RE G I O NAL
C O MPARIS O NS 2014 REGIONALöppna COMPARISONS jämförelser 2014 P ublic Healt ublic h
Public Health
Regional Comparisons 2014 Public Health You are welcome to use quotes from the text or diagrams in the report, provided that you state the source, but you may not use the text in any commercial context. The National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions have the sole right to decide how this work may be used, in accordance with the Act (1960:729) on Copyright in Literary and Artistic Works (Copyright Act). Images, photographs and illustrations are also protected by the Copyright Act and you must have the copyright holder’s permission to use them.
National Board of Health and Welfare: Article number 2015-9-2, ISBN 978-91-7555-336-8
Photo: InaAgency (Cover). Production: Edita Bobergs AB Print: Edita Bobergs AB, september, 2015 Preface
The Swedish Government has commissioned the National Board of Health and Welfare, in conjunction with the Public Health Agency of Sweden and the Swedish Association of Local Authorities and Regions (SALAR), to develop and publish regional comparisons in the field of public health. The first report was published in 2009 and this is the second report in this field. The report pre- sents a number of new indicators in addition to those presented in 2009. The measurement and comparison periods have been chosen in order to make it possible to monitor what has happened since the report of 2009. The aim of this report is to contribute to improving public health by stimu- lating systematic improvement efforts in various organisations at the regional and local level. Together with its members, SALAR has undertaken a develop- ment process that will make work in the next stage easier once this report has been published. The work has led to an online toolbox that will be of assis- tance in the forthcoming analytical and improvement process. This commission has been executed by a project group consisting of Marianne Aggestam, Petra Sundlöf and Martin Lindblom from the National Board of Health and Welfare, Elisabeth Skoog Garås from SALAR and Marlene Makenzius from the Public Health Agency of Sweden. The steering group was made up of Mona Heurgren from the National Board of Health and Welfare, Ulrika Johansson from SALAR and Saman Rashid from the Public Health Agency of Sweden. The project group has received valuable feedback from the following experts throughout the process: Per-Olof Östergren, Professor of Social Epidemiology, Lund University; Bo Burström, Professor of Social Medicine, Karolinska In- stitutet; Margareta Kristensson, Professor in Social and Preventive Medicine, Linköping University and a Scientific Advisor to the National Board of Health and Welfare; Juan Merlo, Professor of Social Epidemiology, Lund University. In addition, several specialists from each of the organisations have provided valuable input. We would specifically like to thank all the representatives from county councils and municipalities who participated in the work to produce a new regional comparison of public health for 2014.
Lars-Erik Holm Håkan Sörman Johan Carlson Director General Director General Director General National Board of Swedish Association of Public Health Health and Welfare Local Authorities and Regions Agency of Sweden
Contents
New indicator Preface...... 3 Altered indicator
Summary ...... 9
INTRODUCTION...... 11
Aim...... 11
Limitations ...... 11
The report’s outline and appendices ...... 11
Regional comparisons public health ...... 12
What is an indicator? ...... 13.
MATERIAL, METHOD AND PROCEDURE...... 14
What do the comparisons show? ...... 14
Presentation of the data ...... 15
Confidence intervals ...... 15
Municipal reporting ...... 16
County and county council reporting...... 16
PUBLIC HEALTH ...... 17
What determines health?...... 17
Health equality ...... 18
Public health and sustainable development ...... 19
Strategic public health efforts at the regional and local level ...... 19
National public health policy perspective ...... 20
International public health policy perspective ...... 21
THE HEALTH OF THE POPULATION ...... 22
Overall health status ...... 22
1. Life expectancy ...... 22
2. Self-assessed general health ...... 27
3. Obesity...... 30
4. Dental health ...... 34
Incidence of disease ...... 37
5. Myocardial infarction ...... 37
6. Lung cancer ...... 41
Mortality...... 43
7. Policy-related avoidable mortality...... 43
8. Avoidable deaths from ischaemic heart disease...... 46 Mental ill-health ...... 48
9. Impaired mental well-being ...... 48
10. Regular treatment with soporifics or sedatives...... 52
11. Suicide and deaths involving uncertain intent ...... 56
Injuries...... 58
12. Injuries among children...... 58
13. Fall-related injuries among the elderly...... 60
SOCIAL CONDITIONS AND LIVING CONDITIONS ...... 63
The first years ...... 63.
14. Vaccination of children – measles-mumps-rubella (MMR) ...... 63
15. Children’s participation in preschool ...... 66
16. Teachers with formal training in preschools ...... 69
Education, work and self-sufficiency...... 72
17. Eligibility for upper-secondary school...... 72
18. Completed upper-secondary education...... 76
19. Young people who neither work nor study...... 79
20. Long-term unemployment ...... 83
21. Long-term assistance...... 86
Participation in society ...... 89
22. Turnout at elections...... 89 23. Inhabitants’ perceptions of their opportunity to influence
decision-making in the municipality ...... 91
Recreation and transport ...... 93
24. Access to footpaths and cycle paths...... 93
25. Access to parks, green spaces and the countryside...... 96
Safety and social relationships...... 98
26. Safe in school...... 98
27. Unsafe environment - individuals who avoid going out alone...... 100
28. Lack of trust in others...... 103
29. Problems relating to isolation among the elderly...... 106
Domestic violence...... 109
30. Surveying and collaboration...... 109
LIFESTYLE AND LIVING HABITS ...... 112
Physical activity...... 112
31. Sedentary leisure time...... 112
32. Regular physical activity for at least half an hour per day...... 116
33. Participation in activities arranged by sports clubs...... 120
Eating habits ...... 124
34. Consumption of fruit and vegetables...... 124 Tobacco use ...... 128
35. Daily smoking ...... 128
36. Tobacco use during pregnancy...... 132
Alcohol use ...... 135
37. Risky consumption of alcohol...... 135
Patient-reported experiences...... 139
38. Patients in primary care – discussing lifestyle and living habits...... 139
Sexual and reproductive health and rights...... 141
39. Cervical cancer screening ...... 141
40. Unprotected sex – chlamydia...... 143
41. Unprotected sex – teenage abortions...... 145
References...... 149
Appendix 1 Processing data from public health surveys...... 157
Summary 9
Summary
This report follows up on the indicators presented in Re- with different gender or educational backgrounds. gional Comparisons 2009 Public Health. The report contains • The proportion with impaired mental well-being was an indicator-based comparison of public health and re- increasing previously, but this increase appears to have flects different perspectives on public health in the form abated in several county councils and municipalities. of comparisons of the differences in outcomes between However, a higher proportion of women than men still municipalities and between county councils. report impaired mental well-being and the proportion of The results indicate that there are both similarities and younger people with impaired mental well-being has in- major differences between municipalities and between creased in the period 2007–2014. county councils in terms of social conditions, living con- • The prescription of soporifics and sedatives varies mark- ditions, lifestyle habits and health. The intention is that edly between different county councils and between this report will be used as a basis for continuous analyses municipalities. It is especially high among women with and systematic improvement by a range of regional and a low educational level. local public health bodies. Regional comparisons are de- • There are large variations around the country in the pro- scriptive in nature and contain no analysis or assessment portion of pupils who attain the qualifications neces- of the possible causes of differences in outcomes. sary for upper-secondary school and in the proportion of Over half of the indicators display an improved result at pupils who complete their upper-secondary education the national level compared with 2009. This year’s report within four years. also contains a range of new indicators concerning social • Long-term unemployment, measured as the proportion and living conditions for which the outcomes have not de- of the total population, has increased in almost all mu- veloped so favourably. A higher educational level often en- nicipalities when compared with 2009 and varies greatly tails fewer health risks at work, less financial vulnerability between different municipalities. and more influence over one’s own situation. A high edu- • Individuals’ perceptions of a safe and secure environ- cational level increases the chances of finding work and ment have a decisive impact on their well-being. In the of feeling a sense of social solidarity and participation in majority of counties and municipalities, the proportion society. Health inequalities are often the result of worse who avoided going out alone because they were afraid social and living conditions. of being assaulted, robbed or otherwise molested de- Some results in brief: creased. Considerably higher numbers of women than • The average life expectancy in Sweden continues to in- men avoided going out alone. crease, for reasons such as the morbidity and mortality • The population’s lifestyle and living habits vary between from cardiovascular diseases having reduced markedly. municipalities, between county councils and between However, there are relatively large variations within the groups with a low or high educational level. Lifestyle country. In addition, the increase in average life expec- and living habits have improved in several areas, which tancy has not been as large for all groups. Women who can also be deduced from the reduction in the incidence only have pre-upper-secondary education have shown of myocardial infarction and lung cancer. Nevertheless, the least improvement. the incidence of obesity has increased in the majority of • In the majority of county councils and municipalities, county councils and municipalities. there is a considerable proportion of individuals who feel that their health is good, as in previous measure- ments, but there are clear differences between groups 10 Regional Comparisons 2014: Public Health
In summary, the following results can be reported with • In the field of sexual and reproductive health, it appears respect to the population’s lifestyle and living habits: that the development of chlamydia is unchanged be- -- Physical activity has not changed appreciably over the tween the measurement periods. The number of abor- course of the two measurement periods. The results tions is decreasing among teenagers, which is a posi- from barely half of the county councils show a small tive trend, but there are large variations between county improvement. councils with respect to both abortions and chlamydia. -- Daily smoking has decreased in the majority of county councils and municipalities, but is still more common The comparisons in the report take into account differ- among women, particularly those with a low educa- ences between men and women and between groups with tional level. a low, medium or high educational level. In the majority -- Risky use of alcohol has decreased in the majority of of cases, the situation is worse for those with a low educa- county councils, but with large regional and local vari- tional level. This is especially true for women with a low ations. There is a clearer downward trend among young educational level, who often have the least favourable de- men, while the development for younger women has velopment over time in terms of health. not been so positive. -- For patients in primary care who report that they dis- cussed their lifestyle and living habits during a doctor’s appointment, the outcome is unchanged or somewhat worse than that of the previous measurement period, except for a number of county councils which show a positive development. Introduction 11
Introduction
This regional comparison was written primarily for poli- • function as a basis for development, improvement, ticians, officials and accountable managers on national, monitoring, analysis and learning in these organisations regional and local levels in Sweden. The report is directed • initiate local, regional and national analyses and discus- towards organizations and authorities responsible for im- sions concerning the quality and efficiency of these ser- proving health of the population. Due to this, some of the vices delivered by these organisations wording and terminology may, in an international con- • serve as a basis for management and governance. text, be a bit vague even though some clarifications have been inserted in this translation from Swedish to English. LIMITATIONS Regional comparisons for public health were reported It is important to emphasise that the indicators reported for the first time in 2009. This is the report for 2014, pub- here do not provide a complete picture of the field of pub- lished by the National Board of Health and Welfare in con- lic health. The ambition has been to identify important ar- junction with the Swedish Association of Local Authorities eas that have yet to be sufficiently highlighted. At the same and Regions (SALAR) and the Public Health Agency of Swe- time, there is a lack of available data, which often limits den. The starting point for this work has been the experi- the chances of making comprehensive comparisons. ence gained from 2009, something which is also expressed County councils and municipalities often have access to a in the government commission. Consequently, the major- considerably larger number of additional statistics that are ity of indicators reported in 2009 have also been followed not available or comparable at the national level. However, up in this comparison. At the same time the scope of this these local and regional data contribute to the continuous report has been expanded to encompass more indicators analysis of the indicators in this report. than in the previous report. Those added include a range of indicators concerning people’s social and living condi- THE REPORT’S OUTLINE AND APPENDICES tions. The first part contains background information with an The overall goal is for these regional comparisons of introduction, the aim of the commission and a discus- public health to function as an aid to the responsible prin- sion of the method. In addition, there is a description of cipals and providers within the welfare sector in their ef- public health and its context in relation to this report, the forts to promote good public health. In some of these areas role and responsibilities of the municipalities and county there are also guidelines or other evidence-based reports councils in the field of public health, public health policy that should form the basis for local improvement efforts and the factors determining health. and discussions. The National Board of Health and Wel- The second part of the report contains the results of the fare, SALAR and the Public Health Agency of Sweden have indicators presented in this report. This part is divided arranged seminars and regional discussions and have par- into three chapters: health in the population, social and ticipated in network and reference group meetings with living conditions and lifestyle and living habits. Each of representatives of municipalities and county councils these areas is described in more detail in the following in order to discuss areas that are of importance to public chapter on public health. Appendix 1 at the end of this re- health in Sweden, as well as proposals concerning indica- port describes how data from the national public health tors to include in the report. survey and the regional public health surveys in Värmland and Skåne have been processed. AIM The report’s table of contents indicates which indica- Regional comparisons for public health have to: tors have been altered or are new since Regional Compari- • contribute to openness and improved transparency in sons 2009 Public Health. publicly funded organisations and authorities responsi- The results in this report have been presented in a struc- ble for improving the health of the population ture that divides them into the following areas: health in 12 Regional Comparisons 2014: Public Health
the population, social and living conditions and lifestyle analyses with the aim of achieving good public health. habits. Indicators that in one way or another reflect health In 2011, SALAR undertook an evaluation directed at the status, how long we live, how we feel and how health is county councils’ public health chiefs and contacts for distributed among different groups in the population are strategic public health efforts in the municipalities. This collected in the section health in the population. Social showed that Regional Comparisons 2009 Public Health had conditions and living conditions are found in the subse- been received positively. Many of the contacts made use quent section. Social conditions encompass aspects that of specific initiatives to inform the media about the report relate to the social system in which the individual lives. and half stated that collaboration between municipality Living conditions are affected by social conditions and and county council functions well. They also valued the describe the prerequisites of the environment in which fact that, when possible, the reported data was distributed people live and work, i.e. the individual’s specific circum- on the basis of educational background. However, the stances that are affected by such things as the residential report had not stimulated any more extensive improve- environment, working environment and psychosocial en- ment efforts. The evaluation highlighted a desire for an vironment. The social conditions, and to some extend the increased focus on health equality, additional indicators living conditions, are often outside the individual’s im- based on the areas lifestyle habits and health outcomes, mediate control. Lifestyle and living habits, which is cov- as well as further process indicators. In conjunction with ered in the third section of the report, deals with specific the discussions with representatives from municipalities human behaviours in everyday activities over which the and county councils, there was a specific desire that this individual themselves has an influence, for example eat- resolve be reflected to the greatest possible extent in the ing habits, physical activity, tobacco and alcohol use and indicators, preferably through reporting in the form of sleeping and sexual habits. Society can also create good process indicators, in order to identify and monitor what conditions for individuals to make wise choices them- is taking place in these organisations. However, these de- selves with respect to their own lifestyle habits. Lifestyle sires have been difficult to realise as there is a lack of data habits are affected by the social conditions and living con- with national coverage. ditions [1, 2]. Representatives from county councils and municipali- ties have also participated in the work to produce this new REGIONAL COMPARISONS PUBLIC HEALTH regional comparison of public health for 2014, with net- The first report, Regional Comparisons 2009 Public Health, works containing both politicians and civil servants hav- contained 21 indicators in the areas social conditions, life- ing been involved in discussions in giving the work a firm style habits and health effects. The aim of the report was to grounding. One goal was to follow up the report from 2009 stimulate more detailed discussions and analyses in the with an inventory of possible new indicators in the field work to develop public health initiatives at the local and of public health at the national, regional and local level. regional level. Municipalities and county councils share Workshops were used to give representatives from mu- responsibility for public health, which underlines the nicipalities and county councils the opportunity to evalu- need for a well-developed partnership. The report would ate the proposed indicators and choose a number of new also function as an evidence base ahead of continuous indicators through prioritisation discussions. In total, 125
FIGURE 1: An image showing the process involved in the development of new indicators in discussions with representatives from municipali- ties and county councils:
Documentation concerning the indicators removed and the reasons for this
Follow-up of Regional Inventory and assessment indicators Continuous assessment Decision comparisons 2009 Public Health
Individual evaluation Synthesis evaluation and prioritisation and prioritisation into groups
Feedback from discussions at workshops and networking sessions Introduction 13
people from municipalities and county councils have par- • The indicator has to be accepted and evidence-based, e.g. ticipated in this work and a total of 175 proposed indica- based on guidelines, research, legislation, proven expe- tors have been dealt with in this process. This report now rience, consensus or evidence gathered from those it af- contains 41 indicators, equating to about twice as many fects (patients or users in other services). indicators as in 2009. • It has to be possible to influence the indicator so that All parties have strived to ensure that the indicators are principals or providers involved in delivering publicly relevant to public health and shed light on areas that are funded services in municipalities or county councils important to work on with the aim of improving outcomes have the ability to influence the indicator’s outcomes. in the field of public health. Each of the indicators has to • The indicator has to be measurable and it has to be pos- reflect important aspects in the field of public health. sible to measure using continuously collected data avail- able nationwide. WHAT IS AN INDICATOR? An indicator is something that can be measured and is It is also beneficial if the indicator meets the following used to demonstrate a status or a change in a larger system. criteria: Indicators are the tool that is used in the context of follow- • The indicator should have a target level, if possible. up and evaluation at the national level. The National Board • The indicator should cover the entire country and be of Health and Welfare has established a number of criteria possible to break down at different levels. This means an that provide support when adopting and developing indi- ambition to include all municipalities, county councils cators and differentiate these from other key figures and and units in a comparison, encompassing public provid- background variables [3]. The criteria have also served as a ers, as well as private and non-profit organisations with- guide in this commission and are as follows: in the scope of publicly funded services. • The indicator has to state a direction, i.e. that high or low • It should be possible to base the indicator on datasets values express high or low quality and/or effectiveness. that are produced by different stakeholders in the field. • The indicator has to be relevant and highlight an area that it is important to improve and that reflects some di- mension of quality and/or effectiveness in the outcome. • The indicator has to be valid, which means that it meas- ures that which it is intended to highlight and does so in a reliable way in a system that collects data in a similar way year after year. 14 Regional Comparisons 2014: Public Health
Material, method and procedure
Reports involving regional comparisons contain indica- an excess of indicators that focus on the adult population tor-based comparisons. This primarily means that data rather than children or the elderly. The reason for this is is processed in order to report an outcome in accordance that such data are more readily available at the local and with a defined indicator and through a number of differ- regional level. ent identified reporting levels. A presentation of compari- The main difference from the report of 2009 is that there sons at the national level implies stringent requirements are now more indicators that are concerned to a greater ex- on data quality. All data have to be of a good quality at both tent with people’s social and living conditions. the individual level and an overarching level encompass- ing all of the organisations and services involved. They WHAT DO THE COMPARISONS SHOW? also have to be well-developed with respect to their con- Public health is affected by a range of factors. The content tent, coverage and interpretability. Terms and concepts and focus of services are governed by the county councils’ that are used when gathering data have to be well-defined and municipalities’ various goals, priorities and allocation and structural and organisational differences have to be of resources; something which also affects public health taken into account in the production process. In addition, outcomes. On top of these, there are other factors with a data have to be presented in a statistically correct way considerable impact on public health that municipalities in order to protect the integrity of individuals. Regional and county councils have very little opportunity to influ- comparisons are descriptive in nature and the compari- ence. These include the structure of the regional and local sons are commented on so that the reader can more eas- population and socioeconomic circumstances in the form ily interpret the outcome. However, the texts contain no of the population’s educational level and income; fac- analyses setting out the causes of the differences that are tors that are strongly linked to lifestyle habits and health. demonstrated and they make no appraisal of the outcome. These conditions differ to varying degrees in different The next step involves improvement efforts at the regional county councils and municipalities. Other important fac- and local level. This is dependent not only on there being tors are the population density, the structure of the labour sufficient time for analysis and more detailed study, but market and the housing market. In other words, different often also on having sufficient knowledge about various county councils and municipalities have differing prereq- local circumstances that have affected the outcome. Rep- uisites with respect to encouraging good public health. resentatives of those involved in delivering these services A number of background variables are also presented in are in the best position to interpret and evaluate their own this report in order to make it easier to interpret and give a outcomes. greater understanding of the differences illustrated in the Each indicator is presented along with an indicator text comparisons. The background variables reported relate and an explanation of why the area is important to pub- to the structure of the population (size of the population, lic health and why the indicator is included in this report. gender distribution, average age, proportion born abroad) Following that, the data for the indicator are presented in and socioeconomic factors (proportion in paid work, me- diagrams. dian income, proportion with post-secondary education, The results are not to be seen as a comprehensive rating financial vulnerability among children and age). These of how good public health is in municipalities or county variables reflect a variety of conditions that may have some councils. Instead, the intention is to provide a view of the impact on why public health outcomes vary between dif- present situation based on a number of indicators, the ferent county councils and/or municipalities. data for which is sufficiently comprehensive to facilitate However, when comparing municipalities or county nationwide comparisons based on results at the regional councils, it is important to remember that socioeconomic and local level. The indicators have also been identified circumstances, primarily, vary more within, for exam- on the basis of public health policy target areas. When ple, a single county council than they do between county looked at on the basis of a life-long perspective, there is councils. For example, it is not uncommon for there to be Material, Method and Procedure 15
large differences in terms of average income and educa- Longer periods of time should be used for those indica- tional levels between areas encompassing major cities and tors for which there is only a small amount of data. This those in the countryside, something which is not evident is because the statistical uncertainty would be too great in the county council comparisons in this report. In the otherwise and there is a risk of the annual results jump- same way, two municipalities in the same county council ing up and down randomly. Consequently, a balance needs can have completely disparate socioeconomic conditions, to be struck between topicality and statistical certainty. To something that applies not least to municipalities in ma- the extent possible, taking into account the availability of jor city regions. data, the outcomes for indicators are presented in the re- When possible, the results section contains a presenta- port in accordance with the following: tion of the indicators based on inhabitants’ educational • comparisons of municipalities or county councils are background. Depending on the quality, data is presented classified by value at the national level over a long period of time. When the • the nationwide development over time information is available, trends for other groups in the • educational level population are also described. Further analyses at the lo- • distributed by age (in specific cases). cal and regional level can then be performed on the basis of knowledge of the circumstances in the municipality or In general, data distributed by gender are presented for county council in question. county councils, national trends and educational level. When making comparisons, it is also important to take into account the time between intervention and outcome, CONFIDENCE INTERVALS i.e. to be aware that the desired effects are usually only A confidence interval is an interval that, with a predeter- achieved in the long-term. mined level of certainty, encompasses the “true” value of, Finally, it is also advisable to bear in mind that the type for example, a proportion or an average. This is often used of comparison used within the scope of regional compari- in order to estimate the uncertainty of an estimated value sons – differences in average values between municipali- in the case of random samples. The upper and lower limits ties and/or county councils – is not entirely sufficient to for the interval within which there is a 95 per cent certainty allow a more detailed interpretation and assessment of the that the “true” value lies, are normally stated. For example, size of the differences indicated. Nor is it possible to draw this applies to the indicators based on sample surveys such any conclusions concerning whether the municipality or as “Health on Equal Terms” (HLV) and “National Patient county council has any considerable impact on individu- Survey” (NPE). The majority of diagrams show the 95-per als’ health on the basis of these data. Such an assessment cent confidence interval with a line at the bars or dots that requires further studies in the form of multi-level analyses show the value. The confidence interval states the statisti- that also take into account individual variation. However, cal uncertainty for an individual value and when there are this type of analysis is not within the scope of the work on few observations there is an increased scope for random regional comparisons. chance so the confidence interval increases Several of the comparisons in this report are, however, PRESENTATION OF THE DATA based on a random sample, rather than on the total num- In projects of this type, it is always desirable to present data ber of observations within a period of time. For example, that are as up-to-date as possible. It is also advantageous if this applies to diagrams based on the National Board of an indicator is designed so that the effect of improvement Health and Welfare’s health data register. In the case of is visible in the short-term, e.g. annual follow-ups. quality measurements and in conjunction with compari- Indicators and data presenting outcomes are classified sons, it is still the convention to state the statistical un- on the basis of indicator value, i.e. based on the desirable certainty as the outcome must be regarded as one of sev- direction. This normally means that a placement at the top eral possible outcomes of a process that involves a degree of the diagram represents a better outcome then a place- of random chance. It is then that the confidence interval ment lower down. This classification is also undertaken in describes the uncertainty because of this variation. The those cases in which the data is of a lower quality, the dif- importance of illustrating and taking into account the ran- ferences are small and there is greater random variation. dom variation is described in the report Ännu bättre vård For the majority of indicators, it is the case that the organi- – vad kan vi lära från variationen i öppna jämförelser [Even sations and authorities involved have the opportunity to Better Care – What Can We Learn From the Variation in Re- influence the outcome, but not entirely. There are many gional Comparisons] [4]. Please note that the confidence factors to take into account and the variations are often interval does not reflect any other uncertainty such as that due to differences in local and regional conditions. caused by insufficient registration or the fact that many young people did not respond to a survey. 16 Regional Comparisons 2014: Public Health
Municipal reporting County and county council reporting Data at the municipal level is presented classified by out- The report uses the terms county, county council and come in what are known as forest plot diagrams, i.e. as region. The texts describe the services or organisations dots with a confidence interval, with a reference line for concerned and for which the indicator is specifically in- the country. In cases where there is a comparison period, tended. Some indicators are intended more for specific the value for this is indicated with a grey dot. principals and/or the services they are involved in, but Municipal diagrams usually show data that is not dis- most concern more than one principal operating in the tributed by gender as there is too little information in same geographical area. With respect to data at the county many cases. However, the appendix contains indicator council level, the diagrams are structured as bar charts, data distributed by gender for municipalities for which classified by value and with one diagram for women and there are sufficient data. one for men, provided that the data are distributed by gender. Confidence intervals and previous comparison periods are shown in grey. A value for the national aver- age is stated in another colour than that of the bars for the county council. Public Health 17
Public health
The World Health Organization’s (WHO) definition states to the labour market often go along with poorer health and that health is a state of complete physical, mental and so- quality of life, which in turn have an impact on people’s cial well-being and not merely the absence of disease or in- opportunities and capabilities in life [11–17]. firmity [5]. Health encompasses four positive values: a long The work to make health equitable is set out in goals at var- life, healthy life, rich life and equitable life. The definition ious societal levels, in both a national and an international emphasises that good health is to be regarded as a resource perspective. There is also a large number of important for society and its individuals, not a goal in itself [6]. external factors contributing to the health of the popula- Public health, as opposed to the individual’s health, is a tion, for example how the economy and the labour market collective term for the health of the entire population. It are developing, as health is affected by social and living takes into account both the level and the distribution of conditions. In turn, health has an impact on opportunities health. Good public health should thus involve health be- to succeed in school, to access further education, to enter ing as good as possible at the same time as it is as equally the labour market and to develop social relationships. The distributed among different groups in society [7]. challenge is to create the conditions in which everyone Good and equally distributed public health is also cen- can enjoy a long life with good health, regardless of their tral to sustainable development as it is a result of a soci- socioeconomic circumstances [18]. ety’s social, economic and environmental development, For some time now, the development of health and wel- and a satisfactory distribution is also important for the fare has been monitored in a large number of municipali- future development of society [19]. ties using annual welfare reports. At the national level, it Public health is affected by many different factors and is often reported that inhabitants are feeling better and be- encompasses a range of different stakeholders in society; coming healthier, at the same time as the differences be- therefore, it is important to work in a way that crosses sec- tween groups with different social and living conditions toral boundaries. Work involving public health is also usu- are increasing. This has led to four major development ally conducted long-term as many circumstances interact projects for improving public health in Malmö, Region and individuals have varying prerequisites. The responsi- Västra Götaland and Östergötland, as well as in a further bility rests on both the public and the private sector, but twenty municipalities and county councils through SAL- voluntary organisations, not forgetting individuals them- AR’s collaboration with “Together Towards Social Sustain- selves, also have many opportunities to assist and contrib- ability”. Efforts at the local and regional level build on the ute to social development that promotes health [9, 10]. WHO report Closing the gap in a generation, which illus- In autumn 2008, the WHO published the report Closing trates the link between the factors in society that cause ill- the gap in a generation. This report maintains that the un- health and the unequal distribution of health in the popu- equal distribution of health is not a natural phenomenon, lation, the social determinants of health [19]. instead it can be regarded as “the result of a toxic combina- tion of poor social policies and programmes, unfair eco- WHAT DETERMINES HEALTH? nomic arrangements, and bad politics” [11]. The term determinant has come to be used in the discus- There is in all societies some form of social stratifica- sion of public health strategy to denote “factors that have tion, that is to say an unequal distribution of influence, an impact on public health”. There are many factors that resources and access to goods and services. The social interact at many different levels in society, for example position entails that the distribution of determinants var- where and how we live, which environment we live in, ies and results in different advantages and disadvantages childhood and upbringing, our education and our work. that also have an impact on our chances of enjoying good Determinants can both increase and decrease the risk of health. A low educational level, low income and weak links ill-health [2]. 18 Regional Comparisons 2014: Public Health
FIGURE 2. Health determinants, according to Dahlgren and Whitehead, 1991, modified by the Public Health Agency of Sweden [2].
Environment Societal economic strategies
Agriculture Education and foodstu s Recreation Tra c and culture Social Housing insurance Eating habits Narcotics Exercise Un- Social Sex and social employment services Children's relationships Alcohol contact with adults Sleeping Healthcare Working Social Social habits environment Tobacco support networks etc. etc.
Age, gender and inheritance
The majority of factors can be influenced, not least by the gap in a generation, it is vital that action is taken to political decisions in the fields of employment and edu- reduce health inequality when the causes are known and cation policy, while others deal with changes to lifestyle can be influenced and this can be done using reasonable and living habits relating to such aspects as smoking and interventions. The WHO’s independent commission on exercise. Although the individual’s own choices have a social determinants of health, known as the Marmot Com- great importance for their health, factors at the societal mission, concludes that “inequities in health, avoidable and structural level can create favourable conditions and health inequalities, arise because of the circumstances in supportive environments that facilitate good choices. which people grow, live, work, and age, and the systems Factors such as inheritance, gender and age also have an put in place to deal with illness”. The commission submit- impact on public health, but it is rarely possible to influ- ted three recommendations for reducing health inequities ence these. [8, 21]: • improve daily living conditions HEALTH EQUALITY • tackle the unequal distribution of power, money and re- In 1987, the National Board of Health and Welfare pub- sources lished its first public health report, which demonstrated • measure and understand the problem and assess the im- that there were large social differences in health. Twenty- pact of action. seven years have passed since this and on the whole, the population of Sweden has become healthier, but the large This and other commissions within the WHO on social de- social differences in health remain, regardless of age and terminants of health have guided the four regional and lo- gender. According to the latest public health report, they cal development projects in Sweden; the Malmö Commis- have also increased in certain respects [20]. There are cur- sion, Region Västra Götaland’s “Together Towards Social rently large differences in lifespan between those with Sustainability”, Östergötland’s commission and SALAR’s different educational levels and between genders. Social work. “Together Towards Social Sustainability – reduce differences in health can also be found within countries differences in health” [19]. and between countries, for example between the old EU This report focuses on presenting comparisons be- countries and the new ones in Eastern and Central Europe. tween municipalities and between county councils. The According to the report mentioned previously, Closing ambition is to report on both the level and the distribu- Public Health 19
tion of health. Income, occupational affiliation and educa- major changes to the financial system (the economic as- tional level are common variables used to measure equal- pect), which in turn has an impact on the distribution of ity, as is country of birth. The report presents data based resources (the social aspect) [19]. on educational level, when possible. This means that data Economic growth models are increasingly focussing are presented on the basis of the three educational levels on health as a variable that has a major impact on human pre-upper-secondary (in most cases, compulsory school), capital. Good public health contributes to sustainable de- upper-secondary and post-secondary education. Data velopment and economic growth [22, 23]. concerning education has been gathered from Statistics Sweden’s education registry for the population aged 25–74 FIGURE 4: The importance of health to economic growth. Source: Hälsoekonomi och folkhälsoarbete [Health Economics and Public Health years. Education has also been used in regional compari- Initiatives] sons of healthcare in order to reflect equality. Hopefully, measures that more fully reflect the individual’s social po- Lifestyle and living Productivity sition will be developed in future. Supply of labour habits Health The importance of reducing differences in health is il- Education Education Socioeconomics lustrated in a report from the European Commission in Capital accumulation which the economic consequences of health inequality are estimated at close to 10 per cent of GDP [17]. Healthcare Welfare system Economic growth PUBLIC HEALTH AND SUSTAINABLE Societal structure DEVELOPMENT Sustainable development is a term associated with the con- cept of public health. The term was used by the Brundtland There is a strong connection between ill-health and a weak Commission and is defined as “Development that meets local economy, and societies with high rates of ill-health the needs of the present without compromising the ability and absence from work due to illness have difficulty of future generations to meet their own needs” [22, 23]. achieving satisfactory economic development without At the societal level, the term sustainable development combating ill-health. Average life expectancy can be re- encompasses a range of aspects in three different areas: garded as an essential measure of how successful welfare economic, social and environmental. states are in creating the prerequisites for improved living conditions [24, 25].
