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  • 1. Almquist, Ylva B
    et al.
    Landstedt, Evelina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Associations between social support and depressive symptoms: social causation or social selection-or both?2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no 1, p. 84-89Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Numerous studies have demonstrated an association between social support and health, almost regardless of how social support and health have been conceptualised or measured. Even so, the issue of causality has not yet been sufficiently addressed. This issue is particularly challenging for mental health problems such as depressive symptoms. The aim of the present study is to longitudinally assess structural and functional aspects of social support in relation to depressive symptoms in men and women, through a series of competing causal models that, in contrast to many other statistical methods, allow for bi-directional effects.

    METHODS: Questionnaire data from the Northern Swedish Cohort (n = 1001) were utilised for the years 1995 (age 30) and 2007 (age 42). Associations were analysed by means of gender-specific structural equation modelling, with structural and functional support modelled separately.

    RESULTS: Both structural and functional support were associated with depressive symptoms at ages 30 and 42, for men and women alike. A higher level of support, particularly functional support, was associated with a decrease in depressive symptoms over time among men. Among women, there were bi-directional effects of social support and depressive symptoms over time.

    CONCLUSION: Concerning social support and health, the social causation hypothesis seems relevant for men whereas, for women, the associations appear to be more complex. We conclude that preventive and health promoting work may need to consider that the presence of depressive symptoms in itself impedes on women's capability to increase their levels of social support.

  • 2. Almquist, Ylva B.
    et al.
    Landstedt, Evelina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jackisch, J.
    Rajaleid, K.
    Westerlund, H.
    Hammarström, A.
    Growing through asphalt: What counteracts the long-term negative health impact of youth adversity?2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 47-47Article in journal (Other academic)
    Abstract [en]

    Background: Adversity in the family of origin tends to translate into poor health development. Yet, the fact that this is not the always the case has been seen an indicator of resilience. The current study highlights factors outside the context of the family with the potential to counteract the long-term negative influences of social and material adversity in adolescence on general health status.

    Methods: The study was based on the Northern Swedish Cohort born in 1965 (n = 1,001). Measures of social and material adversity, health, and protective factors related to school, peers, and spare time, were derived from questionnaires distributed to the cohort members and their teachers at age 16. Self-rated health was measured at age 43. The main associations were examined by means of ordinal regression analysis, with the role of the protective factors being assessed through interaction analysis.

    Results: Social and material adversity in youth was associated with poorer self-rated health in midlife among males and females alike, net of health status at baseline. However, having an advantaged situation with regard to school, peers, or spare time – particularly in terms of being seen as having good educational and work prospects, as well as a high-quality spare time – appeared to protect against the detrimental influences of disadvantaged circumstances in the family context on subsequent health.

    Conclusions: There are several factors outside the context of the family that seemingly have the potential to buffer against the negative health consequences stemming from having experienced a disadvantaged upbringing. Initiatives targeted at increasing academic motivation and commitment as well as social capital and relationships in youth, may here be of particular relevance.

    Key messages:

    • While the experience of disadvantageous living conditions in adolescence tends to translate into poor health development across the life course, this is not always the case.
    • Advantages related to school, peers, and spare time have the potential of counteracting the negative health impact of an adverse family context.
  • 3.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    The perception of youth health centres' friendliness: does it differ between immigrant and Swedish-Scandinavian youths?2020In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 30, no 4, p. 780-785Article in journal (Refereed)
    Abstract [en]

    Background: Ensuring a good quality service and equal access according to need for all young people is a key objective of the Swedish health system. The aim of this study was to explore youths’ perception of youth health centres’ (YHCs’) friendliness and to assess the differences in perception between immigrant and Swedish-Scandinavian youths.

    Methods: All YHCs in the four northern counties in Sweden were invited (22 centres), and 20 agreed to participate. Overall, 1089 youths aged 16–25 years answered the youth-friendly health services-Sweden questionnaire between September 2016 and February 2017. Thirteen sub-domains of friendliness were identified and their scores were calculated. Multilevel analysis was used to examine the differences in perception between immigrant and Swedish-Scandinavian youths.

    Results: Our sample consisted of 971 Swedish-Scandinavian youths (89.2%) and 118 immigrants (10.8%). Generally, both groups perceived the services to be very friendly. All 13 sub-domains were rated more than three in a four-point scale except for fear of exposure and parental support of psychosocial services. However, immigrant youths perceived YHCs less friendly than their counterparts, particularly regarding the domains of equity, respect, quality and parental support.

    Conclusions: Our study suggests that even though youths perceived YHCs as highly friendly, there is a space for improvement regarding access to health care. Our findings highlight the importance of an open and culturally sensitive attitude of the staff and the need to engage parents and community as a key to improve immigrant youths’ accessibility to health care.

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  • 4.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing the dimensionality of YFHS-Swe; a new questionnaire to assess youth friendliness2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, p. 343-Article in journal (Other academic)
    Abstract [en]

    Background: Ensuring the youth friendliness of health services can increase the utilization of these services and contribute to improve youth’s health. Few validated instruments to assess youth-friendliness exist worldwide and none in Sweden. To assess the youth-friendliness of Swedish youth clinics (differentiated services for youth that exist since the 70s), an adapted version of YFHS WHO+ questionnaire called (YFHS-Swe) was developed. YFHS-Swe proved to have good internal homogeneity and consistency over time. The aim of our study was to perform a psychometric analysis to assure the quality and reliability of the questionnaire, and to assess the dimensionality of YFHS-Swe to identify possible subdomains that might be of importance for policy making.

    Methods: YFHS-Swe was answered by 1,110 youths aged 16 to 25 years visiting 20 youth clinics in Northern Sweden between September 2016 and February 2017. YFHS-Swe was assessed using exploratory and confirmatory factor analysis.

    Results: Thirteen factors could be identified; ability to get contact; access to sexual and reproductive health (SRH) service; access to psychosocial health services; parental support of SRH services; parental support of psychosocial health services; equity with diverse concerns; equity with legal concerns; fear of exposure; respect; privacy and confidentiality; no judgement; quality of consultation and quality of facility. Except for “quality of facility”, all other twelve factors recorded good α reliability ranging from 0.76 to 0.97, good ρ reliability ranging from 0.77 to 0.97 and acceptable measure of fit (SRMR<0.08).

    Conclusions: The YFHS-Swe proved to be credible and suitable for assessing youths-friendliness of the Swedish youth clinics. The identified factors might be of an importance to capture different dimensions of youth friendliness. With some cultural and linguistic adaptations, this instrument can be used in other differentiated youth health services internationally.

    Key messages:

    • YFHS-Swe is credible and suitable instrument in the Swedish context and it can be used as a basis for validating other instruments to assess youth-friendliness in other contexts.
    • The dimensions identified of this novel instrument might be of importance in assessing distinct aspects of friendliness in differentiated health services and might be of importance for policy making.
  • 5. Berg, Noora
    et al.
    Nummi, Tapio
    Bean, Christopher G.
    Westerlund, Hugo
    Virtanen, Pekka
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Institute of Environmental Medicine, Unit of Occupational Medicine, Karolinska Institutet Stockholm, Sweden.
    Risk factors in adolescence as predictors of trajectories of somatic symptoms over 27 years2022In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 32, no 5, p. 696-702Article in journal (Refereed)
    Abstract [en]

    Background: Somatic symptoms among adolescents are common, yet little is known about long-term trajectories of somatic symptoms and the factors in adolescence that shape them. We examined individual, family and school-based factors at age 16 as predictors of trajectories of somatic symptoms over 27 years.

    Methods: Participants from the Northern Swedish Cohort (n = 1001) responded to questions about individual factors (e.g. health behaviours), family factors (e.g. contact with parents, social and material adversity) and school satisfaction at age 16; as well as 10 somatic symptoms at ages 16, 18, 21, 30 and 43. Teacher assessments at age 16 included overall ability at school and peer relations. Age 16 predictors of somatic symptom trajectory group membership were analysed using multinomial logistic regression.

    Results: Poor contact with mother and poor school satisfaction were significant predictors of adverse symptom trajectories among both men and women. Low birth weight and low parental academic involvement were contributing factors for women, while smoking and social adversity were more relevant factors for men.

    Conclusions: Our findings emphasize the importance of a holistic approach that considers the unique contributions of individual, family and school-based factors in the development of trajectories of somatic symptoms from adolescence to middle age.

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  • 6.
    Blomqvist, Ida
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Child and Adolescent Psychiatry.
    Henje Blom, Eva
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Child and Adolescent Psychiatry.
    Hägglöf, Bruno
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Child and Adolescent Psychiatry.
    Hammarström, Anne
    Increase of internalized mental health symptoms among adolescents during the last three decades2019In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 29, no 5, p. 925-931Article in journal (Refereed)
    Abstract [en]

    Background: Previous studies suggest an overall increase of adolescent mental health symptoms globally since the 1980s until today, especially an increase of internalizing symptoms in girls. Due to methodological limitations of these studies, further studies are warranted to obtain a more solid knowledgebase.

    Methods: This study was cross-sectional and compared two separate but geographically identical groups of adolescents in a middle-sized industrial municipality in Northern Sweden at two time-points [(i) 1981, n = 1083, (505 girls, 577 boys), response rate 99.7%; (ii) 2014, n = 682, (338 girls, 344 boys), response rate 98.3%]. All students in their last year of compulsory school were included. The same self-report questionnaire, consisting of four sub-scales (functional somatic-, anxiety-, depressive symptoms and conduct problems), was used at both occasions. Data were analyzed with descriptive statistics, two-way ANOVA and general linear model.

    Results: Symptoms of anxiety and depression and functional somatic symptoms, increased among both boys and girls from 1981 until 2014 (P < 0.001 for all subscales), and the increase of these symptoms was higher in girls. Conduct problems were significantly higher in boys in 1981 and decreased over time so that in 2014 there was no longer a significant difference between boys and girls regarding conduct problems (P = 0.286).

    Conclusion: In this population-based study spanning over 30 years, both girls and boys showed increasing internalizing problems, while conduct problems decreased. To halt this trend, we need a deeper understanding of the impact of the major societal changes that have occurred during the last three decades.

