The aftermath of COVID-19: Mortality impact of the pandemic on older persons in Sweden and other Nordic countries, 2020-2023.

AIMS: The COVID-19 pandemic hit Sweden harder than the other Nordic countries in the early phase, especially among older persons. We compared the impact of the COVID-19 pandemic on mortality especially among older persons during the period 2020-2022 in Sweden, Denmark, Finland and Norway, using four different outcome measures. METHODS: We compared publicly available information on reported cases and deaths in COVID-19 from the World Health Organization COVID-19 Dashboard, age-specific mortality rates, life expectancy at age 65 years and excess mortality from Nordic Statistics database and national statistics and health agencies in Sweden, Denmark, Finland and Norway. RESULTS: The pandemic peaked earlier in Sweden than in Denmark, Finland and Norway, where cases and deaths increased more during 2021 and 2022, also reflected in age-specific death rates among persons aged 70+ years. COVID-19 mortality was highest in Sweden, followed by Finland, Denmark and Norway. Life expectancy declined during 2020 in Sweden but more during 2021 and 2022 in Denmark, Finland and Norway. Excess mortality during 2020-2022 was nearly twice as high in Finland as in the other countries. CONCLUSIONS: COVID-19 mortality was higher in Sweden than in Denmark, Finland and Norway. Life expectancy declined during 2020 in Sweden, was partly regained in 2021 and 2022, while it declined during 2021 and 2022 in Denmark, Norway and Finland. However, excess mortality during 2020-2022 was similar in Sweden, Denmark and Norway and twice as high in Finland. Different mortality outcomes reflect the complexity of the mortality impact of COVID-19.

Mortality in Norway and Sweden during the COVID-19 pandemic 2020-22: A comparative study.

BACKGROUND: Norway and Sweden picked two different ways to mitigate the dissemination of the SARS-CoV-2 virus. Norway introduced the strictest lockdown in Europe with strict border controls and intense virus tracking of all local outbreaks while Sweden did not. That resulted in 477 COVID-19 deaths (Norway) and 9737 (Sweden) in 2020, respectively. METHODS: Weekly number of COVID-19 related deaths and total deaths for 2020-22 were collected as well as weekly number of deaths for 2015-19 which were used as controls when calculating excess mortality. During the first 12-18 months with high rate of virus transmission in the society, excess mortality rates were used as substitute for COVID-19 deaths. When excess mortality rates later turned negative because of mortality displacement, COVID-19 deaths adjusted for bias due to overreporting were used. RESULTS: There were 17521 COVID-19 deaths in Sweden and 4272 in Norway in the study period. The rate ratio (RR) of COVID-19 related deaths in Sweden vs. Norway to the end of week 43, 2022, was 2.11 (95% CI 2.05-2.19). RR of COVID-19 related deaths vs. excess number of deaths were 2.5 (Sweden) and 1.3 (Norway), respectively. RR of COVID-19 deaths in Sweden vs. Norway after adjusting for mortality displacement and lockdown, was 1.35 (95% CI 1.31-1.39), corresponding to saving 2025 life in Norway. If including all deaths in 2022, RR= 1.28 (95% CI 1.24-1.31). CONCLUSIONS: Both COVID-19 related mortality and excess mortality rates are biased estimates. When adjusting for bias, mortality differences declined over time to about 30% higher mortality in Sweden after 30 months with pandemics.

Identifying factors associated with good health and ill health : not just opposite sides of the same coin.

BACKGROUND: Work-related health research has traditionally focused on identifying risks rather than determinants of good health. Our knowledge of variation in ill health is thus greater than our understanding of such variations in good health. PURPOSE: In this study, the associations between work-environment exposures and good health are examined. We are especially interested in contrasting our indices of ill health with a narrow measure of good health. Moreover, the salutary effect of sense of coherence (SOC) is explored, focusing particularly on its moderating role. METHOD: Data stem from the panel of Swedish level of living surveys for 1991 and 2000. The analysis is based on a sample of 2,334 employed men and women. Logistic regressions are used. RESULTS: Assessed work-environment factors are to a large extent related, in a mirrored way, to good health and ill health. The models' fit are, however, generally better for the latter. Our findings also indicate that SOC has a protective role for individuals exposed to work risks such as stress and high physical demands. CONCLUSION: To improve our understanding of what promotes good health, research needs to focus on salutary factors. One such salutary factor explored in this paper is sense of coherence.