FIGURE 3: The term sustainable development and its aspects STRATEGIC PUBLIC HEALTH EFFORTS AT THE REGIONAL AND LOCAL LEVEL The Swedish Government sets out in Bill 2007/08:110 Environmental [26] that certain health promotion interventions require collaboration encompassing all sectors with clear divi- sion of responsibility and goals. This bill also states that Sustainable the municipalities have a direct responsibility for public development health. The county councils are responsible for duties that Social Economic are common to large geographical areas and often require substantial financial resources. Regional development ef- forts become increasingly important as the regions gain greater importance in the work on sustainable develop- ment, where good public health also stimulates good The economic aspect encompasses factors linked to eco- growth. nomic resources, growth and development. The social An evaluation by the Swedish Agency for Public Man- aspect includes people’s needs, development and social agement from 2013 showed that the majority of the coun- resources, while the factors in the environmental aspect try’s municipalities and county councils believed that the involve external environmental conditions such as water, national public health goal guided their public health ef- air, natural resources and people’s interaction with these. forts [27]. Having a specific public health policy or plan The three aspects are interdependent and none is superior does not guarantee that public health initiatives will be to the others or can be regarded as an independent system. satisfactory, even though such a policy can provide sup- An unsustainable development in any of the aspects has port along the way in the work itself. Public health initia- an impact on the others. For example, overconsumption of tives can also be included in other comprehensive stra- natural resources (the environmental aspect) will require tegic documents in municipalities and county councils. 20 Regional Comparisons 2014: Public Health
The Public Health Agency of Sweden monitored how that ensure, for example, more children and young people municipalities and county councils had organised their complete their compulsory schooling with basic qualifi- public health initiatives. In the majority of county coun- cations and the admission requirements for further stud- cils, public health was included in comprehensive plan- ies, there are more opportunities for physical activity in ning documents and around half of the county councils schools, open preschools and family centres are available also had a specific public health policy or strategy. Among or various forms of parental support are offered. the municipalities, it was common for public health to be included in goal documents and half had a public health NATIONAL PUBLIC HEALTH POLICY policy, strategy or action plan. PERSPECTIVE The county councils are responsible for healthcare, In autumn 2000, the National Committee for Public Health which is an arena involving a great deal of contact with submitted its final report Hälsa på lika villkor nationella citizens and patients. Thanks to this, it has been possible mål för folkhälsan. [Health on equal terms-national public to build up a wide-ranging expertise and knowledge of health goals] [31] to the Government. In spring 2003, the public health problems. The Health and Medical Services Riksdag adopted an overall national goal and eleven target Act states that the goal of the healthcare system is good areas for public health efforts as a whole [32]. health on equal terms for the entire population. There also The overall goal of Sweden’s public health policy is to has to be an effort to prevent ill-health and to ensure that create the societal conditions for good health on equal “those who turn to the healthcare system must, when ap- terms for the entire population. This means that the un- propriate, be provided with information about methods of equal distribution of health between and within different preventing disease or injury” [28]. groups is regarded as a key problem. The bill [32] stress- A healthcare system that promotes health aims to im- es the need for coordinated public health reporting that prove the population’s health, as well as the individual’s makes it possible to monitor the policy by analysing and health and health-related quality of life [29]. This involves assessing the effects of the initiatives in the eleven objec- a broad view of healthcare and not one that simply focuses tive domains. The benefit of using determinants as a basis on the treatment of disease. Sweden’s 290 municipalities is that the goals are brought within the reach of political are responsible for a large proportion of the community decisions and can thus be influenced by various societal services provided in the places we live. The municipality initiatives [18, 33]. has a statutory responsibility for certain services such as In spring 2008, the Government chose to clarify the ob- childcare and preschool activities, schools, care of the el- jective domains in the bill En förnyad folhälsopolitik [A re- derly, social services, planning and building matters, wa- newed public health policy] [26]. The intent was to make it ter and sewerage and waste management [9, 10, 30]. The clear that the objective domains are not to be perceived as municipality can decide itself whether it wishes to pro- goals in themselves, but the overall structure of the goals vide other services such as housing, energy, recreational was preserved. In 2012, a communication arrived clarify- activities, cultural activities and services for the enterprise ing that the individual is to have more support in manag- sector. ing their own health through an effective collaboration be- The county administrative board is the Government’s tween public, private and civil society stakeholders. This representative in the 21 counties and has to ensure that the clarification of the policy rests on five important founda- county achieves the goals set by the Riksdag and the Gov- tions: ernment, while taking into account circumstances in the • start – good conditions in which children and young county. With respect to the health promotion and disease people grow up prevention initiatives employed by the county councils, • support – that makes healthy choices easier the aim, in the case of disease prevention, is to reduce risk • protection – effective and secure protection against factors, while health promotion aims is to improve access threats to health to factors that are protective and promote wellness [29]. • collaboration – collective responsibility for good health It can be beneficial to expand and adapt these terms to • strong evidence-based governance – spread knowledge suit other activities in addition to healthcare as the work about methods that work of many principals in the welfare sector involves public health. This then involves working with initiatives and The overall public health goal involves the conditions interventions that aim to prevent the emergence of or af- for health and the distribution of health. The objective fect the course of diseases, injuries or physical, mental or domains build on the determinants of health are based social problems. on the eleven overall objective domains for public health In terms of municipal activities, this can equate to adopted by the Riksdag in 2003 [32]. health promotion or disease prevention interventions Public Health 21
THE NATIONAL PUBLIC HEALTH GOAL: INTERNATIONAL PUBLIC HEALTH POLICY Creating the societal conditions for good health on equal PERSPECTIVE terms for the entire population. The health problems that rich and poor countries have are becoming increasingly similar and they have to be solved. The eleven national objective domains for Sweden’s public The WHO appointed the Commission on Social Determi- health policy are: nants of Health in 2005 [17], charged with investigating 1. participation and influence in society opportunities to achieve health equality and act to ensure 2. economic and social prerequisites global mobilisation. While this work took place several 3. secure and favourable conditions during childhood countries and bodies have joined the Commission as part- and adolescence ners, Sweden among them. The Commission encourages 4. health in working life the WHO and all governments to initiate global interven- 5. environments and products tions that have an impact on the social determinants of 6. health-promoting health services health, with the aim of achieving health equality. 7. protection against communicable diseases Many countries have national public health goals and 8. sexuality and reproductive health public health policy strategies. As time has gone by, there 9. physical activity has been a transition from traditional public health policy 10. eating habits and food to what is known as “The New Public Health” [28]. Swed- 11. tobacco, alcohol, illicit drugs , doping and gambling. ish public health policy is one example of this and places a great deal of focus on the social environment’s importance for public health. The Swedish model is a breakthrough for The public health policy is trans-sectoral and concerns this new way of thinking and is sometime called the third several policy areas, for example education, integration, wave of a public health revolution [37]. This development gender equality, employment, ageing and family [35]. involved the focus being moved from the individual’s Consequently, public health efforts need to have many health resources and prerequisites to issues concerning points of contact with other policy areas. In 2013, the Pub- access to healthcare, the environment, political govern- lic Health Agency of Sweden [28] conducted a follow-up of ance and social and economic development [38]. public health policy at the regional and local level and the Internationally, various different indicators and defini- results indicated that public health policy was facilitated tions are used to measure and monitor public health with- by systematic public health efforts by the majority of the in and between countries over time. It is therefore difficult municipalities, county councils and regions that respond- to compare statistics from different countries. The quality ed. Public health policy is used as a tool for prioritising of international statistics varies with countries’ oppor- initiatives, often in collaboration with other public health tunities to report in accordance with the definitions and stakeholders. However, the overall goal and the eleven ob- with how the statistical terms are interpreted. Variations jective domains are more frequently used in the planning can also be down to the organisations asking for differing of public health initiatives than when following them up, content for the same activity. The EU, the OECD and the making it difficult to follow up efforts in a systematic way. WHO are working to improve the quality of the statistics There is a desire at the local and regional level for clearer by harmonising definitions and the collection of statistics interim goals for public health efforts and further develop- in several areas [39]. ment of the monitoring system [28, 36]. The WHO’s latest review of health differences in Europe The Swedish Agency for Public Management’s evalu- indicates that there is still much to do, even in Sweden. ation of the monitoring system for the national public We have dropped behind in a number of structural under- health policy concluded that it contained deficiencies. lying factors for health and are now lagging behind from These included a lack of interim goals for the national a Nordic perspective when it comes to relative economic public health policy, that there were far too many moni- vulnerability among children, youth unemployment, un- toring indicators and that this made it harder to assess employment among those born abroad and obesity, for whether the national public health goal is achievable [27]. example. Sweden also has the largest differences among individuals with different educational levels among the Nordic countries [21]. 22 Regional Comparisons 2014: Public Health
The health of the population
In recent decades, the health of the population has im- improved treatment methods result in fewer people be- proved substantially. Together with improved lifestyle coming ill and dying [20, 41]. The increased educational habits, the reduction in mortality from a number of causes level of the population as a whole has probably also made of death has contributed to average life expectancy having an important contribution to the increased average life ex- increased. At the same time, it is clear that there has been a pectancy. deterioration in the health trend with respect to the popu- Average life expectancy is reported as the estimated re- lation’s mental health. The social differences in health maining average life expectancy at birth by gender in the have also remained unchanged. period 2009–2013 for people born in Sweden. The esti- mates are based on the risks of death for each year of age. OVERALL HEALTH STATUS The health trend in the population has a fundamental im- portance to overall societal development and also has an F 1.1 – : Average life expectancy at birth. impact on the need for healthcare. Average life expectancy Year 90 and self-assessed general health are two measures that are often used to describe health in general terms and they also paint a picture of the health trend. 85 Dental health and the incidence of obesity in the popu- lation are examples of other indicators that provide some insight into the general state of health, not least due to their strong link to lifestyle and living habits (eating habits 80 and physical activity) and utilisation of healthcare.
1 . LIFE EXPECTANCY 2005–2009 2006–2010 2007–2011 2008–2012 2009–2013 Year Average life expectancy is a general measure that is often Women Men
used to describe health. It can be regarded as an important Source: Population Statistics, Statistics Sweden. measure of how successful welfare states are in creating the prerequisites for improved social and living condi- tions and health. This also reflects how the healthcare For people born 2009–2013, the remaining average life system is able to contribute to increase life expectancy for expectancy is estimated at 83.6 for women and 79.7 for the population through disease prevention and treatment. men. However, there are differences within the country. International comparisons of average life expectancy The differences in average life expectancy between county show that Sweden is among the best in the world. Swed- councils are a maximum of about two years for both wom- ish men live almost the longest of all men – only those in en and men. Iceland, Switzerland, Japan and Australia live longer [40]. There are also large differences in remaining average life Swedish women also live a long time, but, in addition to expectancy between individuals with different education- the countries above, there are a few countries in Southern al levels. In the period 2000–2013, the remaining average Europe that have a higher average life expectancy. life expectancy has increased for all educational groups. Average life expectancy in Sweden is still continuing to However, the increase has not been as large for all groups. increase slowly. In recent decades, it is the reduced mor- Men with upper-secondary education have seen the most tality from cardiovascular diseases (primarily myocardial favourable development, with the remaining average life infarction and stroke) that has made the greatest contri- expectancy at 30 years of age, increasing from 49.0 to 51.2 bution to this increase. Improved lifestyle habits (less years. It has increased least for women with only pre-up- smoking and lower cholesterol and blood pressure) and per-secondary education, from 50.9 to 51.4 years. The dif- The Health of the Population 23
1.2 – . . : Average life 1.3 – . . : Average life expectancy expectancy at 30 years old. at 30 years old. Year Year 60 60
55 55
50 50
00 01 02 03 04 05 06 07 08 09 10 11 12 13 00 01 02 03 04 05 06 07 08 09 10 11 12 13 Year Year Pre-upper-secondary Upper-secondary Post-secondary Pre-upper-secondary Upper-secondary Post-secondary Source: Population Statistics, Statistics Sweden. Source: Population Statistics, Statistics Sweden.
ferences in life expectancy between individuals with low The county councils are responsible for ensuring that and high levels of education are, in total, five years. good healthcare is provided on equal terms and for pre- Factors that have an impact on average life expectancy ventative efforts such as supporting the individual in their are found at the overarching societal level, in the form of choices with respect to diet and exercise habits, for exam- general prerequisites for a good life – as well as at the in- ple. The municipalities’ role covers pretty much all areas dividual level in the form of individual lifestyle choices. of social policy. For example they are actively involved in Many actors have the opportunity to influence average urban and regional planning and housing policy in order life expectancy and they are found at many different levels to create the prerequisites for health-promoting housing in society. The interventions encompass everything from and local environments, in employment policy through legislation to more individually focused measures such as employment initiatives, and in educational initiatives information campaigns and help with smoking cessation. that promote a good school environment. 24 Regional Comparisons 2014: Public Health
F 1.4 – , : Average life expectancy at birth, 2009–2013.
Halland 84.5 Kronoberg 84.3 Stockholm 84.1 Uppsala 84.0 Jönköping 83.8 Blekinge 83.7 Skåne 83.7 SWEDEN 83.6 Västra Götaland 83.5 Västmanland 83.5 Östergötland 83.4 Kalmar 83.3 Dalarna 83.3 Jämtland 83.2 Norrbotten 83.2 Värmland 83.2 Örebro 83.1 Sörmland 83.0 Västerbotten 83.0 Gotland 82.9 Gävleborg 82.7 Västernorrland 82.6
72 74 76 78 80 82 84 86 88 90
2009–2013 2006–2010 Year Source: Population Statistics, Statistics Sweden.
F 1.5 – , : Average life expectancy at birth, 2009–2013.
Halland 80.6 Uppsala 80.6 Kronoberg 80.6 Jönköping 80.2 Stockholm 80.2 Östergötland 80.0 Dalarna 79.8 Västra Götaland 79.8 Skåne 79.7 SWEDEN 79.7 Västmanland 79.6 Gotland 79.5 Blekinge 79.4 Västerbotten 79.4 Kalmar 79.4 Jämtland 79.3 Sörmland 79.1 Örebro 79.0 Värmland 78.9 Gävleborg 78.8 Västernorrland 78.5 Norrbotten 78.5
72 74 76 78 80 82 84 86 88 90
2009–2013 2006–2010 Year Source: Population Statistics, Statistics Sweden. The Health of the Population 25
1.6 – ¡¢£¤¥¦§¨, ª«¡¢: Average life expectancy at birth, 2009–2013.
Lidingö Ovanåker Sala Torsby Danderyd Hultsfred Uppvidinge Trosa Vadstena Kävlinge Torsås Nykvarn Båstad Stockholm Östersund Älvkarleby Täby Ängelholm Örnsköldsvik Vårgårda Markaryd Enköping Dorotea Pajala Tyresö Hörby Norrtälje Berg Kungälv Västerås Nyköping Kalix Vaxholm Värmdö Osby Filipstad Ydre Mörbylånga Skurup Ljungby Åmål Hallstahammar Karlskoga Tranemo Söderköping Strömsund Härjedalen Falkenberg Kristianstad Uddevalla Boden Partille Habo Vara Sundsvall Ekerö Karlskrona Alingsås Bromölla Simrishamn Mora Österåker Lekeberg Sollentuna Falköping Mjölby Ale Lund Mullsjö Sunne Sandviken Vellinge Orust Hallsberg Vilhelmina Tingsryd Strömstad Årjäng Karlsborg Boxholm Skövde Göteborg Ljusdal Kil Köping Malmö Oxelösund Vallentuna Storuman Mellerud Älvdalen Lomma Östhammar Tibro Perstorp Laholm Håbo Aneby Essunga Lerum Hässleholm Nordanstig Sjöbo Svedala Lidköping Ludvika Norrköping Tomelilla Järfälla Mölndal Mariestad Forshaga Högsby Rättvik Trelleborg Malå Varberg Gnesta Botkyrka Landskrona Kungsbacka Åre Dals-Ed Surahammar Nacka Älvsbyn Storfors Sävsjö Ulricehamn Vaggeryd Eskilstuna Söderhamn Upplands-Bro Bollebygd Kungsör Vindeln Leksand Örkelljunga Arvika Ragunda Tranås Karlshamn Götene Vingåker Öckerö Lessebo Skinnskatteberg Avesta Mark Härnösand Åstorp Gullspång Emmaboda Nordmaling Vänersborg Malung-Sälen Solna Bräcke Lycksele Trollhättan Höör Örebro Krokom Hedemora Linköping Huddinge Grästorp Nynäshamn Värnamo Nora Haninge Arjeplog Älmhult Gislaved Kristinehamn Degerfors Tanum Karlstad Oskarshamn Lilla Edet Växjö Vetlanda Borlänge Lindesberg Kinda Vimmerby Skellefteå Vännäs Bjurholm Åtvidaberg Norberg Hudiksvall Gagnef Borgholm Västervik Östra Göinge Eda Gällivare Haparanda Hagfors Halmstad Sölvesborg Övertorneå Töreboda Tjörn Eksjö Gnosjö Katrineholm Lysekil Burlöv Gotland Kiruna Upplands Väsby Munkfors Hammarö Bjuv Uppsala Salem Kumla Fagersta Ödeshög Jokkmokk Strängnäs Hällefors Klippan Umeå Eslöv Hofors Stenungsund Knivsta Motala Vansbro Falun Smedjebacken Sotenäs Arboga Olofström Tierp Bengtsfors Finspång Herrljunga Sundbyberg Bollnäs Robertsfors Jönköping Helsingborg Skara Mönsterås Luleå Tidaholm Nybro Timrå Arvidsjaur Borås Gävle Sollefteå Överkalix Nässjö Hjo Ånge Höganäs Ystad Säter Kramfors Flen Kalmar Södertälje Orsa Heby Ronneby Valdemarsvik Grums Härryda Sorsele Munkedal Åsele Svalöv Alvesta Ockelbo Ljusnarsberg Sigtuna Färgelanda Piteå Svenljunga Hylte Askersund Laxå Norsjö 70 75 80 85 90 70 75 80 85 90 70 75 80 85 90 70 75 80 85 90 Year SWEDEN 2009–2013 2006–2010
Source: Population Statistics, Statistics Sweden. 26 Regional Comparisons 2014: Public Health
¡ 1.7 – £¤¥¦§¨©¡ª, £¡¤: Average life expectancy at birth, 2009–2013.
Danderyd Götene Gotland Åtvidaberg Täby Åre Munkedal Kristinehamn Ekerö Jönköping Luleå Norsjö Bollebygd Boxholm Hjo Nybro Tjörn Jokkmokk Strängnäs Lilla Edet Lidingö Dals-Ed Öckerö Lysekil Dorotea Gagnef Mjölby Eskilstuna Kungälv Oskarshamn Orsa Landskrona Lerum Tidaholm Tibro Sorsele Laholm Norberg Vänersborg Sundsvall Österåker Upplands-Bro Katrineholm Ånge Sollentuna Heby Kinda Sjöbo Hässleholm Arjeplog Sundbyberg Salem Höganäs Örkelljunga Töreboda Knivsta Partille Lycksele Skinnskatteberg Rättvik Svedala Älmhult Hudiksvall Lund Vindeln Nynäshamn Karlskoga Ovanåker Umeå Hedemora Bengtsfors Växjö Nyköping Karlskrona Strömstad Vellinge Valdemarsvik Haninge Vara Kungsbacka Herrljunga Tanum Härjedalen Båstad Uddevalla Helsingborg Emmaboda Uppsala Eksjö Hörby Södertälje Uppvidinge Vaxholm Trelleborg Filipstad Linköping Gislaved Örebro Hällefors Järfälla Sävsjö Finspång Sandviken Kävlinge Nykvarn Robertsfors Kiruna Åstorp Vimmerby Norrtälje Bräcke Torsås Sunne Orust Bromölla Ystad Bjurholm Nacka Säter Botkyrka Bollnäs Falkenberg Värmdö Eda Nordmaling Kungsör Ödeshög Gävle Klippan Håbo Enköping Kalmar Ragunda Varberg Vetlanda Trollhättan Härnösand Vårgårda Vingåker Östhammar Storuman Habo Vännäs Sölvesborg Köping Tingsryd Älvkarleby Strömsund Aneby Tranemo Hammarö Söderhamn Falun Mariestad Tierp Arvika Lekeberg Tranås Skellefteå Gnesta Kil Höör Arboga Arvidsjaur Lomma Ydre Nordanstig Burlöv Tyresö Halmstad Mellerud Kramfors Ulricehamn Sala Boden Munkfors Leksand Gnosjö Ludvika Bjuv Mullsjö Karlsborg Göteborg Hallstahammar Upplands Väsby Mörbylånga Hylte Högsby Ale Karlstad Mönsterås Oxelösund Mora Lidköping Trosa Lindesberg Ängelholm Borlänge Avesta Timrå Alingsås Nora Laxå Sollefteå Grästorp Huddinge Falköping Vilhelmina Färgelanda Krokom Åmål Älvdalen Stenungsund Kumla Markaryd Kalix Nässjö Surahammar Svenljunga Smedjebacken Olofström Vaggeryd Forshaga Perstorp Vadstena Tomelilla Norrköping Hofors Solna Östra Göinge Ljusdal Grums Mark Stockholm Örnsköldsvik Flen Söderköping Borgholm Ronneby Fagersta Vallentuna Östersund Årjäng Berg Härryda Älvsbyn Hallsberg Hagfors Värnamo Askersund Lessebo Gällivare Mölndal Borås Malung-Sälen Ockelbo Alvesta Gullspång Piteå Torsby Essunga Karlshamn Hultsfred Degerfors Ljungby Osby Skurup Åsele Kristianstad Skara Svalöv Överkalix Sigtuna Vansbro Övertorneå Malå Sotenäs Simrishamn Malmö Pajala Västerås Storfors Eslöv Haparanda Skövde Motala Västervik Ljusnarsberg 70 75 80 85 90 70 75 80 85 90 70 75 80 85 90 70 75 80 85 90 Year SWEDEN 2009–2013 2006–2010
Source: Population Statistics, Statistics Sweden. The Health of the Population 27
2 . SELF-ASSESSED GENERAL HEALTH The results indicate a slight positive trend in several Health is not equally distributed throughout the popula- counties and municipalities since the beginning of the tion. Consequently, self-reported health is an important measurement period in 2007 and up until 2014. Men as- way of identifying people with chronic illnesses and/or sess their health to be better than is the case for women, disabilities, and of identifying healthcare requirements a higher proportion of individuals with a high educational [41]. The population’s self-assessed health has been level state that their health is good, and younger people monitored since 1980 using surveys of living conditions state that their health is good more often than older people. – Living Conditions Surveys (ULF/SILC) – from Statistics Sweden (SCB). The surveys show that self-assessed health has deterio- 2.2 – , : Individuals who stated that rated among women with a low educational level. Similar their general health condition is good or very good, 2014. patterns are also visible in the national public health sur- Per cent vey [12], which is the source of the data we have chosen to 100 present in this report. The prerequisites for living environments that promote 75 health are shaped primarily by regional and local stake- holders such as county administrative boards, county councils and regions, municipalities and non-profit or- 50 ganisations, not least for people with disabilities [42]. In terms of the working environment, employers have an 25 important role in shaping working environments that pro- mote health in dialogue with employees’ representatives 0 [43]. Women Men Self-assessed general health is measured on a five- 16–29 year 30–44 year 45–64 year 65–84 year degree scale that is universally recognised within the EU Source: Health on Equal Terms, Public Health Agency of Sweden. [43, 44]. This report presents the proportion of people who responded “very good” or “good” to the question “How do you assess your general health?”.
2.1 – : Individuals who stated that their general 2.3 – , : Individuals who stated that health condition is good or very good, 16–84 years old. their general health condition is good or very good, 35–74 years old, 2014. Per cent 90 Per cent 100
80
75 70
50 60
50 25
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 0 Year Total Women Men Women Men Source: Health on Equal Terms, Public Health Agency of Sweden. Pre-upper-secondary Upper-secondary Post-secondary
Source: Health on Equal Terms, Public Health Agency of Sweden. 28 Regional Comparisons 2014: Public Health
2.4 – , : Individuals who stated that their general health condition is good or very good, 16–84 years old, 2011–2014.
Halland 75 Jönköping 74 Stockholm 73 Gävleborg 71 Västra Götaland 71 Sörmland 71 SWEDEN 71 Uppsala 70 Skåne 70 Kalmar 70 Blekinge 69 Västerbotten 69 Värmland 69 Östergötland 69 Kronoberg 69 Västernorrland 68 Västmanland 68 Dalarna 67 Gotland 67 Örebro 67 Norrbotten 67 Jämtland 63 0 20 40 60 80 100
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
2.5 – , : Individuals who stated that their general health condition is good or very good, 16–84 years old, 2011–2014.
Jönköping 79 Stockholm 77 Halland 77 Kronoberg 77 Skåne 77 Uppsala 76 Västra Götaland 76 SWEDEN 75 Jämtland 75 Kalmar 75 Örebro 74 Östergötland 74 Västerbotten 73 Sörmland 73 Västernorrland 73 Västmanland 72 Gotland 72 Gävleborg 71 Blekinge 71 Värmland 70 Norrbotten 70 Dalarna 69 0 20 40 60 80 100
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. The Health of the Population 29
F¡¢ 2.6 £ ¤¥¦§¨©ª¢«: Individuals who stated that their general health condition is good or very good (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16£84 years old. Skåne (FHS), 18£80 years old. Värmland (LH), 18+ years old.
Vallentuna Grums Filipstad Finspång Täby Göteborg Kungsör Flen Danderyd Skövde Krokom Sölvesborg Kil Båstad Gagnef Älvkarleby Svedala Hylte Torsås Tidaholm Hammarö Ljungby Mjölby Hallstahammar Vellinge Värnamo Kumla Ånge Lund Lidköping Tingsryd Högsby Öckerö Kristianstad Lysekil Färgelanda Solna Enköping Kiruna Robertsfors Kungsbacka Haninge Piteå Sorsele Nacka Söderköping Leksand Emmaboda Järfälla Karlskrona Strängnäs Hedemora Vetlanda Trosa Huddinge Dals-Ed Lidingö Alingsås Ovanåker Vingåker Ängelholm Nässjö Sotenäs Vansbro Österåker Vimmerby Mönsterås Upplands-Bro Ekerö Oskarshamn Hallsberg Munkedal Gislaved Gotland Härjedalen Jönköping Falköping Ulricehamn Vadstena Lomma Eslöv Nora Nordmaling Sollentuna Östra Göinge Uppvidinge Kramfors Kävlinge Södertälje Motala Ljusnarsberg Torsby Bollebygd Arboga Oxelösund Karlstad Helsingborg Gnesta Laxå Ronneby Lerum Sjöbo Karlshamn Bjuv Härryda Stenungsund Herrljunga Pajala Smedjebacken Trelleborg Gävle Grästorp Degerfors Växjö Luleå Söderhamn Mellerud Partille Tanum Tomelilla Nordanstig Älmhult Håbo Bromölla Perstorp Värmdö Lindesberg Jokkmokk Ockelbo Storfors Vänersborg Härnösand Vindeln Uppsala Tyresö Lekeberg Avesta Linköping Vaggeryd Svenljunga Tierp Sunne Uddevalla Tibro Storuman Eda Burlöv Olofström Bjurholm Halmstad Karlskoga Köping Arjeplog Sundbyberg Tjörn Orsa Sollefteå Stockholm Ale Heby Örnsköldsvik Kungälv Landskrona Vara Hofors Åre Åstorp Skellefteå Ludvika Knivsta Götene Vännäs Gullspång Säter Kalmar Munkfors Norsjö Borås Mörbylånga Nybro Älvsbyn Mölndal Sala Botkyrka Skinnskatteberg Forshaga Mariestad Töreboda Vilhelmina Simrishamn Skara Rättvik Norberg Umeå Alvesta Svalöv Arvidsjaur Skurup Upplands Väsby Östhammar Surahammar Klippan Hörby Strömsund Bräcke Arvika Fagersta Kalix Åtvidaberg Tranås Hagfors Timrå Övertorneå Västerås Bollnäs Hällefors Ragunda Örebro Malung-Sälen Valdemarsvik Åsele Ystad Borlänge Älvdalen Överkalix Katrineholm Ljusdal Malå Varberg Essunga Orust Dorotea Hjo Trollhättan Askersund Haparanda Höganäs Mora Kinda Aneby Falun Norrtälje Hultsfred Boxholm Sundsvall Markaryd Åmål Eksjö Falkenberg Östersund Lilla Edet Gnosjö Årjäng Kristinehamn Västervik Habo Laholm Norrköping Boden Mullsjö Höör Borgholm Örkelljunga Nykvarn Sigtuna Strömstad Gällivare Nynäshamn Malmö Eskilstuna Bengtsfors Salem Tranemo Sandviken Hudiksvall Sävsjö Karlsborg Mark Osby Vaxholm Nyköping Vårgårda Lycksele Ydre Hässleholm Berg Lessebo Ödeshög 50 60 70 80 90 50 60 70 80 90 50 60 70 80 90 50 60 70 80 90 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008 LH - Värmland 2012 LH - Värmland 2008 Values with less than 100 respondents are not presented. Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne; Liv och Hälsa (LH) [Life and Health], County Council of Värmland. 30 Regional Comparisons 2014: Public Health
3 . OBESITY 3.1 – : Individuals estimated to have a BMI Obesity and overweight are the cause of a range of health (Body Mass Index) of 30 or higher based on self-reported data, problems with an increased risk of cardiovascular dis- 16–84 years old. eases, type 2 diabetes, stroke, musculoskeletal diseases Per cent 25 and certain forms of cancer such as bowel cancer. Obesity develops through a combination of lifestyle habits, envi- 20 ronmental factors and inheritance. Our eating habits and our level of physical activity are central, with an important 15 cause of overweight being the consumption of a large amount of energy-dense foodstuffs and sweetened drinks 10 in relation to the amount of energy used [45]. Body mass index (BMI) expresses a relationship be- 5 tween height and weight. A high BMI constitutes a risk 0 factor for several diseases. A BMI of 30 or more is classed 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year as obesity. Obesity is among the five most important risk Total Women Men factors in the world for the loss of healthy life years, ac- Source: Health on Equal Terms, Public Health Agency of Sweden. cording to the WHO [45, 46]. In Sweden, the proportion of adults with obesity has doubled since 1980 and close to half of all Swedish peo- ple are now overweight or obese. In 2013, the proportion initiatives in schools and advice for adults [48]. Providing whose weight was normal (BMI 18.5–24.9) was greater information and the prerequisites for good dietary habits among women than among men. Overweight (BMI 25– and encouraging physical activity are vital roles for mu- 29.9) is more common among men than among women. nicipalities and county councils. This applies, not least, Obesity (BMI 30 or more) increased in the period 2004– to environments used by children, adolescents and the el- 2013 [47]. derly. Preschools, schools and care facilities thus have an Obesity among the adult population is used as a results important role in preventative efforts. In addition, mater- indicator in this report. However, it is also essential to nal and paediatric health services have a particularly vital monitor the development of overweight among children role to play with respect to providing information about and adolescents. According to SBU, established obesity is the importance of good diet at an early stage of the child’s difficult to treat and they thus argue that “more effective life. preventative measures are particularly vital”. SBU points to The Health of the Population 31
3.2 - , : Individuals estimated to 3.3 – : : Individuals estimated to have have a BMI (Body Mass Index) of 30 or higher based on a BMI (Body Mass Index) of 30 or higher based on self-reported self-reported data. data, 35–74 years old. Per cent Per cent 30 30
25 25
20 20
15 15
10 10
5 5
0 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Per cent Year 16–29 year 30–44 year 45–64 year 65–84 year Pre-upper-secondary Upper-secondary Post-secondary Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden. Register of Education (UREG), Statistics Sweden.
There are national guidelines describing how the assesses that the likelihood of having the operation varies healthcare system should conduct prevention at the in- between county councils [49]. dividual level and offer assistance to patients who have The results show that the proportion of people with unhealthy eating habits or undertake insufficient physi- obesity has increased in the majority of counties and mu- cal activity [48]. In cases of severe obesity, often in com- nicipalities and that there is a clear difference between bination with other diseases, surgical treatment has been older and younger people. The largest increase has been shown to be effective and has become increasingly com- seen among people aged 45–64. Obesity is more com- mon. SBU states that the BMI limit of 40 is appropriate, or mon among both women and men with a low educational 35 in the event of comorbidity. About 8 000 operations are level, compared with those with a high educational level. currently conducted each year, which is ten times greater For women, obesity is twice as common among those who than at the beginning of the 2000s. However, the quality only have compulsory schooling as it is among those with register the Scandinavian Obesity Surgery Registry (SOReg) post-secondary education. 32 Regional Comparisons 2014: Public Health
3.4 – , : Individuals estimated to have a BMI (Body Mass Index) of 30 or higher based on self-reported data, 16–84 years old, 2011–2014.
Stockholm 11 Värmland 12 Halland 13 Skåne 13 Uppsala 13 Västmanland 13 SWEDEN 14 Västra Götaland 14 Örebro 14 Jönköping 14 Östergötland 14 Kronoberg 14 Västernorrland 15 Jämtland 15 Gotland 16 Kalmar 16 Norrbotten 16 Västerbotten 16 Blekinge 17 Dalarna 17 Gävleborg 18 Sörmland 18 0 5 10 15 20 25 30
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
3.5 – , : Individuals estimated to have a BMI (Body Mass Index) of 30 or higher based on self-reported data, 16–84 years old, 2011–2014.
Halland 9 Kalmar 11 Stockholm 11 Västra Götaland 13 SWEDEN 14 Skåne 14 Västerbotten 14 Gotland 15 Uppsala 15 Jämtland 15 Västmanland 16 Kronoberg 16 Norrbotten 16 Jönköping 16 Dalarna 16 Värmland 17 Västernorrland 17 Gävleborg 17 Blekinge 17 Östergötland 17 Sörmland 17 Örebro 19 0 5 10 15 20 25 30
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. The Health of the Population 33
F¡ 3.6 ¤ ¥¦§¨©ª«¡¬: Individuals estimated to have a BMI (Body Mass Index) of 30 or higher based on self-reported data (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16¤84 years old. Skåne (FHS), 18¤80 years old. Värmland (LH), 18+ years old.