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  • 7. Briones-Vozmediano, E.
    et al.
    Stjärnfeldt, J.
    Larson, F.
    Nielsen, A.
    Eriksson, Malin
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Salazar, M.
    Young men's discourses of health service utilization for Chlamydia infection testing in Stockholm2020In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 30, no Issue Supplement_5, article id ckaa166.854Article in journal (Other academic)
    Abstract [en]

    Background:

    Chlamydia Trachomatis (CT) infection is the most commonly reported sexually transmitted bacterial disease in Sweden, other European countries, as well as globally. CT is often asymptomatic and if it goes untreated it can cause severe reproductive health issues. In Sweden, men test for CT in a much lesser extent than women. The aim of this study is to identify factors influencing Swedish young men to use Health care for CT detection.

    Methods:

    Qualitative study based on 18 semi-structured interviews with young men (18-30 years old) in Stockholm during 2018. A Situational Analysis was conducted (a development of Constructivist Grounded Theory) of the interviews' transcriptions, using Open Code as the software for qualitative analysis in order to code and organize the information obtained. We constructed a situational map to illustrate the positions taken by Swedish young men according to their discourses.

    Results:

    Three ideal types of Swedish young men with different discourses and behaviors towards CT testing were identified: unconcerned men are indifferent about CT and other sexual transmitted infections (STI) and therefore not testing; ambivalent men only test when suspect suffering from an STI and/or are influenced by their social network; Whereas, proactive men test regularly as a way to know they are healthy. The differences between the ideal types are explained by their risk perception, the role of health services, and the positive or negative influence of their social network.

    Conclusions:

    The ideal types of young men identified in this study show a range of discourses linked to their risk perception, the role of health services, and the influence of their social network, which in practice is translated into different behaviours adopted for CT testing. Testing should be encouraged as an important part of CT prevention by educating groups of unconcerned young men about both the consequences of untreated CT and the free testing options available in Sweden.

    Key messages: 

    Swedish young men have different discourses towards CT testing depending on their risk perception, the strategies adopted to test and the positive or negative role of their social network.

    The role of health services and the social support emerged as key factors to promoting testing among Swedish Young men.

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  • 8.
    Brydsten, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Does contextual unemployment matter for health status across the life course?2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no Suppl 1, p. 142-142Article in journal (Refereed)
    Abstract [en]

    Background: Individual health is affected by one’s individual life conditionsand by the context in which individuals live, interact anddevelop. Research shows that living in a neighbourhood withhigh levels of unemployment might affect residents’ health, atleast partially independent of own labour market status.However, how such contextual-individual transactions playout across the life course is unknown. The present study aims:(i) to examine whether neighbourhood unemployment isrelated to health status across the life course independently ofthe individual employment from adolescence to middle age(age 16 to 42); and (ii) to analyse whether this relationship isobservable at four specific life course periods from adolescenceto middle age (age 16, 21, 30 and 42).

    Methods: A 26-year prospective Swedish cohort (n = 1010), linked toregister data on neighbourhood unemployment. Individualemployment and functional somatic symptoms were measuredby self-reported questionnaire data. Two models of hierarchallinear regressions were built: a longitudinal analysis, and a setof age-specific cross-sectional analyses at each age.

    Results: The longitudinal analysis showed an independent contributionof neighbourhood unemployment and individual employmenton FSS across the life course. The cross-sectional analysisshowed an association at age 30, when accounting forindividual employment, but no association was found at age21 and 42.

    Conclusions: Neighbourhood unemployment has a significant relationshipwith functional somatic symptoms across the life course. Thereseems to be an age-specific pattern where neighbourhoodunemployment may have stronger implications in earlyadulthood than in other phases of the life course

    Key messages:

    • High neighbourhood unemployment predicts higher levelsof individual FSS across the life course, independently ofown labour market position, socioeconomic status andeducation
    • These findings stress the importance of neighbourhoodunemployment for current health status as well as development of health status across the life course, particular duringearly adulthood
  • 9.
    Brydsten, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Strandh, Mattias
    Umeå University, Faculty of Social Sciences, Department of Social Work. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Johansson, Klara
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Youth unemployment and functional somatic symptoms in adulthood: results from the Northern Swedish cohort2015In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 25, no 5, p. 796-800Article in journal (Refereed)
    Abstract [en]

    Background: Little is known about the possible long-term health consequences of youth unemployment. Research indicates that unemployment may lead to socioeconomic downward mobility and mental health problems, but we still lack knowledge of the long-term health consequences of youth unemployment. This article examines the potential long-term association between youth unemployment and functional somatic symptoms in adulthood. 

    Methods: The ‘Northern Swedish cohort’ was used with data from five data collections, from 1981 (age 16) until 2007 (age 42). Youth unemployment was measured as months in unemployment between age 16 and 21, and health outcome as functional somatic symptoms (an index of 10 items of self-reported symptoms). Linear regression was used to analyse the relationship between months in youth unemployment and functional somatic symptoms at age 21 and age 42, stratified for women and men and adjusted for potential confounders, such as time spent in education at age 21 and later unemployment between age 21 and 42. 

    Results: Youth unemployment was significantly related to functional somatic symptoms at age 21 for men after controlling for confounders, but not for women. Among men, the association remained for functional somatic symptoms at age 42, after controlling for confounders. 

    Conclusions: Adolescence seems to be a sensitive period during which unemployment could have remaining health effects in adulthood, at least for men, though assumptions of causality are tentative and more research is needed.

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    Youth unemployment and functional somatic symptoms in adulthood
  • 10.
    Brännström, Inger
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Persson, Lars Åke M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Towards a framework for outcome assessment of health intervention: Conceptual and methodological considerations1994In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 4, no 2, p. 125-130Article in journal (Refereed)
    Abstract [en]

    We provide a framework for assessing the outcome of community-based intervention programmes for the promotion of cardiovascular health at local level. Particular attention is therefore given to conceptual components connected with community participation in health programmes and to methodological approaches in the evaluation of cardiovascular disease (CVD)-prevention programmes. In a search of the literature covering more than 20 years (1966–1988) in 2 databases (MEDLINE and SOCA), we found that the concepts of ‘community participation’ and ‘community involvement’ have mainly been used during the latter half of the study period. The concepts were often used interchangeably and with no statement as to their precise meanings. The methodological examination of 2 well-known community-based CVO-preventive programmes revealed that most of the scientific papers from these programmes dealt with health behavioural and/or medical effects. The suggested framework presented in this study is designed as a longitudinal process analysis focusing on critical key steps along the path from input to output. The suggested research strategy is problem-orientated, inter-disciplinary and based on a multi-method approach.

  • 11.
    Cashman, Matthew R.
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Strandh, Mattias
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Högberg, Björn
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Does fear-of-failure mediate the relationship between educational expectations and stress-related complaints among Swedish adolescents?: A structural equation modelling approach2023In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 34, no 1, p. 101-106Article in journal (Refereed)
    Abstract [en]

    Background: This study investigated the possible mediating role of fear-of-failure between educational expectations and adolescent stress-related complaints with a specific focus on gender differences among Swedishadolescents, and related these findings more broadly to school-related demands and stress-related complaints.

    Methods: A total of N¼ 5504 Swedish adolescents (Mage¼ 15 years, SD ¼ 0.0 years, 50.2% girls) were drawn from the2018 Swedish Programme for International Student Assessment study for our investigation. We used structural equation models to explore if fear-of-failure mediates the relationship between educational expectations and negativeaffect, with a specific focus on gender differences. Educational expectations were utilized in the measurement model.Fear-of-failure was constructed as a latent mediating variable. Negative affect was constructed as a latent variableand utilized as an outcome variable. We subsequently undertook bootstrapping tests of indirect effects and nonlinear comparisons of indirect effects to assess the reliability of the results.

    Results: Fear-of-failure partially mediatedthe association between educational expectations and negative affect (39%). Our gender-specific structural equation model demonstrated that this relationship was more pronounced for girls, suggesting girls are more vulnerable to negative affect as a result of experiencing higher levels of fear of failing.

    Conclusions: The findingssuggest that fear-of-failure partially explains the association between educational expectations and negativeaffect and that this association is more pronounced for girls. This study provides insights into better understanding adolescent stress-related complaints, and the differential role fear of failing has in regards to gender.

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  • 12.
    Emmelin, Maria
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Dahlgren, Lars
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Pol-ethical considerations in public health.: The views of Swedish health care politicians1999In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 9, no 2, p. 124-130Article in journal (Refereed)
    Abstract [en]

    Background: Public health policy is often concerned with the conflicting values emanating from the individually formulated ethics for curative care and more collectively oriented ethics. In this study we have focused on the pol-ethical considerations involved in Swedish health care politicians' assessment of public health measures. Methods: We described a hypothetical situation in a questionnaire, where a community has a 50% excess mortality for disease X, compared to the national average. Scientific disagreements were identified and discussed. The respondents gave their preference for a specific intervention strategy and considered, on a graded scale, 17 different value statements related to ethical principles and intervention strategies. Results: Only one out of 451 politicians preferred the alternative ‘no intervention’. The majority preferred an intervention including active involvement of primary health care. There was overall strong support for equity and beneficence. A factor analysis gave a model for the association between ethical values, political affiliation and choice of intervention strategies. The relative weights of autonomy and equity were strongly related to political affiliation. Conclusions: Among Swedish health care politicians there is consensus about the value of performing interventions in public health when the problem is large, even if there is some uncertainty about the consequences. Their overall strong support for equity and beneficence implies that these principles are crucial when formulating policies for interventions. Politicians need to state their ethical standpoint explicitly so that we as citizens can judge their decisions and actions based on our own political ideology and support for basic ethical principles.

  • 13. Eriksson, C.
    et al.
    Skoog, T.
    Kimber, Birgitta
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Supporting implementation of resilience training among school-aged children - RESCUR in Sweden2020In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 30, no Supplement_5, article id ckaa165.385Article in journal (Other academic)
    Abstract [en]

    Issue: What is needed to facilitate implementation of an intervention when scaling up and scaling out the program?

