE) questionnaire, which enables aggregating attribute-level answers into a quality weight score.

We analysed the resulting capability distribution by comparing subgroups. Subgroups were formed along axes of inequality that we selected based on theoretical reasoning and relevance. We stratified into groupings of plurality and disadvantage, based on the human dignity principle and the needs and solidarity principle featured in the Swedish platform for healthcare priority-setting. While disadvantage factors come with inherent need-related disadvantages that explain inequality, such as unemployment, no such normatively acceptable reason exist for plurality factors, such as gender.

The results averaged per individual showed marked inequalities for the disadvantage groups of individuals with poor self-rated health, long-term sick leave unemployment, and payment difficulties. For plurality groups, the largest inequalities occurred in groups with lower education and groups residing in urban areas, but generally inequalities were lower than disadvantage groups.

On the population level, the largest aggregated disability inequalities occurred for self-reported ever NEET (persons who were ever involuntarily not in employment, education or training from age 16 to 29) and payment difficulties groups. Additionally, we assessed the contribution of covariates to these inequalities by counterfactually altering one covariate at a time in a multinomial logistic model of the CALY-SWE attribute-level answers. The most relevant covariates were employment situation, financial difficulties, income, and age group.

For policy-making, this indicates the importance of both plurality and disadvantage inequality axes. Prioritization should adopt nuanced contextualizations of inequality when broadening the perspective beyond healthcare to wider public health and social welfare, for example, elderly care and education.

Purpose: Our aim was to elicit a value set for Capability-Adjusted Life Years Sweden (CALY-SWE); a capability-grounded quality of life instrument intended for use in economic evaluations of social interventions with broad consequences beyond health.

Methods: Building on methods commonly used in the quality-adjusted life years EQ-5D context, we collected time-trade off (TTO) and discrete choice experiment (DCE) data through an online survey from a general population sample of 1697 Swedish participants. We assessed data quality using a score based on the severity of inconsistencies. For generating the value set, we compared different model features, including hybrid modeling of DCE and TTO versus TTO data only, censoring of TTO answers, varying intercept, and accommodating for heteroskedasticity. We also assessed the models’ DCE logit fidelity to measure agreement with potentially less-biased DCE data. To anchor the best capability state to 1 on the 0 to 1 scale, we included a multiplicative scaling factor.

Results: We excluded 20% of the TTO answers of participants with the largest inconsistencies to improve data quality. A hybrid model with an anchor scale and censoring was chosen to generate the value set; models with heteroskedasticity considerations or individually varying intercepts did not offer substantial improvement. The lowest capability weight was 0.114. Health, social relations, and finance and housing attributes contributed the largest capability gains, followed by occupation, security, and political and civil rights.

Conclusion: We elicited a value set for CALY-SWE for use in economic evaluations of interventions with broad social consequences.

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

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and measures to prevent the spread of the virus challenged public health practice at the local level in Sweden. The objective of this study was to explore the impact of the pandemic on the prevention of alcohol, drugs and tobacco (ADT) in Sweden during 2020-21 considering socio-demographic context.

METHODS: Data were collected through the Public Health Agency's survey on ADT prevention in Swedish municipalities (N = 290). This study used data from 2020 and 2021, with a response rate of 90% and 88%, respectively. Survey data were analyzed in logistic regression models (odds ratios, P < 0.05, 95% confidence intervals) against variables of education level, income level and population size from national registers.

RESULTS: A majority (n = 198, 76%) of the municipalities reported a decrease in ADT prevention during the pandemic. No correlation between the decrease in ADT prevention and socio-demographic conditions was detected. A majority (2020: n = 165, 63%; 2021: n = 174, 68%) of the municipalities also reported that ADT prevention was adapted, however less common in smaller municipalities and municipalities where residents had lower levels of education and lower incomes.

CONCLUSION: ADT prevention carried out by municipalities in Sweden was initially (2020) deeply affected by the preventive strategies against COVID-19. Adaptation of activities was less common in municipalities with more vulnerable socio-demographic situation. In policy, practice and research, the findings are important not only for continued progress on the national goal of equity in health but also for preparedness for future crises.

Introduction: Capability-adjusted life years Sweden (CALY-SWE) are a new Swedish questionnaire-based measure for quality of life based on the capability approach. CALY-SWE are targeted towards use in cost-effectiveness evaluations of social welfare consequences. Here, we first motivate the measure both from a theoretical and from a Swedish policy-making perspective. Then, we outline the core principles of the measure, namely the relation to the capability approach, embedded equity considerations inspired by the fair-innings approach, and the bases for which capabilities should be considered. The aims were to 1) the most vital capabilities for individuals in Sweden, 2) to define a sufficient level of each identified capability to lead a flourishing life, and to 3) develop a complete questionnaire for the measurement of the identified capabilities.

