[¼Death of despair« among young adults is most common in the sparsely populated regions in the north of Sweden]. / ¼Död av förtvivlan« är vanligare bland unga vuxna i skogslänen.

Case and Deaton have introduced the term ¼Death of Despair« to describe the increased mortality in the United States in young adults and middle-aged persons due to suicide and alcohol and drug use. A corresponding development is found in Sweden among young adults, in contrast to other parts of Western Europe. In Sweden, the disadvantageous development has been particularly evident in the sparsely populated regions in the north of Sweden. The explanation for the adverse development, both in the US and Sweden, might be the ongoing de-industrialization which especially affects young, low-educated men in sparsely populated areas.

The missing middle of childhood.

Middle childhood, between six and twelve years, is a critical bridge between earlier childhood and adolescence with rapid physical and psychological transitions. Most of the world's 2.6 billion young people, of which the middle childhood age group is a significant portion, live in low- and middle-income countries. Many live in environments that place them at high and growing risk for mental ill-health, injuries, and adoption of risky behaviours that often lead to non-communicable diseases in later years. Still, middle childhood, the 'missing middle,' is omitted from global health information systems, targeted policies, and strategies. The dearth of internationally comparable and standardised indicators on middle childhood in major international development agency databases hampers age-appropriate policy and programme development. Better understanding of the needs of this increasingly vulnerable population is critical. Middle childhood needs to be an explicit focus within child-focused research and implementation. Standardised, comprehensive, and relevant indicators are required to quantify the contribution of middle childhood to the global burden of disease and to facilitate interventions, monitoring, and evaluation, to ensure that all children flourish and thrive.

The Swedish intersectoral national public health policy: effects on child and adolescent health.

BACKGROUND: To improve health, intersectoral cooperation is often advocated. However, only few studies have reported health effects of this approach. Sweden has adopted a national public health policy (NPHP), which focuses on intersectoral primary prevention of disorders and injuries. AIM: To investigate the effects of the NPHP, on child and adolescent health in Sweden during the period 2000-19. METHODS: In the first step, the most important improvements in disorders and injuries, assessed as DALYs and incidences, were identified using the GBD Compare database. In the second step, primary prevention methods for these disorders and injuries were identified. In the third step, the relative importance of various government agents for these preventive measures was assessed using Google searches. RESULTS: Out of 24 groups of causes of disease or injury, only two groups demonstrated an incidence decrease: neoplasms and transport injuries. Leukaemia neoplasms might be prevented by reducing parental smoking, reducing outdoor air pollution and having the mother take folate supplements before getting pregnant. Transport injuries might be prevented by speed restrictions, and physically separating pedestrians from vehicle transport. Most of the primary prevention work was done by government agencies, like the Swedish Transport Agency, which worked independently of the National Institute of Public Health. CONCLUSION: Governmental agencies outside the health carried out most of the effective primary preventive efforts, almost independently of the NPHP.

Mortality trends for young adults in Sweden in the years 2000-2017.

AIM: Mental health problems in young people seem to be on the rise and more so in Sweden than in other locations. The aim was to compare the development of mortality rates for young adults in Sweden with Western Europe in total. METHODS: Young adults were defined as individuals aged 20-34 years and the study period was 2000-2017. Mortality data were derived from the Institute of Health Metrics and Evaluation. RESULTS: During the period 2000-2017, the mortality rate in young adults in Sweden stayed about the same, while in Western Europe as a whole the mortality rate decreased by 42%. The leading explanation for the unfavourable Swedish development was deaths due to drug use, mainly opioids, which increased by 60% during this period. The other major causes of death decreased both in Sweden and Western Europe, but decreased more slowly in Sweden. The differences in the rate of decrease between Sweden and Western Europe were for self-harm (27%), transport injuries (12%), unintentional injuries (31%) and for neoplasms (23%). The unfavourable development in Sweden resembled the development in the USA. CONCLUSIONS: The risks of four of the five leading causes of death in this age group were affected by the individuals' social conditions. The unfavourable mortality development in young adults in Sweden was mainly due to substance use. A contributing cause might be the change in the Swedish healthcare system that introduced competition between providers, which might have encouraged providers to prescribe opioids.