Lidingö Ljungby Landskrona Orsa Danderyd Tranemo Örnsköldsvik Emmaboda Täby Ronneby Dals-Ed Klippan Solna Karlskrona Högsby Svalöv Härryda Höör Karlsborg Sotenäs Sundbyberg Örebro Töreboda Degerfors Stockholm Stenungsund Hudiksvall Kalix Partille Mellerud Vännäs Storuman Mölndal Sundsvall Ljusdal Sollefteå Nacka Ängelholm Enköping Kinda Lund Gävle Alvesta Värmdö Värnamo Boden Jokkmokk Tyresö Norrköping Tingsryd Hjo Kalmar Ulricehamn Hylte Smedjebacken Järfälla Upplands-Bro Grästorp Vindeln Vallentuna Västerås Skara Mjölby Lomma Härnösand Skurup Hällefors Lerum Nybro Ystad Storfors Öckerö Sigtuna Söderhamn Sunne Uppsala Orust Hallsberg Ludvika Sollentuna Krokom Markaryd Köping Kungälv Jönköping Söderköping Malå Knivsta Herrljunga Tibro Avesta Simrishamn Lekeberg Eskilstuna Ljusnarsberg Kungsbacka Nyköping Håbo Perstorp Göteborg Österåker Burlöv Flen Bjuv Linköping Laholm Sala Färgelanda Hedemora Falun Osby Valdemarsvik Eda Älmhult Gotland Åmål Hallstahammar Varberg Götene Östra Göinge Säter Umeå Tidaholm Norberg Åsele Vimmerby Östhammar Mönsterås Kungsör Växjö Strängnäs Bengtsfors Ragunda Vellinge Västervik Norsjö Haparanda Hammarö Mörbylånga Bromölla Vilhelmina Åtvidaberg Mora Vara Vingåker Halmstad Arvika Pajala Filipstad Hässleholm Eslöv Heby Ovanåker Huddinge Trelleborg Tierp Bräcke Åre Lessebo Gagnef Nordmaling Torsås Vetlanda Karlskoga Timrå Falkenberg Arboga Skinnskatteberg Kramfors Ekerö Ale Motala Sorsele Borlänge Lidköping Lycksele Dorotea Borgholm Helsingborg Nässjö Övertorneå Trollhättan Uppvidinge Hultsfred Härjedalen Borås Skellefteå Upplands Väsby Älvkarleby Vadstena Leksand Fagersta Askersund Bjurholm Örkelljunga Katrineholm Hagfors Båstad Malung-Sälen Kristinehamn Sjöbo Luleå Essunga Nora Surahammar Bollebygd Överkalix Årjäng Grums Karlstad Oskarshamn Sölvesborg Strömsund Östersund Vänersborg Norrtälje Älvdalen Strömstad Gnesta Gullspång Robertsfors Tanum Kiruna Tomelilla Nordanstig Karlshamn Bollnäs Lindesberg Hofors Berg Ockelbo Lilla Edet Ånge Munkfors Olofström Aneby Svedala Mark Laxå Boxholm Höganäs Kristianstad Arvidsjaur Eksjö Malmö Piteå Arjeplog Gnosjö Trosa Vårgårda Oxelösund Habo Uddevalla Kävlinge Älvsbyn Mullsjö Tjörn Rättvik Kumla Nykvarn Alingsås Munkedal Hörby Nynäshamn Gislaved Lysekil Falköping Salem Mariestad Svenljunga Forshaga Sävsjö Södertälje Kil Torsby Vaggeryd Haninge Åstorp Finspång Vaxholm Tranås Sandviken Vansbro Ydre Skövde Botkyrka Gällivare Ödeshög 0 10 20 30 0 10 20 30 0 10 20 30 0 10 20 30 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008 LH - Värmland 2012 LH - Värmland 2008 Values with fewer than 100 respondents are not presented. Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne; Liv och Hälsa (LH) [Life and Health], County Council of Värmland. 34 Regional Comparisons 2014: Public Health
4 . DENTAL HEALTH Public Dental Service [51]. Maternal and paediatric health Dental health is an important part of individuals’ qual- services also present good opportunities to discuss the ity of life and well-being. The quality of the teeth can be importance of good oral and dental health. Creating good said to have a double connection with dietary habits as conditions for dental health, for example good diet, is par- the diet affects dental health and the quality of the teeth ticularly important in schools and care facilities. affects dietary intake. The public health policy area “Good This report contains information for adults, but in or- eating habits”, highlights the importance of good den- der to facilitate preventative efforts and in the case of im- tal health for the ability to consume food. There are also provements, it is important to monitor information about diseases that are suspected to have a direct association children and adolescents. Such data, for example the pro- with dental health, for example cardiovascular diseases, portion of children without tooth decay, are often avail- respiratory tract diseases, cancers and diabetes. Studies able at the local and regional level. have also shown that periodontitis in pregnant women The results indicate that the proportion of women with can increase the risk of the child having a low birth weight good dental health has increased in the majority of coun- [50]. Good dental health also has an impact on nutritional ties. The picture for men has not developed as positively. intake. This is of particular importance among the elderly Individuals aged 16–29 state to a somewhat greater extent as a good diet is an important factor to maintaining health that they have good dental health than the elderly, and the into old age. Social life and quality of life are also affected by dental health. 4.2 – , : Individuals who stated that Despite the dental health of the population as a whole they consider their dental health to be fairly good or very good, 16–84 years old, 2014. having improved, there are still large socioeconomic dif- ferences. In the national public health survey, blue-collar Per cent 100 workers stated that they had worse dental health than white-collar workers and they more frequently refrain from seeking dental care, in spite of its necessity, than 75 white-collar workers in the same situation [12]. Dental health is normally a good indicator of children 50 and adolescents’ general health as dental health is strong-
ly associated with lifestyle, utilisation of care, economic 25 circumstances and knowledge about what is required to maintain good health. The county councils are responsible 0 for preventative initiatives targeting good oral and dental Women Men health, not least with respect to children and adolescents 16–29 year 30–44 year 45–64 year 65–84 year given the fact that about 84 per cent of all children and ad- Source: Health on Equal Terms, Public Health Agency of Sweden. olescents up to 18 years of age are patients of the Swedish
4.1 – : Individuals who stated that they consider 4.3 – : : Individuals who stated that their dental health to be fairly good or very good, 16–84 years old. they consider their dental health to be fairly good or very good, 35–74 years old. Per cent 90 Procent 90
80 80
70 70
60 60
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Total Women Men Year Pre-upper-secondary Upper-secondary Post-secondary Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden. Register of Education (UREG), Statistics Sweden. The Health of the Population 35
4.4 – , : Individuals who stated that they consider their dental health to be fairly good or very good, 16–84 years old, 2011–2014.
Värmland 82 Västernorrland 80 Kronoberg 80 Västerbotten 80 Jämtland 80 Jönköping 79 Örebro 79 Uppsala 78 Västmanland 78 Halland 78 Sörmland 76 SWEDEN 76 Dalarna 76 Blekinge 76 Stockholm 76 Västra Götaland 76 Gotland 76 Östergötland 75 Norrbotten 74 Skåne 74 Gävleborg 74 Kalmar 72 0 20 40 60 80 100
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
4.5 – , : Individuals who stated that they consider their dental health to be fairly good or very good, 16–84 years old, 2011–2014.
Värmland 76 Västerbotten 76 Blekinge 76 Kronoberg 76 Halland 75 Jönköping 72 Östergötland 71 Kalmar 71 Västernorrland 71 Skåne 71 Örebro 70 Västmanland 70 SWEDEN 70 Uppsala 70 Västra Götaland 70 Gotland 70 Gävleborg 69 Dalarna 69 Stockholm 68 Sörmland 68 Jämtland 67 Norrbotten 66 0 20 40 60 80 100
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. 36 Regional Comparisons 2014: Public Health
F 4.6 ¢ £¤¥¦§¨©ª: Individuals who stated that they consider their dental health to be fairly good or very good (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16¢84 years old. Värmland (LH), 18+ years old.
Danderyd Norberg Trosa Värnamo Tranås Malung-Sälen Söderköping Eslöv Österåker Skara Ljusdal Bengtsfors Hammarö Sala Strömstad Tidaholm Vellinge Rättvik Älvsbyn Östhammar Sunne Ulricehamn Karlshamn Norrtälje Öckerö Munkfors Ystad Vingåker Kungsbacka Nacka Hjo Hofors Kiruna Mellerud Överkalix Bjurholm Hylte Trollhättan Sorsele Älmhult Mörbylånga Kramfors Heby Karlstad Svenljunga Strömsund Nässjö Kil Vårgårda Lekeberg Ljusnarsberg Sundsvall Ludvika Gotland Järfälla Bollebygd Bollnäs Lindesberg Högsby Leksand Lysekil Nora Eskilstuna Härryda Sotenäs Lycksele Kumla Falun Ånge Mariestad Mönsterås Ljungby Gävle Strängnäs Hallsberg Karlsborg Herrljunga Stockholm Gullspång Växjö Kristianstad Hudiksvall Nybro Arvika Älvkarleby Gnesta Älvdalen Lerum Karlskrona Mark Gällivare Köping Bräcke Tingsryd Töreboda Jönköping Tyresö Ovanåker Åtvidaberg Robertsfors Grästorp Sollefteå Södertälje Laxå Falkenberg Gislaved Kinda Skinnskatteberg Kalix Täby Munkedal Katrineholm Huddinge Hagfors Enköping Oskarshamn Flen Nordmaling Ale Vadstena Jokkmokk Lidköping Timrå Värmdö Emmaboda Laholm Linköping Vimmerby Ockelbo Forshaga Åmål Göteborg Övertorneå Borgholm Grums Årjäng Landskrona Östersund Borås Malmö Vallentuna Lessebo Härnösand Haninge Botkyrka Upplands-Bro Söderhamn Surahammar Sigtuna Varberg Alvesta Tibro Aneby Kungälv Västerås Smedjebacken Bjuv Gagnef Tanum Kungsör Boxholm Stenungsund Ekerö Torsås Bromölla Umeå Askersund Sollentuna Burlöv Krokom Vänersborg Oxelösund Båstad Haparanda Skellefteå Kristinehamn Eksjö Uppvidinge Tranemo Trelleborg Gnosjö Ragunda Karlskoga Arjeplog Habo Storfors Dals-Ed Dorotea Höganäs Borlänge Malå Åsele Hörby Åre Falköping Lilla Edet Höör Orsa Arvidsjaur Degerfors Klippan Götene Vansbro Skövde Lomma Uddevalla Vindeln Hallstahammar Mullsjö Markaryd Arboga Sundbyberg Nykvarn Alingsås Motala Västervik Nynäshamn Lund Örebro Ängelholm Osby Halmstad Uppsala Vara Perstorp Ronneby Storuman Hultsfred Salem Härjedalen Nyköping Norrköping Simrishamn Avesta Säter Boden Sjöbo Vännäs Fagersta Pajala Skurup Eda Vetlanda Valdemarsvik Örnsköldsvik Vilhelmina Hässleholm Svalöv Torsby Piteå Berg Svedala Mölndal Solna Helsingborg Sävsjö Kävlinge Orust Upplands Väsby Tomelilla Luleå Hedemora Norsjö Vaggeryd Mjölby Hällefors Finspång Vaxholm Sölvesborg Partille Nordanstig Ydre Tjörn Filipstad Sandviken Åstorp Knivsta Lidingö Färgelanda Ödeshög Mora Tierp Olofström Örkelljunga Kalmar Håbo Essunga Östra Göinge 50 60 70 80 90 50 60 70 80 90 50 60 70 80 90 50 60 70 80 90 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 LH - Värmland 2012 LH - Värmland 2008
Values with fewer than 100 respondents are not presented.
Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Liv och Hälsa (LH) [Life and Health], County Council of Värmland. The Health of the Population 37
responses indicate that women have better dental health 5 . MYOCARDIAL INFARCTION than men. A higher educational level has a clear associa- In spite of the mortality having decreased in recent years, tion with good dental health. cardiovascular diseases still constitute a public health problem in our country. According to the national cardiac INCIDENCE OF DISEASE care guidelines from 2011, acute coronary artery disease The burden of disease is a comprehensive measure used is one of the most common causes of hospital admission to describe and monitor the incidence and severity of dis- and death in Sweden [54]. eases and to describe changes to public health. Incidence The mortality rate following an infarct has been de- reporting applies to the major public health diseases such creasing for a long time and continues to decline in Swe- as cancer, cardiovascular diseases and stroke. However, den; nevertheless, infarction continues to be one of the back pain, Alzheimer’s and injuries caused by falls are commonest causes of death among those who are 85 or also morbidities that have a high incidence [52]. As previ- older, followed by cancer [12]. ously mentioned, there are a number of risk factors for the The incidence of myocardial infarction can be reduced burden of disease for example smoking, risky alcohol con- further, for example through lifestyle changes with respect sumption, air pollution, unhealthy eating habits and sed- to smoking, alcohol, food and physical activity. Healthy entary leisure time [52]. In addition, there are risk factors lifestyle habits have major impact on the number of indi- connected to social and living conditions that also have an viduals suffering from myocardial infarction. Prevention impact on the burden of disease. The incidence of myo- carried out by various organisations is very important, but cardial infarction and lung cancer are presented in this this is also about providing good social and living condi- report. Despite the incidence of cardiovascular diseases tions in society that are able to make a contribution to the having continued to decrease, it is these diseases that are situation developing favourably. Both municipalities and responsible for the greatest burden of disease in Sweden. county councils are important stakeholders. In addition, their incidence is higher among people with low educational levels and the report Folkhälsan i Sverige – 5.1 – : Incidence rate of myocardial infarction per Årsrapport 2014 [Public Health in Sweden – Annual Report 100 000 inhabitants 20–79 years old. Age-standardised. 2014] sets out that the risk of myocardial infarction has Number per 100 000 inhabitants also increased somewhat since 1994 among women with 1 000 pre-upper-secondary education [12]. The incidence of cancer has increased at the same time 800 as mortality from cancer has decreased, which is seen in the increase in the relative five and ten-year survival 600 rates. This can be explained by improved screening, diag- nosis and treatment [53]. At the same time, women with 400 only pre-upper-secondary education have a higher risk 200 of both contracting cancer and dying from it, compared with those who have a high educational level. For men, 0 there are fewer diagnoses among those with a low edu- 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 Year cational level, despite the mortality being higher in this Total Women Men Source: The National Patient Register and the Swedish Cause of Death Register, group [53]. the National Board of Health and Welfare. 38 Regional Comparisons 2014: Public Health
5.2 – : , : Incidence rate of 5.3 – : , : Incidence rate of myocardial infarction per 100 000 inhabitants 35–79 years old. myocardial infarction per 100 000 inhabitants 35–79 years old. Age-standardised. Age-standardised. Number per 100 000 inhabitants Number per 100 000 inhabitants 1 250 1 250
1 000 1 000
750 750
500 500
250 250
0 0 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 Year Year Pre-upper-secondary Upper-secondary Post-secondary Pre-upper-secondary Upper-secondary Post-secondary Source: The National Patient Register and the Swedish Cause of Death Register, the Source: The National Patient Register and the Swedish Cause of Death Register, the National Board of Health and Welfare. Register of Education (UREG), National Board of Health and Welfare. Register of Education (UREG), Statistics Sweden. Statistics Sweden.
Municipalities can promote healthy lifestyle habits incidence has almost halved since the beginning of the when they come into contact with various target groups 1990s. The incidence among women is lower than among in preschools, schools, cultural and leisure activities and men. However, the reduction in incidence among women social services, but the principal can also do much as an has been less strong than the change seen among men. employer. County council services can work actively dur- There are also big differences here between groups with ing patient encounters to promote health and prevent dis- differing educational backgrounds, with the differences ease [55]. between men with pre-upper-secondary education and In 2013, 239 people aged 20–79 per 100 000 inhabitants post-secondary education being greatest. The outcome suffered from myocardial infarctions in Sweden and this also indicates that the incidence varies between county councils by up to 200 cases per 100 000 inhabitants. The Health of the Population 39
5.4 – , : Incidence rate of myocardial infarction per 100 000 inhabitants 20–79 years old, age-standardised, 2013.
Stockholm 103 Kalmar 129 Värmland 132 Uppsala 135 Västra Götaland 141 SWEDEN 141 Kronoberg 141 Gotland 143 Halland 144 Skåne 145 Örebro 146 Jönköping 152 Jämtland 156 Sörmland 156 Blekinge 157 Västmanland 163 Östergötland 164 Västerbotten 166 Västernorrland 166 Dalarna 166 Gävleborg 167 Norrbotten 171 0 100 200 300 400 500 600 700
2013 2007 Number per 100 000 inhabitants Source: The National Patient Register and the Swedish Cause of Death Register, the National Board of Health and Welfare.
5.5 – , : Incidence rate of myocardial infarction per 100 000 inhabitants 20–79 years old, age-standardised, 2013.
Stockholm 284 Halland 301 Västra Götaland 318 Kalmar 319 Västmanland 319 Kronoberg 328 Uppsala 337 SWEDEN 342 Sörmland 344 Jämtland 344 Skåne 348 Jönköping 349 Västernorrland 353 Östergötland 367 Örebro 368 Värmland 378 Gotland 378 Västerbotten 396 Gävleborg 402 Blekinge 411 Dalarna 443 Norrbotten 500 0 100 200 300 400 500 600 700
2013 2007 Number per 100 000 inhabitants Source: The National Patient Register and the Swedish Cause of Death Register, the National Board of Health and Welfare. 40 Regional Comparisons 2014: Public Health
F 5.6 £ ¤¥¦§¨©ª«: Incidence rate of myocardial infarction per 100 000 inhabitants 20£79 years old, age-standardised, 2009£2013.
Danderyd Bengtsfors Kalmar Årjäng Nacka Vännäs Kävlinge Piteå Lidingö Västervik Bjurholm Hedemora Sollentuna Linköping Trollhättan Bräcke Vaxholm Varberg Tibro Hallstahammar Solna Hjo Gnesta Oskarshamn Täby Göteborg Gullspång Vilhelmina Tyresö Grästorp Flen Gotland Ekerö Vadstena Sala Sandviken Kungsbacka Lidköping Karlskoga Haparanda Båstad Härnösand Södertälje Mörbylånga Stockholm Kungsör Motala Smedjebacken Ödeshög Karlshamn Skara Skinnskatteberg Höganäs Falkenberg Leksand Bollnäs Salem Borgholm Höör Svalöv Järfälla Tranemo Luleå Värnamo Vallentuna Tjörn Lilla Edet Olofström Lysekil Norrtälje Sölvesborg Torsås Strömstad Färgelanda Sigtuna Laxå Kil Eslöv Åsele Värmdö Nykvarn Ystad Avesta Helsingborg Boxholm Gnosjö Dorotea Forshaga Surahammar Östra Göinge Trelleborg Vellinge Sundsvall Finspång Sunne Söderhamn Lomma Nyköping Ronneby Storuman Upplands-Bro Strängnäs Hultsfred Övertorneå Alingsås Valdemarsvik Norrköping Högsby Vårgårda Örkelljunga Eskilstuna Lycksele Knivsta Mölndal Eksjö Hudiksvall Lerum Gävle Storfors Strömsund Partille Haninge Svedala Herrljunga Tranås Östhammar Arboga Nora Vänersborg Robertsfors Hallsberg Skurup Skövde Grums Heby Hylte Uppsala Vingåker Malmö Vara Sotenäs Tidaholm Botkyrka Örnsköldsvik Dals-Ed Borås Töreboda Degerfors Ljungby Åre Kristianstad Ockelbo Huddinge Mellerud Laholm Lindesberg Ängelholm Mariestad Älvsbyn Ydre Tanum Katrineholm Skellefteå Ludvika Lekeberg Åmål Norberg Boden Vetlanda Aneby Köping Säter Falköping Håbo Vindeln Kinda Karlsborg Östersund Nybro Kramfors Lund Berg Oxelösund Kalix Umeå Halmstad Ånge Arvidsjaur Orust Nynäshamn Hagfors Hörby Härryda Uppvidinge Bromölla Arjeplog Munkfors Ale Alvesta Fagersta Karlstad Öckerö Perstorp Hofors Växjö Götene Emmaboda Vansbro Sundbyberg Trosa Ljusdal Kiruna Ulricehamn Lessebo Ragunda Tomelilla Munkedal Jönköping Osby Nordanstig Västerås Karlskrona Arvika Orsa Stenungsund Tierp Hässleholm Mora Bollebygd Askersund Filipstad Jokkmokk Örebro Åstorp Mullsjö Hällefors Kungälv Mjölby Härjedalen Älvkarleby Hammarö Markaryd Vaggeryd Mönsterås Uddevalla Falun Sävsjö Ljusnarsberg Svenljunga Habo Klippan Burlöv Vimmerby Timrå Bjuv Älvdalen Rättvik Borlänge Simrishamn Sjöbo Krokom Mark Nordmaling Eda Essunga Åtvidaberg Gislaved Torsby Älmhult Enköping Malung-Sälen Malå Österåker Gagnef Ovanåker Gällivare Upplands Väsby Kumla Sorsele Norsjö Söderköping Tingsryd Landskrona Överkalix Nässjö Kristinehamn Sollefteå Pajala 0 200 400 600 800 0 200 400 600 800 0 200 400 600 800 0 200 400 600 800 Number per 100 000 inhabitants SWEDEN 2009–2013 2004–2008
Source: The National Patient Register and the Swedish Cause of Death Register, the National Board of Health and Welfare. The Health of the Population 41
6 . LUNG CANCER cultural and recreational facilities. A number of health ef- Lung cancer is the fifth most common form of cancer in fects related to the environment can arise even in the early Sweden and the commonest cause of cancer-related death. years of life, while others only manifest later in life [56]. It is one of the cancers with the worst prognosis. Tobacco Three indicators for lung cancer are presented in re- smoking is the primary cause of lung cancer [53]. gional healthcare comparisons: survival, incidence of Women’s mortality from lung cancer increased sharply multidisciplinary treatment conferences and time until from 1987–2013, but this upward trend looks to have halted treatment decision is made. An early diagnosis has an [54]. A smaller proportion of lung cancers, between 5 and impact on survival, but the disease’s incidence is reduced 10 per cent, are said to be due to hereditary factors. Aside primarily by preventative measures, particularly the pre- from smoking, there are a number of more general risk vention of smoking, and in combination with the above- factors such as high alcohol consumption, unhealthy eat- mentioned more general risk factors that municipalities ing habits, low levels of physical activity, overweight and can have an impact on. passive smoking. In 2012, 3.53 individuals per 10 000 inhabitants con- Other risk factors in combination with smoking are tracted lung cancer. This number is largely unchanged contact with asbestos or inhalation of radon, which can be from that at the beginning of the 2000s when viewed as present in residential and workplace environments, and a total, but the incidence among women has increased air pollution. Radon is found in ground, air and water, but somewhat over the course of this century. Large differ- may also be present in building materials. ences are visible between inhabitants with different edu- In 2013, 3 652 new cases of lung cancer were diagnosed cational backgrounds, with the incidence being higher in Sweden, 1 869 of which were in men and 1 783 in wom- mainly in women with pre-upper-secondary education. en. Most become ill in their 70s [53]. The outcome also indicates that the incidence varies be- Children’s exposure to various environmental factors tween county councils from 1.4 to 4.7 cases per 10 000 in- differs from that of adults as they are developing faster and habitants. County councils in northern Sweden have seen eat and drink more in relation to their body weight. The a more favourable trend with a lower incidence than in indoor and outdoor environments in which they grow up central and southern Sweden. are largely public spaces such as preschools, schools and
6.1 – : Incidence rate of lung cancer per 10 000 6.2 – : Incidence rate of lung cancer per inhabitants. Age-standardised. 10 000 inhabitants 35–74 years old, age-standardised, 2008–2012. Number per 10 000 inhabitants 8 Number per 10 000 inhabitants 8
6 6
4 4
2 2
0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0 Year Total Women Men Women Men Source: The Swedish Cancer Register, the National Board of Health and Welfare. Pre-upper-secondary Upper-secondary Post-secondary Source: The Swedish Cancer Register, the National Board of Health and Welfare. Register of Education (UREG), Statistics Sweden. 42 Regional Comparisons 2014: Public Health
6.3 – , : Incidence rate of lung cancer per 10 000 inhabitants, age-standardised, 2012.
Jönköping 1.17 Norrbotten 1.31 Västerbotten 2.51 Blekinge 2.60 Västernorrland 2.65 Uppsala 2.91 Dalarna 2.99 Jämtland 3.09 Kalmar 3.10 Sörmland 3.11 Västra Götaland 3.21 Västmanland 3.27 Värmland 3.33 SWEDEN 3.34 Gävleborg 3.39 Gotland 3.51 Kronoberg 3.57 Örebro 3.58 Stockholm 3.60 Halland 3.75 Östergötland 3.88 Skåne 4.63 0 1 2 3 4 5 6
2012 2009 Number per 10 000 inhabitants Source: The Swedish Cancer Register, the National Board of Health and Welfare.
6.4 – , : Incidence rate of lung cancer per 10 000 inhabitants, age-standardised, 2012.
Västernorrland 1.36 Norrbotten 1.61 Gotland 2.17 Jönköping 2.26 Jämtland 2.55 Västerbotten 2.61 Västmanland 3.12 Kalmar 3.34 Västra Götaland 3.35 Värmland 3.46 Sörmland 3.68 SWEDEN 3.83 Uppsala 3.86 Örebro 3.88 Blekinge 3.95 Gävleborg 4.15 Dalarna 4.40 Stockholm 4.49 Halland 4.67 Kronoberg 4.68 Östergötland 4.73 Skåne 5.07 0 1 2 3 4 5 6
2012 2009 Number per 10 000 inhabitants Source: The Swedish Cancer Register, the National Board of Health and Welfare. The Health of the Population 43
MORTALITY 7 . POLICY-RELATED AVOIDABLE MORTALITY Two indicators connected to mortality are presented in Med Health policy interventions are considered here to this section: policy-related avoidable mortality and avoid- be interventions that aim to reduce harmful alcohol con- able deaths from ischaemic heart disease. sumption, smoking and road traffic accidents with a dead- Policy-related avoidable mortality is a systemic indicator ly outcome. In Sweden, mortality in road traffic accidents that measures mortality in a number of selected diagno- has decreased since the end of the 1980s [54]. In terms of sis and causes of death such as lung cancer, oesophageal harmful alcohol consumption, this can be related to more cancer, cirrhosis of the liver and road traffic accidents. The than 60 different conditions including cardiovascular dis- other indicator measures diagnoses and causes of death ease, liver damage, cancer and mental ill-health [58, 59]. for ischaemic heart disease. Policy-related avoidable mortality continues to decline. It has been suggested that policy-related avoidable mor- The indicator was previously limited to individuals aged tality is not an optimal indicator in its current form and 1–74, but has now been expanded to cover the ages 1–79 be- that it is difficult for the target audience to know what cause of the increased average life expectancy since 2009 to do with the outcome. In addition, further diagnoses [12]. should also be included to broaden the indicator and in order to reflect more preventive work affecting the mortal- ity rates that are policy-related. 7.1 – : Policy-related avoidable mortality The National Board of Health and Welfare is planning a per 100 000 inhabitants, 1–79 years old. Age-standardised. development project that will involve the indicators being Number per 100 000 inhabitants reviewed and adapted to reflect mortality, with a greater 80 focus on current disease trends in the population. This in- dicator is also the subject of discussion in other countries. 60 There may need to be a clearer definition in order to iden- tify premature deaths from causes that reflect initiatives 40 in the field of public health. It would perhaps be better to have several separate indicators instead of overall system- ic indicators for mortality. 20 The account in this report is based on the fact that the indicator has been identified as a monitoring indicator 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 since 2009. In addition, this is complemented by a new Year indicator, avoidable death from ischaemic heart disease. Total Women Men The commonest underlying cause of death is cardiovascu- Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. lar disease, although mortality has reduced since the end of the 1980s. Tumours are the next most common cause of death [54]. 44 Regional Comparisons 2014: Public Health
7.2 – : , : Policy-related 7.3 – : , : Policy-related avoidable avoidable mortality per 100 000 inhabitants, 35–79 years old. mortality per 100 000 inhabitants, 35–79 years old. Age-standardised. Age-standardised. Number per 100 000 inhabitants Number per 100 000 inhabitants 140 140
120 120
100 100
80 80
60 60
40 40
20 20
0 0 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 Year Year Pre-upper-secondary Upper-secondary Post-secondary Pre-upper-secondary Upper-secondary Post-secondary Source: The Swedish Cause of Death Register, the National Board of Health and Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. Register of Education (UREG), Statistics Sweden. Welfare. Register of Education (UREG), Statistics Sweden.
Policy-related avoidable mortality has decreased slowly outcome are addiction clinics and primary care services over the course of this century, with women having a low- that undertake preventative work involving alcohol and er mortality rate than men. In addition, there are differ- tobacco. ences between individuals who have different educational Examples of organisations within the municipalities backgrounds, with mainly men who have only pre-upper- are planning departments whose work involves traffic secondary education having a higher mortality. safety on roads, footpaths and cycle paths in collaboration There is also a clear upward trend in mortality among with central government and the Swedish Transport Ad- women with a low educational level. There is considerable ministration. General outreach units from social services variation between county councils in the figures for both and units working with addiction from substance also women and men, although the mortality rate is lower for work with prevention in order to reach certain vulnerable women. Examples of county council organisations that groups that are at a greater risk of being affected by mortal- work with interventions that can have an impact on the ity linked to these diagnoses. The Health of the Population 45
7.4 – , : Policy-related avoidable mortality per 100 000 inhabitants, 1–79 years old, age-standardised, 2010–2013.
Jönköping 22.7 Västerbotten 23.7 Kronoberg 25.7 Halland 26.1 Jämtland 27.2 Norrbotten 29.7 Västra Götaland 29.9 Värmland 31.0 Gävleborg 31.3 SWEDEN 32.0 Västmanland 32.0 Örebro 32.2 Västernorrland 32.3 Dalarna 32.7 Kalmar 32.8 Stockholm 33.1 Uppsala 33.7 Blekinge 34.2 Östergötland 34.7 Skåne 37.3 Sörmland 39.9 Gotland 40.4 0 10 20 30 40 50 60 70
2010–2013 2006–2009 Number per 100 000 inhabitants Source: The Swedish Cause of Death Register, the National Board of Health and Welfare.
7.5 – , : Policy-related avoidable mortality per 100 000 inhabitants, 1–79 years old, age-standardised, 2010–2013.
Jämtland 31.9 Västerbotten 36.6 Norrbotten 40.4 Kronoberg 40.4 Dalarna 42.6 Västernorrland 43.2 Gotland 43.3 Blekinge 44.0 Jönköping 44.0 Västra Götaland 45.0 Värmland 45.8 Östergötland 46.1 SWEDEN 47.2 Uppsala 47.8 Kalmar 48.5 Stockholm 48.8 Västmanland 49.4 Halland 50.2 Örebro 51.0 Sörmland 52.2 Skåne 53.7 Gävleborg 56.2 0 10 20 30 40 50 60 70
2010–2013 2006–2009 Number per 100 000 inhabitants Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. 46 Regional Comparisons 2014: Public Health
8. AVOIDABLE DEATHS FROM ISCHAEMIC 8.2 – : , : Avoidable deaths HEART DISEASE from ischaemic heart disease per 100 000 inhabitants 35–79 years old. Age-standardised. This indicator shows mortality from ischaemic heart dis- Number per 100 000 inhabitants ease as a complement to the previous indicator. This in- 250 cludes mortality from cardiac diagnoses. Ischaemic heart disease is caused by impaired oxygen supply to the heart 200 and acute myocardial infarction is the predominant cause of death in this category. Mortality varies strongly at differ- 150 ent ages and the risk doubles between the ages of 60 and 70 years [60]. 100 There is considerable variation between county coun- 50 cils in the figures for both women and men, although the
mortality rate is considerably lower for women. The trend 0 diagram shows that mortality from ischaemic heart dis- 2007 2008 2009 2010 2011 2012 2013 Year ease has decreased sharply for both sexes over the years, Pre-upper-secondary Upper-secondary Post-secondary but the mortality is still considerable and this is the com- Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. monest underlying cause of death. This development shows that a considerable proportion of deaths can be avoided, either through medical interventions or lifestyle changes. There are differences between different educa- tional groups, although mortality has decreased in recent decades, regardless of educational level.
8.1 – : Avoidable deaths from ischaemic heart 8.3 – : , : Avoidable deaths from disease per 100 000 inhabitants age 1–79, 2010–2011. ischaemic heart disease per 100 000 inhabitants 35–79 years Age-standardised. old. Age-standardised. Number per 100 000 inhabitants Number per 100 000 inhabitants 200 250 175 200 150
125 150 100
75 100
50 50 25
0 0 1312111009080706050403020100999897 2007 2008 2009 2010 2011 2012 2013 Year Year Total Women Men Pre-upper-secondary Upper-secondary Post-secondary Source: The Swedish Cause of Death Register, the National Board of Health Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. and Welfare. The Health of the Population 47
8.4 – , : Avoidable deaths from ischaemic heart disease per 100 000 inhabitants 1–79 years old, 2012–2013. Age-standardised.
Jämtland 19.4 Uppsala 19.5 Halland 21.3 Kronoberg 22.3 Stockholm 22.4 Värmland 23.2 Blekinge 24.2 Skåne 24.8 SWEDEN 26.7 Sörmland 26.9 Kalmar 27.5 Västmanland 28.2 Västra Götaland 28.4 Västerbotten 29.4 Östergötland 30.4 Norrbotten 30.5 Gävleborg 30.6 Gotland 31.4 Dalarna 32.2 Örebro 33.1 Jönköping 33.6 Västernorrland 34.2 0 25 50 75 100 125
2012–2013 2010–2011 Number per 100 000 inhabitants Source: The Swedish Cause of Death Register, the National Board of Health and Welfare.
8.5 – , : Avoidable deaths from ischaemic heart disease per 100 000 inhabitants 1–79 years old, 2012–2013. Age-standardised.