Material and methods: For the selection of capabilities, we used a Delphi process with Swedish civil society representants. To inform the questionnaire development, we conducted a web survey in three versions, with each Swedish 500 participants, to assess the distribution of capabilities that resulted from the Delphi process in the Swedish population. Each version was formulated with different strictness so that less strict wordings of a capability level would apply to a larger share of participants. All versions also included questions on inequality aversion regarding financial, educational, and health capabilities.

Results: The Delphi process resulted in the following six capabilities: Financial situation & housing, health, social relations, occupations, security, and political & civil rights. We formulated the final phrasing for the questionnaire based on normative reasons and the distribution of capabilities in the population while taking into account inequality aversion.

Conclusion: We developed a capability-based model for cost effectiveness economic evaluations of broader social consequences, specific to the Swedish context.

Aims: Measures against COVID-19 potentially impact quality of life in different ways. The capability approach by Amartya Sen with a broad and consistent framework for measuring quality of life is suited to capture the various consequences. We aimed to examine (a) whether individuals experienced change in 10 capability dimensions during the first half of 2020, (b) which dimensions were affected most, and (c) whether changes were unequally distributed in terms of gender, education, income, geography, housing, living situation and place of birth.

Methods: We assessed self-reported capability change in Sweden in 10 capability dimensions in a cross-sectional online survey among 500 participants on a five-item Likert scale. We analysed the distribution of answers by comparing the balance of positive and negative perceived changes and used mixed effects logistic regression to examine associations with background characteristics of the participants.

Results: Reported perceived negative changes outweighed positive changes, and a higher proportion stated negative perceived changes if they also stated having low capability in the same dimension. In the capabilities of financial situation, political resources and health, the proportions of perceived negative change were highest. Odds for perceived negative change compared to no or positive change were higher for higher incomes, living in medium-sized municipalities, being born outside Europe, living in the south of Sweden, and renting instead of owning housing.

Conclusions: Self-reported negative capability change, and associated inequalities related to socioeconomic position, place of birth and regional residence should be of concern for policymakers.

Background: According to post-structural policy analyses, policies and interventions aiming at reducing social inequalities have been found to be part in producing and reifying such inequalities themselves. Given the central role of health inequalities on the public health policy agenda globally it seems important to examine the way policy on health inequalities may potentially counteract the goal of health equity. The aim of this intersectional policy analysis, was to critically analyze the representation of health inequalities in a government bill proposing a national strategy on alcohol, drugs, tobacco and gambling, to examine its performative power, and to outline alternative representations.

Method: A post-structural approach to policy analysis was combined with an intersectional framework. The material was analyzed through an interrogating process guided by the six questions of the “What’s the problem represented to be?” (WPR) approach. Thus, the underlying assumptions of the problem representation, its potential implications and historical background were explored. In a final step of the analysis we examined our own problem representations.

Results: The recommendations found in the gender and equity perspective of the bill represented the problem of health inequalities as a lack of knowledge, with an emphasis on quantitative knowledge about differences in health between population groups. Three underlying assumptions supporting this representation were found: quantification and objectivity, inequalities as unidimensional, and categorization and labelling. The analysis showed how the bill, by opting into these partly overlapping assumptions, is part of enacting a discourse on health inequalities that directs attention to specific subjects (e.g., vulnerable) with special needs (e.g., health care), in certain places (e.g., disadvantaged neighborhoods). It also showed how underlying processes of marginalization are largely neglected in the bill due to its focus on describing differences rather than solutions. Finally, we showed how different intersectional approaches could be used to complement and challenge this, potentially counteractive, problem representation.

Conclusions: The problem representation of health inequalities and its underlying assumptions may have counteractive effects on health equity, and even though some of its strengths are raised, it seems to be profoundly entangled with a system resisting the kind of change that the bill itself advocates for. If carefully used, intersectionality has the potential to support a more comprehensive and inclusive equality-promoting public health policy and practice.

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

INTRODUCTION: The aim of this study was to rank capabilities and suggest a relevant set of capabilities for the Swedish context to inform the development of capability-adjusted life years (CALYs). CALYs is a quality of life measure for policy making based on the capability approach by Amartya Sen.

MATERIALS AND METHODS: A Swedish governmental review proposed the following 10 relevant capabilities: time, financial situation, mental/physical health, political resources, knowledge, living environment, occupation, social relations, security, and housing. Researchers in health-related disciplines from 5 universities ranked these capabilities from 1 to 10 (most to least important) in a web-based cross-sectional survey; 115 of 171 responses were eligible.

RESULTS: Health, social relations, and financial situation were deemed most important. Stratification by gender, research field, and age group revealed few differences. We found that it was possible to rank capabilities and that health, social relations, and financial situation were ranked highest by a non-representative sample of researchers and doctoral students from health-related disciplines at five Swedish universities.

CONCLUSIONS: The revealed ranking is dependent on the metric and must be further explored. The findings support continued development of CALYs for monitoring and evaluating outcomes in public health and social-welfare interventions.

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