    Description of the problem: RESCUR: Surfing the Waves (Jag vill, jag kan, jag törs!) is a new resilience curriculum, developed in 2012-2015 by researchers in six European Universities, to foster the psychosocial development of children and give them tools to deal with challenging situations. It aims at increasing children's resilience, i.e. their capacity to cope with disadvantages, crises, changes and stress without breaking down. The RESCUR project in Sweden consists of a Randomized Controlled Trial among children of the ages 6-12 in schools or social services. RESCUR is a pedagogic material, which requires training before getting access to the intervention. The training consists of two days and a follow-up day as well as observation and supervision. The project has been evaluated from two perspectives: implementation and effects. For a theoretically promising method to work at all, the method must be implemented effectively and correctly. Implementation was documented through self-evaluations, reported by group leaders after six months, and observations made according to a formalized checklist. The implementation of the method is fundamental to properly evaluating the effects of the method.

    Results: The model used to train and support people who implemented the intervention seems to have worked according to the self-reports and the observations of lessons, which noted good implementation quality in the activities that were carried out every week by the majority of teachers and group leaders. The observed implementation was exemplary or very strong among 56 % in schools (n = 41) and 41 % in social services (n = 12).

    Lessons: An important challenge in health promotion is ensuring that an intervention is implemented in an efficient way. Recruiting participants and training implementers are basic requirements for successful trials.

    Key messages:

    The implementation of the health promoting method is fundamental to properly evaluating the effects of the method. Therefore, an educational and monitoring component is needed.

    Different implementers can achieve the high-quality implementation of an intervention. Training, observation, feedback, supervision and educational material all supported the implementation of RESCUR.

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  • 14.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    What constitute health promoting living environments from children's perspectives?2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 508-Article in journal (Other academic)
    Abstract [en]

    Background: Swedish research on the effects of living environment on children's health is limited, and very few studies bring up children’s own views and experiences from their everyday lives. The overall aim of this study is to explore what constitutes health promoting living environments from children’s own perspectives.

    Methods: This is an ongoing qualitative exploratory study, building on children’s active involvement using Photovoice method. Schoolchildren in grade five, living in a medium sized Swedish municipality were equipped with digital cameras to document places of importance for their well-being. These photographs were discussed in sex-stratified focus groups. By discussing their photos, the children could identify and portray their choices of places, which gave valuable insights of how they view their worlds and what they perceive as health promoting in their living environments. Data were initially analyzed thematically.

    Results: Children presented photos from their homes showing mostly their own rooms and their computers, sports- and other facilities for leisure activities as well as photos from playgrounds, forests and neighborhood venues. These places were all perceived as important for their wellbeing. Preliminary analyzes reveal how these places in different ways are characterized as; Places allowing Socializing; Places for Activities; Places for Relaxation, and Places providing a sense of Freedom. Having a Space of one’s own was also perceived as important for well-being.

    Conclusions: A safe environment, allowing positive activities, relaxation, togetherness as well as freedom and a space of one’s own, characterizes health-promoting places for Children in a Swedish context.

    Key messages:

    • Children are active actors in their living environments and are well aware of aspects in their living environments of importance for their well-being.
    • Children’s voices and experiences needs to be taken into account in the planning and design of health promoting living environments.
  • 15.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Lindgren, Urban
    Umeå University, Faculty of Social Sciences, Department of Geography and Economic History.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Child health and place: How is neighborhood social capital associated with child health injuries?2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 41-41Article in journal (Other academic)
    Abstract [en]

    Background: Child health inequalities can be explained by social determinants of health, including neighborhood social capital. Swedish research about place effects on children's health is limited. This project aims to contribute to knowledge on how neighborhood social capital may influence child health in the Swedish context. The overall research questions were: What is the incidence rate of child injuries in the living environments among boys and girls? What are the associations between neighborhood social capital and child injuries?

    Methods: Child injury data from the Umeå SIMSAM Lab were utilized, with data from all children 0-12 years of age, living in Umeå municipality during 2006-2009. Individual child injury and residential area data were linked to a neighborhood social capital index, where 49 defined neighborhoods were assigned a score from low- high in social capital, based on people’s perceptions about their neighborhoods. Individual, household and neighborhood demographic and socioeconomic variables (country of birth, educational level, income and family type) were also extracted from the Umeå SIMSAM lab. Logistic regression analyses were conducted to analyze factors associated with child injury.

    Results: We observed 3930 injury events that occurred in the living environments, experienced by 24 000 children who lived in 14 767 households within 49 neighborhoods. The incidence rate of child injuries was about 72.5/1000 for boys and 60/1000 for girls. The odds for child injures was lower in neighborhoods with high social capital compared to neighborhoods with low social capital (OR 0.87 95%CI 0.80-0.95) after controlling for demographic and socioeconomic factors at individual, household and neighborhood level. The protective effects of neighborhood social capital were stronger for girls than boys.

    Conclusions: Neighborhood social capital may have a protective effect on child injuries and especially so for girls.

    Key messages:

    • Neighborhood conditions have a significant influence on child health inequalities in the Swedish context, including inequalities in child injuries.
    • Mobilization of neighborhood social capital might be good investment for reducing child injuries.
  • 16. Feldman, I.
    et al.
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Haggstrom, J.
    Sampaio, F.
    Lindkvist, M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Effectiveness of the Salut Program: a universal health promotion intervention for parents & children2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no Suppl 1, p. -253, article id ckw171.037Article in journal (Refereed)
    Abstract [en]

    Background: There is a lack of evidence for the effectiveness of health promotion interventions during pregnancy and early childhood. This study aims to investigate the effectiveness of the Salut Programme, a universal health promotion intervention in a Swedish County, compared to care as usual.

    Methods: A register-based retrospective observational study design is used with respect to both exposures and outcomes. Outcomes of interest during pregnancy, delivery and the child’s first three years of life included: direct indications of health risks, such as birth weight, Apgar scores, hospitalization, delivery; and indicators of poor health, such as child’s and mother’s hospital visits, and parents’ number of paid days for care of sick child. We compared outcomes of interest for both parents and children during pre- (children born 2002-2004) and post- (born 2006-2008) measure periods for the intervention (n = 1891 children, n = 1599 mothers), and non-intervention groups (n = 12723 children, n = 10544 mothers). Our analysis strategy combined difference-in-difference estimation with matching. A complementary analysis was carried out on the longitudinal subsample of women who gave birth in both the pre- and post- measure periods.

    Results: No significant changes were found in the difference-in-difference analysis. A few significant changes were found between intervention and non-intervention groups in the longitudinal analysis; for the Apgar scores 1 and 5 minutes (p < 0.001), and hospitalization during the first three years after birth for mothers (p = 0.002).

    Conclusions: Adding the Salut Programme to the care as usual provided minor effects on children’s and mothers’ health, for the outcomes used in this study. However, the health outcomes may impact child public health in the long-time perspective.

    Key message: In this study of the effectiveness of a universal health promotion intervention, the Salut Programme, some positive impact was found on child and maternal health outcomes

  • 17.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Environmental Medicine.
    Stjernberg, Nils
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Prevalence of respiratory and hyperreactivity symptoms in relation to levels of criteria air pollutants in Sweden1997In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 7, no 3, p. 291-296Article in journal (Refereed)
    Abstract [en]

    Our knowledge of the adverse health effects from exposure to low levels of air pollution is still insufficient. Early indicators, such as respiratory symptoms, need more attention. We made use of the fact that possible weak effects can be detected more easily when the relevant exposure and other determinants are well controlled. A postal questionnaire was sent to random samples of inhabitants registered as residing in the Vicinity of 55 centrally located air quality monitoring stations in Swedish towns. There were 6,109 questionnaires (76%) returned. Multivariate analyses with confounding control were used to examine the effects of different levels of criteria pollutants on the prevalence of symptoms. The ranges of the half year values were 9-32 and 2-16 mu g/m(3) for nitrogen dioxide and sulphur dioxide respectively. Logistic regression analyses showed higher risks for respiratory problems such as coughs, throat irritation and nose irritation among the persons most exposed, The associations were most obvious for nitrogen dioxide exposure among women. The suggested effects of air pollution exposure cannot be medically evaluated today but they are nevertheless interesting since they are found within common levels usually considered to be safe.

  • 18. Fritzell, S.
    et al.
    Källberg, H.
    Busch, H.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Income-related inequalities in mental health in Sweden and the role of social determinants2019In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 29, no Suppl 4, p. 233-233Article in journal (Other academic)
    Abstract [en]

    Background: Mental health is an increasing concern in all European countries as the burden of mental disorders continue to grow and cause substantial suffering and costs to societies. Furthermore, research shows there are social inequalities in the distribution of mental illness. This study aims to increase knowledge on income-related inequalities in mental health in Sweden and the role of social determinants.

    Methods: Drawing on a national survey (Health on Equal Terms) representative of the population aged 16-84, years 2010-2015 (n = 57107) we quantify the income-related inequality in mental health and estimate the contribution of social determinants of the inequality. Poor mental health is defined as a value of at least 3, based on the general health questionnaire (GHQ)-12. Income is measured as yearly disposable income. Income related inequalities in mental health are quantified by the concentration index and decomposed using the Wagstaff-type decomposition analysis.

    Results: Preliminary results show that the income inequalities in mental health, as measured by the overall concentration index in mental health was - 0,16 (95% CI -0.17 to -0.15), indicating income inequalities to the disadvantage of those less affluent. The determinants that contributed most to the inequalities were employment, financial strain and experiencing harassment. Together they explained 43 % of the income inequalities in mental health. Generally, socio-economic factors had highest importance for the inequalities found, while demographic factors and psychosocial factors were of smaller importance.

    Conclusions: The income related inequalities in mental health are substantial in Sweden. Recently, a national target of reducing the preventable inequalities in health within a generation was adopted. To improve surveillance of inequalities and inform policy we need to closely follow the development of inequalities in mental health and to disentangle the contribution of specific social determinants.

    Key messages

    • Income-related inequalities in mental health in Sweden are considerable.

    • Socio-economic factors had highest importance for the inequalities found, while demographic factors and psychosocial factors were of smaller importance.

  • 19. Fritzell, S.
    et al.
    Trygg, Nadja
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Public Health Agency of Sweden, Solna, Sweden.
    Busch, H.
    Bremberg, S.
    Inequalities in determinants and mental health in Sweden: results from a governmental initiative2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 124-124Article in journal (Other academic)
    Abstract [en]

    Mental health is an increasing concern in all European countries. Social inequalities may appear both in the distribution of mental health and the social and economic consequences. In 2016, the government commissioned The Public Health Agency of Sweden (PHAS) to increase knowledge on socioeconomic determinants of mental health problems. The present study addresses the social distribution of mental health problems and what mediates this.