Halland 53.9 Kronoberg 54.4 Uppsala 61.1 Stockholm 64.8 Gotland 68.5 Jönköping 69.5 Östergötland 71.7 Sörmland 73.7 Västra Götaland 73.7 SWEDEN 73.8 Skåne 75.0 Kalmar 77.5 Dalarna 78.7 Gävleborg 79.9 Västerbotten 80.1 Västmanland 80.4 Jämtland 81.1 Örebro 83.5 Värmland 83.7 Västernorrland 84.9 Blekinge 89.5 Norrbotten 109.2 0 25 50 75 100 125
2012–2013 2010–2011 Number per 100 000 inhabitants Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. 48 Regional Comparisons 2014: Public Health
MENTAL ILL-HEALTH itants, but also in their capacity as employers with respect Mental ill-health is a general term encompassing a range of the workplace climate and work-related stress. Other of different aspect of mental problems. This applies to relevant factors are access to green spaces, noise, traffic everything from self-reported problems such as fatigue, planning and communications. worry and anxiety, to depression and other manifest men- Several initiatives targeting adolescent mental health tal illnesses such as schizophrenia. There is also a great are being implemented by county councils, but at the deal of suffering among the close relatives and friends of same time, the National Board of Health and Welfare as- those with mental ill-health [42]. sesses that there are deficiencies in this area in terms of first-line medical care. Roles need to be clearly defined, 9 . IMPAIRED MENTAL WELL-BEING setting out how primary care services, paediatric and ado- Den Mental ill-health in the population is often measured lescent psychiatric services, school health services, guid- using surveys and interview studies. Impaired mental ance centres for young people and paediatric health ser- well-being is an extensive public health problem and vices are to work with mental health. The National Board many different studies show sharp increases in the 1990s of Health and Welfare also identifies deficiencies in the among adolescents. information given to young people about where they can This increase now appears to have halted, but there is turn for help and support [61]. still a high incidence of this problem, particularly among young women [12, 61]. Similarly, the proportion of adoles- cents who seek psychiatric care for anxiety and depression 9.1 – : Individuals who estimated to have a has increased since the 1990s, primarily among young weakened general mental health based on the General Health mothers with a low educational level [61]. Questionnaire GHQ12, 16–84 years old. Psychiatric diagnoses constitute the second largest Per cent 35 group of diagnoses for which people are certified sick and receiving compensation from the Swedish Social Insur- 30 ance Agency, and the largest among women [62]. 25
Mental well-being is affected by a range of different 20 factors such as the individual’s ability to deal with stress, unemployment, financial vulnerability, social isolation 15 or capacity to maintain a good lifestyle. This involves a 10 secure environment in which to grow up with the oppor- 5 tunity to have a good schooling and to subsequently find 0 work and participate in society. 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year Municipalities and county councils have a specific re- Total Women Men
sponsibility for their inhabitants’ mental health, not sim- Source: Health on Equal Terms, Public Health Agency of Sweden. ply in terms of their services involving contact with inhab- The Health of the Population 49
9.2 - , , : Individuals who 9.3 - , , : Individuals who estimated to have a weakened general mental health based on estimated to have a weakened general mental health based on the General Health Questionnaire GHQ12. the General Health Questionnaire GHQ12.
Per cent Per cent 35 35
30 30
25 25
20 20
15 15
10 10
5 5
0 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Per cent Per cent 16–29 year 30–44 year 45–64 year 65–84 year 16–29 year 30–44 year 45–64 year 65–84 year Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden.
This indicator is measured using twelve questions 9.4 – : Individuals who estimated to have a based on the Global Health Questionnaire (GHQ12), which weakened general mental health based on the General Health is designed to measure mental ill-health. Questionnaire GHQ12, 35–74 years old, 2014. The proportion of people with self-reported impaired Per cent 25 mental well-being has previously been increasing in the majority of county councils and municipalities, but has 20 remained largely unchanged in the period from 2007 to
2014. It is still the case that a larger proportion of women 15 than men state that they have impaired mental well-be- ing. There is also a clear pattern between the age groups; 10 younger people are more likely to state they have impaired mental well-being and the proportion has increased 5 among younger people in the period from 2007 to 2014. The association with education is not as distinct as that 0 Women Men of many other indicators, and individuals with post-sec- ondary education are more likely to have impaired mental Pre-upper-secondary Upper-secondary Post-secondary Source: Health on Equal Terms, Public Health Agency of Sweden. well-being than those with a lower educational level. Register of Education (UREG), Statistics Sweden. 50 Regional Comparisons 2014: Public Health
9.5 – , : Individuals who estimated to have a weakened general mental health based on the General Health Questionnaire GHQ12, 35–74 years old, 2011–2014.
Kalmar 15 Gävleborg 15 Jönköping 16 Kronoberg 16 Halland 17 Västernorrland 17 Jämtland 17 Gotland 17 Västerbotten 17 Norrbotten 18 Västmanland 18 Värmland 18 Uppsala 19 Dalarna 19 Sörmland 19 Östergötland 20 SWEDEN 20 Blekinge 21 Stockholm 21 Örebro 22 Västra Götaland 22 Skåne 23 0 5 10 15 20 25 30
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
9.6 – , : Individuals who estimated to have a weakened general mental health based on the General Health Questionnaire GHQ12, 35–74 years old, 2011–2014.
Blekinge 8 Västernorrland 10 Jönköping 11 Kronoberg 11 Jämtland 11 Halland 13 Dalarna 13 Uppsala 14 Värmland 14 Skåne 14 Norrbotten 14 Örebro 14 Gävleborg 14 Östergötland 14 SWEDEN 14 Sörmland 14 Västerbotten 15 Gotland 15 Västra Götaland 15 Kalmar 15 Västmanland 16 Stockholm 17 0 5 10 15 20 25 30
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. The Health of the Population 51
F 9.7 ¡ ¢£¤¥¦§¨©: Individuals who estimated to have a weakened general mental health based on the General Health Questionnaire GHQ12 (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16¡84 years old. Skåne (FHS), 18¡80 years old. Värmland (LH), 18+ years old.
Oskarshamn Nyköping Arboga Pajala Vansbro Båstad Hudiksvall Älvsbyn Bollebygd Karlskoga Härjedalen Karlsborg Tibro Höör Gävle Kinda Hällefors Östhammar Södertälje Gällivare Mariestad Nybro Vännäs Ljungby Kalmar Sollentuna Solna Hjo Falkenberg Ljusnarsberg Sölvesborg Vadstena Alingsås Vara Norrköping Ulricehamn Ängelholm Smedjebacken Härnösand Lindesberg Lekeberg Leksand Partille Herrljunga Ale Arvidsjaur Eskilstuna Kalix Håbo Tjörn Hörby Tranås Lerum Uppvidinge Järfälla Mörbylånga Sigtuna Arjeplog Kil Ovanåker Torsby Heby Karlstad Högsby Mönsterås Österåker Filipstad Askersund Söderköping Söderhamn Kristinehamn Alvesta Vallentuna Växjö Sandviken Hylte Olofström Borås Landskrona Borgholm Sjöbo Strängnäs Gnesta Laxå Sorsele Karlshamn Sundbyberg Kramfors Kungsbacka Östersund Vetlanda Nordmaling Robertsfors Varberg Osby Vindeln Markaryd Katrineholm Malå Öckerö Berg Forshaga Örebro Ludvika Orust Laholm Tomelilla Motala Vellinge Ånge Sotenäs Lessebo Norberg Lidköping Västervik Älmhult Västerås Munkedal Falköping Borlänge Knivsta Grästorp Tyresö Emmaboda Uppsala Storuman Svenljunga Boden Kungsör Lysekil Skellefteå Falun Degerfors Valdemarsvik Färgelanda Trosa Örkelljunga Värnamo Fagersta Vänersborg Munkfors Jokkmokk Skinnskatteberg Hofors Trollhättan Nordanstig Åmål Arvika Helsingborg Sala Vingåker Mora Bromölla Flen Älvkarleby Jönköping Linköping Ljusdal Sollefteå Kumla Kristianstad Upplands Väsby Örnsköldsvik Mjölby Haninge Piteå Skara Tierp Eslöv Bengtsfors Uddevalla Timrå Umeå Nora Övertorneå Gotland Burlöv Sunne Kungälv Skövde Svalöv Ragunda Luleå Lidingö Åstorp Vimmerby Mark Hultsfred Göteborg Tranemo Ystad Köping Huddinge Överkalix Sundsvall Haparanda Värmdö Säter Surahammar Mellerud Upplands-Bro Gullspång Simrishamn Halmstad Stockholm Eda Stenungsund Ronneby Grums Dorotea Åtvidaberg Nässjö Ekerö Dals-Ed Åsele Nacka Klippan Storfors Kävlinge Danderyd Bjuv Hagfors Trelleborg Avesta Essunga Tingsryd Härryda Lund Bjurholm Strömstad Älvdalen Malmö Gislaved Gagnef Hässleholm Botkyrka Götene Lycksele Vilhelmina Aneby Täby Norsjö Mölndal Boxholm Töreboda Enköping Karlskrona Eksjö Strömsund Krokom Årjäng Gnosjö Rättvik Kiruna Hammarö Habo Vaggeryd Ockelbo Hedemora Mullsjö Torsås Hallstahammar Skurup Nykvarn Tanum Malung-Sälen Svedala Nynäshamn Bräcke Finspång Orsa Salem Vårgårda Perstorp Lomma Sävsjö Hallsberg Åre Oxelösund Vaxholm Tidaholm Lilla Edet Bollnäs Ydre Östra Göinge Höganäs Norrtälje Ödeshög 0 10 20 30 0 10 20 30 0 10 20 30 0 10 20 30 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008 LH - Värmland 2012 LH - Värmland 2008 Values with less than 100 respondents are not presented. Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne; Liv och Hälsa (LH) [Life and Health], County Council of Värmland. 52 Regional Comparisons 2014: Public Health
10 . REGULAR TREATMENT WITH The indicator shows the number of regular users of ben- SOPORIFICS OR SEDATIVES zodiazepines and related medications among those aged Several studies conclude that mental ill-health is common 20–79 per 1 000 inhabitants. A regular user is regarded as among the population; these include the national public an individual who consumes an average of at least one half health survey, mentioned in the previous section, and of the defined daily dose (DDD) per day over the course of Statistics Sweden’s living conditions surveys. Sleep prob- one year. In this context it should be noted that there is lems and problems with angst, worry and anxiety have currently no set recommended level for what this con- increased in recent decades, primarily among young peo- sumption should look like. ple. A higher proportion of women in these surveys state The results show that there are clear differences in terms that they suffer from one or more of the problems named of the regular use of soporifics and sedatives, both between above. Women aged 16–24 are affected particularly often women and men and between individuals with different and more frequently report problems with angst, worry or educational levels. Women are more likely to consume anxiety than women in other age groups [12]. these medications than men and the proportion of regular Psychoactive medications are commonly used to treat users is higher among individuals with lower educational mental ill-health and are used in both out-patient and levels than those with higher educational levels. in-patient care. The approved medications for short-term The regular use of soporifics and sedatives was relative- treatment of pathological anxiety and temporary sleep ly constant in Sweden in the period 2009–2013. The result disturbances are benzodiazepines and related medica- also indicates that the level of regular use varied substan- tions. They are also used to treat milder forms of worry tially between county councils and municipalities. At the and anxiety. county council level, the number of regular users aged Psychoactive medications for adults are normally pre- 20–79 per 1 000 inhabitants varied from 22 to 37. No major scribed by general practitioners and psychiatrists and changes are demonstrated in relation to the period used sometimes by physicians specialising in internal medi- for comparison, 2009. The relatively large differences be- cine. However, benzodiazepines have the potential to tween county councils may be explained by factors such cause side-effects, particularly when consumed in large as mental ill-health being unequally distributed between quantities and over long periods of time. They are also county councils and the existence of differences within the classed as narcotics and their use can induce depend- country in terms of the practice of prescribing these medi- ence and result in problems relating to their abuse. Con- cations (further information in the separate info. box). sequently, it is important that these medications are not It is important to continue monitoring variations be- prescribed for long periods [63]. tween county councils with respect to the regular used of soporifics and sedatives.
10.1 – : Individuals regularly using (≥0.5 DDD/day) 10.2 – , : Individuals regularly using benzodiazepines per 1 000 inhabitants, 20–79 years old. (≥0.5 DDD/day) benzodiazepines per 1 000 inhabitants, Age-standardised. 30–64 years old, 2013. Age-standardised. Number per 100 000 inhabitants 60 Number per 100 000 inhabitants 60 50 50 40 40 30 30 20 20 10 10 0 2006 2007 2008 2009 2010 2011 2012 2013 Year 0 Total Women Men Women Men Source: The Swedish Prescribed Drug Register, the National Board of Health Pre-upper-secondary Upper-secondary Post-secondary and Welfare. Source: The Swedish Prescribed Drug Register, the National Board of Health and Welfare. Register of Education (UREG), Statistics Sweden. The Health of the Population 53
10.3 – , : Individuals regularly using (≥0.5 DDD/day) benzodiazepines per 1 000 inhabitants, 20–79 years old, 2013. Age-standardised.
Sörmland 27.7 Örebro 27.7 Norrbotten 29.3 Västernorrland 30.8 Östergötland 32.6 Dalarna 33.4 Gotland 34.7 Västerbotten 35.9 Blekinge 36.1 Jämtland 36.8 Halland 37.0 Stockholm 38.1 Uppsala 38.4 Jönköping 39.0 Gävleborg 39.3 SWEDEN 39.4 Västmanland 42.3 Skåne 43.2 Kalmar 43.3 Värmland 46.2 Västra Götaland 47.7 Kronoberg 48.4 0 10 20 30 40 50 60 2013 2009 Number per 100 000 inhabitants
Source: The Swedish Prescribed Drug Register, the National Board of Health and Welfare.
10.4 – , : Individuals regularly using (≥0.5 DDD/day) benzodiazepines per 1 000 inhabitants, 20–79 years old, 2013. Age-standardised.
Örebro 16.5 Sörmland 17.1 Västernorrland 19.2 Östergötland 19.5 Norrbotten 19.6 Dalarna 20.3 Jämtland 21.0 Västerbotten 21.1 Gotland 22.1 Halland 23.4 Jönköping 24.1 Gävleborg 24.4 Uppsala 24.6 Blekinge 24.6 SWEDEN 25.1 Stockholm 25.4 Västmanland 27.1 Skåne 27.2 Kalmar 28.2 Kronoberg 29.1 Värmland 30.0 Västra Götaland 31.0 0 10 20 30 40 50 60 2013 2009 Number per 100 000 inhabitants
Source: The Swedish Prescribed Drug Register, the National Board of Health and Welfare. 54 Regional Comparisons 2014: Public Health
F 10.5 ¡ ¢£¤¥¦§¨©: Individuals regularly using (≥0.5 DDD/day) benzodiazepines per 1 000 inhabitants, 20¡79 years old, 2013. Age-standardised.
Jokkmokk Burlöv Tjörn Tranås Kiruna Säter Fagersta Halmstad Ödeshög Danderyd Norrköping Åstorp Gällivare Malung-Sälen Tranemo Härryda Gagnef Sundsvall Sotenäs Sala Malå Älvdalen Falkenberg Mellerud Storuman Eslöv Filipstad Nässjö Pajala Vårgårda Upplands-Bro Västerås Åre Järfälla Bollebygd Haninge Robertsfors Habo Skara Tomelilla Lekeberg Timrå Vilhelmina Bjuv Örnsköldsvik Ånge Svenljunga Hammarö Berg Laxå Vimmerby Kalmar Boxholm Emmaboda Strömsund Sigtuna Nyköping Hörby Hedemora Mariestad Nykvarn Vaxholm Huddinge Munkfors Gnosjö Tyresö Falköping Helsingborg Örebro Finspång Degerfors Ockelbo Trosa Kramfors Vellinge Tidaholm Hallsberg Höör Torsås Karlstad Kinda Mullsjö Alingsås Kristianstad Lindesberg Håbo Herrljunga Munkedal Rättvik Borlänge Uppsala Östra Göinge Högsby Dorotea Markaryd Skövde Piteå Perstorp Nora Kungsbacka Umeå Grums Ovanåker Krokom Sölvesborg Simrishamn Bjurholm Arboga Karlsborg Trelleborg Vaggeryd Smedjebacken Nordanstig Höganäs Kumla Arjeplog Sandviken Upplands Väsby Norsjö Ljusnarsberg Lund Söderhamn Valdemarsvik Nacka Tibro Vallentuna Mjölby Svedala Ragunda Strömstad Flen Varberg Sundbyberg Tanum Härjedalen Gotland Norberg Arvidsjaur Götene Östersund Uddevalla Söderköping Södertälje Ängelholm Växjö Mora Värmdö Kungsör Malmö Hällefors Salem Österåker Ljungby Eskilstuna Sjöbo Essunga Gnesta Sunne Västervik Surahammar Ronneby Skinnskatteberg Vansbro Kristinehamn Östhammar Täby Tingsryd Årjäng Lomma Torsby Stenungsund Färgelanda Linköping Vännäs Gävle Överkalix Åsele Lidingö Mörbylånga Lessebo Hylte Älvsbyn Ystad Landskrona Strängnäs Åtvidaberg Klippan Bromölla Oxelösund Mönsterås Avesta Lysekil Haparanda Botkyrka Storfors Nybro Askersund Vara Enköping Alvesta Värnamo Kil Köping Mölndal Örkelljunga Båstad Vetlanda Borås Luleå Älvkarleby Eksjö Uppvidinge Gislaved Grästorp Hjo Öckerö Vingåker Sollefteå Ulricehamn Partille Laholm Kävlinge Sävsjö Skurup Knivsta Lerum Aneby Åmål Övertorneå Heby Mark Borgholm Kalix Ljusdal Kungälv Lilla Edet Norrtälje Nordmaling Olofström Bengtsfors Sollentuna Svalöv Karlshamn Hagfors Hofors Motala Oskarshamn Ale Falun Vadstena Stockholm Tierp Sorsele Hudiksvall Hallstahammar Trollhättan Ydre Karlskrona Dals-Ed Arvika Bräcke Boden Hässleholm Töreboda Härnösand Orsa Orust Göteborg Leksand Ekerö Lidköping Eda Vindeln Lycksele Nynäshamn Gullspång Katrineholm Bollnäs Älmhult Vänersborg Ludvika Karlskoga Jönköping Hultsfred Skellefteå Solna Osby Forshaga 0 20 40 60 0 20 40 60 0 20 40 60 0 20 40 60 Number per 100 000 inhabitants. SWEDEN 2013 2009
Source: The Swedish Prescribed Drug Register, the National Board of Health and Welfare. The Health of the Population 55
THE USE OF SOPORIFICS AND SEDATIVES TENDS TO VARY The review of the healthcare-related factors care consump- IN LINE WITH THE INCIDENCE OF MENTAL ILL-HEALTH tion, differences in organisation of the healthcare system and specialist expertise showed there were no major differ- In 2014, the National Board of Health and Welfare carried ences between the county councils that had high propor- out a minor analysis within the scope of the commission tions of regular users of soporifics/sedatives and those with Regional Comparisons Healthcare concerning the use of low proportions. Nor were there any major differences in soporifics and sedatives that focused on geographic dif- the cost of specialist psychiatric care. ferences. The background to this analysis was the previ- ous year’s county council comparisons, which showed that There were, however, some signs of covariance with regard there were very large differences between county councils to the regular use of soporifics and sedatives and the inci- in terms of the regular prescription of such medications, dence of psychiatric symptoms in the population. County e.g. Regional Comparisons 2013 Healthcare. councils with high regular use of soporifics and sedatives also had the highest number of current cases of mental The aim of this analysis was to chart whether, and in which illnesses and behavioural disorders. Västra Götaland also case to what extent, there is covariance between different had the highest proportions of current cases of affective background factors – linked to both healthcare and the disorders and neurotic, stress-related and somatoform dis- populations living conditions and health – and the use of orders in the country, at the same time as Södermanland soporifics and sedatives. The term covariance refers to a had among the lowest proportions. Kronoberg also had situation in which there is a correlation between the vari- relatively low proportions of current cases within this dis- ables studied in that high values for one variable – in this ease category. The Swedish Social Insurance Agency’s re- case the regular used of soporifics and sedatives – appear port states: It can thus be concluded from the figures for together with high values in another variable and vice ver- absence from work due to psychiatric diagnoses from 2014 sa, i.e. low values in one variable appear together with low that the risk of becoming ill with a psychiatric diagnosis is values in the other. This study specifically looked at those highest in Västra Götaland. county councils that had the highest and the lowest val- ues, respectively, for the indicator “Regular treatment with However, the review of the lifestyle-related factors showed soporifics and sedatives”. The county councils in question that there were no major differences between the county were Västra Götaland and Kronoberg (high values) and Sö- councils in question. Nor were there any differences in the dermanland and Örebro (low values). regional socioeconomic structures or the labour market that could be linked to the recorded differences in the indi- The National Board of Health and Welfare used official sta- cator “Regular treatment with soporifics or sedatives”. tistics and published reports and compared a number of factors at the county council level, among them a range of Accordingly, the results from the analysis indicate that there healthcare-related factors such as the organisation of the is some covariance between the use of soporifics/sedatives healthcare system, specialist expertise and the cost of spe- and the incidence of mental ill-health in the population. To cialist dental care. some extent the indicator probably also reflects different treatment traditions within the healthcare system in differ- A number of lifestyle-related factors, e.g. alcohol consump- ent parts of the country, in that there are differences be- tion, tobacco use and physical activity, were also studied at tween county councils in terms of standard practice with the county council level on the basis of self-reported data respect to the prescription of these medications. from the national public health survey from 2013. Other factors reviewed and compared between the county coun- cils and in relation to the indicators covered the regional socioeconomic structure (the average income and educa- tional level of the population) and the structure of the la- bour market (labour market focus, unemployment levels, etc.). 56 Regional Comparisons 2014: Public Health
11 . SUICIDE AND DEATHS INVOLVING port any suicides that have taken place within four weeks UNCERTAIN INTENT of when the victim last made contact with the healthcare According to the NASP – the National Centre for Suicide system. Research and Prevention of Mental Ill-Health – suicide can The indicator shows the number of suicides and deaths be regarded as a public health problem. involving uncertain intent in the period 2011–2013. The The suicide rate has been slowly declining for several outcome has not changed appreciably over time. When decades, but this trend has come to a halt for the past two looked at with respect to educational background, the years [54]. same trend as in many other indicators can be seen, name- It is important that people contemplating suicide are ly that people with a low educational level have a higher discovered in time. Organisations, families and close suicide rate and this is particularly prominent among men friends can play a vital role by being aware of these condi- with a low educational level. tions. This also applies to society as a whole and to several INJURIES levels of care within the healthcare system. Municipalities The number of deaths resulting from injuries has in- and county councils come into contact with individuals creased in Sweden since the end of the 1990s, having previ- through health and social services and schools, which al- ously been declining for a couple of decades. lows them to take action to prevent suicide by identifying those at risk. The care guide (e.g. Vårdguiden is a care guide on the 11.2 – : , : Suicides and deaths webb for patients) refers people contemplating suicide to with undetermined intent per 100 000 inhabitants, 35–79 years primary care centres, psychiatric clinics, guidance centres old. Age-standardised. for young people, paediatric and adolescent psychiatric Number per 100 000 inhabitants 40 services, the church, school health services, student health and national helplines. In addition, there are a range of as- sociations that work to prevent mental ill-health and sui- 30 cide in society and offer the opportunity to make contact with people in a similar situation, as well as other close 20 friends or relatives who have been affected.
The National Board of Health and Welfare recommends 10 that the healthcare system put in place structured suicide risk assessments, i.e. assessments that take place in a sim- 0 ilar way and in accordance with a defined structure. This 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 risk assessment should take place in conjunction with the Year Pre-upper-secondary Upper-secondary Post-secondary diagnosis and then at regular intervals while there is a risk Source: The Swedish Cause of Death Register, the National Board of Health and of suicide. The healthcare system is also obliged, pursu- Welfare. Register of Education (UREG), Statistics Sweden. ant to the statutory reporting obligation in Sweden, to re-
11.1 – : Suicides and deaths with undetermined 11.3 – : , : Suicides and deaths intent per 100 000 inhabitants. Age-standardised. with undetermined intent per 100 000 inhabitants, 35–79 years old. Age-standardised. Number per 100 000 inhabitants 40 Number per 100 000 inhabitants 40
30 30
20 20
10 10
0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 0 Year 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 Total Women Men Year Pre-upper-secondary Upper-secondary Post-secondary Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. Register of Education (UREG), Statistics Sweden. The Health of the Population 57
11.4 – , : Suicides and deaths with undetermined intent per 100 000 inhabitants, 2011–2013. Age-standardised.
Dalarna 5.0 Jönköping 6.4 Västerbotten 7.3 Västernorrland 7.7 Norrbotten 7.7 Halland 8.0 Östergötland 8.1 Jämtland 8.5 Skåne 8.6 Blekinge 8.7 Västra Götaland 9.0 SWEDEN 9.4 Gävleborg 9.5 Uppsala 9.7 Värmland 9.7 Västmanland 10.0 Örebro 10.0 Kalmar 10.2 Kronoberg 10.5 Sörmland 11.0 Stockholm 11.8 Gotland 20.7 0 10 20 30 40
2011–2013 2008–2010 Number per 100 000 inhabitants Source: The Swedish Cause of Death Register, the National Board of Health and Welfare.
11.5 – , : Suicides and deaths with undetermined intent per 100 000 inhabitants, 2011–2013. Age-standardised.
Västerbotten 14.3 Västernorrland 19.3 Västra Götaland 20.1 Blekinge 20.1 Halland 20.5 Stockholm 21.4 Skåne 21.6 Gotland 22.1 RIKET 22.2 Jämtland 22.5 Sörmland 22.8 Jönköping 22.9 Uppsala 23.4 Gävleborg 23.6 Norrbotten 23.7 Kronoberg 23.7 Värmland 24.0 Östergötland 24.2 Dalarna 24.2 Örebro 27.7 Västmanland 30.0 Kalmar 30.6 0 10 20 30 40
2011–2013 2008–2010 Number per 100 000 inhabitants Source: The Swedish Cause of Death Register, the National Board of Health and Welfare. 58 Regional Comparisons 2014: Public Health
INJURIES of injuries varying between 481 and 1693 per 100 000 chil- Children, adolescents and the elderly run the greatest risk dren. Nonetheless, some consideration should be given to of suffering an accident and being injured. Falls are the the fact that admission practices can vary between hospi- most common cause of injuries among both the young tals, which may affect the results. Fewer children were in- and the old, followed by road traffic accidents. While jured in 2013 than in 2009 in the majority of county coun- men dominate the statistics in terms of injuries occurring cils. At the same time, the results show that the number prior to the age of retirement, women are overrepresented of childhood injuries in Sweden as a whole has remained among those injured later in life. relatively stable since the beginning of this century. The Injuries are one of the leading causes of permanent dis- results also indicate that boys are considerably more likely ability and lost life years for the individual and also cost to be injured than girls. society a great deal. If the number of injuries and deaths is to be reduced, it is important to continue working to make Sweden safer. 12 . INJURIES AMONG CHILDREN The municipalities are responsible for designing safe en- The number of deaths among children caused by injuries vironments for children with respect to play and traffic, for has been decreasing markedly in Sweden for many years. example. Regular inspections of equipment in play parks This is largely due to a long-established tradition of accident for children, together with adopting a safety perspective prevention and trans-sectoral initiatives for the creation of in the design of all new play parks for children, can con- safe environments for children. In spite of this, many chil- tribute to promoting safety for all children. Conducting in- dren are still injured and injuries caused by accidents are ventories of accident risks in the road traffic environment, still the most common cause of death among children aged introducing speed limits and speed-reduction measures, 0–15 years. Children are particularly vulnerable to injuries. ensuring that the municipal road network is regularly Because they are developing, there is a risk of suffering fur- maintained and regular snow clearing can be used to in- ther injuries, at the same time as the injuries they suffer can crease traffic safety. have serious consequences [64, 65]. Another important aspect of accident prevention is The incidence and cause of injuries both vary with the information and education targeted at both children and child’s gender and age. Boys are considerably more likely their parents. In partnership with other stakeholders, the to be injured than girls. At earlier ages, this is explained municipality can actively participate in campaigns to in- by factors such as boys’ bodily functions developing at form the public about traffic safety and, for example, work a later stage and, in the case of older children, boys take to increase the use of bicycle helmets. Schools can also greater risks than girls [64]. In Sweden, as in other Europe- make a contribution, for example by providing informa- an countries, falls, together with traffic-related accidents, tion and educating pupils about traffic safety in partner- are behind a considerable proportion of injuries that occur ship with the police. The county councils also play an in childhood. Younger children primarily suffer from inju- important role in these educational efforts through pae- ries in conjunction with falls, while both falls and traffic- diatric health services and encounters with children and related accidents are behind a large proportion of injuries parents. among older children [64–66]. Both international and Swedish research shows that children who live in less favourable socioeconomic cir- 12.1 – : Children that have received inpatient cumstances run a greater risk of being injured as a result of care caused by an injury event per 100 000 children aged accidents [66–69]. For example, there is an increased risk 0–6 years old.
of road traffic accidents and accidents relating to violence. Number per 100 000 inhabitants The differences between children from different socioeco- 1 200 nomic groups also tend to become greater the older the 1 100 children become [20, 70], The indicator shows the number of children per 100 000 1 000 aged 0–6 years who are admitted to hospital as a result 900 of injuries in 2013. The data comes from the National Board of Health and Welfare’s register of patients admit- 800 ted to hospital and takes into account injuries and cases 700 of poisoning in accordance with the codes for extraneous causes. 01 02 03 04 05 06 07 08 09 10 11 12 13 In 2013, the number of injuries amounted to an aver- Year Total Girls Boys age of 824 per 100 000 children. However, there are major differences at the county council level, with the number Source: The National Patient Register, the National Board of Health and Welfare. The Health of the Population 59
12.2 – , : Children that have received inpatient care caused by an injury event per 100 000 children aged 0–6 years old, 2013.
Stockholm 410 Uppsala 436 Sörmland 596 Jönköping 678 Gävleborg 703 SWEDEN 720 Skåne 738 Värmland 745 Norrbotten 788 Jämtland 790 Blekinge 796 Östergötland 802 Västra Götaland 820 Halland 826 Örebro 888 Kronoberg 964 Dalarna 1 018 Västernorrland 1 030 Kalmar 1 139 Västerbotten 1 187 Västmanland 1 271 Gotland 1 562 0 500 1 000 1 500 2 000 2 500
2013 2009 Number per 100 000 inhabitants Source: The National Patient Register, the National Board of Health and Welfare.
12.3 – , : Children that have received inpatient care caused by an injury event per 100 000 children aged 0–6 years old, 2013.
Stockholm 548 Uppsala 577 Kronoberg 891 Norrbotten 917 SWEDEN 922 Skåne 928 Jönköping 974 Sörmland 979 Västra Götaland 1 011 Värmland 1 022 Gävleborg 1 082 Örebro 1 091 Halland 1 092 Östergötland 1 122 Kalmar 1 190 Dalarna 1 197 Västerbotten 1 293 Västernorrland 1 363 Jämtland 1 367 Västmanland 1 438 Blekinge 1 474 Gotland 1 822 0 500 1 000 1 500 2 000 2 500
2013 2009 Number per 100 000 inhabitants Source: The National Patient Register, the National Board of Health and Welfare. 60 Regional Comparisons 2014: Public Health
13 . FALL-RELATED INJURIES AMONG THE The results show that there are major differences be- ELDERLY tween county councils and between municipalities, in- Falls are a common cause of injury in Sweden and are an cluding a larger number of hospital admissions as a result extensive public health problem, particularly among the of fall-related injuries among the elderly in northern Swe- elderly. Two thirds of those who die as a results of fall- den. The total number of fall-related injuries in the age related injuries are 65 or older, as are half of all those who group 65–79 has decreased somewhat since the previous receive hospital care as a result [71]. measurement period, while the number of fall-related in- Elderly women are more likely to suffer from injuries juries has increased in those over 80 years of age. Women than elderly men and research shows that there are also are more likely to injure themselves than men, something marked differences in the risk of injury relating to socio- which applies to both age groups. economic status, marital status and country of birth [72, A range of interventions have been shown to be effec- 73]. Fall-related injuries can have serious consequences in tive in terms of protecting individuals from falling and in- the form of suffering and reduced quality of life, for exam- juring themselves. Some examples of these are initiatives ple problems with movement, isolation and increased de- focused on physical activity and balance training for the pendence on others. Many falls result in hip fractures that, elderly, adaptations to their surroundings, snow clearance in addition to resulting in the suffering of those affected, and gritting in winter, good outdoor lighting, treatment for also carry a considerable societal cost. osteoporosis, regular reviews of medication and eye tests. The number of fall-related injuries among the elderly is Several of these are dependent on cooperation between increasing steadily in Sweden, something which is asso- municipality and county council. At the municipal level, it ciated with factors such as the ageing demographic com- can be valuable to begin reporting falls locally in order to position of the welfare state. The elderly are increasingly provide an overview of the general pattern or injuries that remaining fit and active and are living longer, at the same can subsequently be used to guide the work of drawing up time as the proportion that is frail is increasing due to im- an action plan. It should be possible to follow the statistics proved healthcare which is able to save many of their lives over time and comparisons can then be made with the in- [74]. From a European perspective, Sweden has not devel- cidence of injuries in other municipalities. This data can oped as well as many other countries in terms of reducing then be used to draw up a concrete plan indicating how the number of deaths of elderly people caused by various the municipality will be structuring its preventative ef- types of injury, with the exception of traffic-related inju- forts. This should concentrate on certain high-risk envi- ries [75]. ronments and individuals who are particularly vulnerable, Many individual factors related to lifestyle habits and which is an assessment that should be made in conjunc- health have an impact on the risk of being injured with ad- tion with the healthcare system. vancing age. For example, a number of international and Swedish studies have shown that life-long physical activ- ity leads to a reduced risk of falls [76, 77]. Diet, smoking, 13.1 – , : Inpatient cases caused by alcohol consumption and recreational activities are other fall injuries, individuals aged 65 and older, per 100 000 important lifestyle-related factors [78, 79]. The risk factors inhabitants, 2011–2013. Number per 100 000 inhabitants for falls include falls in blood pressure, underlying disease, 8 000 low bodyweight and the use of medication [71, 80–82]. 7 000 The indicator shows the average number of hospital ad- 6 000 missions resulting from fall-related injuries among indi- viduals aged 65 and older per 100 000 people in this age 5 000 group in the period 2011–2013. Data have been gathered 4 000 from the National Board of Health and Welfare’s register of 3 000 patients admitted to hospital. Hospital admissions prac- 2 000
tices can vary between hospitals, which may have an im- 1 000
pact on the results. 0 The number of hospital admissions resulting from fall- Women Women Men Men 65–79 year 80 and older 65–79 year 80 and older related injuries among those aged 65 and over in the pe- riod 2011–2013 amounted to an average of 2 637 per 100 000 Women 2011–2013 Men 2011–2013 2008–2010 inhabitants’ in that age group. Source: The National Patient Register, the National Board of Health and Welfare. The Health of the Population 61
13.2 – , : Inpatient cases caused by fall injuries, individuals aged 65 and older, per 100 000 inhabitants, 2011–2013.