Intergenerational class mobility and cardiovascular mortality among Swedish women: a population-based register study.

Class inequalities in cardiovascular disease (CVD) mortality are well documented, but the impact of intergenerational class mobility on CVD mortality among women has not been studied thoroughly. We examined whether women's mobility trajectories might contribute to CVD mortality beyond what could be expected from their childhood and adult social class position. The Swedish Work and Mortality Data Base provided childhood (1960) and adulthood (1990) social indicators. Women born 1945-59 (N=791 846) were followed up for CVD mortality 1990-2002 (2019 deaths) by means of logistic regression analysis. CVD mortality risks were estimated for 16 mobility trajectories. Gross and net impact of four childhood and four adult classes, based on occupation, were analysed for mortality in ischemic heart disease (IHD), stroke, other CVD, - and all CVD. Differences between the two most extreme trajectories were 10-fold, but the common trajectory of moving from manual to non-manual position was linked to only a slight excess mortality (OR=1.26) compared to the equally common trajectory of maintaining a stable non-manual position (reference category). Moving into adult manual class resulted in an elevated CVD mortality whatever the childhood position (ORs varied between 1.42 and 2.24). After adjustment for adult class, childhood class had some effect, in particular there was a low risk of coming from a self-employed childhood class on all outcomes (all ORs around=0.80). A woman's own education had a stronger influence on the mortality estimates than did household income. Social mobility trajectories among Swedish women are linked to their CVD mortality risk. Educational achievement seems to be a key factor for intergenerational continuity and discontinuity in class-related risk of CVD mortality among Swedish women. However, on mutual adjustment, adult class was much more closely related to CVD mortality than was class in childhood.

Does intergenerational social mobility among men affect cardiovascular mortality? A population-based register study from Sweden.

BACKGROUND: Socioeconomic inequalities in cardiovascular mortality are well documented. The aim here is to examine the relation between childhood and adulthood class as well as the role of unique intergenerational social mobility trajectories in such mortality. METHODS: Data were obtained from Swedish registries. Childhood and adulthood information were from the 1960 and 1990 censuses. Men born 1945-59 (809,199) were followed-up for four cardiovascular mortality outcomes 1990-2002 (5533 deaths) by means of Cox regressions. Three different approaches were applied to study mobility between four main classes. RESULTS: In mutually adjusted models, the effect of a manual adulthood class (compared with non-manuals) was clearly larger (hazard ratios (HR) were 1.56 for MI, 1.70 for stroke, 1.64 for other cardiovascular disease (CVD), 1.62 for all CVD) as for a manual childhood class (1.38, 1.17, 1.24 and 1.28, respectively). This also applied to unclassifiable, while there were few systematic findings for self-employed. When adjusting for education level, childhood class was still significant for MI, other and all CVD, but adulthood class was significant for all outcomes. Trajectory-specific analyses revealed that mobile men from non-manual to manual had significantly higher mortality than mobile from manual to non-manual and stable non-manuals, but not significantly lower than stable manuals. CONCLUSIONS: Cardiovascular mortality was clearly structured by adulthood class, but not as consistently structured by childhood class. The mediating role of education suggests that a major part of life-course disadvantages or advantages in relation to CVD was due to achieved education.

Is the impact of job control on stroke independent from socioeconomic status?: a large-scale study of the Swedish working population.