    Drawing on patient registry data of the population from 2014 and a national survey representative of the population aged 16-84, years 2013-2016 (n = 155339) we analyze how mental health is distributed in social groups and what determinants mediate poor mental health. Outcomes include psychiatric in- and outpatient care (numbers and cases/1000), and for self-reported measures (ie. GHQ, stress, anxiety) odds ratios (OR) from multivariate logistic regression, adjusting for social and economic determinants.

    Preliminary results show that most outcomes in self-reported poor mental health and psychiatric diagnoses were more common among women. Social patterns differed between diagnoses.

    Among working ages in- and outpatient care, low educated showed fourfold increased risk of psychotic disorders, while neurotic stress related disorders showed a doubled risk among low educated. Care for any mental disorder (excluding dementia) was more common among lower educated men and women aged 65+ but had a reverse social gradient. In analyses modelling the risk of poor mental health (GHQ12), controlling for background-, social and economic factors in particular financial strain (OR 2.42, CI 2.11-2.77) mediated poor mental health among women 25-64.

    An educational gradient was found in most mental health outcomes with more pronounced gradient in more severe outcomes. Patterns differ by age groups, social group, and outcome. Results will be used to inform practitioners and policy makers at national and regional level to decrease inequalities in mental health.

    Key messages:

    • Social inequalities in mental health and its’ determinants are found in most age groups, and most outcomes studied.

    • Focusing on living conditions, particularly economic strain is essential for achieving equity in mental health.

  • 20. Fritzell, S.
    et al.
    Trygg, Nadja
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Public Health Agency of Sweden, Solna, Sweden.
    Busch, H.
    Bremberg, S.
    Scoping the evidence on mental health inequalities and underlying determinants in Sweden2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 316-316Article in journal (Other academic)
    Abstract [en]

    Mental health is an increasing concern in all European countries. Social inequalities may appear in both the distribution of mental health and the social and economic consequences. In 2016, the government commissioned The Public Health Agency of Sweden (PHAS) to increase the knowledge on mental health inequalities and their underlying determinants. In all, 18 research projects were initiated within different universities in Sweden and PHAS.

    Research questions addressed dimensions of inequality such as age, gender, SES, sexual orientation and disability. PHAS involved researchers from the fields of social medicine, epidemiology and economics to explore all levels of social determinants, different mechanisms, interacting forces of inequalities and consequences of disease. Evidence from scoping literature reviews were coupled with analyses of Swedish data on a range of outcomes; from positive mental health to in-patient care.

    Preliminary results have been discussed in joint workshops and show social inequalities in mental health in all age groups in Sweden, including small children, with a more pronounced gradient in severe outcomes. Generally, the results points towards policy actions focusing girls and women, low income earners, those experiencing financial strain, hbtq persons and persons with disability. Also, the interaction of different dimensions of inequality need consideration.

    The project is a collaboration between PHAS and a range of research disciplines all joining to discuss mental health and inequalities. Though challenging as interpretations may differ due to field of research, overall it has allowed for a broad approach and joint learning as experts have collaborated. This is a step towards understanding country specific determinants of mental health inequalities. Combined, the results make up a knowledge base that will guide policy makers and practitioners to develop efficient policies and practices in order to decrease inequalities in mental health.

    Key messages:

    • Combining evidence from international literature with context specific secondary data analyses improves its local relevance.

    • Collaboration between research fields enables a more comprehensive basis for decision making.

  • 21. García-Moya, Irene
    et al.
    Johansson, Klara
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ragnarsson, Susanne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergström, Erik
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Petersen, Solveig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    School experiences in relation to emotional and conduct problems in adolescence: a 3-year follow up study2019In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 29, no 3, p. 436-441Article in journal (Refereed)
    Abstract [en]

    Background: Mental health in adolescents has become a major public health issue. This study examined school experiences in relation to mental health (emotional problems and conduct problems) from early to middle adolescence.

    Methods: This longitudinal 3-year follow up study used data from the Swedish Study of Health in School Children in Umeå. Analyses were conducted in 1379 participants that were attending grade six in 2003 or 2006 (age 12 years). KIDSCREEN-52 was used to assess school experiences and the Strengths and Difficulties Questionnaire for emotional and conduct problems. Statistical analyses included repeated measures ANOVA and multiple linear regressions.

    Results: Positive school experiences decreased while emotional and conduct problem scores increased from grades six to nine. Positive school experiences were negatively associated with emotional and conduct problem scores and contributed to the explanation of mental health scores in middle adolescence after controlling for background factors. When baseline mental health problem scores were taken into account the association with early school experiences disappeared (except for conduct problems in boys). However, incorporating concurrent school experiences in the analysis increased the levels of explanation for emotional and conduct problem scores further.

    Conclusions: The results of this study confirm that school experiences are linked to emotional and conduct problems. That link may be stronger for conduct problems. In addition, the association of school experiences in early adolescence with later mental health may be overridden by concurrent school experiences in middle adolescence.

  • 22. Gillander Gådin, Katja
    et al.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A possible contributor to the higher degree of girls reporting psychological symptoms compared with boys in grade nine?2005In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 15, no 4, p. 380-385Article in journal (Refereed)
    Abstract [en]

    Background: It is a recurrent finding that adolescent girls report psychological symptoms in a higher degree compared with boys. The explanations for this difference vary, but the psychosocial school environment has never been a focus in these explanations. The aim of this study was to analyse whether psychosocial factors at school were associated with a high degree of psychological symptoms among boys and girls in grade nine, with a special focus on sexual harassment.

    Methods: The study was based on a cross-sectional study including 336 pupils (175 girls and 161 boys) in grade nine (about 15 years old), who answered an extensive questionnaire. The non-response rate was negligible (< 1%). Logistic regression analysis was used to analyse whether school-related factors (teacher support, classmate support, sexual harassment), body image, and parental support were associated with a high degree of psychological symptoms.

    Results: Sexual harassment at school was associated with a high degree of psychological symptoms among girls.

    Conclusions: Sexual harassment must be acknowledged as a negative psychosocial school environmental factor of importance for the high degree of psychological ill-health symptoms among girls compared with boys.

  • 23.
    Gunnarsdóttir, Hrafnhildur
    et al.
    Department of Health Sciences, University West, Trollhättan, Sweden. School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
    Hensing, Gunnel
    School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden..
    Poor school connectedness in adolescence and adulthood depressiveness: a longitudinal theory-driven study from the Northern Sweden Cohort2021In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 31, no 4, p. 797-802Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Foundations for mental health are laid early in family and school life. Family climate embraces the emotional connections within a family, and school connectedness embraces both functional and affective dimensions of relationship with school. Based on the lack of theory-driven and longitudinal epidemiological studies addressing public mental health, the aim of this longitudinal study was to investigate the associations between adolescents' school connectedness, family climate and depressiveness in adulthood, by relying on Bronfenbrenner's ecological theory.

    METHODS: The data are from the Northern Swedish Cohort, and the sample consists of 481 women and 526 men born in 1965 who participated in data collection at age 16, 21, 30 and 43. The generalized linear model method with random intercepts was used to examine the associations between family climate and school connectedness and depressiveness in adulthood.

    RESULTS: Poor school connectedness was associated with depressiveness in adulthood [β = 0.038 (95% CI 0.018-0.058) P ≤ 0.001], but poor family climate was not [β = 0.014 (95% CI -0.004-0.032)]. No difference in associations was observed between those experiencing social/material adversities in adolescence.

    CONCLUSIONS: This study shows that poor school connectedness in adolescence can affect depressiveness in adulthood. The study confirms the complex processes that determine mental health and proposes a theoretical approach appealing to public mental health research. In addition, this study concludes that more life-course studies are needed to advance the knowledge of the mechanisms behind the associations between family climate and school connectedness and depressiveness in adulthood.

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  • 24.
    Gustafsson, Per E
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Persson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Socio-economic disadvantage and body mass over the life course in women and men: results from the Northern Swedish Cohort2012In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 22, no 3, p. 322-327Article in journal (Refereed)
    Abstract [en]

    Background: Obesity and body mass in adulthood relate both to current and to childhood socio-economic status, particularly in women, but the underlying life course processes are not known. This study aims at examining whether the life course socio-economic status—body mass association in women and men is explained by the cumulative risk or adolescent sensitive period models whether associations are similar at different life course stages; and whether health behaviours explain the associations.

    Methods: A total of 476 women and 517 men participated in this 27-year prospective cohort study (participation rate 93%). Body mass index was assessed at the age of 16 and 43 years and self-reported at the age of 21 and 30 years. Information on socio-economic status by own or parental (age 16 years) occupation, smoking, snuff, alcohol, physical activity and diet was collected at each age.

    Results: In women, cumulative socio-economic status and socio-economic status in adolescence were related to body mass index at the age of 16, 21, 30 and 43 years and to the 27-year change in body mass, independently of health behaviours and for adolescent socio-economic status also of later socio-economic attainment. Associations were generally stronger for body mass at older age. In men, associations were mostly non-significant, although health behaviours contributed strongly to body mass.

    Conclusions: In women, both the sensitive period (in adolescence) and cumulative risk models explain the socio-economic–body mass link. Efforts to reduce the social inequality in body mass in women should be directed at the early life course, but focusing on unhealthy behaviours might not be a sufficient approach.

  • 25.
    Gustafsson, Per
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Socialmedicin.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Socialmedicin.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Cumulative contextual and individual disadvantages over the life course and adult functional somatic symptoms in Sweden2015In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 25, no 4, p. 592-597Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:: Disadvantage, originating in one's residential context or in one's past life course, has been shown to impact on health in adulthood. There is however little research on the accumulated health impact of both neighbourhood and individual conditions over the life course. This study aims to examine whether the accumulation of contextual and individual disadvantages from adolescence to middle-age predicts functional somatic symptoms (FSS) in middle-age, taking baseline health into account.

    METHODS:: The sample is the age 16, 21, 30 and 42 surveys of the prospective Northern Swedish Cohort, with analytical sample size n = 910 (85% of the original cohort). FSS at age 16 and 42, and cumulative socioeconomic disadvantage, social adversity and material adversity between 16 and 42 years were operationalized from questionnaires, and cumulative neighbourhood disadvantage between 16 and 42 years from register data.

