Anneli Ivarsson

I stora delar av den offentliga sektorn försvåras prioritering av insatser eftersom forskning om insatsernas kostnadseffektivitet saknas. Ändå måste prioriteringsbesluten fattas. Hur kan beslutsunderlagen i denna situation bli bättre? I artikeln presenteras ett verktyg för att göra en rimlighetsbedömning avseende kostnadseffektiviteten av sådana insatser för barn och unga — Kalkylverktyg för insatser mot social utsatthet (KAMSO). Metoden och ett beräkningsexempel presenteras. Både den samhällsekonomiska kostnadseffektiviteten med vunna goda år som utfallsmått och de finansiella fördelningseffekterna beskrivs. Artikeln avslutas med en diskussion om utvecklingsmöjligheter för KAMSO.

Aim: To assesses the long-term cost-effectiveness of a population-based screening to detect social-emotional problems at 3-years-old combined with an evidence-based intervention to prevent mental health problems. Methods: A decision-analytic Markov model compares two alternatives 1) all 3-years-old get screened for social-emotional problems, and parents for children at a high risk receive a generic targeting parenting intervention 2) no screening and no intervention. The cohort of 3-year-old is modeled until they are 19 years old. The screening test is the ASQ:SE and the intervention was given to children with scores that suggest social-emotional problems. The model considered development of anxiety, conduct problems, and ADHD, over the 16 years. The analyses were done from a societal and healthcare perspectives. Health outcomes were assessed with DALYs averted. Results: Results suggest that the probability of population-based screening for social-emotional problems combined with the parenting intervention to high risk-children being cost-effective is high, adopting a societal and healthcare perspective, 98% and 97% each. From a societal perspective, the likelihood of cost saving is high, 85 %. The combination of screening and intervention strongly dominated the comparator. Conclusions: The findings align with previous research; prevention aimed at children’s mental health disorders will likely yield high investment returns. Successful implementation of population-based screening for social-emotional problems combined with an effective evidence-based parenting intervention might be an important way to contribute to sustainable and efficient mental health care. Key messages: • The impact of combining population-based screening with intervention is encouraging when considering a long-term view. • Prevention aimed at children’s mental health will likely yield high investment return.

Background: Social-emotional difficulties in early childhood are associated with a range of outcomes across the life course and are related to socioeconomic factors. The aim of this study was to examine intersectional inequalities in social-emotional problems in preschool children relating to their parents’ income, education and country of birth in addition to investigating the public health implications. Methods: This population-based study with a repeated cross-sectional design in the Västerbotten County of Sweden used the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) for children aged 3 in child health care services over the years of 2014-2018 and socio-economic information from national population registers. The effective sample of 8,823 individuals was analyzed using additive binomial regression in combination with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) approach to estimate risk differences for social-emotional problems across 27 intersectional groups and discriminatory accuracy. Results: Average risk differences generally increased in the groups where multiple dimensions of social inequality intersected, with risk differences as high as 18% (95% CI 8 to 28%) and 25% (95% CI 14 to 37%) compared to the most advantaged category. The discriminatory accuracy of all three included regression models was estimated as moderate, but improved in a slight but statistically significant way with the addition of social inequalities. Conclusions: This study increases our understanding of intersectional and social inequalities in social-emotional problems in preschool children. It supports the need for universal public health policies in addition to policies targeting more vulnerable groups when addressing this issue, consistent with the concept of proportionate universalism. An intersectional research perspective including discriminatory accuracy could increase our knowledge of health inequities and improve public health effectiveness. Key messages: • Intersecting dimensions of social inequalities are associated with an increased risk of social-emotional problems in children aged 3. • Universal public health policies are needed in addition to policies targeting vulnerable population groups with regards to social-emotional problems in young children.

Undervisning i global hälsa förekommer i olika former vid samtliga läkarutbildningar i Sverige, och på vissa håll har kursmoment med fokus på internationell hälsa funnits i över trettio år. I denna artikel presenteras utvecklingen av global hälsa vid Sveriges läkarutbildningar – från dåtid till nutid och framtid. Textbidrag har inkommit från respektive lärosäte och sammanställts av Helena Nordenstedt och Hampus Holmer.

Assessing disparities in health-related quality of Life (HRQoL) is important as a part of health-related disparities in the society. The aim of this study was to explore HRQoL among 12-year-olds in Sweden in terms of differences between years 2005 and 2009 and disparities related to sociodemographic background. During the school years 2005 and 2009, a total of 18,325 sixth grade students in Sweden were invited to a celiac disease screening study; 13,279 agreed to participate. Jointly with the celiac screening, the children answered a questionnaire that included EuroQol 5 Dimensions-youth (EQ-5D-Y) and their parents responded to separate questionnaires about their own and their child’s country of birth, family structure, their employment status, occupation, and education. In total 11,009 child-parent questionnaires were collected. Logistic regression was used to study differences in HRQoL between 2005 and 2009, and between various sociodemographic subgroups. Compared with 2005, children in 2009 reported more pain (OR: 1.20, 95% CI: 1.1–1.3) and more mood problems (OR: 1.35, 95% CI: 1.2–1.5). In general, girls reported more pain and mood problems and had more disparities than boys. There were no significant differences based on parents’ occupation, however, children of parents with low or medium education levels reported less “mood problems” than those of parents with high education levels (OR: 0.65, 95% CI: 0.46–0.92) and (OR: 0.84, 95% CI: 0.73–0.96), respectively. A slight variation was seen in HRQoL between children with different migration background. Girls living in small municipalities reported more pain (OR: 1.51, 95% CI: 1.14–2.01), and problems performing usual activities (OR: 3.77, 95% CI: 2.08–6.84), compared to girls living in large municipalities. In addition, children living with two parents had less mood problems than children living in other family constellations. More children reported pain and mood problems in 2009 compared with 2005. To study future trends, health outcomes among children in Sweden should continue to be reported periodically. More efforts should be invested to increase the awareness of health-related disparities as highlighted in this study especially for girls living in small municipalities and children of parents with high education level.