Methadone-related deaths among youth and young adults in Sweden 2006-15.

AIMS: To identify methadone-related deaths and determine the prevalence among youth and young adults in Sweden 2006-15. DESIGN, SETTING AND PARTICIPANTS: National retrospective registry study comparing data from all forensic autopsy examinations and toxicology cases involving methadone during 2006-15 in individuals aged 15-29 years with police records, previous pharmaceutical prescriptions and health-care episodes. MEASUREMENTS: Multinomial logistic regression. To assess the factors contributing to the deaths, we compared individuals with and without previous substance use treatment and opioid use-related diagnoses with regard to previous opioid agonist treatment (OAT), psychiatric care and previous pain medication. To assess the circumstances of deaths, we analyzed the presence of other drugs and other factors at time of death. FINDINGS: We identified 269 methadone-related deaths, and the rate increased during the study period. Seventy-two (27%) cases had not previously received substance use treatment, 112 (42%) had received treatment but had no opioid use-related diagnosis and 85 (32%) had received treatment and had an opioid use-related diagnosis. In total, only 10 individuals had been prescribed methadone during the year before death. Prescriptions of benzodiazepines (60%), antidepressants (62%) and opioids for pain (22%) the year before death were common. Most deaths occurred during sleep with a time lag from ingestion of methadone. CONCLUSION: Prescription opioid- and methadone-related deaths increased in the group aged 15-29 years in Sweden between 2006 and 2015. Exposure to non-prescribed methadone and prescribed benzodiazepines, antidepressants and opioids for pain appears to be common in drug-related deaths in youth and young adults in Sweden.

Cross-sectoral cooperation at the ministerial level in three Nordic countries - With a focus on health inequalities.

To reduce health inequalities requires interventions that address the social determinants of health. The responsibilities, at the ministerial level, for these determinants are mainly situated outside the ministry of health. Accordingly, interventions to reduce health inequalities require coordination between the ministry of health and other ministries. Yet, a large literature in public administration has demonstrated that cross-sectoral cooperation is hard to achieve. The goal of this paper was to examine whether inter-ministerial cooperation relating to the reduction of health inequalities is occurring in practice. Semi-structured interviews were performed with senior officials at 26 ministries in Finland, Norway, and Sweden. The interviews were analyzed both qualitatively and quantitatively. The point of departure was a question if the ministries had initiated substantial measures, such as reforms, regulations, funding, or fiscal strategies, aiming to promote health equity in the population and, if so, if this was done in cooperation with other ministries. The informants reported 80 measures intended to promote health equity and stated inter-ministerial cooperation for 65 of these measures. Many informants described that cooperation between the ministries was routine and well-functioning. Thus, there was no recorded lack of inter-ministerial cooperation. However, the measures that were reported, seemed to be insufficient to reduce health inequalities, both due to lack of extent and lack of effectiveness. This might be due to insufficient political commitment to tackle health inequalities. If so, the WHO Health in All Policies approach might not be effective.

Rural-urban mortality inequalities in four Nordic welfare states.

In the Nordic countries, there are ambitious welfare policies that might reduce rural-urban health disparities. AIM: To investigate the effect of population density on health in four Nordic countries. METHODS: The health outcomes analysed were life expectancy and potential years of life lost. The effect of population density was appraised as the difference in life expectancy/ potential years of life lost by a 10-fold increase of population density. RESULTS: In Finland, Norway and Sweden, mortality rates were consistently higher in less densely populated municipalities. These disparities increased over time. Conclusions: The welfare efforts to offset rural-urban disparities have mostly not been sufficient.