    RESULTS:: Results showed accumulation of disadvantages jointly explained 9-12% of FSS variance. In the total sample, cumulative neighbourhood and socioeconomic disadvantage significantly predicted FSS at age 42 in the total sample. In women, neighbourhood disadvantage but not socioeconomic disadvantage contributed significantly, whereas in men, socioeconomic but not neighbourhood disadvantage contributed significantly. In all analyses, associations were largely explained by the parallel accumulation of social and material adversities, but not by symptoms at baseline.

    CONCLUSION:: In conclusion, the accumulation of diverse forms of disadvantages together plays an important role for somatic complaints in adulthood, independently of baseline health.

  • 26.
    Hajdarevic, Senada
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Hvidberg, Line
    Lin, Yulan
    Donnelly, Conan
    Gavin, Anna
    Lagerlund, Magdalena
    Pedersen, Anette F
    Rasmussen, Birgit H
    Runesdotter, Sara
    Vedsted, Peter
    Tishelman, Carol
    Awareness of sunburn in childhood, use of sunbeds and change of moles in Denmark, Northern Ireland, Norway and Sweden2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no 1, p. 29-35Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Malignant melanoma (MM) is increasing rapidly in Northern Europe. To reduce incidence and mortality through earlier diagnosis, public awareness of MM is important. Thus, we aim to examine awareness of risk factors and a symptom of MM, and how awareness varies by country and socio-demographic factors in Denmark, Northern Ireland (NI), Norway and Sweden.

    METHODS: Population-based telephone interviews using the 'Awareness and Beliefs about Cancer' measure were conducted in 2011 among 8355 adults ≥50 years as part of the International Cancer Benchmarking Partnership Module 2. Prevalence ratios (PRs) with 95% confidence intervals were calculated.

    RESULTS: In these four countries, lowest awareness was found for 'sunburn in childhood' (63%), whereas awareness was high for 'use of sunbeds' (91%) and 'mole change' (97%). Lack of awareness of 'sunburn in childhood' was more prevalent among respondents from Norway [PR = 1.38 (1.28-1.48)] but less prevalent among respondents from Northern Ireland (NI) [PR = 0.78 (0.72-0.85)] and Sweden [PR = 0.86 (0.79-0.93)] compared with respondents from Denmark. Lack of awareness of 'use of sunbeds' was more prevalent among respondents from Norway [PR = 2.99 (2.39-3.74)], Sweden [PR = 1.57 (1.22-2.00)], and NI [PR = 1.65 (1.30-2.10)] compared with respondents form Denmark. Being a man, age ≥70, living alone, and having lower education, were each independently associated with lack of MM-awareness.

    CONCLUSIONS: The results indicate relatively low awareness of 'sunburn in childhood' as a risk factor for MM, and important disparities in MM-awareness across countries and socio-demographic groups. Improved and more directed initiatives to enhance public MM-awareness, particularly about 'sunburn in childhood', are needed.

  • 27.
    Hallman, David
    et al.
    Högskolan i Gävle, Akademin för hälsa och arbetsliv, Avdelningen för arbetshälsovetenskap och psykologi, Arbetshälsovetenskap. Högskolan i Gävle, Centrum för belastningsskadeforskning..
    Januario, Leticia
    Högskolan i Gävle, Akademin för hälsa och arbetsliv, Avdelningen för arbetshälsovetenskap och psykologi, Arbetshälsovetenskap. Högskolan i Gävle, Centrum för belastningsskadeforskning..
    Mathiassen, Svend Erik
    Högskolan i Gävle, Akademin för hälsa och arbetsliv, Avdelningen för arbetshälsovetenskap och psykologi, Arbetshälsovetenskap. Högskolan i Gävle, Centrum för belastningsskadeforskning..
    Heiden, Marina
    Högskolan i Gävle, Akademin för hälsa och arbetsliv, Avdelningen för arbetshälsovetenskap och psykologi, Arbetshälsovetenskap. Högskolan i Gävle, Centrum för belastningsskadeforskning..
    Wahlström, Viktoria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    P09-09 Hybrid work and temporal patterns of sedentary behavior in a 24-hour compositional perspective2022In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 32, no Supplement_2Article in journal (Refereed)
    Abstract [sv]

    Background

    During the COVID-19 pandemic, many white-collar workers were requested to exclusively work from home (WFH), which may have affected their sedentary behavior. In Sweden, having less severe restrictions than many other countries, workers were allowed to alternate between WFH and work at the office (WAO), so called hybrid work. Understanding how hybrid work influences total sedentary behavior and its temporal distribution is an important issue for future health promotion. This study aimed to investigate to what extent office workers changed their temporal pattern of sedentary behavior during days WFH compared to WAO, considering age and gender as potential moderators.

    Methods

    Data were collected from May to December 2020 in office workers (n = 199). Their mean age was 42 (SD 10) years and 55% were women. Physical behaviors were measured using a thigh-worn accelerometer (AxivityAX3) for seven consecutive days. A diary identified working hours, time-in-bed and days WFH or WAO. Time-use was classified as short (0-5 min), moderate (5-30 min) and long bouts (>30 min) of sedentary behavior (SB), non-SB, and time-in-bed during workdays (WAO and WFH) and non-workdays. We used Compositional data analysis to express data as 24-hour compositions and linear mixed models to estimate difference in 24-hour compositions between day types (within worker), including age and gender as covariates and moderators.

    Results

    We found that workdays (WFH and WAO) were associated with proportionally less time-in-bed relative to time awake, more time SB relative to non-SB, and more time in longer relative to shorter sedentary bouts, compared to non-workdays (all p > 0.001). WFH was associated with more time-in-bed relative to awake and more SB relative to non-SB than WAO (p > 0.05), but the differences for sedentary bouts were not significant. Younger workers and women had more SB, and women accumulated more time than men in longer relative to shorter bouts of SB. However, age and gender did not affect differences between day types.

    Conclusions

    Working from home influenced 24-hour time-use in office workers by increasing sedentary behavior in total, while its temporal pattern was unchanged. Results contribute to evidence that can support organizational policies on hybrid work.

  • 28. Hammarström, A.
    et al.
    Korhonen, J.
    Blomqvist, I.
    Hägglöf, Bruno
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Child and Adolescent Psychiatry.
    Increase of internalised mental health symptoms over the last 33 years among adolescents2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, p. 271-272Article in journal (Other academic)
    Abstract [en]

    Background: Mental health among young people is of increasing public health importance. Several studies comparing the 1990ies with today suggest an increase of internalised mental health problems among adolescent girls. The development among adolescent boys is less clear. The aim of this study was to analyse the development of mental health among adolescence from the early 1980ies until today with regard to internalised and externalised symptoms among both boys and girls.

    Methods: Two cohorts were compared consisting of all pupils in the last year of compulsory school in Luleå (Sweden) in 1981 (n = 1083, response rate 99.7%) and in 2014 (n = 682, response rate 98.3%). The same questionnaire was used with validated questions about symptoms of mental health. Confirmatory factor analysis were performed in order to validate the proposed a priori factor structure of the mental health measures; anxiety symptoms, depression symptoms, functional somatic symptoms and externalised symptoms.

    Results: Symptoms of anxiety, depression and functional somatic symptoms increased among both boys and girls from 1981 until 2014 (p < 0.001 for all symptoms and for both boys and girls). Externalised symptoms decreased, especially among boys (p < 0.001 for both boys and girls). These changes between the cohorts were confirmed using multivariate regression techniques (controlling for parental socioeconomic status and parental country of origin) for each measure of mental health. among boys and girls.

    Conclusions: Symptoms of internalised mental health have increased among 16-year old boys and girls over the last 33 years while externalised symptoms have decreased, especially among boys. Public health actions need to be initiated in order to stop the increase and prevent internalised mental health problems among teenagers.

    Key messages:

    • A longer period than 20 years is needed in order to detect an increase in internalised mental health symptoms among adolescent boys.
    • Adolescent girls have the highest level and the highest increase in these symptoms during a period of 33 years, while externalised mental health symptoms have decreased mostly among adolescent boys.
  • 29.
    Hammarström, Anne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Virtanen, Pekka
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Are the health consequences of temporary employment worse among low educated than among high educated?2011In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 21, no 6, p. 756-761Article in journal (Refereed)
    Abstract [en]

    Background: Despite the inconsistent findings of the growing amount of research analysing the possible health consequences of temporary employment, there is a lack of heterogeneous perspectives. The aim of the study was to analyse whether the health consequences of temporary employment are worse among low educated compared with high educated, after control for health-related selection.

    Methods: A 26-year follow-up study of a cohort of all school leavers in a middle-sized industrial town in northern Sweden was performed between 1981 and 2007. Of those still alive of the original cohort, 94% participated during the whole period. For this study, a sample of participants with temporary and permanent employment contracts between the age of 30 and 42 years was selected (n = 660).

    Results: In multivariate logistic regression analyses, an additive synergistic interaction effect was found for low education and high exposure to temporary employment in relation to suboptimal self-rated health, after controlling for health-related selection and sex. An additive antagonistic interaction was found between low education in combination with high exposure to temporary employment in relation to psychological distress, whereas no interaction was found for depressive symptoms.

    Conclusion: Our hypothesis regarding worse health effects of temporary employment among low educated was partly confirmed. Our results indicate the need to analyse temporary employment from a more heterogeneous perspective as well as in relation to different health outcomes.

  • 30.
    Hellström, Olle
    Vansbro Health Care Unit, Linköping University, Linköping, Sweden.
    Health promotion in general practice: on meanings and aims in interaction1994In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 4, no 2, p. 119-124Article in journal (Refereed)
    Abstract [en]

    The enterprise of health promotion in medicine involves a responsibility of distinguishing between the concepts of health and absence of disease and of reflecting on the notions of illness and sickness. In this paper the importance of human dialogue is stressed both as a means and end of the doctor-patient relationship and as the main means of genuine health promotion. The outcome of health work is proposed to depend mainly on the way the patients are encountered. Their efforts to make themselves seen as being sick should not on all occasions be diagnosed and treated. By means of a reflected, dialogic practice patients may be listened to and inspired to reconstruct their symbol-based relationship to the world of meaning. The conception of health primarily includes man&#039;s relationship to himself. Illness is looked upon as the subject&#039;s experience of illhealth, whereas disease is understood as a functional imbalance of bodily organs. There is a tacit meaning in being ill (and found sick) that can be realized and attended to best in close relationship with the patient. Physicians – preferably general practitioners – involved in health promotion should, it is concluded, both assist the patients to give up their sick role and continually elaborate their own professional competence to see and successfully encounter the manifold specifically human issues underlying their patients&#039; presented symptoms. health promotiondisease preventiongeneral practiceinteractionaction research.