Socioeconomic inequalities in cardiovascular disease seem to widen or endure in Sweden. However, research on inequalities in antecedent cardiovascular risk factors (CVRFs), and particularly what underpins them, is scarce. The present study aimed 1) to estimate income-related inequalities in eight biological cardiovascular risk factors in Swedish middle-aged women and men; and 2) to examine the contribution of demographic, socioeconomic, behavioural and psychosocial determinants to the observed inequalities. Participants (N = 12,481) comprised all 40- and 50-years old women and men who participated in the regional Västerbotten Intervention Programme in Northern Sweden during 2008, 2009 and 2010. All participants completed a questionnaire on behavioural and psychosocial conditions, and underwent measurements with respect to eight CVRFs (body mass index; waist circumference; total cholesterol; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol; triglycerides; systolic/diastolic blood pressure; glucose tolerance). Data on cardiovascular risk, psychosocial and health behaviours were linked to national register data on income and other socioeconomic and demographic factors. To estimate income inequalities in each CVRF concentration indexes were calculated, and to examine the contribution of the underlying determinants to the observed inequalities a Wagstaff-type decomposition analysis was performed separately for women and men. Health inequalities ranged from small to substantial with generally greater magnitude in women. The highest inequalities among women were seen in BMI, triglycerides and HDL-cholesterol (Concentration index = − 0.1850; − 0.1683 and − 0.1479 respectively). Among men the largest inequalities were seen in glucose regulation, BMI and abdominal obesity (Concentration index = − 0.1661; − 0.1259 and − 0.1172). The main explanatory factors were, for both women and men socioeconomic conditions (contributions ranging from 54.8 to 76.7% in women and 34.0–72.6% in men) and health behaviours (contributions ranging from 6.9 to 20.5% in women and 9.2 to 26.9% in men). However, the patterns of specific dominant explanatory factors differed between CVRFs and genders. Taken together, the results suggest that the magnitude of income-related inequalities in CVRFs and their determinants differ importantly between the risk factors and genders, a variation that should be taken into consideration in population interventions aiming to prevent inequalities in manifest cardiovascular disease.

In many societies, growing up in a large family is associated with receiving less parental time, attention, and financial support. As a result, children with a large number of siblings may have worse physical and mental health outcomes than children with f

Implementing a parental support programme in a complex setting will benefit from being preceded by a thorough examination of the intervention and the target context and the development of clear implementation strategies based on the results of that examination. This study provides insights into how and by whom knowledge on implementation is applied during the launch of a health promotion programme, and these insights might help increase the rate of adoption and the use of such programmes and thereby increase their effectiveness.

It is well established that the pregnancy and the first years of life are important for future childhood health and body weight. Even though current evidence suggests that both parents are important for childhood health, the influence that parents’ BMI and socio-demography has on toddlers’ BMI has so far received little attention. This study aimed to increase our knowledge on the association between toddlers’ and parents’ BMI, in relation to family socio-demography. Further, the aim was to investigate the interaction between the mothers’ and fathers’ BMI in relation to their child’s BMI. A total of 697 children with a median age of 18 months (range 16-24 months) participated in the study along with their mothers (n = 697) and fathers (n = 674). As regards representability, our parental sample had a lower proportion of immigrants and the parents were more gainfully employed compared to parents in the rest of Sweden (when the child was 18 months old). The parents completed a questionnaire on parental and child health. Data on parental weight, height, and socio-demographics were recorded along with the child’s weight and height measured at an ordinary child health care visit. We used the thresholds for children’s BMI that were recommended for surveillance by the Royal College of Paediatrics and Child Health in 2012 based on the WHO reference population. Among the toddlers, 33 % had a BMI above the WHO 85th percentile and 14 % had a BMI above the WHO 95th percentile. The probability of a toddler having a BMI above the WHO 95th percentile was significantly increased if either the mother or father was overweight (BMI ≥ 25 kg/m2). Furthermore, we found a positive synergistic effect between the mother and father being overweight and their child having a BMI above the WHO 85th percentile. No associations were found between the toddlers’ BMI and the family’s socio-demographics, but there were associations between the parents’ BMI and the family’s socio-demographics. High BMI is common even in toddlers in this population. The risk increases if one parent is overweight, and it increases even more if both parents are overweight. The results in this study confirm the importance of considering familial risk factors when examining child health and BMI at ordinary child health care visits already at an early age.