Uppsala 2 770 Sörmland 2 771 Östergötland 2 819 Gävleborg 2 843 Blekinge 2 930 Västmanland 2 978 Halland 3 008 Örebro 3 038 Västra Götaland 3 085 Värmland 3 128 Västernorrland 3 136 Gotland 3 139 SWEDEN 3 180 Kalmar 3 236 Dalarna 3 268 Jönköping 3 269 Skåne 3 279 Norrbotten 3 305 Stockholm 3 390 Kronoberg 3 566 Jämtland 3 637 Västerbotten 3 765 0 1 000 2 000 3 000 4 000
2011–2013 2008–2010 Number per 100 000 inhabitants Source: The National Patient Register, the National Board of Health and Welfare.
13.3 – , : Inpatient cases caused by fall injuries, individuals aged 65 and older, per 100 000 inhabitants, 2011–2013.
Blekinge 1 726 Uppsala 1 749 Östergötland 1 761 Gävleborg 1 766 Sörmland 1 828 Örebro 1 844 Västmanland 1 862 Västra Götaland 1 881 Gotland 1 897 Halland 1 911 Västernorrland 1 937 Skåne 1 947 SWEDEN 1 985 Dalarna 2 031 Jönköping 2 053 Värmland 2 075 Norrbotten 2 115 Stockholm 2 156 Kalmar 2 177 Kronoberg 2 180 Västerbotten 2 405 Jämtland 2 497 0 1 000 2 000 3 000 4 000
2011–2013 2008–2010 Number per 100 000 inhabitants Source: The National Patient Register, the National Board of Health and Welfare. 62 Regional Comparisons 2014: Public Health
F 13.4 ¡ ¢£¤¥¦§¨©: Inpatient cases caused by fall injuries, individuals aged 65 and older, per 100 000 inhabitants, 2011¡2013.
Vingåker Askersund Lund Ånge Ödeshög Enköping Norrköping Burlöv Knivsta Nordanstig Örnsköldsvik Laxå Dals-Ed Gullspång Vaxholm Vilhelmina Olofström Upplands-Bro Kristinehamn Jokkmokk Vallentuna Vårgårda Sävsjö Kalix Ekerö Järfälla Årjäng Sunne Gävle Avesta Simrishamn Söderköping Hallstahammar Habo Herrljunga Bollebygd Tomelilla Hallsberg Göteborg Håbo Täby Nynäshamn Piteå Flen Salem Ronneby Söderhamn Munkedal Älmhult Trollhättan Kristianstad Ovanåker Mullsjö Kungälv Falun Hammarö Partille Norberg Storuman Nykvarn Hedemora Botkyrka Ljusnarsberg Ydre Götene Tranemo Hagfors Hofors Klippan Ljusdal Ystad Östhammar Tjörn Pajala Åsele Öckerö Haparanda Trelleborg Bräcke Strängnäs Lidköping Forshaga Emmaboda Kinda Svalöv Borgholm Jönköping Bollnäs Vetlanda Gnosjö Södertälje Hultsfred Lomma Uppsala Sundsvall Skövde Leksand Tanum Valdemarsvik Köping Lessebo Kävlinge Tidaholm Gotland Sala Österåker Sjöbo Åre Orsa Lilla Edet Sollentuna Nyköping Boden Trosa Motala Eskilstuna Gällivare Orust Uddevalla Bromölla Vännäs Markaryd Ockelbo Bjuv Falköping Mjölby Tibro Storfors Alvesta Värmdö Haninge Halmstad Karlskoga Lerum Ulricehamn Östra Göinge Nässjö Sandviken Eslöv Berg Rättvik Lindesberg Hylte Mönsterås Mora Mellerud Mark Tierp Torsås Vellinge Oxelösund Högsby Nybro Strömstad Älvkarleby Hörby Filipstad Lekeberg Gnesta Krokom Härjedalen Karlshamn Höganäs Nacka Arvika Sölvesborg Åstorp Mölndal Norsjö Härryda Osby Arjeplog Malmö Vänersborg Västerås Bengtsfors Strömsund Åtvidaberg Vimmerby Aneby Töreboda Oskarshamn Grästorp Varberg Robertsfors Sigtuna Hässleholm Värnamo Skellefteå Surahammar Örkelljunga Ludvika Vaggeryd Lysekil Kungsbacka Tranås Helsingborg Perstorp Kramfors Landskrona Vadstena Linköping Karlskrona Lycksele Essunga Kiruna Stenungsund Sollefteå Laholm Ale Alingsås Tingsryd Skinnskatteberg Falkenberg Karlstad Umeå Skurup Arboga Hjo Kalmar Mörbylånga Örebro Danderyd Lidingö Boxholm Härnösand Degerfors Nordmaling Säter Malung-Sälen Borås Solna Nora Grums Karlsborg Uppvidinge Tyresö Vansbro Fagersta Växjö Upplands Väsby Norrtälje Vara Älvsbyn Svedala Hällefors Luleå Östersund Kil Ljungby Gagnef Vindeln Sotenäs Ängelholm Eda Stockholm Finspång Gislaved Västervik Sundbyberg Smedjebacken Färgelanda Borlänge Övertorneå Båstad Eksjö Skara Dorotea Timrå Överkalix Heby Sorsele Åmål Mariestad Höör Munkfors Kungsör Kumla Torsby Bjurholm Arvidsjaur Svenljunga Älvdalen Malå Katrineholm Huddinge Hudiksvall Ragunda 0 2500 5000 0 2500 5000 0 2500 5000 0 2500 5000 Number per 100 000 inhabitants. SWEDEN 2011–2013 2008–2010
Source: The National Patient Register, the National Board of Health and Welfare. Social Conditions and Living Conditions 63
Social conditions and living conditions
Social conditions and living conditions are defined as in- Measles, mumps and rubella used to be common child- dicator areas in this report and are described in more detail hood diseases, caused by three different viruses. Contract- in the introduction. These terms are included in what are ing any of these diseases is not normally dangerous, but in defined here as factors that have an impact on health. So- some cases they can result in serious complications and cial conditions encompass such aspects as affect societal even death. The measles virus can be eradicated with a suf- systems in which individuals live, which are often outside ficiently high vaccination rate, but the WHO’s statistic in- of the individual’s immediate control, such as legislation dicate that 164 000 children died in a measles outbreak in and the welfare system. Living conditions describe the cir- 2008. The majority of these children lived in low-income cumstances of the environment in which people live and countries. The Public Health Agency of Sweden reports work and that are more centred on the individual such as that the WHO has received data about 34 000 verified cases the residential environment, working environment and of measles in Europe in 2011, 8 of whom are reported to psychosocial environment [1, 2, 18]. Living conditions are have died [84]. Serious side-effects of the MMR vaccine are affected by the social conditions. rare and the benefits at the group level clearly outweigh the risks [85]. THE FIRST YEARS The vaccines used in Sweden are effective and the vac- The first years of life are very important to a person’s fu- cination rate is high, which provides a good level of pro- ture health, something that recent research into the brain’s tection against these diseases. Because these diseases are development has demonstrated [20]. A good start in life, widespread throughout the world, those who have not with nutritious food, good care and stimulation, as well as been vaccinated run an increased risk of being infected access to qualified healthcare to some extent forms the ba- abroad. sis of, for example, success in school and health and well- being. At the same time, the structural conditions during childhood have a strong impact on children’s health. In many ways, the family’s social position has a decisive im- 14.1 – : Vaccination of children – measles- pact on what resources and what stimulation the child is mumps-rubella (MMR) offered during their childhood and on what health risks Per cent the child is subject to. 100 14 . VACCINATION OF CHILDREN 95
– MEASLES-MUMPS-RUBELLA (MMR) 90 All children are offered vaccinations by paediatric health services and in schools in accordance with a programme 85 that provides protection against nine diseases: polio, diph- theria, tetanus, whooping cough, infections caused by 80 Haemophilus influensae type b, serious diseases caused by Streptococcus pneumoniae and measles, mumps and Jan 93 Jan 96 Jan 99 Jan 02 Jan 05 Jan 08 Jan 11 Jan 14 rubella (MMR). Girls are also offered vaccination against Year Total human papilloma virus (HPV), which can cause cervical Source: Public Health Agency of Sweden. cancer [83]. 64 Regional Comparisons 2014: Public Health
To prevent these diseases regaining a foothold, 95 per Data from Örebro and Uppsala are collected from in- cent of the population have to be immune, either through dividualised vaccination registers and are thus not com- vaccination or as a result of past natural infection. How- pletely comparable with others. In these, the vaccination ever, there are groups of parents who choose not to allow rate is calculated as the proportion of all children on the their children to be vaccinated and the rate of vaccination population register who are vaccinated, not the propor- has decreased to below 90 per cent in some municipali- tion of all children registered with paediatric primary care ties. Consequently, local outbreaks can occur, especially of centres as in the other county councils. measles [83]. The proportion of children who have received the MMR The MMR vaccine has been included in the general vac- vaccine has increased in the majority of counties since cination programme in Sweden since 1982 and is offered 2009. In January 2014, 97.4 per cent of all children born in to children at the age of 18 months and 6–8 years [83]. Pae- 2011 had been vaccinated. The majority of county councils diatric health services annually compile data concerning have a vaccination rate of around 97–98 per cent. the vaccination status of registered 2-year olds and report these to the Public Health Agency of Sweden.
14.2 – : Vaccination of children – measles-mumps-rubella (MMR). Vaccination status registered in January 2014 among children born in 2011.
Örebro 98.8 Kalmar 98.7 Halland 98.6 Östergötland 98.5 Kronoberg 98.3 Värmland 98.3 Västerbotten 98.2 Sörmland 98.1 Blekinge 98.1 Västernorrland 98.0 Jönköping 98.0 Norrbotten 98.0 Gävleborg 97.6 Västra Götaland 97.6 Dalarna 97.4 Skåne 97.3 Västmanland 97.3 SWEDEN 97.3 Gotland 97.1 Jämtland 96.9 Stockholm 96.0 Uppsala 95.1
82 84 86 88 90 92 94 96 98 100
January 2014 January 2009 Per cent Source: Public Health Agency of Sweden. Social Conditions and Living Conditions 65
F¡¢£ 14.3 ¤ ¥¡¦§¨©ª«£¬: Vaccination of children – measles-mumps-rubella (MMR). Vaccination status registered in January 2014 among children born in 2011.
Arjeplog Sundsvall Kinda Essunga Arvidsjaur Älvsbyn Falköping Eslöv Borgholm Sollefteå Karlsborg Boxholm Karlshamn Sollentuna Upplands-Bro Bräcke Älmhult Västervik Haninge Dals-Ed Perstorp Bromölla Lessebo Grästorp Växjö Ljusnarsberg Timrå Hylte Gävle Skövde Tomelilla Laxå Hallsberg Ragunda Mjölby Mellerud Lomma Tjörn Nykvarn Mullsjö Norrköping Arvika Kiruna Mörbylånga Degerfors Falkenberg Högsby Nora Rättvik Ulricehamn Norberg Nordmaling Trollhättan Nacka Krokom Ovanåker Karlstad Falun Herrljunga Oxelösund Eda Hofors Hallstahammar Robertsfors Vara Lund Strömstad Storuman Värnamo Kristianstad Botkyrka Töreboda Partille Mark Nynäshamn Vårgårda Ale Tingsryd Norrtälje Ånge Kil Sävsjö Gnesta Ödeshög Kungsbacka Västerås Ockelbo Östra Göinge Linköping Lidingö Nässjö Malmö Övertorneå Borås Tierp Tibro Österåker Ludvika Vellinge Vännäs Södertälje Höganäs Järfälla Fagersta Bengtsfors Mariestad Sandviken Vingåker Bollebygd Motala Aneby Simrishamn Härjedalen Lidköping Sotenäs Uppvidinge Danderyd Nybro Trelleborg Surahammar Haparanda Laholm Smedjebacken Svalöv Berg Ängelholm Kumla Örnsköldsvik Norsjö Hammarö Sala Värmdö Sunne Gällivare Härnösand Emmaboda Nordanstig Osby Varberg Tyresö Ekerö Lycksele Alingsås Östhammar Älvdalen Båstad Uddevalla Höör Lilla Edet Nyköping Habo Göteborg Katrineholm Mölndal Jönköping Alvesta Stockholm Lindesberg Ronneby Gnosjö Jokkmokk Ystad Finspång Hultsfred Lysekil Hörby Trosa Orust Tranås Kalix Kungälv Upplands Väsby Årjäng Mönsterås Sigtuna Bjuv Götene Forshaga Hällefors Heby Härryda Färgelanda Leksand Älvkarleby Torsby Håbo Huddinge Åmål Kristinehamn Tanum Gotland Uppsala Åre Lekeberg Hudiksvall Flen Burlöv Umeå Ljusdal Valdemarsvik Kalmar Skara Enköping Kramfors Skellefteå Söderköping Knivsta Vaxholm Filipstad Gullspång Malå Hedemora Avesta Ljungby Pajala Söderhamn Hagfors Vadstena Sölvesborg Munkedal Vetlanda Skurup Klippan Vilhelmina Gagnef Östersund Åtvidaberg Kungsör Sjöbo Helsingborg Örkelljunga Orsa Kävlinge Piteå Malung-Sälen Vansbro Säter Askersund Vallentuna Vindeln Luleå Olofström Markaryd Grums Halmstad Karlskoga Täby Strömsund Mora Vimmerby Landskrona Bjurholm Tranemo Svedala Sundbyberg Dorotea Strängnäs Torsås Salem Munkfors Åstorp Karlskrona Stenungsund Skinnskattberg Örebro Gislaved Köping Sorsele Svenljunga Solna Öckerö Storfors Vaggeryd Arboga Borlänge Tidaholm Oskarshamn Eksjö Bollnäs Ydre Eskilstuna Hässleholm Vänersborg Åsele Lerum Hjo Boden Överkalix 85 90 95 100 85 90 95 100 85 90 95 100 85 90 95 100 Per cent SWEDEN January 2014 January 2009 1 Fewer than 30 children. 2 Fewer than 30 children on January 2009. 3 Incorrect data, not shown. 4 Data missing in January 2009. Source: Public Health Agency of Sweden. 66 Regional Comparisons 2014: Public Health
15 . CHILDREN’S PARTICIPATION IN The Swedish Education Act stipulates that all children PRESCHOOL in Sweden are to be offered preschool from the age of one Children’s learning begins even before they start school. year and the municipalities are now also obliged to offer Attending preschool has been shown to be important to places to parents taking parental leave or who are unem- learning in several areas. International studies have es- ployed. The Act also states that municipalities are to offer tablished that society benefits from children’s learning in childcare places within four months of the requirement preschool. Children learn to communicate and interact, for a preschool place being registered – what is known as learn to understand concepts and can express what they the childcare guarantee. The child must be offered a place are doing in words. Children in preschool also receive as close to their home as possible. Nevertheless, not all training in maths, language and reading and writing ear- municipalities are able to comply with these obligations. lier, which provides them with a big advantage over those It is important that a parent who wants a place in pre- of the same age who do not attend preschool [86]. school for their child gets one as soon as possible. If not, Sweden has extensive childcare provision that com- there is a risk that the child will miss out on the stimu- pares favourably with that of other countries when re- lation and learning development preschool can provide. garded in terms of accessibility. Other countries in Europe Furthermore, waiting too long can also have a knock-on where there is extensive childcare provision and a large effect for the entire family if, for example, a parent has to proportion of children attend preschools are Denmark, decline a job offer as a result. Finland and France. These countries are also among those . in the EU where central government subsidises childcare the most [87]. The indicator shows the proportion of children in the 15.1 – : Children enrolled at preschool ages 1–5 who were enrolled in a preschool on 15 October aged 1–5 years old. 2013. The results show that 84 per cent of all 1–5-year olds Per cent in Sweden were enrolled in a preschool in 2013, which 95 means that there has never been so many children attend- 90 ing preschool. The proportion of children enrolled has been increasing steadily for some time; three years ago the 85 proportion of 1–5-year olds was 82 per cent and ten years 80 ago it was 75 per cent. However, there are differences between counties and 75 between municipalities, but the proportion of children 70 enrolled has increased in pretty much all counties. Some explanations for this may be the 525 hours of free pre- 00 01 02 03 04 05 06 07 08 09 10 11 12 13 school per year for 3–5-year olds, the municipalities’ ob- Total Year ligation to provide places for children of the unemployed Source: The Swedish National Agency for Education. and those taking parental leave and an increased interest in preschool and its educational content. Social Conditions and Living Conditions 67
15.2 – : Children enrolled at preschool aged 1–5 years old, 2013.
Jämtland 87.5 Västernorrland 86.5 Gotland 86.2 Norrbotten 86.0 Blekinge 85.8 Sörmland 85.7 Gävleborg 85.4 Västerbotten 85.2 Örebro 85.0 Halland 84.8 Kronoberg 84.7 Skåne 84.5 Västmanland 84.3 Östergötland 84.3 Kalmar 83.9 Stockholm 83.8 SWEDEN 83.8 Västra Götaland 82.4 Uppsala 81.7 Värmland 81.6 Jönköping 81.1 Dalarna 80.1 0 20 40 60 80 100
2013 2010 Per cent Source: The Swedish National Agency for Education. 68 Regional Comparisons 2014: Public Health
F 15.3 ¡ ¢£¤¥¦§¨©: Children enrolled at preschool aged 1–5 years old, 2013.
Sorsele Bjuv Umeå Uddevalla Överkalix Kalmar Båstad Smedjebacken Åsele Ängelholm Haparanda Falkenberg Kalix Arjeplog Nässjö Bengtsfors Ånge Mark Gävle Flen Ragunda Uppvidinge Vadstena Habo Vellinge Gotland Fagersta Lysekil Skurup Gällivare Mjölby Malmö Nykvarn Tibro Hallstahammar Mullsjö Grästorp Jokkmokk Partille Ödeshög Storfors Strängnäs Gislaved Orsa Grums Piteå Vara Haninge Kävlinge Mora Landskrona Årjäng Vaxholm Täby Lomma Falköping Hällefors Örebro Aneby Kungälv Hedemora Nordanstig Laholm Osby Degerfors Karlstad Oskarshamn Falun Malå Olofström Hörby Vänersborg Lycksele Boden Leksand Filipstad Timrå Älvsbyn Lidköping Hylte Hudiksvall Järfälla Upplands-Bro Åmål Östersund Lerum Stockholm Perstorp Skellefteå Norberg Tingsryd Askersund Håbo Sollentuna Lidingö Kil Luleå Värnamo Nynäshamn Bjurholm Arvidsjaur Forshaga Borås Munkedal Ljungby Alingsås Söderhamn Mölndal Kramfors Åre Töreboda Nybro Karlskoga Lilla Edet Vallentuna Rättvik Nora Ovanåker Dorotea Enköping Dals-Ed Sundsvall Arvika Sundbyberg Gagnef Svalöv Vingåker Vaggeryd Tierp Värmdö Kungsbacka Ale Vännäs Sandviken Kumla Härryda Mörbylånga Svedala Ystad Arboga Vårgårda Bräcke Helsingborg Örnsköldsvik Heby Sigtuna Danderyd Finspång Skinnskatteberg Orust Gullspång Ulricehamn Tranås Trosa Mariestad Göteborg Sölvesborg Tomelilla Nyköping Mellerud Trollhättan Västervik Köping Linköping Götene Kristianstad Åtvidaberg Tyresö Ljusnarsberg Laxå Västerås Bollnäs Borlänge Oxelösund Alvesta Torsås Markaryd Älvkarleby Karlshamn Hjo Högsby Ockelbo Vimmerby Härjedalen Strömsund Surahammar Hammarö Berg Sävsjö Lund Hässleholm Österåker Tidaholm Ekerö Öckerö Åstorp Mönsterås Karlskrona Skara Kinda Essunga Krokom Örkelljunga Östra Göinge Strömstad Munkfors Burlöv Gnesta Valdemarsvik Hofors Sunne Solna Eda Svenljunga Storuman Kungsör Boxholm Eslöv Sotenäs Borgholm Vetlanda Lessebo Älmhult Uppsala Ydre Bollebygd Varberg Tranemo Eksjö Norrköping Södertälje Färgelanda Säter Eskilstuna Katrineholm Älvdalen Norsjö Halmstad Nacka Sala Nordmaling Upplands Väsby Sjöbo Emmaboda Kiruna Lindesberg Sollefteå Vilhelmina Östhammar Bromölla Torsby Ludvika Herrljunga Robertsfors Stenungsund Höör Avesta Härnösand Söderköping Gnosjö Tjörn Ronneby Simrishamn Botkyrka Salem Skövde Växjö Hallsberg Tanum Motala Ljusdal Övertorneå Vindeln Huddinge Lekeberg Klippan Trelleborg Malung-Sälen Hultsfred Vansbro Höganäs Karlsborg Jönköping Pajala Norrtälje Knivsta Kristinehamn Hagfors 40 60 80 100 40 60 80 100 40 60 80 100 40 60 80 100
Per cent SWEDEN 2013 2010 1 Data missing.
Source: The Swedish National Agency for Education. Social Conditions and Living Conditions 69
16 . TEACHERS WITH FORMAL TRAINING IN proportion varying between 37 and 74 per cent. There are PRESCHOOLS also large differences between municipalities. The pro- Competent staff are the key to a successful preschool and portion of employees in preschools with teaching degrees it is important for there to be staff who have undergone in Sweden has remained relatively stable for some time, university teacher training specialising in children of aside from the years 2000–2008, when the proportion was preschool age. To comply with the curriculum, staff must somewhat lower. have a good knowledge of childhood development and To comply with the curriculum, staff must have a good learning and the ability to adapt the educational environ- knowledge of childhood development and learning and ment to this. the ability to adapt the educational environment to the The Education Act stipulates that preschools in Sweden requirements that exist. Preschools with qualified and are to have staff who are qualified for the teaching that is experienced staff are well placed to do this. The Educa- to be conducted. In addition to preschool teachers, there tion Act stipulates that the principal has to ensure that have to be other staff such as nursery nurses whose ex- staff in preschools have the opportunity to take part in in- pertise contributes to encouraging the children’s develop- service training. They have to then chart and analyse the ment and learning [89, 90]. There are few other countries requirements for in-service training on the basis of staff in Europe that place such requirements on the qualifica- needs and in relation to the role of preschools. Long-term, tions of preschool staff. The need for preschool staff with sustainable quality improvement is dependent on the in- a higher education is not regarded as obvious everywhere, service training being based on both the development re- with the work of support staff being regarded in many quirements in preschools and research and proven experi- countries as something that can be carried out by people ence [90]. with vocational skills [91]. In Sweden, a clear difference is noticeable between municipal and independent preschools in terms of the proportion of staff with teaching qualifications. The pro- 16.1 – : Employees within preschools with formal portion of qualified preschool teachers is clearly higher in teacher training. municipal preschools than in independent preschools – a Per cent 65 difference that has become more marked in the past ten years [88]. This measure shows the number of full-time equivalent 60 employees in preschools with preschool teaching qualifi- cations, recreational instructor qualifications or teaching 55 qualifications, divided by the number of full-time equiva- lent employees in preschools. All employees in preschools 50 who work with children are considered when calculating the number of full-time equivalent employees (excluding cleaning and kitchen staff). 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year In 2013, an average of 53.3 per cent of employees in pre- Total schools had some form of teaching qualification. Howev- Source: The Swedish National Agency for Education. er, there are large differences between counties, with this 70 Regional Comparisons 2014: Public Health
16.2 – : Employees within preschools with formal teacher training, 2013.
Jönköping 73.9 Kalmar 70.9 Värmland 70.5 Gävleborg 67.7 Norrbotten 66.0 Blekinge 62.6 Örebro 61.2 Kronoberg 59.4 Västernorrland 59.2 Västra Götaland 58.2 Västerbotten 58.2 Halland 57.9 Västmanland 57.1 Östergötland 56.7 Skåne 55.8 Dalarna 55.0 Jämtland 54.9 Sörmland 54.1 SWEDEN 53.5 Gotland 51.3 Uppsala 47.1 Stockholm 36.8 0 20 40 60 80 100
2013 2008 Per cent Source: The Swedish National Agency for Education. Social Conditions and Living Conditions 71
F 16.3 ¡ ¢£¤¥¦§¨©: Employees within preschools with formal teacher training, 2013.
Sunne Bjuv Lomma Enköping Jönköping Härnösand Askersund Söderköping Hammarö Hudiksvall Övertorneå Strängnäs Boden Sjöbo Hallsberg Hylte Sandviken Bengtsfors Svedala Älvdalen Vetlanda Örnsköldsvik Markaryd Borlänge Forshaga Orust Mora Strömstad Götene Munkfors Lund Årjäng Ovanåker Ulricehamn Hässleholm Gällivare Nybro Gävle Surahammar Flen Tranås Varberg Vadstena Kumla Kalmar Uddevalla Timrå Munkedal Hjo Orsa Nordanstig Klippan Tibro Östersund Falun Malmö Habo Hällefors Skellefteå Vindeln Lysekil Tierp Laholm Uppvidinge Hofors Borås Mark Dals-Ed Torsås Vänersborg Helsingborg Bjurholm Karlstad Örkelljunga Västerås Nordmaling Tjörn Västervik Nässjö Högsby Hultsfred Vaggeryd Storfors Åre Mariestad Kil Östhammar Perstorp Borgholm Sollefteå Tidaholm Åtvidaberg Essunga Rättvik Kungsbacka Malung-Sälen Piteå Katrineholm Hallstahammar Vännäs Kramfors Mörbylånga Ludvika Nynäshamn Karlshamn Älmhult Halmstad Uppsala Ödeshög Vårgårda Kristinehamn Eksjö Arboga Färgelanda Älvsbyn Ockelbo Hörby Vilhelmina Arvidsjaur Umeå Landskrona Krokom Storuman Nykvarn Haparanda Avesta Vara Motala Eskilstuna Salem Finspång Värnamo Norberg Malå Norrköping Fagersta Kiruna Mullsjö Örebro Vansbro Norrtälje Falköping Trollhättan Mölndal Kävlinge Lindesberg Gislaved Pajala Gnesta Mönsterås Oxelösund Öckerö Lycksele Älvkarleby Skara Filipstad Robertsfors Olofström Sotenäs Stenungsund Sundbyberg Grums Ronneby Härryda Ragunda Oskarshamn Båstad Ljusdal Tyresö Leksand Hedemora Skurup Burlöv Degerfors Växjö Sorsele Kungsör Norsjö Östra Göinge Bräcke Åsele Alingsås Lerum Upplands Väsby Nora Ånge Sölvesborg Södertälje Lidköping Överkalix Vingåker Knivsta Ystad Dorotea Ljusnarsberg Heby Mellerud Emmaboda Mjölby Danderyd Grästorp Bollebygd Tomelilla Sollentuna Jokkmokk Lekeberg Eda Upplands-Bro Bollnäs Arvika Alvesta Boxholm Gullspång Falkenberg Säter Sigtuna Åstorp Eslöv Svenljunga Stockholm Tranemo Lessebo Kinda Strömsund Söderhamn Torsby Sundsvall Järfälla Kalix Ljungby Berg Nacka Skövde Kungälv Osby Lidingö Ängelholm Simrishamn Linköping Solna Luleå Karlsborg Nyköping Arjeplog Vellinge Karlskrona Sala Österåker Bromölla Hagfors Svalöv Täby Valdemarsvik Vimmerby Göteborg Ekerö Sävsjö Partille Tanum Håbo Lilla Edet Tingsryd Gotland Vaxholm Herrljunga Laxå Gnosjö Haninge Töreboda Gagnef Ale Vallentuna Kristianstad Karlskoga Höör Botkyrka Köping Aneby Trosa Huddinge Åmål Höganäs Smedjebacken Värmdö Trelleborg Skinnskatteberg Härjedalen Ydre 0 25 50 75 100 0 25 50 75 100 0 25 50 75 100 0 25 50 75 100 Per cent SWEDEN 2013 2008
Source: The Swedish National Agency for Education. 72 Regional Comparisons 2014: Public Health
Education, work and self-sufficiency
Education has a very important impact on young people’s it is mainly the parents’ educational level that has a major future opportunities. Completing compulsory school is importance in terms of the children’s results. Not being essential if they are to go on to upper-secondary school, eligible for upper-secondary school is also more common which is now usually a basic requirement for finding among the children of non-professionally qualified work- work. Education and work are factors that protect against ers than among the children of more senior professionals social problems, unemployment and ill-health. [92]. In addition, there is an inverse relationship between ed- The indicator shows the proportion of pupils eligible for ucation, work and health, in that health has an impact on the national vocational programmes at upper-secondary the chances of being successful in school, of completing school, which is the lowest level of eligibility. The eligibil- further study programmes and finding work. The overall ity requirements are a minimum of a pass in the subjects goal of Swedish public health policy is to create the condi- Swedish or Swedish as a second language, English and tions for good health and the challenge is to create this for mathematics, as well as five other subjects. The data is all, regardless of socioeconomic circumstances. Financial based on the municipality in which the pupils are regis- aid and unemployment have been identified as risk fac- tered as residents. tors that can have a detrimental impact on health develop- In 2013, 87.6 per cent of the pupils in year 9 were eligi- ment and thus also increase the burden of disease. ble to apply to a vocational programme. This means that about 12 per cent of those pupils who finished compul- 17 . ELIGIBILITY FOR UPPER SECONDARY sory school in spring 2013 had not achieved the eligibil- SCHOOL ity requirements. A higher proportion of girls than boys Education is one of the most important prerequisites for achieved the eligibility requirements. The results also young people’s future opportunities. The earlier someone show that the eligibility rate for upper-secondary school concludes their education, the worse their future pros- varies between counties and between municipalities. The pects tend to be and adults who have only completed com- proportion of pupils who achieve eligibility for upper- pulsory school have considerably fewer opportunities in secondary school has decreased slowly over the course of the labour market. A higher educational level also reduces large parts of this century [41]. an individual’s risk of early death, ill-health and psycho- Municipalities are responsible for providing schools, social problems such as criminality, abuse, self-harm and within the framework set out in the Education Act, cur- difficulties supporting themselves financially [92]. ricula and other regulations. They determine how schools Education can have an impact on health through several are to be organised and also have to ensure that schools mechanisms such as lower health risk in the workplace, have the resources, prerequisites and opportunities re- higher incomes and less financial vulnerability and stress. quired. Education can also have an impact on people’s way of life If the proportion eligible for upper-secondary school and make them better equipped to find and take in infor- is to be increased, it is important that absenteeism in mation about, for example, health-related behaviour [41]. compulsory school is reduced and that pupils who need Accordingly, spending money on schools and children’s additional support actually receive it. A wide-ranging col- education can be seen, from a public health perspective, laboration between organisations with clear procedures as an investment and is an important aspect of early inter- has been shown to succeed in terms of reducing school ventions aimed at preventing ill-health. absenteeism [93]. Absenteeism is often an indication of There are strong links between socioeconomic back- psychosocial problems and investigating its causes can re- ground and children’s grades in compulsory school, and sult in pupils being given the right support. In some cases Education, work and self-sufficiency 73
an intervention in school such as a motivational coaching 17.1 – : Pupils in grade 9 in compulsory school discussion is sufficient, while other pupils may require qualifying for upper secondary school to the national vocational programmes. extensive interventions that involve social services or pae- Per cent diatric and adolescent psychiatric services. 100 Schools should work to identify and capture those pupils who are performing poorly and are at risk of not 95 achieving the goals at an early stage. Many schools cur- rently offer after-school homework support and some also offer extra teaching in holidays to provide specific support 90 and assistance led by qualified teachers. In this way, pupils with high rates of absenteeism can get the opportunity to 85 catch up. Encouraging school attendance and supporting pupils who are in need of this is both a social and a finan- 2011 2012 2013 cial investment for society. The earlier the intervention, Year the greater the chance of it being successful. Total Girls Boys Source: The Swedish National Agency for Education, Statistics Sweden. 74 Regional Comparisons 2014: Public Health
17.2 – . : Pupils in grade 9 in compulsory school qualifying for upper secondary school to the national vocational programmes, 2013.
Gotland 93.9 Halland 92.6 Jämtland 91.8 Norrbotten 91.5 Kalmar 90.9 Värmland 90.7 Västerbotten 90.7 Stockholm 90.4 Blekinge 90.3 Kronoberg 90.3 Uppsala 89.7 SWEDEN 89.1 Västra Götaland 88.9 Skåne 88.8 Dalarna 87.6 Jönköping 87.6 Östergötland 87.3 Sörmland 87.1 Västmanland 86.6 Västernorrland 86.6 Gävleborg 85.2 Örebro 85.2 0 20 40 60 80 100
2013 2011 Per cent Source: The Swedish National Agency for Education, Statistics Sweden.
17.3 – . : Pupils in grade 9 in compulsory school qualifying for upper secondary school to the national vocational programmes, 2013.
Halland 90.6 Uppsala 89.8 Norrbotten 88.3 Jönköping 88.2 Stockholm 88.0 Västerbotten 87.4 Skåne 87.2 Värmland 86.7 SWEDEN 86.6 Gotland 86.5 Jämtland 86.1 Västra Götaland 86.0 Kalmar 86.0 Dalarna 85.9 Östergötland 85.5 Sörmland 85.5 Kronoberg 85.3 Blekinge 84.8 Västernorrland 83.8 Västmanland 82.8 Örebro 82.0 Gävleborg 80.5 0 20 40 60 80 100
2013 2011 Per cent Source: The Swedish National Agency for Education, Statistics Sweden. Education, work and self-sufficiency 75
F¡ 17.4 £ ¤¥¦§¨©ª¡«: Pupils in grade 9 in compulsory school qualifying for upper secondary school to the national vocational programmes, 2013.