BACKGROUND AND PURPOSE: The main purpose of this study was to test whether the impact of job control on stroke mortality is independent of socioeconomic factors. METHODS: This was a register-based cohort study of nearly 3.5 million working people (25 to 64 years of age in the 1990 Swedish Census) with a 5-year follow-up for stroke mortality. Job control was aggregated to the data from a secondary data source (job exposure matrix). Gender-specific Poisson regressions were performed. RESULTS: Compared with high job control occupations, low job control was significantly related to hemorrhagic (relative risk, 1.54; 95% CI, 1.10 to 2.17) and all-stroke mortality (relative risk, 1.50; 95% CI, 1.11 to 2.03) in women but not in men. The significance of job control in women was independent of all confounders included (marital status, education level, and occupational class). Class-specific analyses indicated a consistent effect of job control for most classes (significant for female lower nonmanuals). However, low job control did not increase the risk of stroke mortality in upper nonmanuals. CONCLUSIONS: Job control was significantly related to hemorrhagic and all-stroke mortality in women but not in men.

The contribution of maternal working conditions to socio-economic inequalities in birth outcome.

The aims of this study were to examine the association between maternal working conditions and birth outcomes, and to determine the extent to which these contributed to class inequalities in six birth outcomes. We used an existing job exposure matrix developed from survey data collected in 1977 and 1979 to apply occupational-level information on working conditions to the national Swedish Registry, including approximately 280,000 mothers and 360,000 births during the period 1980--1985. Data were analysed using multivariate logistic regressions. Low levels of job control, high levels of physical demands and job hazards were more common in manual compared to non-manual classes. The self-employed had intermediate levels of such exposures. Job exposures, particularly low levels of job control, were generally and significantly associated with higher risks for low birthweight, very low birthweight, small for gestational age, all preterm, very preterm and extremely preterm births, but not with mortality. Compared to middle non-manuals (the reference group), lower non-manual and manual classes had higher risks for all birth outcomes, and these risks were nearly all significant. The highest odds ratios were found for skilled and unskilled manual workers in the manufacturing sector, with ratios between 1.35 and 2.66 (all significant). Job control explained a considerable proportion of inequalities in all birth outcomes. Job hazards contributed particularly to very low birthweight and extremely preterm birth, and physical demands to low birthweight and all preterm births. In conclusion, class differences in maternal working conditions clearly contributed to class differences in low birthweight (explained fraction 14-38%), all preterm births (20-46%), very (14-46%) and extremely (12-100%) preterm births. For very low birthweight and small for gestational age, there was a similar contribution in the manufacturing sector only. For all birth outcomes, class differences could still be detected after working conditions were taken into consideration.

The societal cost of alcohol consumption: an estimation of the economic and human cost including health effects in Sweden, 2002.

This article estimates the societal cost of alcohol consumption in Sweden in 2002, as well as the effects on health and quality of life. The estimation includes direct costs, indirect costs and intangible costs. Relevant cost-of-illness methods are applied using the human capital method and prevalence-based estimates, as suggested in existing international guidelines, allowing cautious comparison with prior studies. The results show that the net cost (i.e. including protective effects of alcohol consumption) is 20.3 billion Swedish kronor (SEK) and the gross cost (counting only detrimental effects) is 29.4 billion (0.9 and 1.3% of GDP). Alcohol consumption is estimated to cause a net loss of 121,800 QALYs. The results are within the range found in prior studies, although at the low end. A large number of sensitivity analyses are performed, indicating a sensitivity range of 50%.

Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice.