  • 31. Herrmann, A.
    et al.
    Amelung, D.
    Fischer, H.
    Wilkinson, P.
    Nilsson, Maria
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Barbier, C.
    Dubois, G.
    Aall, C.
    Sauerborn, R.
    Promoting health under the Paris Climate Agreement: results from a European mixed-methods study2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 170-170Article in journal (Other academic)
  • 32. Hicks, B.
    et al.
    Veronesi, G.
    Ferrario, M.
    Cesana, G.
    Iacoviello, L.
    Palmieri, L.
    Kuulasmaa, K.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Sans, S.
    Kee, F.
    Differential susceptibility to allostatic load and educational inequalities in coronary heart disease2020In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 30, p. V73-V73Article in journal (Other academic)
    Abstract [en]

    Background: Differential exposure to lifestyle factors may mediate the association between education and cardiovascular disease (CVD). However, differential susceptibility (the effect of exposure to the same “dose” of risk factors differs across groups) may also elevate CVD risk but the causal pathways remain unclear. Allostatic Load (AL) is a marker of cumulative biological burden resulting from mal-adaptation to chronic stressors. We aimed to examine the role of differential exposure and susceptibility to AL and other factors in coronary heart disease (CHD) educational gradients in Europe.

    Methods: 51,328 35-74-year-old participants originally free of CVD from 21 European cohorts in the BiomarCaRE consortium were identified and followed for a median of 10 years to their first CHD event. We defined an AL score as the sum of z-scores of 8 markers from the cardiovascular, metabolic, and inflammatory systems. To investigate the mediating role of AL (and smoking, alcohol and BMI) on educational differences in CHD incidence we applied marginal structural models and three-way decomposition on gender-specific additive hazards models.

    Results: AL was a significant mediator of the association between educational status and CHD. The highest proportion mediated was observed in women, with 28% (95%CI 20% to 44%) attributable to differential exposure and 8% (95%CI 0% to 16%) to differential susceptibility. In men, AL mediated 16% of the increased CHD risk in the less educated, with 2% (95%CI 0%-6%) attributable to differential susceptibility. The effects of smoking, alcohol and BMI were relatively small for men and women, with a limited role of differential susceptibility.

    Conclusions: While we found evidence of differential susceptibility to AL on CHD, effects were modest and the mediating effect of AL (and other lifestyle factors) was predominately via differential exposure. Controlling disproportionate exposure to AL may help reduce CHD morbidity among those with lower education.

  • 33.
    Hintermeier, M.
    et al.
    General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany; Population Medicine and Health Research, Bielefeld University, Bielefeld, Germany.
    Pernitez-Agan, S.
    International Organization of Migration, United Nations, Manila, Philippines.
    Lopez, J.
    International Organization of Migration, United Nations, Manila, Philippines.
    Wickramage, K.
    International Organization of Migration, United Nations, Manila, Philippines.
    Gottlieb, N.
    Population Medicine and Health Research, Bielefeld University, Bielefeld, Germany.
    Baroudi, Mazen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Rohleder, S.
    Population Medicine and Health Research, Bielefeld University, Bielefeld, Germany.
    Flores, S.
    Department of Public Health and Caring Sciences, Stockholm University, Stockholm, Sweden.
    Mohsenpour, A.
    Population Medicine and Health Research, Bielefeld University, Bielefeld, Germany.
    Bozorgmehr, K.
    General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany; Population Medicine and Health Research, Bielefeld University, Bielefeld, Germany.
    Covid-19 among migrants, refugees, and internally displaced persons: systematic review and synthesis of the global empirical literature2023In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 33, no Supplement_2, article id ckad160.550Article in journal (Refereed)
    Abstract [en]

    National pandemic response and preparedness plans aim at mitigating the spread of infectious diseases and protecting public health. Yet, they often fail to consider migrants. Evidence from the pandemic's early phase indicates that migrants are disproportionally affected by the Covid-19 pandemic and its consequences. Yet, synthesized evidence quantifying the magnitude of inequalities in infection risk, consequences of disease, or consequences of public health measures is lacking. We conducted a systematic review of the literature from 12/2019 to 11/2021 to synthesise the empirical evidence in this field. We considered all types of articles and study designs. The synthesis of evidence was divided into qualitative and quantitative analysis. Out of 6961 studies we included 243 to describe the heterogenous research landscape in terms of design, population, country context, and outcomes reported. The qualitative synthesis (n = 44) highlights the complex interplay of social and Covid-19 related factors at macro-, meso- and micro-level, resulting in high exposure, risk of infection, impacts of public health measures, and health impacts for migrants. The meta-analysis of n = 45 quantitative studies shows that migrants have an elevated risk of infection (RR: 2.46 (95%CI: 1.96-3.07)) compared to non-migrants, but a similar risk of hospitalization (RR: 1.05 (95%CI: 0.80-1.37)). Among those hospitalized, migrants have a lower risk of mortality (RR: 0.57 (95%CI: 0.32-1.03)). Yet, population-based excess mortality tends to be higher among migrants compared to non-migrants (RR: 1.30 (95%CI: 0.90-1.89)). Overall, high heterogeneity in reporting and quality of primary studies hampered the comparability of data. The qualitative results highlight the syndemic nature of the crisis, with cascading effects and interactions among socio-economic and health inequalities. They also illustrate the lack of evidence on some migrant categories, e.g., labor migrants, undocumented migrants, and returnees.

  • 34.
    Hitimana, Regis
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krantz, G.
    Nzayirambaho, M.
    Semasaka Sengoma, J. P.
    Condo, J.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health related quality of life determinants for Rwandan women after delivery2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 436-Article in journal (Other academic)
    Abstract [en]

    Health related quality of life determinants for Rwandan women after delivery. Does Antenatal care utilization matter? Maternal health conditions are still a major problem in most low-income countries. The postpartum health status and the effect of antenatal care utilization on health are relatively under researched. This study aims at (1) assessing whether receipt of antenatal care according to Rwandan guidelines is associated with mother’s health-related quality of life (HRQoL) and (2) exploring determinants associated with mother’s HRQoL in the first year (1-13 months) after delivery in Rwanda. In 2014 a cross-sectional survey was conducted on 922 women from Kigali City and Northern province of Rwanda, who gave birth in the period of 1–13 months prior to survey. The study population was randomly selected and interviewed using a questionnaire. HRQoL was measured using EQ-5D-3L. Average values of HRQoL were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care on HRQoL was tested in two multivariable linear regression models - with EQ-5D weights and the Visual Analogue Scale score as outcomes respectively - with ANC adequacy and socio-demographic and psychosocial variables as predictors. Mean HRQoL was 0.92 using EQ-5D and 69.58 using EQ-VAS. Fifteen per cent reported moderate pain/discomfort and 1% reported extreme pain/discomfort, 16% reported being moderately anxious/depressed and 3% reported being extremely anxious/depressed. Having more than one child and being cohabitant or single/not married was associated with significantly lower HRQoL, while having good social support and belonging to the highest wealth quintile was associated with higher HRQoL. Antenatal care utilization was not associated with HRQoL among postpartum mothers. Policy makers should address the social determinants of health, and promote social networks among women. There is a need to assess the quality of Antenatal care in Rwanda.

    Key messages:

    • Health related quality of life among postpartum mothers is high. Pain or discomfort and anxiety of depression are most prevalent problems.
    • Antenatal care utilization was not associated with HRQoL among postpartum mothers. Rather social determinants of health are important in determining mother's HRQoL
  • 35.
    Holmlund, Sofia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Ntaganira, J.
    Edvardsson, K.
    Semasaka Sengoma, J. P.
    Hussein, K.
    Ngarina, M.
    Small, R.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Health professionals' experiences and views of obstetric ultrasound in Rwanda2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 367-Article in journal (Other academic)
    Abstract [en]

    Background: The World Health Organizatiońs new recommendations for antenatal care (ANC) include one ultrasound examination before 24 weeks of gestation. Implementation of ultrasound in ANC in low resource countries has been shown to increase pregnant women’s compliance to ANC visits, and facilitate detection of high-risk pregnancies. The aim of this study was to explore Rwandan health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

    Methods: A cross-sectional questionnaire study involving physicians (n = 222), obstetricians (n = 29), nurses (n = 387) and midwives (n = 269) managing pregnant women in RWANDA was performed, as part of the CROss Country Ultrasound Study (CROCUS). Data were collected at 106 health facilities from November 2016 – March 2017.

    Preliminary results: One third of the participants performed ultrasound examinations (32.3%) and the majority on a daily basis (60.1%). The ultrasound examination where most participants reported high level skills was evaluation of the fetal heart rate (69.0%). A majority reported no skills or low level skills (79.9%) for ultrasound examination of the fetal heart, aorta and pulmonary artery. A majority (65.0%) reported that lack of ultrasound training of the ultrasound operator sometimes led to suboptimal pregnancy management. Almost all participants (91.3%) agreed that ANC would be improved if midwives were qualified to perform basic ultrasound examinations.

    Conclusions: The vast majority of health professionals in the study believed that maternity care can be improved if midwives learn to perform basic ultrasound examinations. Additional training of physicians performing obstetric ultrasound was also suggested to increase the quality of obstetric ultrasound surveillance and to further improve maternal and fetal health outcomes.