Danderyd Kinda Storfors Torsby Oxelösund Markaryd Arvidsjaur Robertsfors Rättvik Eksjö Smedjebacken Finspång Lidingö Kramfors Lysekil Hofors Vellinge Överkalix Heby Landskrona Nykvarn Svenljunga Uppvidinge Hagfors Täby Herrljunga Åre Härjedalen Lomma Trosa Sölvesborg Karlskoga Vaxholm Enköping Örnsköldsvik Göteborg Öckerö Solna Eda Östhammar Ystad Uppsala Motala Gnosjö Tjörn Essunga Simrishamn Kiruna Svedala Lidköping Älvkarleby Tibro Luleå Hässleholm Botkyrka Värmdö Mölndal Salem Orsa Lerum Arvika Bengtsfors Habo Bollebygd Umeå Karlshamn Kumla Sollentuna Höganäs Sala Köping Alingsås Jokkmokk Skövde Degerfors Malå Orust Trelleborg Ludvika Borgholm Åmål Munkedal Ödeshög Hjo Gotland Grästorp Strömstad Tanum Sunne Kil Svalöv Aneby Vårgårda Mönsterås Upplands Väsby Nacka Pajala Nynäshamn Falköping Nora Kalmar Haninge Kristinehamn Hörby Ljungby Tomelilla Lessebo Perstorp Kävlinge Eslöv Örkelljunga Gävle Söderhamn Sotenäs Huddinge Laxå Askersund Storuman Osby Vansbro Hallstahammar Härryda Strömsund Säter Borlänge Karlsborg Sävsjö Haparanda Färgelanda Lund Söderköping Kristianstad Sigtuna Årjäng Hällefors Ronneby Södertälje Kungsbacka Håbo Sjöbo Hylte Mörbylånga Järfälla Sundbyberg Tidaholm Norberg Höör Torsås Ulricehamn Kungälv Tranås Mjölby Fagersta Mullsjö Arboga Västervik Malmö Vännäs Falun Östra Göinge Trollhättan Karlstad Gällivare Hudiksvall Vilhelmina Ängelholm Jönköping Mellerud Hultsfred Hammarö Norsjö Eskilstuna Åtvidaberg Piteå Skara Norrtälje Grums Forshaga Helsingborg Upplands-Bro Surahammar Bjuv Laholm Norrköping Berg Ekerö Ovanåker Vaggeryd Tingsryd Knivsta Växjö Vetlanda Ånge Älvsbyn Lekeberg Ragunda Munkfors Skurup Stockholm Timrå Ljusnarsberg Båstad Värnamo Tranemo Högsby Vimmerby Gnesta Vänersborg Lindesberg Bromölla Krokom Burlöv Gullspång Dals-Ed Mark Klippan Sandviken Kalix Österåker Kungsör Sollefteå Malung-Sälen Linköping Vingåker Valdemarsvik Mariestad Nordmaling Västerås Ockelbo Vallentuna Nyköping Ale Övertorneå Boden Tyresö Töreboda Nybro Oskarshamn Åstorp Nordanstig Partille Tierp Lycksele Vadstena Uddevalla Älmhult Örebro Bollnäs Boxholm Borås Avesta Katrineholm Götene Hedemora Filipstad Hallsberg Varberg Olofström Älvdalen Arjeplog Östersund Härnösand Gislaved Bjurholm Leksand Karlskrona Sundsvall Bräcke Gagnef Lilla Edet Ljusdal Dorotea Halmstad Skellefteå Flen Skinnskatteberg Stenungsund Vindeln Alvesta Sorsele Strängnäs Vara Mora Ydre Falkenberg Nässjö Emmaboda Åsele 60 70 80 90 100 60 70 80 90 100 60 70 80 90 100 60 70 80 90 100 Per cent SWEDEN 2013 2011 1 Fewer than 30 pupils.
Source: The Swedish National Agency for Education, Statistics Sweden. 76 Regional Comparisons 2014: Public Health
18 . COMPLETED UPPER-SECONDARY Although upper-secondary school is voluntary, there EDUCATION are strong grounds for the municipalities to assist pupils Education is an important factor protecting against social in completing their upper-secondary education as this problems and a low educational level increases the risk of, has an impact on individuals’ chances of finding work, for example, unemployment, financial difficulties, exclu- going on to further education and participating in society. sion and mental ill-health. Completed upper-secondary Young people aged 16–19 who neither work nor study are education provides additional options in the form of fur- covered by the municipalities’ information liability. This ther studies and better opportunities in the labour market. means that the municipalities must ensure they have in- A lack of education, combined with early unemployment, formation about what young people who are not attend- also increases the risk of long-term difficulties entering ing upper-secondary school are doing and offer them the labour market. Given the strong link between edu- appropriate individual interventions. Many use specific cational level and health described in previous sections, employment projects to help young people find jobs. It with education having been shown to have an impact is a challenge for society to get those young people who on health through several mechanisms, there is much to are thinking of dropping out of upper-secondary school or indicate that a lower educational level can lead to worse who have already done so to go back to school. The pro- health. ject Plug-In, which is a partnership between SALAR, five Swedish upper-secondary education differs from its regions and about 50 municipalities and is partly funded equivalent in other European countries. Since the upper- by the EU, has been underway since 2012. The aim is to secondary school reform at the beginning of the 1990s, capture those pupils who are at the most risk of dropping all young people in Sweden have had the right to study out of upper-secondary school and motivate those young at upper-secondary school, regardless of their grades in people who have dropped out to return to school and com- compulsory school. However, those who have not passed plete their studies. The project runs for several years and mathematics, Swedish and English are referred to one of has still not been fully evaluated. However, some factors the upper-secondary school individual introductory pro- linked to success are a comprehensive focus on the pupil, grammes. This has led to nearly all young people – over a reinforced connection to the school and flexibility with 99 per cent – choosing to study further after compulsory respect to organisation and teaching content [95]. school. At the same time, it has become more common to drop out of education. A pupil’s parents’ educational level and ethnic background are factors that have been shown to be of great significance to how successful they are in
upper-secondary school [94]. 18.1 – : Pupils who completed an The indicator shows the proportion of pupils registered upper-secondary school programme within 4 years as resident in the municipality in year 1 of upper-second- (municipality averages). ary school who have completed a programme within four Per cent 85 years. This encompasses the proportion of pupils in year 1 of all upper-secondary school programmes on 15 Octo- ber 2009 who were not in upper-secondary school the two 80 previous years and who received a leaving certificate from a programme in 2013 or earlier. In Sweden, an average of just over three quarters of the 75 pupils who begin upper-secondary school completed their upper-secondary school studies within four years, which is a slightly higher proportion than in 2009. However, there are large variations between different 2008 2009 2010 2011 2012 2013 Year counties and between different municipalities and a high- Total Women Men
er proportion of women than men who completed their Source: The Swedish National Agency for Education, Statistics Sweden. studies within this period. Education, work and self-sufficiency 77
18.2 – . : Pupils who completed an upper-secondary programme within 4 years, 2013.
Halland 83.2 Kalmar 83.0 Kronoberg 82.8 Jönköping 81.9 Västerbotten 81.5 Blekinge 80.3 Sörmland 80.1 Uppsala 80.1 Värmland 80.0 SWEDEN1 79.7 Västra Götaland 79.7 Östergötland 79.7 Gotland 79.3 Skåne 79.3 Norrbotten 78.8 Örebro 78.7 Dalarna 77.8 Gävleborg 77.7 Stockholm 77.3 Jämtland 76.0 Västmanland 75.4 Västernorrland 75.0 0 20 40 60 80 100
1 Refers to municipality average. 2013 2009 Per cent Source: The Swedish National Agency for Education, Statistics Sweden.
18.3 – . : Pupils who completed an upper-secondary programme within 4 years, 2013.
Halland 79.7 Jönköping 78.5 Kalmar 77.6 Kronoberg 77.5 Gotland 77.3 Värmland 76.7 Dalarna 76.5 Sörmland 76.1 Västerbotten 75.5 Västra Götaland 75.2 SWEDEN1 74.9 Örebro 74.8 Östergötland 74.2 Jämtland 74.0 Västernorrland 74.0 Skåne 73.7 Västmanland 73.5 Gävleborg 73.2 Blekinge 72.6 Stockholm 72.2 Uppsala 70.5 Norrbotten 67.9 0 20 40 60 80 100
1 Refers to municipality average. 2013 2009 Per cent Source: The Swedish National Agency for Education, Statistics Sweden. 78 Regional Comparisons 2014: Public Health
F 18.4 ¡¢£¤¥¦§: Pupils who completed an upper-secondary programme within 4 years, 2013.
Hammarö Torsås Smedjebacken Rättvik Danderyd Halmstad Borås Borlänge Vellinge Mjölby Ulricehamn Hallsberg Ystad Skövde Öckerö Landskrona Piteå Storuman Linköping Vadstena Töreboda Herrljunga Vara Grums Kungsör Karlsborg Ödeshög Norrtälje Tibro Lycksele Finspång Nordanstig Båstad Tidaholm Vansbro Strömstad Vindeln Sölvesborg Hjo Norsjö Kungsbacka Vaggeryd Gällivare Värmdö Högsby Växjö Nykvarn Nynäshamn Lekeberg Mark Degerfors Burlöv Vilhelmina Boxholm Forshaga Gnesta Uppvidinge Sävsjö Götene Östra Göinge Habo Trollhättan Örebro Stockholm Täby Markaryd Köping Essunga Tjörn Tomelilla Salem Hagfors Kil Älmhult Emmaboda Oxelösund Nybro Höganäs Falkenberg Botkyrka Pajala Kumla Robertsfors Håbo Vallentuna Vaxholm Ronneby Lindesberg Oskarshamn Sollentuna Säter Luleå Simrishamn Falun Vimmerby Ale Kävlinge Örnsköldsvik Hultsfred Valdemarsvik Tranemo Falköping Sandviken Bengtsfors Vetlanda Sotenäs Varberg Heby Karlskrona Lomma Mora Vårgårda Bollebygd Sundsvall Örkelljunga Trelleborg Helsingborg Hörby Färgelanda Åmål Trosa Norberg Mölndal Höör Gävle Perstorp Mörbylånga Gullspång Kristinehamn Haninge Skurup Lerum Nyköping Söderhamn Dorotea Nässjö Uppsala Stenungsund Mönsterås Ludvika Järfälla Avesta Skara Mullsjö Karlskoga Upplands-Bro Borgholm Skellefteå Hofors Göteborg Ängelholm Kalmar Östhammar Klippan Lund Sjöbo Sala Lilla Edet Kinda Strängnäs Arboga Tierp Årjäng Berg Arvika Ragunda Ljungby Munkedal Härnösand Jokkmokk Ydre Osby Malå Flen Övertorneå Tranås Sollefteå Bjurholm Vänersborg Tyresö Huddinge Ånge Hällefors Karlstad Hudiksvall Filipstad Härjedalen Knivsta Bromölla Mellerud Mariestad Orust Krokom Nora Österåker Gnosjö Timrå Svenljunga Kramfors Kristianstad Nordmaling Jönköping Vingåker Åre Sundbyberg Laxå Grästorp Eslöv Bjuv Malung-Sälen Katrineholm Ljusnarsberg Orsa Tanum Vännäs Motala Arvidsjaur Åtvidaberg Älvkarleby Hedemora Fagersta Eksjö Strömsund Sigtuna Kiruna Karlshamn Kungälv Hallstahammar Munkfors Ljusdal Tingsryd Norrköping Bräcke Uddevalla Alvesta Älvdalen Storfors Lysekil Solna Surahammar Upplands Väsby Nacka Askersund Svedala Åsele Leksand Söderköping Bollnäs Malmö Lidköping Umeå Enköping Eda Ekerö Aneby Västervik Sorsele Sunne Gotland Åstorp Boden Laholm Hässleholm Älvsbyn Ockelbo Eskilstuna Svalöv Värnamo Södertälje Härryda Alingsås Gislaved Lessebo Olofström Västerås Skinnskatteberg Gagnef Ovanåker Östersund Överkalix Lidingö Torsby Kalix Haparanda Partille Hylte Dals-Ed Arjeplog 40 60 80 100 40 60 80 100 40 60 80 100 40 60 80 100 Per cent Municipality average. 2013 2011
Source: The Swedish National Agency for Education, Statistics Sweden. Education, work and self-sufficiency 79
19 . YOUNG PEOPLE WHO NEITHER WORK school or drop out of it currently have major difficulties NOR STUDY finding work [100]. Education and employment are two of the most important There are several studies that have investigated upper- factors that protect health by giving people increased op- secondary school drop-out among young people, most of portunities to influence their own lives. Youth unemploy- which have a qualitative focus [101, 102]. These studies are ment is considerable higher than unemployment among often interview-based and have contributed to increasing older people and has also increased [12]. In addition, youth our understanding of the mechanisms underlying drop- unemployment is higher in Sweden than in other coun- out, but more studies are needed in this area, both qualita- tries such as Norway and Denmark [12]. Studies show that tive and quantitative [101, 102]. the longer a person is out of work, the greater the risk of, This report studies the incidence of young people aged for example, social problems and that they are not able to 16–25 who neither work nor study. The measure used by establish themselves in the labour market. Theme Group Youth (Mucf) [103], which was previously High youth unemployment also has an impact on those proposed by the central government commission of in- who are working as the fear of unemployment increases quiry in this area [100], is used here. In order to be included and, according to the Public Health Agency of Sweden, this in the group of those who neither work nor study, the indi- is particularly prevalent among young women [12]. The vidual must, over the course of a complete calendar year: link between unemployment and ill-health is well-known • not have had an income over the base amount [97], but because young people belong to the healthiest • not have been in receipt of student aid, been registered portion of the population, it can be difficult to see any on some form of education or training programme or tangible changes in the health of this group [98]. Never- have studied Swedish for immigrants (SFI) for more than theless, it is possible to see the consequences for the de- 60 hours terminants of health, particularly in terms of lifestyle and • not have commuted for work to Norway or Denmark living habits such as smoking and alcohol use. In addition, negative consequences manifest as mental problems [98]. This measure is similar to that used in Europe, called With respect to the entire lifespan, there are studies that NEET (not in education, employment or training) [103]. show early unemployment doesn’t just increase the risk When analysing the results, please observe that the group of later unemployment, it also increases the risk of health also includes individuals who are, for example, taking sab- problems and unhealthy lifestyle habits, which can lead to baticals or studying abroad [93, 103]. both physical and mental ill-health in the long-term [98]. In conjunction with debates concerning the labour For example, the National Board for Youth Affairs has im- market and employment, a large number of different lev- plemented a further analysis of the results of the national els of youth unemployment are often presented, which is public health survey and this indicates that it is consider- partly due to the groups of individuals that are included ably more common for young unemployed people to be in the statistics (students, short-term jobs, register data, sedentary than those who are working [99]. interviews, etc.) and partly due to the group with which There have been many changes in recent decades that this is compared (the entire population, the entire labour have affected the young. Among these, the age at which force, and the proportion of those who are unemployed). young people establish themselves in the labour market There continues to be a need to develop and complement has increased, partly due to increased requirements for this data at the national, regional and local level. education, unemployment is at a higher level overall and The national trend has varied somewhat, with a tempo- the labour market has become more unstable, with young rary peak in the recession year 2009. The results for 2012 people’s jobs often being short-term and temporary [100]. show that 9.3 per cent of women and men aged 16–25 nei- The labour market establishment pattern in Sweden dif- ther worked nor studied. The results vary between mu- fers from that of many other European countries in that nicipalities and there is a difference in 9 percentage points many young people in Sweden have short-term jobs inter- between the highest and the lowest proportions. At the spersed with short periods of unemployment. With time, county level, the variation is 4 percentage points, for both however, these jobs can lead to permanent employment. women and men. Those young people who do not start upper-secondary 80 Regional Comparisons 2014: Public Health
There are several areas for improvements, and these can 19.1 – : Individuals (16–25 years old) who neither involve everything from having an working method that work nor study during a full calendar year. encourages everyone to complete compulsory school and Per cent 12 upper-secondary school, to providing assistance to those who are not achieving goals or are at risk of dropping out of 10 upper-secondary school. As noted in the previous section, the development project Plug-In is currently underway 8 and its aim is to support pupils who have dropped out or 6 are considering dropping out of upper-secondary school. In addition to such initiatives, there needs to be more local 4
cooperation between the enterprise sector, municipalities 2 and schools. Not least to help the programmes available in 0 school better reflect the needs and circumstances of the la- 2008 2009 2010 2011 2012 Year bour market. The causal link between unemployment and Total Women Men
ill-health goes both ways; accordingly, unemployment Source: Theme Group Youth in Working Life, Statistics Sweden. can lead to ill-health, just as impaired health reduces the chances of finding a new job. It is therefore important to assist those who are unemployed find a new job as quickly as possible. Education, work and self-sufficiency 81
19.2 – . : Individuals (16–25 years old) who neither work nor study during a full calendar year, 2012.
Uppsala 7.3 Västerbotten 7.4 Halland 7.7 Jönköping 8.1 Stockholm 8.7 Norrbotten 8.7 Jämtland 8.8 Kalmar 9.0 Östergötland 9.0 Kronoberg 9.1 Västra Götaland 9.3 SWEDEN 9.4 Västernorrland 9.4 Gotland 9.7 Örebro 9.8 Värmland 10.0 Blekinge 10.5 Dalarna 10.7 Skåne 11.0 Sörmland 11.0 Västmanland 11.1 Gävleborg 11.8 0 2 4 6 8 10 12
Per cent Source: Theme Group Youth in Working Life, Statistics Sweden. 2012 2011
19.3 – . : Individuals (16–25 years old) who neither work nor study during a full calendar year, 2012.
Jönköping 7.1 Västerbotten 7.5 Uppsala 7.5 Halland 7.8 Norrbotten 8.0 Kronoberg 8.1 Kalmar 8.8 Östergötland 8.9 Stockholm 9.0 Västra Götaland 9.1 SWEDEN 9.2 Jämtland 9.3 Dalarna 9.5 Gotland 9.6 Örebro 9.8 Västernorrland 10.2 Värmland 10.4 Västmanland 10.4 Skåne 10.6 Blekinge 10.6 Gävleborg 10.9 Sörmland 11.1 0 2 4 6 8 10 12
Per cent Source: Theme Group Youth in Working Life, Statistics Sweden. 2012 2011 82 Regional Comparisons 2014: Public Health
F 19.4 ¡¢£¤¥¦§: Pupils who completed an upper-secondary programme within 4 years, 2013.
Lund Halmstad Osby Västervik Lomma Kävlinge Kumla Smedjebacken Sorsele Jokkmokk Huddinge Ronneby Täby Ale Sunne Bollnäs Ekerö Stenungsund Norrköping Filipstad Lidingö Vimmerby Heby Tierp Tanum Örebro Mariestad Orsa Umeå Håbo Ockelbo Hedemora Kungsbacka Salem Sundbyberg Malung-Sälen Aneby Tranås Hallsberg Uppsala Gällivare Älvdalen Nordmaling Åre Nykvarn Högsby Boden Habo Stockholm Lysekil Eskilstuna Jönköping Vadstena Laxå Uppvidinge Luleå Sotenäs Boxholm Sandviken Tjörn Ljungby Avesta Vänersborg Vaxholm Gislaved Härnösand Borlänge Kalmar Oskarshamn Vårgårda Olofström Vallentuna Strömsund Timrå Essunga Varberg Ödeshög Kinda Trollhättan Norsjö Mönsterås Upplands-Bro Ljusdal Vetlanda Gnosjö Bräcke Sjöbo Kiruna Höganäs Sundsvall Nynäshamn Lekeberg Storuman Borås Haninge Laholm Mellerud Sävsjö Bollebygd Nybro Sala Värmdö Alingsås Årjäng Hässleholm Vellinge Mjölby Finspång Tibro Linköping Kalix Karlskrona Askersund Knivsta Göteborg Falköping Kungsör Älmhult Munkedal Ovanåker Östra Göinge Mullsjö Karlshamn Sollefteå Söderhamn Kungälv Upplands Väsby Storfors Köping Växjö Arvika Lilla Edet Botkyrka Ydre Vännäs Ludvika Lindesberg Härryda Mörbylånga Herrljunga Munkfors Danderyd Rättvik Torsås Oxelösund Värnamo Strängnäs Älvsbyn Kramfors Orust Järfälla Höör Vingåker Österåker Krokom Hylte Motala Karlsborg Övertorneå Berg Sölvesborg Vindeln Skara Svalöv Degerfors Dorotea Sigtuna Helsingborg Åmål Örnsköldsvik Ystad Vilhelmina Hofors Tranemo Hjo Nordanstig Katrineholm Vaggeryd Östersund Eslöv Kil Sollentuna Falun Robertsfors Bromölla Pajala Grästorp Alvesta Hagfors Bjurholm Mark Kristianstad Tomelilla Skövde Norrtälje Karlskoga Burlöv Härjedalen Nässjö Gnesta Älvkarleby Vansbro Tingsryd Kristinehamn Bjuv Solna Ånge Mora Forshaga Östhammar Lidköping Simrishamn Hallstahammar Mölndal Markaryd Överkalix Haparanda Färgelanda Nyköping Hudiksvall Surahammar Trosa Ulricehamn Tidaholm Ljusnarsberg Öckerö Enköping Hultsfred Ragunda Lerum Vara Skurup Torsby Ängelholm Eksjö Norberg Åsele Piteå Emmaboda Dals-Ed Fagersta Nacka Hammarö Södertälje Skinnskatteberg Svedala Lycksele Uddevalla Malmö Strömstad Västerås Åtvidaberg Klippan Leksand Säter Örkelljunga Landskrona Hällefors Götene Perstorp Falkenberg Svenljunga Gävle Eda Tyresö Malå Valdemarsvik Grums Partille Söderköping Nora Åstorp Karlstad Gotland Hörby Flen Skellefteå Båstad Trelleborg Lessebo Arjeplog Arvidsjaur Bengtsfors Gullspång Gagnef Borgholm Arboga Töreboda 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 Per cent SWEDEN 2012 2011
Source: Theme Group Youth in Working Life, Statistics Sweden. Education, work and self-sufficiency 83
20 . LONG-TERM UNEMPLOYMENT other reports to instead use the proportion of long-term The link between unemployment and ill-heath is well- unemployed in relation to the group of those who are un- known – unemployment can contribute to ill-heath and employed. ill-health can contribute to unemployment [12, 97, 98]. Long-term unemployment in the population has in- Unemployment can increase the risk of developing un- creased considerably since the comparison year 2009, but healthy lifestyle habits and reinforce those that are already the increase has levelled off and is now at the same level established [12]. Studies also show that unemployment as in 2013, i.e. 3.8 per cent at the national level. However, increases the risk of mental ill-health and cardiovascular these results do not show whether the group is changeable disease [12]. In subsequent studies, cardiovascular disease – whether it contains new people who have become long- may also be explained by causes other than unemploy- term unemployed as others have found work, or the same ment specifically [104]. The most well-researched area people who remain long-term unemployed. is the connection to mental ill-health (stress, anxiety, The distribution within the country is large and long- psychosomatic symptoms, etc.) [104], with studies hav- term unemployment at the county level is 2.4–5.5 per cent ing shown, for example, that the unemployed are twice of the population for 2014. This is considerably higher than as likely to have mental problems, compared with those in 2009 and the distribution within the country is also who work [98]. Nevertheless, there is also research into the greater. The variation becomes even greater when compar- effects of unemployment on physical health that shows a ing municipalities. Long-term unemployment in the mu- clear link to ill-health in both cross-sectional analyses and nicipalities has increased since 2009, at the same time as longitudinal studies [98]. However, it is not just the unem- the variation between municipalities has increased. The ployed who can be affected by ill-health; their children are variation between municipalities is large. also more likely to suffer from ill-health than other chil- Central government, county councils, municipalities dren [96]. and labour market stakeholders need to become more in- There are several theories as to why unemployment can volved in order to reduce the risk of individuals ending up lead to ill-health. While earlier studies focused on the link in long-term unemployment (through education, training to finances, more recent studies have focused more on fac- and other forms of support), as well as to reduce the risk of tors such as stress and having less control over one’s own ill-health in this population. Interventions targeted at in- life [98]. Other research links the causes to identity, status dividuals who only have pre-upper-secondary education and opportunities to interact with others [98, 105]. Longi- should be given special priority [97]. The municipality can tudinal studies confirm the incidence of mental ill-health also establish partnerships with the local enterprise sec- among the unemployed, but also that their mental health tor. Other important stakeholders are the voluntary sector improves significantly when they return to work [12, 104]. and social enterprises, which work to help integrate peo- It is more common for individuals who only have a pre- ple into the labour market. upper-secondary education to be unemployed than those who have a higher educational level, and for women to have a somewhat lower employment rate than men [12]. 20.1 – : Individuals in the population aged 25–64 Long-term unemployment is also more common among years old who have been registered as unemployed or in individuals with various forms of disability who have programmes with activity support for at least six months. considerably more trouble establishing themselves in the Per cent 6 labour market, particularly if they have attended a special school. An international comparison shows that there are 5 large differences in Sweden in terms of the proportion of 4 unemployed young people, compared with the rest of the population, and the number of those born abroad who are 3 unemployed, compared with those born in Sweden [106]. 2 In addition to educational background, the risk of unem- ployment is greater for those who have previously been 1 unemployed or have been in receipt of financial assistance 0 [106]. 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year The measure used for long-term unemployment in this Total Women Men report is the proportion of the population who have been Source: The Swedish Public Employment Service. unemployed for six months or more. It is common for 84 Regional Comparisons 2014: Public Health
20.2 – . : Individuals in the population aged 25–64 years old who have been registered as unemployed or in programmes with activity support for at least six months, 2014.
Uppsala 2.35 Dalarna 2.87 Halland 2.99 Västerbotten 3.08 Jämtland 3.10 Stockholm 3.25 Jönköping 3.31 Norrbotten 3.38 Västra Götaland 3.43 Kalmar 3.48 SWEDEN 3.69 Värmland 3.79 Gotland 3.95 Örebro 3.97 Kronoberg 4.09 Skåne 4.28 Västernorrland 4.31 Östergötland 4.52 Västmanland 4.74 Blekinge 4.87 Sörmland 5.16 Gävleborg 5.51 0 1 2 3 4 5 6
2014 2009 Per cent Source: The Swedish Public Employment Service.
20.3 – . : Individuals in the population aged 25–64 years old who have been registered as unemployed or in programmes with activity support for at least six months, 2014.
Uppsala 2.57 Halland 2.95 Stockholm 3.04 Västerbotten 3.26 Dalarna 3.27 Norrbotten 3.36 Jämtland 3.53 Jönköping 3.58 Kalmar 3.65 Värmland 3.86 Västra Götaland 3.86 SWEDEN 3.91 Gotland 3.94 Örebro 4.19 Kronoberg 4.45 Västernorrland 4.71 Västmanland 4.71 Östergötland 4.96 Skåne 5.11 Gävleborg 5.31 Blekinge 5.40 Sörmland 5.43 0 1 2 3 4 5 6
2014 2009 Per cent Source: The Swedish Public Employment Service). Education, work and self-sufficiency 85
20.4 ¡ ¢£¤¥¦§¨©: Individuals in the population aged 25¡64 years old who have been registered as unemployed or in programmes with activity support for at least six months, 2014.
Danderyd Lund Nora Sundsvall Vaxholm Enköping Nybro Markaryd Vallentuna Söderköping Ängelholm Karlshamn Täby Vännäs Luleå Härnösand Knivsta Pajala Gällivare Hofors Tjörn Vansbro Svalöv Järfälla Ekerö Götene Ockelbo Grums Lomma Härjedalen Ödeshög Älvkarleby Kungälv Ale Linköping Munkfors Lerum Essunga Kalmar Mellerud Österåker Rättvik Lilla Edet Filipstad Öckerö Robertsfors Vara Bjuv Östhammar Vadstena Klippan Nordmaling Lekeberg Upplands Väsby Ludvika Åsele Stenungsund Aneby Upplands-Bro Strömsund Habo Älmhult Bräcke Uppvidinge Sunne Ystad Älvsbyn Hallsberg Kungsbacka Hammarö Sala Ragunda Malung-Sälen Umeå Ljusdal Västerås Kiruna Nynäshamn Övertorneå Gislaved Lidingö Hörby Lidköping Växjö Svenljunga Höganäs Norberg Kramfors Norrtälje Oskarshamn Färgelanda Hässleholm Bjurholm Mörbylånga Falkenberg Dals-Ed Oxelösund Alvesta Värmdö Vimmerby Valdemarsvik Mariestad Askersund Piteå Sundbyberg Karlskoga Tyresö Heby Skövde Ånge Håbo Jokkmokk Hylte Hallstahammar Nykvarn Hjo Norsjö Nässjö Härryda Hedemora Surahammar Söderhamn Arjeplog Vaggeryd Nyköping Bromölla Strömstad Jönköping Osby Åstorp Åre Sigtuna Sävsjö Vilhelmina Sjöbo Kalix Haparanda Orust Nordanstig Gotland Gullspång Tranemo Kil Hagfors Burlöv Tanum Falun Skara Vänersborg Bollebygd Arvidsjaur Boden Östra Göinge Ydre Eksjö Tierp Tibro Svedala Sorsele Borlänge Töreboda Lysekil Orsa Gnosjö Finspång Smedjebacken Simrishamn Emmaboda Helsingborg Vellinge Vindeln Lindesberg Motala Torsby Arvika Lycksele Karlskrona Leksand Eslöv Karlstad Åmål Älvdalen Stockholm Mjölby Kristinehamn Gagnef Huddinge Uddevalla Laxå Trosa Vetlanda Trelleborg Kristianstad Säter Ljungby Tomelilla Vingåker Sollentuna Herrljunga Ovanåker Fagersta Storuman Haninge Mönsterås Bollnäs Eda Kumla Borås Kungsör Partille Boxholm Avesta Köping Mölndal Tidaholm Göteborg Sollefteå Nacka Vårgårda Ljusnarsberg Katrineholm Varberg Skurup Örkelljunga Lessebo Höör Båstad Bengtsfors Ronneby Mullsjö Berg Hällefors Arboga Årjäng Kinda Forshaga Olofström Borgholm Gnesta Degerfors Perstorp Malå Skinnskatteberg Sölvesborg Storfors Munkedal Laholm Torsås Karlsborg Värnamo Örnsköldsvik Botkyrka Mark Grästorp Örebro Gävle Solna Tingsryd Tranås Norrköping Uppsala Åtvidaberg Överkalix Malmö Mora Strängnäs Halmstad Eskilstuna Sotenäs Östersund Timrå Sandviken Krokom Hudiksvall Hultsfred Flen Ulricehamn Alingsås Västervik Landskrona Kävlinge Dorotea Falköping Södertälje Salem Skellefteå Högsby Trollhättan 0 2 4 6 8 10 0 2 4 6 8 10 0 2 4 6 8 10 0 2 4 6 8 10 Per cent SWEDEN 2014 2009
Source: The Swedish Public Employment Service. 86 Regional Comparisons 2014: Public Health
21 . LONG-TERM ASSISTANCE of long-term assistance recipients at the same time as the Assistance is an economic aid under the Social Services proportion of the total population in receipt of assistance Act and is a part of the welfare system in municipality. in the municipality is low. The assistance is a protection that comes into place if an The proportion of the total population in receipt of as- individual is unable to receive unemployment insurance sistance in the municipality gives an indication of the pro- or otherwise unable to support themselves. The pro- portion of the population who are financially vulnerable. portion of the population who are in receipt of assistance At the municipal level, the distribution of the proportion has not changed much, while the statistics show that the of assistance recipients is quite large, which is illustrated proportion of those receiving assistance who do so in the in the latest edition of Regional Comparisons of Assistance long-term continues to increase [107]. Unemployment is 2014 [107]. the most common reason why individuals are unable to In terms of the distribution between counties, the ma- support themselves financially and require assistance. jor city regions have a higher proportion of long-term as- Young single mothers and people born abroad are over- sistance recipients and the distribution at the municipal represented among those receiving assistance. level is very large. A long-term requirement for assistance can make it Long-term assistance is an important indicator to mon- more difficult to gain a permanent foothold in the labour itor in the field of public health, together with changes to market, with may also mean that the individual’s health deteriorates [107]. The indicator reflects the proportion of all adults in re- 21.1 – : Individuals aged 18 and older who has ceipt of assistance (18 years and older) who received long- received long-time assistance (10–12 months of the year). term assistance (10–12 months over the course of the year). According to Chapter 4, Section 1 of the Social Services Act, Per cent 45 applicants will receive such assistance as provides a rea- sonable standard of living, which means this is a relatively small amount compared to families who have the means 40 by which to support themselves. Changes to income levels
in recent years have resulted in a large difference between 35 those who are receiving assistance and the rest of society
[60]. Close to 37 per cent of the total amount of assistance 30 in Sweden is provided to people who are in receipt of long- term assistance. When analysing this indicator, it is important to also 2010 2011 2012 2013 Year take into account the proportion of the total population Total who are receiving assistance, as municipalities with plen- Source: The Social Assistance Register, the National Board of Health and Welfare. tiful resources may, for example, have a high proportion Education, work and self-sufficiency 87
long-term unemployment as this is the primary reason effects that can promote public health. However, the mu- why people apply for assistance. Individuals in receipt nicipalities need to develop additional joint procedures of long-term assistance may have a greater requirement to improve how they collaborate with other stakeholders. for health promotion interventions, compared to other This applies to social services and Arbetsförmedlingen, for groups. Arbetsförmedlingen (the Swedish public employ- example. In addition, social services in the municipalities ment service), social services, the Swedish Social Insur- have, since 2013, been given more opportunities to refer ance Agency and primary care services are other important those in receipt of assistance to practical training or skills stakeholders in this context. These organisations’ ability courses if Arbetsförmedlingen has been unable to offer to collaborate and coordinate their efforts can have a ma- any appropriate employment interventions. jor impact on the chances of achieving satisfactory societal
21.2 – : Individuals aged 18 and older who has received long-time assistance (10–12 months of the year), 2013.
Gotland 21.6 Jämtland 22.5 Norrbotten 25.1 Kalmar 28.7 Västerbotten 29.6 Värmland 30.3 Gävleborg 30.7 Kronoberg 31.8 Jönköping 32.0 Västernorrland 32.0 Dalarna 33.2 Sörmland 33.4 Halland 34.6 Blekinge 35.4 Örebro 35.5 SWEDEN 36.7 Västmanland 38.2 Uppsala 38.8 Skåne 38.9 Västra Götaland 39.3 Stockholm 41.1 Östergötland 43.8 0 10 20 30 40 50
2013 2010 Per cent Source: The Social Assistance Register, the National Board of Health and Welfare. 88 Regional Comparisons 2014: Public Health
F 21.3 ¡¢£¤¥¦§: Individuals aged 18 and older who has received long-time assistance (1012 months of the year), 2013.