Unemployment among young people and mental health: A systematic review.

Aim: The aim of this systematic review is to obtain a better understanding of the association between unemployment among young people and mental health. Methods: After screening the title and abstract of 794 articles drawn from four electronic databases, 52 articles remained for full-text reading. Of these, 20 studies met the inclusion criteria and were assessed on methodological quality. All steps were performed independently by two reviewers. Finally, a total of 17 articles were included in the systematic review. Results: Analysis of cross-sectional studies (N = 5) showed an association between unemployment among young people and mental health. An effect of unemployment on mental health was found when considering cohort studies (N = 12) that did not control for confounders (7/7). When controlling for confounders except mental health at baseline, this effect decreased in most studies leading to mixed results, although the majority (6/8) still found an effect. However, when taking mental health at baseline into account as one of the confounders, only a minority of studies (3/8) found a significant effect of unemployment on mental health. Conclusions: This systematic review showed an association between unemployment among young people and mental health. However, whether there is a causal relationship is less clear. More evidence from, for example, natural experiments and longitudinal studies that control for confounding variables, especially mental health at baseline, is required to better understand the association and potential causation between unemployment among young people and mental health.

Antidepressant medication might increase the risk of self-harm injuries: findings in 17 OECD countries.

Clinical trials suggest that antidepressants increase the risk of self-harm injuries (SHI). The aim was to investigate associations between antidepressants' use and the rate of change of SHI in 17 countries over the period 2000-16, with initial levels of SHI taken into account. The rate of change of SHI seems mainly (81%) determined by initial rates. The rate of SHI decreased in most countries. The decrease was slower in countries with a high level of antidepressants' use and in countries with an increase of depressive disorders. The study indicates that the use of antidepressants might increase the risk of SHI.

Suicide rates in European OECD nations converged during the period 1990-2010.

PURPOSE AND METHODS: The aim of this study was to investigate, with multiple regression analyses, the effect of selected characteristics on the rate of decrease of suicide rates in 21 OECD (Organisation for Economic Co-operation and Development) nations over the period 1990-2010, with initial levels of suicide rates taken into account. RESULTS: The rate of decrease seems mainly (83%) to be determined by the initial suicide rates in 1990. In nations with relatively high initial rates, the rates decreased faster. The suicide rates also converged. CONCLUSION: The study indicates that beta convergence alone explained most of the cross-national variations.

Mortality rates in OECD countries converged during the period 1990-2010.

AIMS: Since the scientific revolution of the 18th century, human health has gradually improved, but there is no unifying theory that explains this improvement in health. Studies of macrodeterminants have produced conflicting results. Most studies have analysed health at a given point in time as the outcome; however, the rate of improvement in health might be a more appropriate outcome. METHODS: Twenty-eight OECD member countries were selected for analysis in the period 1990-2010. The main outcomes studied, in six age groups, were the national rates of decrease in mortality in the period 1990-2010. The effects of seven potential determinants on the rates of decrease in mortality were analysed in linear multiple regression models using least squares, controlling for country-specific history constants, which represent the mortality rate in 1990. RESULTS: The multiple regression analyses started with models that only included mortality rates in 1990 as determinants. These models explained 87% of the intercountry variation in the children aged 1-4 years and 51% in adults aged 55-74 years. When added to the regression equations, the seven determinants did not seem to significantly increase the explanatory power of the equations. CONCLUSIONS: The analyses indicated a decrease in mortality in all nations and in all age groups. The development of mortality rates in the different nations demonstrated significant catch-up effects. Therefore an important objective of the national public health sector seems to be to reduce the delay between international research findings and the universal implementation of relevant innovations.

The rate of country-level improvements of the infant mortality rate is mainly determined by previous history.