    Key messages:

    • Physicians managing pregnant women need more training in obstetric ultrasound.
    • Midwives need to be educated in performing obstetric ultrasounds.
  • 36.
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Ian Dowbiggin, The sterilization movement and global fertility in the twentieth century.2008In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 19, no 1, p. 121-Article in journal (Other (popular science, discussion, etc.))
  • 37.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Somali-Swedish Research Cooperation for Health (SSRCH): a joint initiative by Somali and Swedish Universities to guide the Somali health system recovery process2020In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 30, no Supplement_5Article in journal (Other academic)
    Abstract [en]

    In the fragile Somali state, there is a research imperative to effectively guide health systems recovery, which is crucial in the national rebuilding process for societal stability and peace. Our collaboration has its roots in the early 1980's, was cut short by the civil war and revived in 2014 to meet the need for health research capacity in Somalia today. Somali universities, representing different regions (East Africa University, University of Hargeisa, Galkayo University, Benadir University, Puntland Health Science University, Amoud University, and recently Somali National University) formed a consortium with Swedish universities (Umeå, Lund, Uppsala, Karolinska Institutet and Dalarna) and Somali diaspora professionals. Most recently we joined forces with the Public Health Agency of Sweden, linking us to the National Institute of Health Somalia (NIHS). A joint action programme for capacity building in health research has been developed, as outlined in the article “Rebuilding research capacity in fragile states: the case of a Somali-Swedish global health initiative” (Glob Health Action, 2017;10:1;1348693). We have a model for working collaboratively across regions and cultural barriers, creating hope for real change. As a first step, priority was given to research capacity development of faculty staff at the Somali universities' health faculties and Ministries of Health. A 'training of trainers' course in health research methodology was carried out during 2016-2018, supported by WHO-based Alliance for Health Policy and Systems Research. This has fostered health research as an integral component of these universities' academic development process. Institutional and research capacity in public health has a key role in rebuilding national health services for better health and wellbeing and to reach the SDGs (goals 3, 5, 10, 16).

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  • 38.
    Janlert, Urban
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Winefield, Anthony H.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Length of unemployment and health-related outcomes: a life-course analysis2015In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 25, no 4, p. 662-667Article in journal (Refereed)
    Abstract [en]

    Background: Most previous studies on the effects of length of unemployment on health have focused on the duration of continuous spells of unemployment rather than on the cumulative length of intermittent spells. This study analysed the relationship between the cumulative length of intermittent spells of unemployment and different health-related outcomes using data from a longitudinal study of school leavers. Methods: All pupils who completed compulsory schooling in 1981 in a medium-sized town in northern Sweden (N=1083) were followed for 14 years with repeated questionnaires including questions about unemployment, health and health behaviour. Results: Men tended to react with a steady state or a levelling off of health symptoms with increased unemployment, whereas women showed deteriorating health symptoms. For health behaviour the reverse occurred. Women's health behaviour was less connected with increased unemployment while men's health behaviour tended to deteriorate. Conclusion: Cumulative length of unemployment is correlated with deteriorated health and health behaviour. Long-term unemployment, even as a result of cumulated shorter employment spells over a number of years should be an urgent target for policy makers.

  • 39.
    Johansson, Helene
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sorensen, J.
    Dalton, J.
    Jenkins, P.
    Jerden, L.
    Lifestyle counseling in primary care: The views of family physicians in United States and Sweden2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, p. 333-Article in journal (Other academic)
    Abstract [en]

    Background: The role of primary care professionals in lifestyle counseling is receiving attention at the national level in many countries. The U.S. and Sweden are two countries currently establishing priorities in these areas. A study comparing the countries demonstrates large differences between the extents that family physicians report being engaged in counseling on lifestyle issues, and how important they perceive it to be (Weinehall et al. Counseling on lifestyle habits in the United States and Sweden. BMC Family Practice 2014;15:83).

    With the overall aim of facilitating lifestyle counselling in primary care, the objective of the present qualitative study was to explore further the views of American and Swedish family physicians about lifestyle counseling, in order to clarify the differences in attitudes and practices in the two countries.

    Methods: In total, twenty-nine semi-structured interviews were conducted with family physicians representing the county councils of Stockholm and Dalarna in Sweden, and the Bassett Healthcare Network, Upstate New York, U. S. Data were analyzed using qualitative content analysis.

    Results/Conclusions: Preliminary results show that the majority of the informants in both countries believe that addressing lifestyle issues is important and a natural part of their work. However, the study indicates that the U.S. physicians to a higher extent work in a more systematic way with risk factor management and routinely ask about lifestyle habits as part of existing work processes. They also expressed to a higher extent that they themselves, despite lack of time, must engage in lifestyle counseling, due to limited access to collegial support and referral services. The Swedish doctors, on the other hand, are able to limit their own role and responsibility due to support from other professions in the health care center/access to referral services.

    Key messages:

    • This study provide insight into how Swedish and U.S family physicians view the role of behavioral risk factor management in their clinical practice.
    • Understanding professionals ‘take’ on lifestyle interventions, is invaluable, as they serve on the ‘front line’ in the battle to improve health outcomes in both countries.
  • 40.
    Johansson, Klara
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Parental leave and increased physical activity of fathers and mothers-results from the Northern Swedish Cohort2014In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 24, no 6, p. 935-940Article in journal (Refereed)
    Abstract [en]

    Background: Physical activity is an important public health issue. Factors shown to be associated with physical activity are parenthood and country-level gender equality, while the importance of individual gender equality (in parenthood or in general) remains to explore. In Scandinavia, where parental leave can be shared equally between mothers and fathers, parental leave is one dimension of gender equality in parenthood. The aim of this study was to investigate parental leave in relation to increased physical activity among men and women. Methods: Participants in the Northern Swedish Cohort with a child born 1993-2005 (n = 584) were investigated with questionnaires at ages 21 and 42; register data on parental leave between ages 28 and 42 were obtained from Statistics Sweden. The relationships between parental leave between ages 28 and 42 and meeting WHO guidelines for physical activity at age 42, as well as changes in physical activity between ages 21 and 42, were tested with multinomial regression, controlling for socio-economic status and birth year of the child. Results: For women, the length of parental leave was not associated with increased physical activity or with meeting WHO guidelines at age 42. For men, parental leave was associated with increased physical activity, controlling for socio-economic status and age of the child, but not with meeting WHO guidelines for physical activity at age 42. Conclusions: A gender non-traditional out-take of parental leave might be associated with an increase in physical activity among men at the lower end of the physical activity spectrum, but not among women.

  • 41.
    Jonsson, F.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Strömsten, Lotta M. J.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Paths of adversity linking adolescent socioeconomic conditions to adult functional somatic symptoms2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no Suppl 1, p. 227-227Article in journal (Refereed)
    Abstract [en]

    Background: While research examining the health impact of early socioeconomic conditions suggests that effects may exist independently of or jointly with adult socioeconomic position, studies exploring other pathways are few. Following a chain of risk life course model, this study examine if the socioeconomic conditions of the family contributes to an adverse social and material environment across life ultimately affecting functional somatic symptoms in adulthood.

    Methods: Mediation was examined using path analysis on prospective data from a sample of 987 individuals residing in Luleå, Sweden in 1981 and who answered surveys at age 16, 21, 30 and 42. Early socioeconomic conditions was assessed at age 16 by using the parents occupation. The participant’s own occupation was measured at age 21 and 30. At age 21 and 30, social adversity comprised of items pertaining to stressful life events, while material adversity included items of unfavorable economic conditions. Functional somatic symptoms was examined at age 42 as a summary of self-reported physical symptoms, palpitation and sleeping difficulties occurring during the last 12 months.

    Results: The results suggested that the association between socioeconomic conditions at age 16 and functional somatic symptoms at age 42 (r = .068) could be explained by two plausible pathways. Through own class at age 21 and then through material (B = .064, 95% CI = .004 – .123) and social adversity (B = .067, 95% CI = .019 – .114) at age 30.

    Conclusions: Growing up in an unfavorable socioeconomic setting might be a source for later adversities, and these might largely explain the effects of early disadvantage on later health. Thus, improved social and financial living conditions for people from poor backgrounds could avert adult stress-related health problems.

    Key messages:

    • Chains of life events may be central to understand socioeconomic health effects
    • Breaking life course chains might avert adult health effects of early disadvantage
  • 42. Jonzon, R.
    et al.
    Lindkvist, P.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Structural and procedural barriers to health assessment for asylum seekers and other migrants: an explorative survey in Sweden2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 133-133Article in journal (Refereed)
  • 43.
    Jonzon, Robert
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Publ Hlth Agcy Sweden, Stockholm, Sweden.
    Lindkvist, P.
    Johansson, E.
    A state of limbo - in transition between two contexts - health assessments upon arrival in Sweden as perceived by former Eritrean asylum seekers2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 136-137Article in journal (Other academic)
  • 44.
    Junuzovic, Mensura
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine. Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Malmö, Sweden.
    Rietz, Anders
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine.
    Jakobsson, Ulf
    Lunds universitet.
    Midlöv, Patrik
    Lunds universitet.
    Eriksson, Anders
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine.
    Firearm deaths in Sweden2019In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 29, no 2, p. 351-358Article in journal (Refereed)
    Abstract [en]

    Background: Sweden’s firearm legislation obligates physicians to report patients that are deemed unsuitable to possess a firearm. This study aimed to explore the involvement of firearm use in firearm fatalities and to evaluate physician reporting concerning cases of firearm deaths.

    Methods: Fatal firearm suicides and homicides in Sweden were studied for the years 2012–2013, accidental deaths and undetermined manner of deaths for the period 1987–2013. Police reports and autopsy protocols were collected from the National Board of Forensic Medicine, healthcare data in 1 year before the fatality from the National Board of Health, and information about physician reports and firearm licences from the Swedish Police.

    Results: A total of 291 firearm deaths (213 suicides, 52 accidental deaths, 23 solved homicides and 3 cases with undetermined manner of death) were identified. Firearm suicides were positively correlated with the number of licensed firearm owners. Legal firearm use predominated in firearm suicides and accidental deaths, illegal in homicides. No suicide victim or shooter in an accidental death was previously reported by a physician to the police according to the firearm law. The majority of the shooters in accidental deaths and suicides had no registered health care visits. Less than half (42%) of all suicide victims had a previous health care contact due to mental health problems. Conclusions: Not one single suicide victim nor any shooter in accidental deaths in the present study had been reported according to the firearm law, bringing the evidence of a suboptimal framework.