Sotenäs Älvkarleby Östhammar Flen Mörbylånga Gullspång Munkfors Tranås Laxå Munkedal Hällefors Vadstena Essunga Sala Ovanåker Markaryd Åre Sollefteå Vänersborg Älvdalen Hagfors Perstorp Ödeshög Strömstad Leksand Trelleborg Umeå Norsjö Hylte Östra Göinge Borås Olofström Ekerö Gnesta Luleå Töreboda Gagnef Vaggeryd Kungsbacka Haparanda Tidaholm Boxholm Partille Borgholm Herrljunga Strängnäs Sundsvall Storfors Hjo Vellinge Eskilstuna Vansbro Svedala Kungsör Höganäs Vilhelmina Karlskoga Oskarshamn Vindeln Hultsfred Lidingö Västervik Uppvidinge Båstad Mellerud Kumla Malung-Sälen Mariestad Danderyd Halmstad Jokkmokk Mönsterås Eslöv Lerum Nybro Bollebygd Norrtälje Sundbyberg Färgelanda Gnosjö Ljusnarsberg Falkenberg Valdemarsvik Östersund Bromölla Laholm Sorsele Härnösand Åstorp Salem Burlöv Gällivare Svalöv Alvesta Forshaga Hörby Sjöbo Vaxholm Ljungby Gävle Vårgårda Härjedalen Vetlanda Mjölby Askersund Sunne Svenljunga Falun Fagersta Tyresö Sävsjö Enköping Höör Dals-Ed Lekeberg Örnsköldsvik Säter Karlsborg Nacka Sollentuna Vännäs Bollnäs Arvika Nässjö Grästorp Söderköping Filipstad Ludvika Malå Lysekil Nykvarn Älmhult Mora Degerfors Järfälla Mölndal Ragunda Ockelbo Timrå Kil Bräcke Kramfors Stenungsund Sandviken Övertorneå Rättvik Alingsås Värmdö Nordanstig Strömsund Nyköping Härryda Torsby Emmaboda Varberg Köping Oxelösund Hudiksvall Tjörn Borlänge Torsås Skara Ale Åtvidaberg Krokom Vimmerby Avesta Huddinge Skinnskattberg Hallsberg Bjurholm Nynäshamn Vingåker Tranemo Haninge Lilla Edet Norberg Grums Lindesberg Örebro Storuman Vara Mark Finspång Kiruna Ängelholm Värnamo Kungälv Tingsryd Täby Österåker Malmö Simrishamn Eksjö Bengtsfors Tierp Arjeplog Hofors Skellefteå Karlskrona Pajala Klippan Jönköping Trollhättan Tanum Bjuv Heby Norrköping Trosa Nordmaling Arboga Uppsala Åmål Tibro Sölvesborg Öckerö Berg Örkelljunga Götene Motala Åsele Aneby Knivsta Nora Eda Skurup Kalmar Lund Mullsjö Habo Kristinehamn Landskrona Robertsfors Ulricehamn Sigtuna Kristianstad Överkalix Ystad Gislaved Stockholm Ljusdal Ånge Ronneby Helsingborg Orust Älvsbyn Hedemora Västerås Arvidsjaur Lomma Karlstad Göteborg Kinda Hallstahammar Hässleholm Linköping Årjäng Orsa Ydre Södertälje Gotland Surahammar Falköping Boden Kalix Skövde Osby Botkyrka Dorotea Uddevalla Katrineholm Högsby Kävlinge Lessebo Lidköping Lycksele Piteå Tomelilla Växjö Solna Smedjebacken Håbo Hammarö Upplands Väsby Söderhamn Karlshamn Upplands-Bro Vallentuna 0 20 40 60 0 20 40 60 0 20 40 60 0 20 40 60 Per cent SWEDEN 2013 2010 1 Data missing.
Source: The Social Assistance Register, the National Board of Health and Welfare. Participation in society 89
Participation in society
Participation and influence in society is one of the fun- more representative and equal. It is also a way for citizens damental prerequisites of health. People need to have the to participate in various societal issues. Consequently, there opportunity to influence their own social conditions and is concern voiced in the public discussion regarding a low the society in which they live as a lack of power and op- turnout among younger people and those with a foreign portunities for influence is linked to ill-health [108, 109]. A background [58, 112]. variety of factors can have an impact on how much some- There are many other ways to be democratically active one participates, for example the availability of work, club aside from actively voting, for example by being a member activities and social networks [12, 108, 109]. Furthermore, of a political party or representing other groups in society. the sense of community and that life has meaning is one One way to capture the area of participation and influ- of the explanations for why some people are able to cope ence is to monitor turnout at elections over time and among with stressful situations better than others. Participation different groups. This reports looks at turnout in municipal is measured through factors such as democratic participa- council elections, which involves a certain measure of in- tion in the form of turnout at elections, as well as through fluence in the local democratic process [58, 112]. inhabitants’ perceptions of their opportunity to influence Turnout in the last general municipal council elections decision-making. in 2014 was 82.8 per cent, an increase for the second elec- tion in a row following the previous downward trend. 22 . TURNOUT AT ELECTIONS Turnout varied between municipalities from 60.2 to 92 per Turnout at general elections is often used as a measure cent. Turnout in the municipal council election in 2014 of democratic participation. There is also a link between was somewhat lower than in the Riksdag election (85.8 per a lack of democratic participation and ill-health, with cent), but about the same as for the county council election groups that have low turnout at elections having lower (82.4 per cent). self-rated health [58, 110]. Aside from the political parties’ own efforts to increase Turnout at elections in Sweden has increased stead- the turnout, much can be done at the national, regional and ily since the 1910s, but there are distinct differences be- tween different groups. Groups with a high educational level and high income, those who are married/cohabiting, 22.1 – : Eligible voters who participated in municipal election of those citizens who are enrolled in the professionals and those who are employed have the high- electoral register. est turnout at elections. Women have a higher turnout at Per cent elections than men, and the youngest and oldest sections 100 of the population have a somewhat lower turnout. These 95 patterns have been relatively stable over time. In the pe- riod 1994–2002, turnout at elections decreased, primarily 90 among those groups who already had lower turnouts, but turnout has increased again at the past two elections. This 85 increase has taken place primarily among those groups who previously had a low turnout. 80 In recent years, turnout has been more equal, but there are still larger differences today than prior to the drop in 73 76 79 82 85 88 91 94 98 02 06 10 14 turnout of the 1990s [111]. Year Total High turnout at elections is often said to strengthen the Source: The Election Authority, Statistics Sweden. legitimacy of the democratic system and to make politics 90 Regional Comparisons 2014: Public Health
22.2 ¢ £¤¥¦§¨©ª: Eligible voters who participated in municipal election of those citizens who are enrolled in the electoral register, 2014.
Lomma Uppsala Mark Bräcke Vellinge Herrljunga Sävsjö Järfälla Habo Tibro Orsa Svalöv Danderyd Linköping Karlskoga Hedemora Öckerö Österåker Karlshamn Hofors Hammarö Sotenäs Eksjö Upplands-Bro Kungsbacka Smedjebacken Ängelholm Tingsryd Vaxholm Orust Överkalix Tomelilla Lerum Grästorp Älvdalen Malå Ekerö Salem Vetlanda Lycksele Mörbylånga Partille Robertsfors Högsby Bollebygd Håbo Östhammar Ljungby Täby Skellefteå Vilhelmina Munkedal Kungälv Örnsköldsvik Tierp Arvika Kävlinge Essunga Härnösand Hörby Härryda Ödeshög Norrtälje Strömsund Örebro Krokom Gnosjö Mullsjö Gnesta Rättvik Norsjö Ydre Båstad Östra Göinge Köping Knivsta Motala Vara Nynäshamn Trosa Skara Kalix Ragunda Tjörn Oskarshamn Älvsbyn Härjedalen Piteå Ronneby Laholm Solna Uppvidinge Svedala Lund Oxelösund Söderhamn Hultsfred Söderköping Vaggeryd Storfors Sjöbo Lidköping Nässjö Emmaboda Filipstad Karlsborg Gotland Alvesta Ljusnarsberg Lidingö Älvkarleby Lysekil Hallstahammar Lekeberg Vänersborg Trollhättan Åmål Vårgårda Gävle Simrishamn Hagfors Boxholm Sunne Norrköping Gällivare Gagnef Strängnäs Ludvika Surahammar Vingåker Lindesberg Nybro Fagersta Aneby Skövde Bromölla Eskilstuna Värmdö Sölvesborg Vansbro Olofström Vallentuna Ulricehamn Vindeln Helsingborg Nykvarn Dorotea Arboga Lilla Edet Vadstena Vimmerby Älmhult Gullspång Kinda Jönköping Arvidsjaur Ljusdal Åtvidaberg Norberg Bollnäs Storuman Varberg Vännäs Skurup Jokkmokk Hjo Sollentuna Malung-Sälen Örkelljunga Stenungsund Åre Bjurholm Hällefors Alingsås Ystad Sollefteå Sundbyberg Forshaga Mjölby Kiruna Hylte Hallsberg Degerfors Tanum Upplands Väsby Tyresö Värnamo Färgelanda Göteborg Leksand Höör Kramfors Markaryd Götene Östersund Västerås Mellerud Valdemarsvik Sundsvall Hudiksvall Torsby Falköping Finspång Pajala Kil Katrineholm Skinnskatteberg Arjeplog Karlstad Enköping Flen Bengtsfors Umeå Ale Åsele Landskrona Karlskrona Timrå Heby Haninge Mölndal Sala Nordmaling Huddinge Borgholm Avesta Kristianstad Sigtuna Mönsterås Falkenberg Berg Dals-Ed Kumla Ockelbo Gislaved Klippan Tranås Halmstad Osby Perstorp Falun Ovanåker Nordanstig Sorsele Säter Borlänge Ånge Burlöv Askersund Lessebo Stockholm Övertorneå Växjö Tranemo Grums Årjäng Nyköping Kungsör Munkfors Bjuv Luleå Laxå Hässleholm Malmö Torsås Mariestad Borås Åstorp Boden Sandviken Töreboda Strömstad Nacka Västervik Mora Södertälje Kalmar Uddevalla Eslöv Botkyrka Tidaholm Nora Trelleborg Eda Höganäs Kristinehamn Svenljunga Haparanda 60 70 80 90 100 60 70 80 90 100 60 70 80 90 100 60 70 80 90 100 Per cent SWEDEN 2014 2010
Source: The Election Authority, Statistics Sweden. Participation in society 91
local level. In terms of the municipalities, this can involve or over, which can be interpreted as “acceptable” based providing more information about the right to vote and de- on Statistics Sweden’s investigation of citizens’ interpre- veloping methods that aim to make it easier for individuals tation of the grade. to vote. Greater cooperation between various associations No municipality achieved over 55, which is the equiva- can also be one way to reach more of those eligible to vote lent of “satisfactory”. in the municipality. The citizen survey also includes specific questions about contact, information, impact and trust – which are 23 . INHABITANTS’ PERCEPTIONS OF THEIR all expected to contribute towards the overall NII score. OPPORTUNITY TO INFLUENCE DECISION- For municipalities, information achieves the highest MAKING IN THE MUNICIPALITY grade, while impact gets the lowest grade among both Participation and influence in society is one of eleven women and men. national objective domains in public health and encom- For the purposes of future improvement, it is impor- passes several policy areas. Important stakeholders in this tant for the municipalities to review all four areas (in- context are municipalities, county administrative boards, formation, contact, impact and trust) and investigate regions, county councils and various municipalities, as whether there are any differences related to gender, age well as the voluntary sector. Influence and the opportu- and socioeconomic factors. Statistics Sweden’s final re- nity to have an impact can be measured at several differ- port on the citizen survey also presents results based ent levels in society and in relation to different welfare on age group and type of place, as well as on how long services. Citizens’ perceptions of their opportunity to in- individuals have lived in the municipality. Integrating fluence decision-making give an indication of any needs such local results can supply improvement efforts with for development in, for example, a municipality [110]. further valuable information. Some municipalities also Allowing the inhabitants of a municipality to participate conduct their own surveys that may also give an indica- in decision-making and taking account of their views can tion of what can be improved. increase the quality of municipal services. Statistics Sweden’s citizen survey (medborgarunder- sökning) contains what is known as the municipality’s Satisfaction-Influence Index (Nöjd-Inflytande-Index, NII). This is based on three questions about opportu- nities to influence decision-making in the municipal- 23.1 – : Citizens' possibility of inuencing the decision-making in the municipality, based on three questions ity. The questions cover how satisfied the respondent is with the satisfaction of inuence, index on a scale of 1–100. with the transparency of and their influence on the mu- Index nicipality’s decision-making and services, how well this 45 meets their own expectations and how close they believe 43 this situation is to a possible ideal situation [113]. This citizen survey has been carried out by Statistics 41 Sweden since 2005. A total of 256 Swedish municipalities have participated and the majority of these have partici- 39 pated more than once. This report presents a combina- tion of the results from autumn 2013 and spring 2014. 37 The results for the municipalities’ NII amounted to an average of 40 in the measurement period 2013/2014. The Spring Autumn Spring Autumn Spring Autumn Spring index varied between 29 and 52 among the participating 2011 2011 2012 2012 2013 2013 2014 municipalities. There were clear differences between Total Women Men women and men. Half of the municipalities that partici- Source: The Swedish Citizen Survey, Statistics Sweden. pated in the survey in 2013/2014 achieved an index of 40 92 Regional Comparisons 2014: Public Health
23.2 ¡ ¢£¤¥¦§¨©: Citizens' possibility of in¯uencing the decisionmaking in the municipality, based on three questions about satisfactory with in¯uence, index on a scale of 1¡100, autumn 2013 or spring 2014 (see explanation below for measurement period).
Danderyd Ljungby Essunga Orust Markaryd Nykvarn Filipstad Oskarshamn Boxholm Nyköping Finspång Ovanåker Karlstad Skara Forshaga Oxelösund Kävlinge Umeå Färgelanda Pajala Robertsfors Östhammar Gagnef Partille Säter Karlskoga Gnesta Perstorp Hammarö Sandviken Gnosjö Piteå Lekeberg Vallentuna Grums Ragunda Lomma Åtvidaberg Grästorp Sala Luleå Ängelholm Gullspång Salem Sölvesborg Boden Gällivare Simrishamn Nacka Burlöv Göteborg Skurup Tranås Osby Habo Skövde Fagersta Sundsvall Hagfors Smedjebacken Kalmar Tingsryd Hallsberg Sollefteå Kungsbacka Tjörn Hallstahammar Sollentuna Linköping Torsås Haparanda Sorsele Olofström Vaxholm Heby Sotenäs Sigtuna Bromölla Hedemora Stockholm Arvika Båstad Herrljunga Storfors Halmstad Eskilstuna Huddinge Storuman Hjo Falköping Hultsfred Strömsund Lund Ronneby Hällefors Sundbyberg Sunne Skinnskatteberg Härjedalen Surahammar Svedala Borås Svalöv Härryda Jönköping Vansbro Hässleholm Höganäs Sävsjö Karlsborg Östra Göinge Högsby Södertälje Karlshamn Götene Hörby Tanum Landskrona Munkedal Höör Tibro Mjölby Solna Kalix Tierp Mora Värmdö Katrineholm Timrå Motala Gävle Kil Tomelilla Sjöbo Jokkmokk Kiruna Torsby Tidaholm Söderhamn Klippan Tranemo Öckerö Trelleborg Knivsta Trollhättan Alingsås Uddevalla Kramfors Trosa Avesta Valdemarsvik Kristinehamn Tyresö Hylte Vänersborg Krokom Täby Härnösand Gotland Kungsör Töreboda Järfälla Hofors Köping Upplands-Bro Skellefteå Nordanstig Laholm Uppsala Uppvidinge Strängnäs Laxå Vadstena Övertorneå Växjö Lessebo Vara Flen Gislaved Lidingö Varberg Haninge Vimmerby Lidköping Vellinge Håbo Svenljunga Lilla Edet Vetlanda Mellerud Alvesta Lindesberg Vilhelmina Rättvik Aneby Ljusdal Vindeln Strömstad Arboga Ljusnarsberg Vingåker Upplands Väsby Arjeplog Ludvika Vårgårda Vaggeryd Arvidsjaur Lycksele Värnamo Ale Askersund Lysekil Västervik Falkenberg Bengtsfors Malmö Västerås Helsingborg Berg Malung-Sälen Ydre Kumla Bjurholm Malå Ystad Ockelbo Bjuv Mariestad Åmål Söderköping Bollebygd Mark Ånge Ulricehamn Bollnäs Mullsjö Åre Vännäs Borgholm Munkfors Årjäng Hudiksvall Borlänge Mölndal Åsele Kinda Botkyrka Mönsterås Åstorp Norsjö Bräcke Mörbylånga Älmhult Dals-Ed Nora Älvdalen Stenungsund Degerfors Norberg Älvkarleby Örnsköldsvik Dorotea Nordmaling Älvsbyn Falun Eda Norrköping Ödeshög Karlskrona Ekerö Norrtälje Örebro Kristianstad Eksjö Nybro Örkelljunga Kungälv Emmaboda Nynäshamn Östersund Leksand Enköping Nässjö Österåker Lerum Eslöv Orsa Överkalix 20 30 40 50 60 20 30 40 50 60 20 30 40 50 60 20 30 40 50 60 Index Mean value Autumn 2013 Spring 2014
Source: The Swedish Citizen Survey, Statistics Sweden. Participation in society 93
RECREATION AND TRANSPORT Children’s freedom of movement has decreased and Physical activity is an important prerequisite for good some contributory factors are that the physical conditions health. People are of course in control of their own life- along routes to school have become increasingly unsafe, style habits, but they are affected by societal conditions. with greater distances to schools and greater volumes of By improving the physical environment, it is possible to traffic [115]. It is important to think through how footpaths encourage movement, particularly among those who are and cycle paths are built, their characteristics, safety, light- least active [114–116]. ing and maintenance, as these factors are also decisive to Statistics Sweden’s citizen survey measures the popu- the degree to which they are used by different groups. In- lation’s attitudes and the societal conditions for such fac- ternational studies also indicate a link between cycle in- tors as recreation and opportunities to actively transport frastructure and the proportion who cycle [116, 117]. The yourself (walking and cycling). The survey is conducted public health policy report 2010 contained proposals for twice a year and municipalities choose whether to par- measures to improve the physical environment in order ticipate and how often. This report uses the results from to stimulate the population to become more physically ac- autumn 2013 and spring 2014, when a total of 119 munici- tive, but these have not yet been implemented fully [120]. palities participated at least once. The citizen survey con- Citizens’ views on the accessibility of footpaths and cy- tains questions in several areas, for example how the re- cle paths give an indication of any requirements for devel- spondent rates living in the municipality and what they opment, but this covers more than the actual accessibility. think about municipal services. The results indicate an Expectations also understandably have an impact, as does average grade on a ten-point scale. Statistics Sweden has how often people use footpaths and cycle paths them- investigated how the grade is perceived by asking groups selves. There are also other factors in the citizen survey to state where on the scale different assessments fit. The that can expand knowledge in this area. This involves is- survey indicates that below 5 can be classed as “not ac- sues relating to how satisfied citizens are with the charac- ceptable”, 6–7 as “satisfactory”, while 8 and over is inter- preted as “extremely satisfied”.
24.1 – : Citizens' assessment of the availability of 24 . ACCESS TO FOOTPATHS AND CYCLE footpaths and cycle paths in the municipality, on a scale of 1–10. PATHS Average rating Research indicates that people in “walkable” areas are 7.0 more physically active, independent of individual factors. An attractive environment that makes movement easier 6.5 has more impact on the rate of physical activity than pro- viding information to individuals. It is also beneficial to provide sufficient opportunities to transport yourself in a 6.0 physically active way to and from work, school, services, etc. [115–117]. 5.5 Choosing to cycle instead of driving doesn’t just have an impact on your own health, it also has major benefits Spring Autumn Spring Autumn Spring Autumn Spring for the entire economy and an environmental impact. If 2011 2011 2012 2012 2013 2013 2014 one per cent – of the population choose to cycle to work Total Women Men instead of driving a car, carbon dioxide emissions would Source: The Swedish Citizen Survey, Statistics Sweden. decrease by 55 million tons per year [117]. 94 Regional Comparisons 2014: Public Health
teristics of footpaths and cycle paths in terms of lighting, 24.2 – , - : Citizens' assessment of maintenance, snow clearance and traffic safety. However, lighting, maintenance, snow clearance, trac safety on footpaths the results of these are not presented at the municipal lev- and cycling paths, on a scale of 1–10. el in this report. Average rating The citizen survey’s questions about views on accessi- 7.0 bility of footpaths and cycle paths are presented using an 6.5 average grade on a ten-point scale. With respect to the ac- cessibility of footpaths and cycle paths for all municipali- 6.0
ties, the average grade was 6.1 among men and 6.2 among 5.5 women. Women’s average grade is equivalent to satisfac- 5.0 tory in 57 per cent of the participating municipalities,
while men were satisfied in 55 per cent of these munici- 4.5 palities. The average grade has been relatively stable in re-
cent years. Spring Autumn Spring Autumn Spring Autumn Spring In the questions concerning the quality of footpaths 2011 2011 2012 2012 2013 2013 2014 and cycle paths, both women and men gave traffic safety Lighting Maintenance the highest grade (6.0 = satisfactory), while snow clearing Snow clearance Trac safety received the lowest grade, but still managed to reach the Source: The Swedish Citizen Survey, Statistics Sweden. level of satisfactory (5.3). Participation in society 95
24.3 ¡¢£¤¥¦§¨: Citizens' assessment of the availability of footpaths and cycle paths in the municipality, on a scale of 110, autumn 2013 or spring 2014 (see explanation below for measurement period).
Sunne Essunga Orust Umeå Härnösand Filipstad Oskarshamn Linköping Avesta Finspång Ovanåker Karlstad Söderköping Forshaga Oxelösund Hammarö Söderhamn Färgelanda Pajala Halmstad Strängnäs Gagnef Partille Lomma Hjo Gnesta Perstorp Lund Sjöbo Gnosjö Piteå Burlöv Götene Grums Ragunda Landskrona Uddevalla Grästorp Sala Motala Karlsborg Gullspång Salem Ulricehamn Gotland Gällivare Simrishamn Järfälla Tjörn Göteborg Skurup Helsingborg Mora Habo Skövde Tranås Båstad Hagfors Smedjebacken Mjölby Osby Hallsberg Sollefteå Växjö Sundsvall Hallstahammar Sollentuna Kumla Vimmerby Haparanda Sorsele Danderyd Kungälv Heby Sotenäs Kalmar Hofors Hedemora Stockholm Gävle Jokkmokk Herrljunga Storfors Upplands Väsby Arvika Huddinge Storuman Karlshamn Vännäs Hultsfred Strömsund Fagersta Tingsryd Hällefors Sundbyberg Bromölla Värmdö Härjedalen Surahammar Vaggeryd Kinda Härryda Svedala Vänersborg Svenljunga Hässleholm Höganäs Sävsjö Karlskoga Säter Högsby Södertälje Kristianstad Hylte Hörby Tanum Sigtuna Uppvidinge Höör Tibro Nacka Ockelbo Kalix Tierp Ängelholm Robertsfors Katrineholm Timrå Ljungby Leksand Kil Tomelilla Kävlinge Valdemarsvik Kiruna Torsby Håbo Örnsköldsvik Klippan Tranemo Olofström Torsås Knivsta Trollhättan Haninge Östhammar Kramfors Trosa Alingsås Svalöv Kristinehamn Tyresö Ronneby Hudiksvall Krokom Täby Stenungsund Norsjö Kungsör Töreboda Boden Flen Köping Upplands-Bro Skara Rättvik Laholm Uppsala Lerum Munkedal Laxå Vadstena Lekeberg Luleå Lessebo Vara Övertorneå Ale Lidingö Varberg Solna Vansbro Lidköping Vellinge Sölvesborg Nordanstig Lilla Edet Vetlanda Eskilstuna Alvesta Lindesberg Vilhelmina Östra Göinge Aneby Ljusdal Vindeln Åtvidaberg Arboga Ljusnarsberg Vingåker Falun Arjeplog Ludvika Vårgårda Trelleborg Arvidsjaur Lycksele Värnamo Gislaved Askersund Lysekil Västervik Tidaholm Bengtsfors Malmö Västerås Falköping Berg Malung-Sälen Ydre Nyköping Bjurholm Malå Ystad Sandviken Bjuv Mariestad Åmål Boxholm Bollebygd Mark Ånge Falkenberg Bollnäs Mullsjö Åre Nykvarn Borgholm Munkfors Årjäng Strömstad Borlänge Mölndal Åsele Kungsbacka Botkyrka Mönsterås Åstorp Jönköping Bräcke Mörbylånga Älmhult Karlskrona Dals-Ed Nora Älvdalen Markaryd Degerfors Norberg Älvkarleby Skinnskatteberg Dorotea Nordmaling Älvsbyn Borås Eda Norrköping Ödeshög Skellefteå Ekerö Norrtälje Örebro Öckerö Eksjö Nybro Örkelljunga Vaxholm Emmaboda Nynäshamn Östersund Mellerud Enköping Nässjö Österåker Vallentuna Eslöv Orsa Överkalix 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 Average rating Mean value Autumn 2013 Spring 2014
Source: The Swedish Citizen Survey, Statistics Sweden. 96 Regional Comparisons 2014: Public Health
25 . ACCESS TO PARKS, GREEN SPACES AND assessments of the impact on health when planning phys- THE COUNTRYSIDE ical environments in order to find balance in any conflicts Proximity to parks, green spaces and recreation areas is between goals [126]. very important as these create good conditions for physi- The citizen survey’s questions about views on the acces- cal activity. The more supportive environments, spaces sibility of parks, green spaces and the countryside are pre- and facilities there are in the local area, the greater the sented using an average grade on a ten-point scale. chances of its inhabitants being regularly physically active With respect to the accessibility of parks, green spaces [117]. and the countryside for all municipalities, the average The countryside itself has an effect that promotes the grade was 7.7 among men and 7.8 among women. This health of people of all ages, both physically and mentally; means that both women and men were satisfied with the parks and green spaces are thus important to individuals accessibility of parks, green spaces and the countryside in various stages of life [115, 118] and for all socioeconomic in all participating municipalities. The average grade has groups in the population [121]. Children need good condi- been relatively stable in recent years. tions in which to explore their local environment as this The average grade for the additional question concern- is beneficial to their physical, mental and social develop- ing the cleanliness of parks and public spaces is somewhat ment [115, 122]. lower than that for accessibility. Citizen’s views on the accessibility of parks, green spaces and the countryside provide an indication of any requirements for development, but the actual accessibil- 25.1 – : Citizens' assessment of the availability of ity is not everything. Naturally, people’s expectations have parks, green spaces and nature in the municipality, on a scale of 1–10. an impact on the responses and the extent to which they Average rating spend time in parks, green spaces and the countryside. 9.0 When residential areas grow and become denser, the number of green spaces decreases. Consequently, the Na- 8.5 tional Board of Housing, Building and Planning has drawn up guidance in order to ensure access to green spaces close to housing [123]. The Public Health Agency of Sweden has 8.0 also drawn up guidance that can be used to assess the proximity to and the attractiveness of green spaces [121], 7.5 as well as a document providing support and inspiration when creating sustainable living environments that pro- Spring Autumn Spring Autumn Spring Autumn Spring mote health. For many years now, there has also been a 2011 2011 2012 2012 2013 2013 2014 manual for planning active lives in built environments Total Women Men that is based on past research in this area [116, 117, 119, Source: The Swedish Citizen Survey, Statistics Sweden. 125]. Municipalities and county councils can also conduct Participation in society 97
25.2 ¡ ¢£¤¥¦§¨©: Citizens' assessment of the availability of parks, green spaces and nature in the municipality, on a scale of 1¡10, autumn 2013 or spring 2014 (see explanation below for measurement period).
Karlsborg Kristianstad Essunga Orust Vaxholm Vallentuna Filipstad Oskarshamn Nacka Boden Finspång Ovanåker Danderyd Mjölby Forshaga Oxelösund Rättvik Falköping Färgelanda Pajala Arvika Karlskrona Gagnef Partille Alingsås Ale Gnesta Perstorp Jokkmokk Hudiksvall Gnosjö Piteå Härnösand Skara Grums Ragunda Hammarö Valdemarsvik Grästorp Sala Sölvesborg Tingsryd Gullspång Salem Tidaholm Sigtuna Gällivare Simrishamn Olofström Götene Göteborg Skurup Åtvidaberg Ljungby Habo Skövde Skinnskatteberg Vaggeryd Hagfors Smedjebacken Värmdö Gislaved Hallsberg Sollefteå Lekeberg Östra Göinge Hallstahammar Sollentuna Öckerö Linköping Haparanda Sorsele Båstad Lund Heby Sotenäs Ulricehamn Svenljunga Hedemora Stockholm Boxholm Jönköping Herrljunga Storfors Hjo Norsjö Huddinge Storuman Leksand Sandviken Hultsfred Strömsund Gotland Eskilstuna Hällefors Sundbyberg Tranås Upplands Väsby Härjedalen Surahammar Ronneby Nykvarn Härryda Svedala Kungsbacka Vimmerby Hässleholm Höganäs Sävsjö Borås Kungälv Högsby Södertälje Landskrona Kumla Hörby Tanum Säter Falun Höör Tibro Lerum Skellefteå Kalix Tierp Motala Uddevalla Katrineholm Timrå Uppvidinge Sundsvall Kil Tomelilla Fagersta Avesta Kiruna Torsby Haninge Luleå Klippan Tranemo Ockelbo Umeå Knivsta Trollhättan Robertsfors Bromölla Kramfors Trosa Tjörn Stenungsund Kristinehamn Tyresö Östhammar Håbo Krokom Täby Vänersborg Vännäs Kungsör Töreboda Kinda Munkedal Köping Upplands-Bro Karlshamn Nyköping Laholm Uppsala Sjöbo Övertorneå Laxå Vadstena Svalöv Vansbro Lessebo Vara Trelleborg Markaryd Lidingö Varberg Söderköping Burlöv Lidköping Vellinge Järfälla Lilla Edet Vetlanda Ängelholm Alvesta Lindesberg Vilhelmina Falkenberg Aneby Ljusdal Vindeln Mora Arboga Ljusnarsberg Vingåker Söderhamn Arjeplog Ludvika Vårgårda Osby Arvidsjaur Lycksele Värnamo Kalmar Askersund Lysekil Västervik Halmstad Bengtsfors Malmö Västerås Lomma Berg Malung-Sälen Ydre Nordanstig Bjurholm Malå Ystad Karlstad Bjuv Mariestad Åmål Flen Bollebygd Mark Ånge Karlskoga Bollnäs Mullsjö Åre Växjö Borgholm Munkfors Årjäng Mellerud Borlänge Mölndal Åsele Kävlinge Botkyrka Mönsterås Åstorp Strängnäs Bräcke Mörbylånga Älmhult Hylte Dals-Ed Nora Älvdalen Sunne Degerfors Norberg Älvkarleby Torsås Dorotea Nordmaling Älvsbyn Gävle Eda Norrköping Ödeshög Solna Ekerö Norrtälje Örebro Strömstad Eksjö Nybro Örkelljunga Hofors Emmaboda Nynäshamn Östersund Helsingborg Enköping Nässjö Österåker Örnsköldsvik Eslöv Orsa Överkalix 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 Average rating Mean value Autumn 2013 Spring 2014
Source: The Swedish Citizen Survey, Statistics Sweden. 98 Regional Comparisons 2014: Public Health
SAFETY AND SOCIAL RELATIONSHIPS Several studies indicate that a high proportion of pupils A fundamental prerequisite for social development is in Swedish schools feel safe in school [131–133], and Swe- that there are societal institutions that fulfil their com- den is also well-placed internationally in terms of pupil mitments and do not discriminate against individuals safety. The results of a European study concerning abusive or groups. Such institutions can be formal or informal. behaviour in schools show that Swedish pupils are safest Another component that is just as important is the indi- of all in comparison with other EU and OECD countries vidual’s power over their own situation and their active [134]. participation in social life. Exclusion often goes along SALAR conducts an annual survey of Swedish pupils to with a lack of participation in decision-making and not find out their views on school and teaching. Pupils in both being able to fulfil your social and cultural obligations in municipal and independent schools in years 5 and 8 take society, but this is also connected to work, education and part in the survey. Around 104 000 pupils from a total of health. Social security systems are therefore important as 192 municipalities took part in the survey in school year they can reinforce people’s own capacity, capability and 2012/13. influence and provide support and protection to those The majority – around 93 per cent of pupils in year 5 – who are vulnerable. Swedish policy also emphasises the state that they feel safe in school. However, the proportion importance of the active participation of civil society, i.e. of pupils who feel safe varies and there are relatively large allowing organisations, private companies, trade unions differences between some of the municipalities. About the and other stakeholders to be involved in decision-making same proportion of girls as boys have stated that they feel processes that have an impact on people’s lives. safe in school (results are not shown in the diagram). Our lifestyle habits are affected by people around us and At the same time, there are pupils who do not feel the the networks we belong to in both positive and negative same sense of safety (on average around 6–7 per cent). Ac- ways. Our relationships can also improve our chances of cordingly, it is important that schools work consciously to enjoying good health. Aside from the fact that they con- take action with the aim of improving safety. stitute social support and contribute to a sense of security, If the school environment is to be characterised by safe- connection and participation, they also act as special in- ty and peace and quiet in which to study, pupils, teachers formation channels. Many studies have shown that isola- and other staff must feel a sense of collective responsibil- tion, particularly a lack of close relationships, is associ- ity for the working environment and respect one another. ated with poorer health and shorter lifespan [127]. Pupils should have the opportunity to shape the learning environment, for example by drawing up the school rules. 26 . SAFE IN SCHOOL It is also important that schools work together with the Schools must offer pupils an environment characterised pupils’ guardians. by stability, safety and peace and quiet in which to study. Systematic programmes to prevent bullying have been Those who feel safe find it easier to learn and develop as shown to be effective tools in the fight against bullying. people. Children who feel safe achieve better results and Evaluations show that both the proportion of bullies and also learn to take responsibility and to voice their opin- the proportion of pupils subject to bullying are on aver- ions. A lack of peace and quiet in school, as well as feelings age lower in schools that have implemented such anti- of not being safe, with the constant fear of being subject to bullying programmes [135, 136]. The programme compo- bullying, abuse and persecution, don’t just put the pupil’s nents that are considered to be most effective are parental future studies and career at risk, but can also have a det- education, increased supervision of school playgrounds, rimental impact on their mental health in the long-term yards and disciplinary measures. Classroom leadership [128–130]. A lack of safety in schools should therefore be and clear rules in the classroom are other important fac- taken extremely seriously. tors, as is the programme being run for a longer period and involving both teachers and pupils [136]. Participation in society 99
¡ 26.1 ¢ £¤¥¦§¨©¡ª: Pupils in grade 5 in compulsory school who answered “agree completely” or “mostly true” in response to the statement “I feel safe at school”, the municipal pupil survey 2013.