STUDY OBJECTIVE: Education, income, and occupational class are often used interchangeably in studies showing social inequalities in health. This procedure implies that all three characteristics measure the same underlying phenomena. This paper questions this practice. The study looked for any independent effects of education, income, and occupational class on four health outcomes: diabetes prevalence, myocardial infarction incidence and mortality, and finally all cause mortality in populations from Sweden and Germany. DESIGN: Sweden: follow up of myocardial infarction mortality and all cause mortality in the entire population, based on census linkage to the Cause of Death Registry. Germany: follow up of myocardial infarction morbidity and all cause mortality in statutory health insurance data, plus analysis of prevalence data on diabetes. Multiple regression analyses were performed to calculate the effects of education, income, and occupational class before and after mutual adjustments. SETTING AND PARTICIPANTS: Sweden (all residents aged 25-64) and Germany (Mettman district, Nordrhein-Westfalen, all insured persons aged 25-64). MAIN RESULTS: Correlations between education, income, and occupational class were low to moderate. Which of these yielded the strongest effects on health depended on type of health outcome in question. For diabetes, education was the strongest predictor and for all cause mortality it was income. Myocardial infarction morbidity and mortality showed a more mixed picture. In mutually adjusted analyses each social dimension had an independent effect on each health outcome in both countries. CONCLUSIONS: Education, income, and occupational class cannot be used interchangeably as indicators of a hypothetical latent social dimension. Although correlated, they measure different phenomena and tap into different causal mechanisms.

Income differences in cardiovascular disease: is the contribution from work similar in prevalence versus mortality outcomes?

The objective of this research is to study the contribution of adverse working conditions to the association between income and cardiovascular disease (CVD), and to analyze differences across prevalence and mortality outcomes. Cross-sectional data from the Swedish Surveys of Living Conditions, 1996-1999 (N = 6,405), and longitudinal registry data for the period 1990-95 (10,916 CVD deaths) were used, including employed wage earners, aged 40-64. Working conditions were assessed through self-reports and imputed from a job exposure matrix, respectively. Multiple logistic and Poisson regressions were applied. There were strong associations between income and CVD. Those in the lowest income quartile had 3.6 (prevalence) and 2.1 (mortality) times higher risk of CVD, compared to those in the highest income quartile (with a gradient for the intermediate groups). In the survey, low job control and physical demands contributed 8-10% to the association between income and CVD prevalence. This contribution was 10% for low job control in the mortality follow-up. A small proportion of the association between income and the prevalence of or mortality from CVD is attributable to working conditions.

Health inequalities by wage income in Sweden: the role of work environment.

The main aim of this study was to explore the mediating role made by work environment to health inequalities by wage income in Sweden. Gender differences were also analysed. Data from the Swedish Survey of Living Conditions for the years 1998 and 1999 were analysed. Employed 20-64-year olds with a registered wage were included (nearly 6000 respondents). Sex-specific logistic regressions in relation to global self-rated health were applied. Those in the lowest income quintile had 2.4 times (men) and 4.3 times (women) higher probability of less than good health than did those in the highest quintile (adjusted for age, family status, country of birth, education level, smoking and full-time work). The mediating contribution of work environment factors to the health gradient by income was 25 per cent (men) and 29 per cent (women), respectively. This contribution was observed mainly from ergonomic and physical exposure, decision authority and skill discretion. Psychological demands did not contribute to such inequalities because mentally demanding work tasks are more common in high income as compared with low income jobs. Using sex-specific income quintiles, instead of income quintiles for the entire sample, gave very similar results. In conclusion, work environment factors can be seen as important mediators for the association between wage income and ill health in Sweden. A larger residual effect of income on health for women as compared with men suggests that one's own income from work is a more important determinant of women's than men's ill health in Sweden.

Does high income buffer the association between adverse working conditions and ill health?

AIM: A study was undertaken to analyse the possible interaction between work environment and income for the probability of self-rated health being less than good. METHODS: Data from the Swedish Survey of Living Conditions for the years 1998 and 1999 were analysed. Employed 20- to 64-year-olds with a registered wage were included (n=5982). The synergy index (SI) was applied, using odds ratios from logistic regressions for men, women, and all. Low and high levels of physical demands, decision authority, skill discretion and psychological demands were separately combined with low- and high-wage income (median split). Full-time work and four sociodemographic factors were controlled for. RESULTS: Significant synergy was found for women when they were exposed to low income and a low level of skill discretion (SI=1.46 [1.01-2.13]), although this was attenuated by education level (SI=1.47 [0.96-2.25]). In general (both sexes), poor health caused by low income and unfavourable work is additive rather than multiplicatively exaggerating the risk among the jointly exposed. CONCLUSION: Work exposures in the form of high physical load, low levels of decision authority and skill discretion, or a high level of psychological demands were significantly related to poor health also when income was high, suggesting that high income does not seem to buffer the detrimental effects of adverse working conditions. As nearly half of employed women were found to be in circumstances marked by synergy, it seems a relevant public health issue to improve these women's conditions at work, by simultaneously increasing, for example, job variety and wages.