BACKGROUND: Studies of country-level determinants of health have produced conflicting results even when the analyses have been restricted to high-income counties. Yet, most of these studies have not taken historical, country-specific developments into account. Thus, it is appropriate to separate the influence of current exposures from historical aspects. METHODS: Determinants of the infant mortality rate (IMR) were studied in 28 OECD countries over the period 1990-2012. Twelve determinants were selected. They refer to the level of general resources, resources that specifically address child health and characteristics that affect knowledge dissemination, including level of trust, and a health related behaviour: the rate of female smoking. RESULTS: Bivariate analyses with the IMR in year 2000 as outcome and the 12 determinants produced six statistically significant models. In multivariate analyses, the rate of decrease in the IMR was investigated as outcome and a history variable (IMR in 1990) was included in the models. The history variable alone explained 95% of the variation. None of the multivariate models, with the 12 determinants included, explained significantly more variation. CONCLUSION: Taking into account the historical development of the IMR will critically affect correlations between country-level determinants and the IMR.

Revisión sistemática del efecto de las advertencias gráficas impresas en los paquetes de cigarrillos sobre el comportamiento de los fumadores / Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior

Aplicamos un método estructurado para evaluar si los fumadores activos a los que se les mostraban advertencias gráficas en los paquetes de cigarrillos tenían una probabilidad mayor de abandonar el hábito, reducir el consumo de cigarrillos o intentar dejar de fumar por comparación con fumadores no expuestos. Seleccionamos 21 artículos de entre casi 2500 publicados entre 1993 y 2013, dando prioridad a la cobertura sobre la pertinencia o la calidad porque preveíamos encontrar muy pocos estudios con resultados comportamentales. Observamos una heterogeneidad muy grande entre los estudios, una calidad metodológica deficiente o muy deficiente y resultados por lo general nulos o contradictorios con respecto a cualquier desenlace explorado. Los datos científicos a favor o en contra del uso de las advertencias gráficas son insuficientes, lo cual hace sospechar que cualquier efecto de estas sobre el comportamiento sería moderado. La determinación del efecto individual de las advertencias gráficas sobre el comportamiento requiere de estudios con diseños metodológicos sólidos y períodos de seguimiento más largos.

We used a structured approach to assess whether active smokers presented with pictorial warnings on cigarette packages (PWCP) had a higher probability of quitting, reducing, and attempting to quit smoking than did unexposed smokers. We identified 21 articles from among nearly 2500 published between 1993 and 2013, prioritizing coverage over relevance or quality because we expected to find only a few studies with behavioral outcomes. We found very large heterogeneity across studies, poor or very poor methodological quality, and generally null or conflicting findings for any explored outcome. The evidence for or against the use of PWCP is insufficient, suggesting that any effect of PWCP on behavior would be modest. Determining the single impact of PWCP on behavior requires studies with strong methodological designs and longer follow-up periods.

Mental health problems are rising more in Swedish adolescents than in other Nordic countries and the Netherlands.

UNLABELLED: Mental health problems increased in adolescents and young adults in Europe between 1950 and 1990, and the cause is largely unknown. Denmark, Finland, the Netherlands, Norway and Sweden form a relatively homogenous group of countries with favourable conditions for children. Our review examined the time trends for mental health problems in these countries between 1990 and 2010. CONCLUSION: In general, there were only small changes in mental health problems in the countries studied. However, we did note a marked rising trend in mental health problems among adolescents in Sweden, which also has more issues with school achievement and unemployment rates.

Might extended education decrease inequalities in health?-a meta-analysis.