  • 45.
    Kardakis, Therese
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jerdén, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Monica E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Johansson, Helene
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lifestyle interventions in primary health care: professional and organizational challenges2014In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 24, no 1, p. 79-84Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Interventions that support patient efforts at lifestyle changes that reduce tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity represent important areas of development for health care. Current research shows that it is challenging to reorient health care toward health promotion. The aim of this study was to explore the extent of health care professional work with lifestyle interventions in Swedish primary health care, and to describe professional knowledge, attitudes and perceived organizational support for lifestyle interventions.

    METHODS: The study is based on a cross-sectional Web-based survey directed at general practitioners, other physicians, residents, public health nurses and registered nurses (n = 315) in primary health care.

    RESULTS: Fifty-nine percent of the participants indicated that lifestyle interventions were a substantial part of their duties. A majority (77%) would like to work more with patient lifestyles. Health professionals generally reported a thorough knowledge of lifestyle intervention methods for disease prevention. Significant differences between professional groups were found with regard to specific knowledge and extent of work with lifestyle interventions. Alcohol was the least addressed lifestyle habit. Management was supportive, but structures to sustain work with lifestyle interventions were scarce, and a need for national guidelines was identified.

    CONCLUSIONS: Health professionals reported thorough knowledge and positive attitudes toward lifestyle interventions. When planning for further implementation of lifestyle interventions in primary health care, differences between professional groups in knowledge, extent of work with promotion of healthy lifestyles and lifestyle issues and provision of organizational support such as national guidelines should be considered.

  • 46.
    Kinsman, John
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stöven, Svenja
    Umeå University, Faculty of Science and Technology, European CBRNE Center.
    Elgh, Fredrik
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology.
    Murillo, Pilar
    Umeå University, Faculty of Science and Technology, European CBRNE Center.
    Sulzner, Michael
    Good practices and challenges in addressing poliomyelitis and measles in the European Union2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, no 4, p. 730-734Article in journal (Refereed)
    Abstract [en]

    Background: All European Union (EU) and European Economic Area (EEA) Member States have pledged to ensure political commitment towards sustaining the region's poliomyelitis-free status and eliminating measles. However, there remain significant gaps between policy and practice in many countries. This article reports on an assessment conducted for the European Commission that aimed to support improvements in preparedness and response to poliomyelitis and measles in Europe.

    Methods: A documentary review was complemented by qualitative interviews with professionals working in International and EU agencies, and in at-risk or recently affected EU/EEA Member States (six each for poliomyelitis and measles). Twenty-six interviews were conducted on poliomyelitis and 24 on measles; the data were subjected to thematic analysis. Preliminary findings were then discussed at a Consensus Workshop with 22 of the interviewees and eight other experts.

    Results: Generic or disease-specific plans exist in the participating countries and cross-border communications during outbreaks were generally reported as satisfactory. However, surveillance systems are of uneven quality, and clinical expertise for the two diseases is limited by a lack of experience. Serious breaches of protocol have recently been reported from companies producing poliomyelitis vaccines, and vaccine coverage rates for both diseases were also sub-optimal. A set of suggested good practices to address these and other challenges is presented.

    Conclusions: Poliomyelitis and measles should be brought fully onto the policy agendas of all EU/EEA Member States, and adequate resources provided to address them. Each country must abide by the relevant commitments that they have already made.

  • 47. Kobayashi, H.
    et al.
    Sahlen, Klas-Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Distributed resources and care choice: formulation through the capability approach2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no Suppl 1Article in journal (Refereed)
    Abstract [en]

    Background: Facing the problem of healthcare resource distribution under a severe healthcare budget constraint, care providers or healthcare authorities are strongly required to cut costs, which could deter individuals from applying for certain types of care services. The study aims to clarify the differences in resources distributed to individuals by formulating empirical data on patients through the capability approach, with a special focus on the opportunity and process aspects of freedom while utilising care services.

    Methods: A process aspect of freedom is captured by patients’ decision making for care services (DM), while an opportunity aspect of freedom is by accessing social services (SS). Distributed resources, nursing services offered to patients, are assumed to be converted to DM and SS through each individual’s utilisation ability of resources for DM and SS. A patient chooses an achievement point (a combination of DM and SS) within her budget set under her evaluation function of ‘well recuperation’. Achievement in DM and SS and ‘well recuperation’ were studied through a questionnaire survey on 116 patients hospitalised at general acute wards in Sweden. Individuals were asked about their physical and mental constraints toward daily living activities through an EQ-5D-3L questionnaire (specifically to examine the dimensions of ‘pain’ and ‘anxiety’).

    Results: The formulated choice set suggested that patients with constraints are less likely to achieve DM than those without any constraints. When individual evaluation is accounted for, the largest amount of resources is distributed to patients with physical and mental constraints, followed by those with physical constraints and those with no constraints.

    Conclusions: The formulation through a capability approach, supported by empirical data, shows that physical and mental constraints of patients’ can restrict their choice set with respect to the process aspect of freedom of care service utilisation.

    Key messages:

    • Capability approach can provide a theoretical background and empirical evidence to justify resource distribution in healthcare, accounting for individual differences in physical or mental conditions
    • Patients with physical or mental constraints have a restricted choice set with respect to the process aspect of freedom of care service utilisation despite additional resource distribution
  • 48.
    Landstedt, Evelina
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, M.
    Complex inequalities of gender and social class in daily smoking among Swedish men and women2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 325-325Article in journal (Other academic)
    Abstract [en]

    Background: Cigarette smoking is a major public health threat. In high income countries, smoking is most prevalent in disadvantaged groups. Little is known about complex inequalitites in smoking based on multiple axes of social positions which would be necessary in designing interventions aiming at reducing smoking rates. The study aimed to describe the prevalence of daily smoking in the adult Swedish population across combinations of the social positions gender and occupational class, and to examine smoking differences attributed to the intersection of gender/occupational class

    Methods: The study sample (N = 61 316, age 26 – 84) was pooled from seven years of the annual cross sectional Swedish national public health surveys (2010 to 2016). The outcome was current daily smoking. Binary variables of gender (man/woman) and occupational class (blue collar/white collar) were used to construct the four category intersection meausure of gender/class. Complex inequalities in daily smoking were estimated by joint-, referent- and excess disparities. Survey year and age were used as covariates.

    Results: The overall daily smoking prevalence was 10.21%. The smoking rates in the categories of gender and occupational class were as follows: white collar men: 6.70%; white collar women: 7.79%; blue collar men: 13.75% and blue collar women: 16.63%. The absolute joint disparity was 9.96 percentage points (CI: 9.14 – 10.79) and that the main contributor to this inequality was occupational class (70.66%). The results of excess disparity further showed that blue collar women were particularly exposed regarding smoking.

    Conclusions: Acknowledging the complexity of disadvantage and privilege regarding daily smoking contributes to an understanding of the situation for multiply marginalised groups, for example blue collar women. The findings may inform future public health interventions to reduce smoking habits.

    Key messages:

    • Acknowledging the complexity of disadvantage and privilege contributes to an understanding of daily smoking across multiply marginalised groups.

    • Blue collar women is a particularly important group to consider in public health efforts to reduce smoking.

  • 49. Larsson, E.
    et al.
    Kilander, H.
    Weinryb, M.
    Vikström, M.
    Petersson, Kerstin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    The Swedish study on improved contraceptive counselling for immigrant women postpartum2020In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 30, no Supplement_5, article id ckaa165.1068Article in journal (Other academic)
    Abstract [en]

    Contraceptive choices postpartum have not previously been studied in Sweden. Being foreign born is a risk factor for induced abortion. Improving postpartum contraceptive counseling could potentially fulfill unmet needs for contraception.

    This is an organizational case study using a Quality Improvement Collaborative (QIC) within the regular healthcare setting at 3 maternal health clinics in Stockholm. The active phase of the study was Sep2018-Sep2019. Quantitative and qualitative methods were combined. Routine registration of choice of postpartum contraception was introduced at the clinics and analyzed focusing on Swedish born and foreign-born women. Midwives and researchers met continuously, and during the active phase every 2-3 months in learning seminars with around 20 participants. During the learning seminars PDSA-cycles were used and areas of improvements for continuous performance measures were chosen. The midwives decided on and tested multiple evidence-based changes in contraceptive counselling and services during action periods. Goals were set and competency building in areas chosen by the midwifes were held. In addition, both foreign- and Swedish born women gave their input to the improvement areas. Qualitative data was analyzed through content analysis from field notes and verbatim transcripts.

    Preliminary results show that the proportion of women choosing an effective contraceptive method (SARC or LARC) among immigrant women increased from 40% to 55% when comparing the start and the end of the project. The midwives reported how they had changed their approach when counselling women who were skeptical about contraception and tried to find a new way to meet women's needs.

    As much as the QIC showed positive results, it was a small-scale study in 3 clinics in one geographical area. A larger study to determine and explain the effectiveness of QIC on the proportion of immigrant women choosing an effective contraceptive method postpartum is planned for 2021-2024.

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  • 50.
    Linander, Ida
    et al.
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS). Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Socialmedicin.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Johansson, Klara
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Which socio-economic measures are associated with psychological distress for men and women?: A cohort analysis2015In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 25, no 2, p. 231-236Article in journal (Refereed)
    Abstract [en]

    Background: There are contradictory results regarding whether there is a social gradient in common mental disorders or not, or if this relation differs for different indicators or by gender. We analysed the relation between various measures of socio-economic position and later psychological distress among men and women in a Swedish context. Methods: The study is based on data from the Northern Swedish Cohort (N= 1001, 93.5% response rate), a 27-year prospective study. Logistic regression was used to explore the relation between various indicators of socio-economic position at age 30 (occupation, education, financial strain, cash margin, unemployment and living primarily on social welfare or unemployment insurance) and psychological distress (age 42), controlling for earlier psychological distress (age 21) and parental occupational class. Register data were used to measure unemployment. All other variables were self-reported, and measured by a questionnaire. Results: Financial strain and living on social welfare or unemployment insurance at age 30 were associated with psychological distress at age 42 for men and women. Poor cash margin and unemployment were only associated with psychological distress in women, after controlling for potential confounders. Low occupational class and low education were not significantly related to later psychological distress. Conclusion: The two most commonly used measures of socio-economic position, occupation and education, were not significantly associated with psychological distress while other, less studied measures were. This study highlights the importance of measuring socio-economic position in several ways when studying common mental disorders, as well as to take gender into account.

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