Widening socioeconomic inequalities in mortality in six Western European countries.

OBJECTIVES: During the past decades a widening of the relative gap in death rates between upper and lower socioeconomic groups has been reported for several European countries. Although differential mortality decline for cardiovascular diseases has been suggested as an important contributory factor, it is not known what its quantitative contribution was, and to what extent other causes of death have contributed to the widening gap in total mortality. METHODS: We collected data on mortality by educational level and occupational class among men and women from national longitudinal studies in Finland, Sweden, Norway, Denmark, England/Wales, and Italy (Turin), and analysed age-standardized death rates in two recent time periods (1981-1985 and 1991-1995), both total mortality and by cause of death. For simplicity, we report on inequalities in mortality between two broad socioeconomic groups (high and low educational level, non-manual and manual occupations). RESULTS: Relative inequalities in total mortality have increased in all six countries, but absolute differences in total mortality were fairly stable, with the exception of Finland where an increase occurred. In most countries, mortality from cardiovascular diseases declined proportionally faster in the upper socioeconomic groups. The exception is Italy (Turin) where the reverse occurred. In all countries with the exception of Italy (Turin), changes in cardiovascular disease mortality contributed about half of the widening relative gap for total mortality. Other causes also made important contributions to the widening gap in total mortality. For these causes, widening inequalities were sometimes due to increasing mortality rates in the lower socioeconomic groups. We found rising rates of mortality from lung cancer, breast cancer, respiratory disease, gastrointestinal disease, and injuries among men and/or women in lower socioeconomic groups in several countries. CONCLUSIONS: Reducing socioeconomic inequalities in mortality in Western Europe critically depends upon speeding up mortality declines from cardiovascular diseases in lower socioeconomic groups, and countering mortality increases from several other causes of death in lower socioeconomic groups.

Alcohol-related deaths contribute to socioeconomic differentials in mortality in Sweden.

BACKGROUND: This study aims at estimating the contribution of alcohol to socioeconomic mortality differentials in Sweden. METHODS: Data were obtained from a Census-linked Deaths Registry. Participants in the 1980 and 1990 censuses were included with a follow-up of mortality 1990-1995. Socioeconomic status was assigned from occupation in 1990 or 1980. Alcohol-related deaths were defined from underlying or contributory causes. Poison regressions were applied to compute age-adjusted mortality rate ratios for all-causes, alcohol-related and other causes among 30-79-year-olds. The contribution of alcohol to mortality differentials was calculated from absolute differences. RESULTS: Around 5% (9,547) of all deaths were alcohol-related (30-79 years). For both sexes, manual workers, lower nonmanuals, entrepreneurs and unclassifiable groups had significantly higher alcohol-related mortality than did upper nonmanuals. Male farmers had significantly lower such mortality. The contribution of alcohol to excess mortality over that of upper nonmanuals was greatest among middle-aged (40-59 years) men who were manual workers or who belonged to a group of 'unclassifiable & others' (25-35%). It was of considerable size also for middle-aged lower nonmanuals (both sexes), male entrepreneurs, female manual workers and 'unclassifiable & others'. Among men, the total contribution of alcohol (30-79 years) was estimated at 16% for manual workers, 10% for lower nonmanuals and 7% for entrepreneurs; and among women, 6% (manual workers, lower nonmanuals) and 3% (entrepreneurs). CONCLUSION: Although deaths related to alcohol were probably underreported (e.g. accidents), alcohol clearly contributes to socioeconomic mortality differentials in Sweden. The size of this contribution depends strongly on age (peak among the middle-aged) and gender (greatest among men).