BACKGROUND: Health is substantially worse in less educated people, and extended education might potentially improve their health. A prerequisite for a beneficial health effect of education is that the effect is absolute. An absolute effect of education means that the health effect comes about independently of any effect on other persons. A relative effect, on the other hand, only contributes to individual competitiveness in relation to others. Studies of natural experiments of extended compulsory education, and other educational-policy changes, provide an option for the analysis of absolute effects of education. Published studies, however, present conflicting results. METHODS: A meta-analysis was performed of European studies where the health effects of extended compulsory or secondary level education on low-educated individuals were investigated. RESULTS: Twenty-two relevant publications were identified. The meta-analysis indicated statistically significant favourable effects of educational reforms on rates of mortality, self-reported poor health and obesity. The effects were, however, small, 1-4%. CONCLUSIONS: An educational reform that typically added one educational year in the least educated group was associated with a mean 2.1% reduction in mortality in men before age 40. This effect might be compared with the total educational gradients of mortality rates in Swedish men at ages 30-64. One extra year of education after compulsory education corresponds to a 41% reduction in mortality, which is 20 times more than the absolute effect of education found in this meta-analysis. Thus, it unlikely that extended compulsory education will substantially improve the health of the least educated individuals.

[Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior]. / Revisión sistemática del efecto de las advertencias gráficas impresas en los paquetes de cigarrillos sobre el comportamiento de los fumadores.

We used a structured approach to assess whether active smokers presented with pictorial warnings on cigarette packages (PWCP) had a higher probability of quitting, reducing, and attempting to quit smoking than did unexposed smokers. We identified 21 articles from among nearly 2500 published between 1993 and 2013, prioritizing coverage over relevance or quality because we expected to find only a few studies with behavioral outcomes. We found very large heterogeneity across studies, poor or very poor methodological quality, and generally null or conflicting findings for any explored outcome. The evidence for or against the use of PWCP is insufficient, suggesting that any effect of PWCP on behavior would be modest. Determining the single impact of PWCP on behavior requires studies with strong methodological designs and longer follow-up periods.

School policies for preventing smoking among young people.

BACKGROUND: School tobacco policies (STPs) might prove to be a promising strategy to prevent smoking initiation among adolescents, as there is evidence that the school environment can influence young people to smoke. STPs are cheap, relatively easy to implement and have a wide reach, but it is not clear whether this approach is effective in preventing smoking uptake. OBJECTIVES: To assess the effectiveness of policies aiming to prevent smoking initiation among students by regulating smoking in schools. SEARCH METHODS: We searched seven electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO and ERIC. We also searched the grey literature and ongoing trials resources. The most recent search was performed in May 2014. SELECTION CRITERIA: We included cluster-randomised controlled trials (c-RCTs) in which primary and secondary schools were randomised to receive different levels of smoking policy or no intervention. Non-randomised controlled trials, interrupted time series and controlled before-after studies would also have been eligible. Cross-sectional studies were not formally included but we describe their findings and use them to generate hypotheses to inform future research. DATA COLLECTION AND ANALYSIS: We independently assessed studies for inclusion in the review, and present a narrative synthesis, as the studies are too limited in quality to undertake a formal meta-analysis. MAIN RESULTS: We found only one study which was eligible for inclusion in the review. It was judged to be at high risk of bias. The study compared two 'middle schools' from two different regions in China. The experimental conditions included the introduction of a tobacco policy, environmental changes, and communication activities, while the control condition was no intervention. After a year's follow-up the study found no differences in smoking prevalence between intervention and control schools. We also described 24 observational studies, the results of which we considered for hypothesis generation. In these, policy exposure was mainly described using face-to-face interviews with school staff members, and the outcome evaluation was performed using self-administered questionnaires. Most studies reported no differences in students' smoking prevalence between schools with formal STPs when compared with schools without policies. In the majority of studies in schools with highly enforced policies, smoking bans extended to outdoor spaces, involving teachers and including sanctions for transgressions, with assistance to quit for smokers plus support by prevention programmes, there was no significant difference in smoking prevalence when compared to schools adopting weaker or no policies. AUTHORS' CONCLUSIONS: Despite a comprehensive literature search, and rigorous evaluation of studies, we found no evidence to support STPs. The absence of reliable evidence for the effectiveness of STPs is a concern in public health. We need well-designed randomised controlled trials or quasi-experimental studies to evaluate the effectiveness of school tobacco policies.