Kungsör Gotland Åre Knivsta Bengtsfors Köping Örnsköldsvik Kristinehamn Grums Trollhättan Arvika Laxå Hallstahammar Bollebygd Avesta Lidingö Trosa Degerfors Ekerö Lidköping Hörby Falun Götene Lilla Edet Mora Gislaved Härryda Ljungby Partille Habo Sala Ljusdal Vimmerby Heby Sollentuna Ljusnarsberg Öckerö Hjo Värmdö Lund Berg Hudiksvall Fagersta Lycksele Eda Karlskrona Borlänge Lysekil Kramfors Malung-Sälen Grästorp Malmö Laholm Rättvik Haninge Malå Lekeberg Surahammar Karlsborg Mellerud Lerum Sävsjö Nynäshamn Mjölby Nybro Sölvesborg Sigtuna Munkedal Orust Ulricehamn Sjöbo Nora Oskarshamn Varberg Västervik Norberg Stenungsund Boxholm Karlskoga Nordanstig Vännäs Gävle Nordmaling Norrköping Värnamo Härjedalen Stockholm Norsjö Älvsbyn Kalix Sundbyberg Osby Göteborg Kristianstad Tanum Ovanåker Högsby Kumla Vetlanda Oxelösund Perstorp Östersund Lessebo Tingsryd Hofors Piteå Alingsås Olofström Robertsfors Ragunda Boden Salem Tyresö Ronneby Borgholm Sunne Vårgårda Skellefteå Essunga Svedala Skurup Gnosjö Örebro Håbo Skövde Kalmar Enköping Vansbro Sollefteå Kungälv Eslöv Upplands Väsby Solna Kävlinge Falköping Övertorneå Sorsele Lindesberg Gullspång Arvidsjaur Sotenäs Luleå Hagfors Arjeplog Storfors Mark Hallsberg Dorotea Strömstad Motala Hammarö Jokkmokk Strömsund Mullsjö Huddinge Munkfors Svalöv Mölndal Järfälla Pajala Mönsterås Kil Skinnskattberg Söderhamn Mörbylånga Ludvika Smedjebacken Tibro Nässjö Markaryd Vadstena Tidaholm Orsa Nykvarn Överkalix Tierp Söderköping Simrishamn Arboga Timrå Tjörn Södertälje Bjurholm Tomelilla Torsås Upplands-Bro Bjuv Torsby Tranås Uppsala Botkyrka Trelleborg Vingåker Vänersborg Bromölla Töreboda Halmstad Västerås Burlöv Uddevalla Krokom Ödeshög Båstad Umeå Aneby Bollnäs Emmaboda Uppvidinge Askersund Ängelholm Filipstad Vaggeryd Bräcke Borås Finspång Valdemarsvik Dals-Ed Flen Forshaga Vallentuna Danderyd Leksand Färgelanda Vara Eksjö Nacka Gnesta Vellinge Falkenberg Norrtälje Gällivare Vilhelmina Herrljunga Sundsvall Haparanda Vindeln Kungsbacka Östra Göinge Helsingborg Växjö Linköping Hedemora Hultsfred Ydre Lomma Landskrona Hylte Ystad Mariestad Nyköping Hällefors Ånge Ockelbo Storuman Härnösand Årjäng Skara Ale Hässleholm Åsele Säter Jönköping Höganäs Åstorp Tranemo Kiruna Höör Åtvidaberg Åmål Sandviken Karlshamn Älmhult Örkelljunga Strängnäs Karlstad Älvdalen Alvesta Svenljunga Katrineholm Älvkarleby Eskilstuna Täby Kinda Österåker Gagnef Vaxholm Klippan Östhammar 60 70 80 90 100 60 70 80 90 100 60 70 80 90 100 60 70 80 90 100 Per cent Average for municipalities presented 2013 1 Fewer than 30 respondents. 2 Less than 70 per cent coverage. 3 Data missing.
Source: The Pupil Survey, the Swedish Association of Local Authorities and Regions. 100 Regional Comparisons 2014: Public Health
27 . UNSAFE ENVIRONMENT – INDIVIDUALS Among the municipal interventions in this area are a WHO AVOID GOING OUT ALONE good home and residential environment, close to services Individuals’ perception of a safe and secure environment and with safe footpaths and cycle paths and good com- is one of the most central human needs and is vital to our munications. This also involves creating natural meeting well-being. Safety comes immediately after our purely points where people can make contact and that stimulate a physical requirements in a classical order of precedence sense of community and a “feeling of we”. Night-time foot of human requirements [137]. patrols and proactive activities for older people are other The safety of the residential area is important to both examples of initiatives that increase safety. Good outdoor comfort and health. A person’s ability to choose where to lighting has a tangible impact on the safety of outdoor en- spend time and what to do is dependent on them feeling vironments and increases comfort [19]. safe in their own neighbourhood. For example, people In the measurement period (2011–2014), somewhat few- have to be able to go for a walk or a run without fear and er people state that they often or sometimes avoid going to feel that there are safe play parks for children [138, 139]. out alone due to the fear of being attacked, robbed or oth- Studies have shown that feeling safe in the area in which erwise molested than in the previous measurement period we live is absolutely the most important factor if a resi- (2007–2010). There are large regional and local variations dential area is to be perceived as good [127]. Residential within the country. Women are considerably more likely environment is also one of the determinants in the public health objective domain “Economic and social prerequi- sites” [140]. 27.2 – , : Individuals who stated that When planning the physical layout of different envi- they often or sometimes avoid going out alone for fear of being attacked, robbed or otherwise molested, 2014. ronments, it is important to take into account the gender equality perspective that both women and men have to be Per cent 50 able to be there and feel safe. There are considerably more
women than men who do not feel safe outdoors. This 40 means that women are more likely to be limited in terms of their freedom of movement and, for example, avoid go- 30 ing out alone when it is dark in order to avoid the risk of violence, molestation and sexual offences. Sometimes, 20 this may involve weighing up different risks against one another, for example by avoiding pedestrian subways and 10 instead crossing heavily trafficked roads or walking or -cy 0 cling on the road instead of a dark or lonely footpath or Women Men cycle path. Public spaces can thus become less accessible 16–29 year 30–44 year 45–64 year 65–84 year for women if these aspects are not factored into the physi- Source: Health on Equal Terms, Public Health Agency of Sweden. cal planning process [19, 141, 142].
27.1 – : Individuals who stated that they often or 27.3 – . : Individuals who stated that sometimes avoid going out alone for fear of being attacked, they often or sometimes avoid going out alone for fear of being robbed or otherwise molested, 16–84 years old. attacked, robbed or otherwise molested, 35–74 years old, 2014.
Per cent Per cent 50 50
40 40
30 30
20 20
10 10
0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year Women Men Total Women Men Pre-upper-secondary Upper-secondary Post-secondary Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden. Participation in society 101
27.4 – , : Individuals who stated that they often or sometimes avoid going out alone for fear of being attacked, robbed or otherwise molested, 16–84 years old, 2011–2014.
Västerbotten 20 Jämtland 21 Dalarna 25 Norrbotten 26 Gotland 26 Kalmar 28 Västernorrland 29 Uppsala 29 Värmland 31 Halland 31 Östergötland 33 Jönköping 33 SWEDEN 33 Stockholm 33 Sörmland 33 Blekinge 33 Västra Götaland 33 Kronoberg 34 Gävleborg 37 Skåne 38 Örebro 41 Västmanland 41 0 10 20 30 40 50
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
27.5 – , : Individuals who stated that they often or sometimes avoid going out alone for fear of being attacked, robbed or otherwise molested, 16–84 years old, 2011–2014.
Västerbotten 3 Gotland 4 Jönköping 4 Norrbotten 4 Jämtland 5 Halland 6 Dalarna 6 Västernorrland 6 Kalmar 7 Blekinge 7 Uppsala 7 Örebro 7 Värmland 8 Kronoberg 8 Sörmland 8 SWEDEN 9 Gävleborg 9 Västra Götaland 9 Östergötland 10 Stockholm 10 Skåne 11 Västmanland 11 0 10 20 30 40 50
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. 102 Regional Comparisons 2014: Public Health
¡ 27.6 £ ¤¥¦§¨©ª¡«: Individuals who stated that they often or sometimes avoid going out alone for fear of being attacked, robbed or otherwise molested, 2011£2014.
Dorotea Vimmerby Varberg Norrköping Åsele Kungsbacka Alvesta Lidingö Sorsele Lund Götene Göteborg Älvdalen Ljungby Nässjö Vänersborg Norsjö Örnsköldsvik Mark Sundbyberg Vindeln Laxå Luleå Lerum Arjeplog Tingsryd Karlskoga Botkyrka Bjurholm Tranås Knivsta Mölndal Storuman Hylte Kalmar Eslöv Malå Smedjebacken Härryda Ystad Jokkmokk Trosa Munkedal Hallstahammar Vilhelmina Mönsterås Vara Gävle Åre Oskarshamn Härnösand Eskilstuna Vansbro Färgelanda Töreboda Upplands Väsby Härjedalen Degerfors Stockholm Örebro Nordmaling Uppvidinge Avesta Köping Berg Askersund Ale Hässleholm Strömsund Umeå Nyköping Partille Rättvik Norrtälje Karlskrona Malmö Malung-Sälen Essunga Linköping Västerås Överkalix Lekeberg Kristinehamn Arboga Ragunda Älmhult Västervik Trollhättan Lycksele Kinda Mariestad Helsingborg Huddinge Bräcke Högsby Surahammar Mellerud Landskrona Robertsfors Oxelösund Vallentuna Aneby Arvidsjaur Ludvika Danderyd Bjuv Pajala Hudiksvall Karlshamn Boxholm Valdemarsvik Hultsfred Katrineholm Bromölla Borgholm Lessebo Lilla Edet Burlöv Kalix Öckerö Fagersta Båstad Ånge Timrå Täby Eda Vännäs Gnesta Trelleborg Eksjö Gällivare Laholm Mjölby Filipstad Östhammar Ekerö Österåker Forshaga Kiruna Tidaholm Olofström Gnosjö Krokom Vingåker Stenungsund Grums Ovanåker Nacka Sandviken Habo Övertorneå Strängnäs Kävlinge Hagfors Gagnef Vadstena Borlänge Hammarö Skellefteå Hjo Tibro Höganäs Heby Lysekil Upplands-Bro Hörby Älvsbyn Nora Växjö Höör Leksand Åmål Alingsås Kil Emmaboda Älvkarleby Falkenberg Klippan Ljusdal Hallsberg Järfälla Lomma Mörbylånga Enköping Motala Mullsjö Arvika Hofors Halmstad Munkfors Kramfors Falun Söderköping Nykvarn Mora Vellinge Håbo Nynäshamn Sotenäs Ljusnarsberg Södertälje Osby Nordanstig Gislaved Sala Perstorp Karlsborg Grästorp Kumla Salem Tierp Gullspång Uddevalla Simrishamn Haparanda Torsås Kristianstad Sjöbo Tanum Svenljunga Boden Skurup Tranemo Ulricehamn Ronneby Piteå Värnamo Kungälv Storfors Dals-Ed Skinnskatteberg Kungsör Sunne Ockelbo Finspång Tyresö Svalöv Strömstad Herrljunga Bollnäs Svedala Säter Bollebygd Söderhamn Värmdö Nybro Falköping Sävsjö Bengtsfors Östersund Solna Tomelilla Vetlanda Sundsvall Borås Torsby Norberg Sölvesborg Karlstad Vaggeryd Hällefors Vårgårda Ängelholm Vaxholm Orust Uppsala Skövde Ydre Sollefteå Jönköping Skara Årjäng Åtvidaberg Lindesberg Lidköping Åstorp Orsa Markaryd Haninge Ödeshög Gotland Flen Sollentuna Örkelljunga Tjörn Hedemora Sigtuna Östra Göinge 0 10 20 30 40 0 10 20 30 40 0 10 20 30 40 0 10 20 30 40 Per cent SWEDEN 2011–2014 2007–2010
Values with fewer than 100 respondents are not presented. Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden. Participation in society 103
to avoid going out alone than men, but the differences be- tions relating to social participation and social support tween the sexes have decreased. The proportion who state [110]. With respect to interventions targeting the elderly, that they avoid going out is lowest among women with proactive activities from the municipality are mentioned post-secondary education, something which is, to some specifically. In the area of social relationships, the munici- extent, likely also a reflection of differences between dif- pality can also provide for a good residential environment ferent residential areas and the perception of them. that invites contact in public spaces such a play parks or other communal outdoor areas. The municipality’s work 28 . LACK OF TRUST IN OTHERS to combat bullying in schools and in workplaces is one Those who trust others are more likely to participate in so- further example of an intervention that can increase trust cial activities; something which in turn also contributes to being people in society. In addition, voluntary organisa- good health. Several studies have also demonstrated that tions also work proactively [19, 138, 139, 143]. a low level of trust in society is linked to an increased risk of ill-health. The degree of trust has played a key role in studies of social capital – a terms that can be defined and measured in various ways. Studies about the importance of social capital to health at the area level have proved increased risks of ill-health and mortality in residential 28.2 – , : I Individuals who stated areas that are characterised by a low level of trust in other that they generally cannot trust people. people [19, 138, 139, 143–145]. Per cent 50 There are large differences between both counties and between municipalities in the proportion who stated that 40 they generally cannot trust other people. The proportion is clearly highest in the youngest age groups, compared 30 to the other age groups. Individuals with post-secondary education are more likely to trust other people than indi- 20 viduals with a lower educational level. In the country as a whole, the level has been relatively stable for the past dec- 10 ade and there have been no major differences between the 0 sexes. 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 The Public Health Agency of Sweden produced a nation- Year 16–29 year 30–44 year 45–64 year 65–84 year al evidence base for the objective domain “Participation Source: Health on Equal Terms, Public Health Agency of Sweden. and influence in society” in 2011 that highlights interven-
28.1 – : Individuals who stated that they 28.3 – , : Individuals who stated that generally cannot trust people, 16–84 years old. they generally cannot trust people, 35–74 years old. Per cent 50 Per cent 50
40 40
30 30
20 20
10 10
0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year Total Women Men Year Pre-upper-secondary Upper-secondary Post-secondary Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden. Register of Education (UREG), Statistics Sweden. 104 Regional Comparisons 2014: Public Health
28.4 – , : Individuals who stated that they generally cannot trust people, 16–84 years old, 2011–2014.
Västerbotten 18 Gotland 21 Halland 22 Norrbotten 23 Jämtland 23 Dalarna 24 Kronoberg 25 Uppsala 25 Värmland 25 Västernorrland 26 Blekinge 26 Sörmland 26 Östergötland 26 SWEDEN 27 Stockholm 27 Västra Götaland 28 Gävleborg 28 Jönköping 28 Västmanland 29 Örebro 29 Kalmar 29 Skåne 31 0 10 20 30 40
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
28.5 – , : Individuals who stated that they generally cannot trust people, 16–84 years old, 2011–2014.
Västerbotten 19 Gotland 22 Kronoberg 22 Gävleborg 23 Västernorrland 23 Dalarna 23 Jönköping 23 Halland 25 Norrbotten 25 Kalmar 25 Västmanland 26 Uppsala 26 Stockholm 27 SWEDEN 27 Värmland 27 Örebro 27 Blekinge 27 Västra Götaland 28 Jämtland 29 Östergötland 30 Sörmland 30 Skåne 32 0 10 20 30 40 2011–2014 2007–2010 Per cent
Source: Health on Equal Terms, Public Health Agency of Sweden. Participation in society 105
F¡ 28.6 £ ¤¥¦§¨©ª¡«: Individuals who stated that they generally cannot trust people (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16£84 years old. Skåne (FHS), 18£80 years old.
Norsjö Alingsås Sigtuna Eskilstuna Vallentuna Härnösand Älvdalen Markaryd Öckerö Tyresö Alvesta Uppvidinge Tjörn Vimmerby Uddevalla Hultsfred Umeå Sollentuna Arboga Kävlinge Sotenäs Värmdö Ockelbo Österåker Skellefteå Dals-Ed Hylte Vindeln Upplands Väsby Strängnäs Olofström Vadstena Täby Hällefors Botkyrka Sorsele Sandviken Dorotea Torsås Borgholm Herrljunga Stockholm Ängelholm Gagnef Tanum Fagersta Södertälje Robertsfors Avesta Borlänge Sölvesborg Arvika Mora Örebro Norberg Kalix Vårgårda Vara Högsby Jokkmokk Lindesberg Boden Tomelilla Nordmaling Heby Hedemora Gislaved Gällivare Åtvidaberg Trollhättan Köping Piteå Säter Kumla Hässleholm Storuman Mölndal Järfälla Huddinge Knivsta Enköping Nora Ystad Nacka Mellerud Håbo Höör Krokom Uppsala Strömsund Sundbyberg Mörbylånga Västervik Laholm Trelleborg Vännäs Tranemo Överkalix Skurup Lidingö Vilhelmina Degerfors Hörby Östra Göinge Smedjebacken Hjo Oskarshamn Valdemarsvik Kristianstad Övertorneå Lilla Edet Surahammar Nässjö Bollebygd Lerum Laxå Eslöv Gotland Tibro Nordanstig Svalöv Ovanåker Östhammar Bjurholm Helsingborg Berg Vänersborg Askersund Sjöbo Orust Mark Tierp Bjuv Varberg Munkedal Färgelanda Örkelljunga Lysekil Falköping Ragunda Åstorp Götene Grästorp Älvkarleby Svedala Falun Gnesta Västerås Malmö Karlsborg Skövde Ljusnarsberg Bromölla Örnsköldsvik Arvidsjaur Lund Osby Vansbro Åsele Flen Burlöv Kungälv Finspång Haparanda Perstorp Tranås Töreboda Söderköping Landskrona Rättvik Åmål Gullspång Klippan Älvsbyn Mariestad Borås Aneby Strömstad Ljungby Halmstad Boxholm Leksand Kramfors Hudiksvall Eda Kungsbacka Nyköping Bollnäs Eksjö Trosa Sundsvall Hallstahammar Filipstad Ekerö Linköping Katrineholm Forshaga Vetlanda Oxelösund Karlshamn Gnosjö Härryda Norrtälje Vingåker Grums Malå Skara Emmaboda Habo Söderhamn Malung-Sälen Ånge Hagfors Stenungsund Lekeberg Karlskrona Hammarö Ulricehamn Kiruna Timrå Kil Karlskoga Bräcke Ale Kristinehamn Pajala Orsa Hallsberg Mullsjö Åre Lomma Göteborg Munkfors Lidköping Värnamo Simrishamn Nykvarn Kinda Svenljunga Båstad Nynäshamn Östersund Lycksele Solna Salem Luleå Hofors Nybro Storfors Växjö Skinnskatteberg Norrköping Sunne Kalmar Sollefteå Haninge Bengtsfors Mjölby Ludvika Sävsjö Älmhult Karlstad Höganäs Torsby Jönköping Danderyd Lessebo Upplands-Bro Essunga Tidaholm Mönsterås Vaggeryd Falkenberg Ljusdal Kungsör Vaxholm Arjeplog Gävle Ronneby Ydre Härjedalen Sala Motala Årjäng Partille Tingsryd Vellinge Ödeshög 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 Per cent SWEDEN ³HLV´ HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008
Values with fewer than 100 respondents are not presented. Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne. 106 Regional Comparisons 2014: Public Health
29 . PROBLEMS RELATING TO ISOLATION to be taken into account in the delivery of all elderly care AMONG THE ELDERLY services [146]. Social activities play an important role in Involuntary isolation is a growing problem in Sweden. well-being and they can increase the sense of belonging Older people are particularly vulnerable and perceive a and meaningfulness. This may involve someone having greater risk of isolation and exclusion, which in turn has a contact with staff, being able to go outdoors and undertak- detrimental impact on their health. Involuntary isolation ing activities that they find agreeable. among the elderly can also be related to physical limita- Social activities such as going outdoors and physical ac- tions such as difficulty moving about outside the home tivity can also improve sleep and appetite and reduce the due to poor health. In addition, involuntary isolation risk of osteoporosis. Elderly care services can have an im- can increase the risk of depression and other physical ill- pact on the outcome by working with, for example, social nesses, give rise to risky alcohol consumption and poorer activities and through adapting support to the individual eating habits. In order to combat such a development, so- to a greater extent. This can contribute to minimising old- ciety should use various means to offer social connections er people’s sense of isolation. that contribute to creating content and meaning for older The National Board of Health and Welfare’s national people who feel isolated. survey is targeted at people over the age of 65 who receive Elderly care is based on fundamental values that imply home-help services or live in sheltered accommodation. the elderly are to be able to choose when and how support However, the data presented in this report only concerns and assistance at home will be provided. This is based on elderly people receiving home-help services. Chapter 5, Section 4 of the Social Services Act (2001:453), In general, it can be concluded that there are somewhat which, in summary, implies that older people are to be fewer women than men who state they feel isolated and able to live a dignified life and feel a sense of well-being. that the results differ very little from the previous meas- The National Board of Health and Welfare’s general ad- urement period. Nevertheless, there are differences be- vice about the fundamental values emphasises safety and tween both counties and between municipalities. meaningful relationships, and the fundamental values are Participation in society 107
29.1 – , : Individuals who answered yes to the question “Do you ever suer from loneliness?”, among elderly over 65 who have home care from the social service in the municipality, 2014.
Jämtland 52 Västmanland 55 Västerbotten 55 Uppsala 55 Stockholm 56 Sörmland 56 Dalarna 57 Västernorrland 57 Halland 57 Västra Götaland 57 SWEDEN 58 Östergötland 58 Gävleborg 58 Norrbotten 58 Gotland 59 Skåne 60 Jönköping 60 Örebro 61 Blekinge 62 Värmland 62 Kronoberg 63 Kalmar 63 0 20 40 60 80 100 2014 2013 Per cent Source: Vad tycker de äldre om äldreomsorgen? [What do the elderly think about geriatric care?], the National Board of Health and Welfare.
29.2 – , : Individuals who answered yes to the question “Do you ever suer from loneliness?”, among elderly over 65 who have home care from the social service in the municipality, 2014.
Jämtland 48 Stockholm 48 Halland 48 Uppsala 48 Västra Götaland 49 Sörmland 49 Västerbotten 49 Västernorrland 49 Västmanland 49 Gävleborg 49 SWEDEN 50 Blekinge 51 Dalarna 51 Värmland 51 Jönköping 52 Norrbotten 52 Skåne 52 Östergötland 52 Kronoberg 53 Örebro 55 Kalmar 55 Gotland 57 0 20 40 60 80 100
2014 2013 Per cent Source: Vad tycker de äldre om äldreomsorgen? [What do the elderly think about geriatric care?], the National Board of Health and Welfare. 108 Regional Comparisons 2014: Public Health
F¡ 29.3 £ ¤¥¦§¨©ª¡«: Individuals who answered yes to the question “Do you ever su±er from loneliness?”, among elderly over 65 who have home care, social service interventions for elderly in the municipality, 2014.
Skinnskatteberg Gävle Malung-Sälen Arvidsjaur Vännäs Partille Strömsund Kristinehamn Trosa Älvdalen Östhammar Uddevalla Nordanstig Strängnäs Götene Hällefors Vallentuna Gislaved Lund Ljusnarsberg Norrtälje Falun Vimmerby Olofström Habo Katrineholm Vadstena Ronneby Täby Kungsbacka Svenljunga Åmål Bräcke Ängelholm Motala Mörbylånga Aneby Gnosjö Ragunda Tranemo Munkedal Umeå Avesta Landskrona Markaryd Tjörn Upplands Väsby Älmhult Vindeln Håbo Skurup Karlstad Nacka Bengtsfors Torsby Västervik Huddinge Borlänge Borgholm Klippan Heby Ödeshög Karlsborg Trelleborg Valdemarsvik Ystad Mölndal Vingåker Lidingö Nyköping Örkelljunga Rättvik Söderköping Mjölby Haparanda Hofors Sunne Hammarö Tingsryd Sotenäs Åre Knivsta Jönköping Växjö Vårgårda Ljusdal Solna Östra Göinge Tanum Tomelilla Ale Orust Ånge Botkyrka Dorotea Perstorp Storuman Forshaga Härjedalen Örnsköldsvik Tranås Båstad Ludvika Boden Norrköping Dals-Ed Tyresö Skellefteå Mark Karlshamn Kiruna Askersund Sala Uppvidinge Laholm Borås Hässleholm Lilla Edet Höganäs Vellinge Pajala Orsa Krokom Danderyd Bollnäs Hagfors Kävlinge Sundsvall Härryda Nynäshamn Nykvarn Arboga Linköping Lysekil Ockelbo Svalöv Kalmar Oskarshamn Salem Vaxholm Sandviken Arvika Smedjebacken Vilhelmina Kalix Vetlanda Östersund Härnösand Skara Nässjö Österåker Berg Kil Bromölla Alingsås Eda Herrljunga Kumla Flen Ulricehamn Sölvesborg Södertälje Hallstahammar Varberg Timrå Munkfors Sollentuna Helsingborg Mullsjö Vara Nordmaling Åstorp Trollhättan Osby Lerum Älvkarleby Sjöbo Robertsfors Eksjö Finspång Hallsberg Lidköping Årjäng Malmö Högsby Gullspång Stockholm Gotland Fagersta Piteå Karlskrona Kristianstad Bjurholm Surahammar Eskilstuna Oxelösund Hörby Ydre Halmstad Gnesta Nybro Enköping Hylte Lessebo Simrishamn Leksand Stenungsund Kramfors Degerfors Kungälv Skövde Mariestad Lindesberg Svedala Tibro Värnamo Emmaboda Köping Bollebygd Bjuv Strömstad Sundbyberg Överkalix Burlöv Grästorp Haninge Alvesta Färgelanda Storfors Grums Lomma Ovanåker Norberg Nora Säter Eslöv Ljungby Sollefteå Örebro Gagnef Vansbro Töreboda Hudiksvall Övertorneå Essunga Åsele Sävsjö Luleå Hultsfred Falköping Åtvidaberg Torsås Höör Upplands-Bro Mora Älvsbyn Vaggeryd Västerås Hjo Mellerud Norsjö Ekerö Falkenberg Filipstad Laxå Uppsala Vänersborg Söderhamn Jokkmokk Järfälla Värmdö Tierp Boxholm Tidaholm Sigtuna Karlskoga Arjeplog Kungsör Gällivare Lycksele Kinda Lekeberg Mönsterås Malå Göteborg Öckerö Hedemora Sorsele 0 25 50 75 100 0 25 50 75 100 0 25 50 75 100 0 25 50 75 100 Per cent SWEDEN 2014 2013 1 Fewer than 30 respondents. 2 Fewer than 30 respondents, 2013.
Source: Vad tycker de äldre om äldreomsorgen? [What do the elderly think about social care for elderly in the municipality?], the National Board of Health and Welfare. Participation in society 109
DOMESTIC VIOLENCE government agencies and voluntary organisations, as well Domestic violence in this context implies any form of as the loss of production, amount to at least SEK 2.5 billion physical, sexual, psychological or honour related violence per year [125]. which concerns members of the household or persons This report looks at two indicators related to domes- otherwise connected through a specified intimate rela- tic violence that are taken from regional comparisons of tionship. Violence is committed by both women and men, municipalities support for victims of crime. The first in- but women are more likely to be the victims of domestic dicator studies the incidence of surveys concerning the violence and the perpetrator is usually a man [147, 148]. extent of violence against adults in the municipalities, Domestic violence is rarely reported to the police. A study while the second measures the incidence of current agree- from the Swedish National Council for Crime Prevention ments concerning collaboration between social services (BRÅ) indicates that about 4 per cent of those who were for youth and adolescent, preschools and schools in the victims of domestic violence in 2012 reported this to the municipalities. police [149]. In addition, few make contact with any form The National Board of Health and Welfare’s general ad- of support organisation. Only 7.0 per cent of women and vice (SOSFS 2014:4) states that the municipality should sur- 3.5 per cent of men who fall victim to domestic violence vey the extent of the problem of violence against women have made contact with social services because of the vio- and of children who have witnessed violence. By doing so lence [149]. The combination of there being so few people the municipality can see whether the interventions used who report domestic violence and few who are reached by meet the needs of the target group [154]. A survey of the the support available means that further stakeholders than municipalities in conjunction with regional comparisons simply the police or social services are needed in order to of support to victims of crime in 2013 included a question reduce the violence and support the victims, the perpetra- concerning whether the municipality surveyed the extent tors and those who are affected by domestic violence. of the problem of violence against adults. This process can involve collecting information from women’s refuges, the 30 . SURVEYING AND COLLABORATION police, schools and the healthcare system that gives an in- Women and men who are the victims of violence are dication of the extent of violence in the municipality. in danger of being affected by a range of consequences Few make contact with social services because of do- that have an impact on their health, with post-traumatic mestic violence [149], which means social services also stress disorder, depression, self-harming, risky use of al- need to work with other stakeholders [148]. Furthermore, cohol and impaired physical health being some common social services’ interventions reach even fewer and com- examples [12, 20, 150]. The health consequences are also plementary interventions from other organisations are serious for children who are often at risk of developing also required. Preschools and schools are important post-traumatic stress disorder, behavioural problems and partners as they have the opportunity to detect children problems in their relationships with others. In addition, who are being harmed. Written procedures concerning there is a risk of them becoming worried, restless and hav- collaboration with these can provide support to staff. A ing difficulties in school, which can itself lead to ill-health stable and effective partnership between social services, [151]. There is also an increased risk of them becoming the preschools and schools is dependent on governance from victims of violence as adults [150]. senior management and a good structure that prevents Among women, the violence can also contribute to barriers. This structure can consist of written contracts or long periods of sick leave [152]. The health consequences agreements with clarifications of who does what, when are more serious for women, compared to the domestic and how. These agreements can also involve the providers violence to which men in heterosexual relationships are who looks after children placed in residential care homes subjected [147, 149, 150]. The gender differences are even in collaborating with schools, or ensuring children have more considerable when it comes to deadly violence – the opportunity to complete their schooling while living women are four to five times more likely to be killed by in protected accommodation. If collaboration is to func- their partner or ex-partner than men [20]. Domestic vio- tion, there needs to be a clear division of responsibility lence also has financial consequences for society as the and a clear mission [155]. costs for municipalities, the healthcare system, central 110 Regional Comparisons 2014: Public Health
In conjunction with regional comparisons of social Municipalities, county councils and voluntary organi- services for youth and adolescent municipalities had to sations have an important role when it comes to domestic respond to survey questions concerning the existence violence. This involves everything from being attentive to of such agreements with external stakeholders (e.g. pre- the problem of domestic violence and providing clear in- schools and schools) at the senior management level formation about the initiatives available in order to ensure in individual cases, as well as to state whether they had that all families receive the support they need. The follow- monitored these agreements. In order for the agreements ing areas for development are among those that appear in to count as current, the answer to both questions had to regional comparisons of support provided to victims of be “yes”. crime 2014: The results indicate that just under half of the munici- • using the opinions of victims of violence in order to de- palities (49 per cent) surveyed the extent of the problem of velop services violence against adults in the municipality at some point • implementing systematic monitoring of interventions in the past two years. This figure was 31 per cent at the time for victims of violence and children who have witnessed of the previous measurement in 2012. However, this only violence covered violence against women, which is why the results • drawing up procedures for ensuring children in protect- are not completely comparable. ed accommodation can go to school With respect to the question concerning agreements • drawing up procedures for detecting violence and sup- with external stakeholders, the results show that a total of porting victims of violence in services for the elderly and 60 per cent of the country’s municipalities have a current people with disabilities agreement with both preschools and schools. • offering information about where to obtain support in The proportion of municipalities that both survey the different languages and in alternative formats. extent of the problem of violence against adults and also have a current agreement with preschools and schools in the specific case of violence amounts to 40 per cent. Participation in society 111
30.1 - municipalities: Domestic violence, the social service in the municipalities answered questions regarding mapping and collaboration with external stakeholders: 1. Domestic violence, the social service in the municipalities answered questions regarding mapping and collaboration with external stakeholders: 2. The social service for children and youth have through agreements cooperated in individual cases together with preschool and schools (has followed up a written agreement adopted at management level and established on 1 November 2012 - 1 November 2013).
Municipality 1. 2. Municipality 1. 2. Municipality 1. 2. Municipality 1. 2. Upplands Väsby Yes No Vetlanda No Yes Munkedal Skinnskatteberg No No Vallentuna Yes Yes Eksjö No Yes Tanum No Yes Surahammar Yes No Österåker No No Tranås No Yes Dals-Ed No Yes Kungsör No No Värmdö Yes No Uppvidinge No Färgelanda Hallstahammar Yes Yes Järfälla No Yes Lessebo No No Ale Yes Yes Norberg Yes No Ekerö No No Tingsryd No Yes Lerum No Yes Västerås No Yes Huddinge Yes Yes Alvesta Yes No Vårgårda Yes Sala No Yes Botkyrka Yes Yes Älmhult No No Bollebygd No Yes Fagersta Yes Yes Salem No No Markaryd Yes Yes Grästorp No Yes Köping Yes Yes Haninge Yes Yes Växjö No Yes Essunga No Yes Arboga No Yes Tyresö No Yes Ljungby No No Karlsborg No No Vansbro No * Upplands-Bro No No Högsby No Gullspång Yes Yes Malung-Sälen No Yes Nykvarn No Yes Torsås No Yes Tranemo Yes Yes Gagnef Yes No Täby No No Mörbylånga No No Bengtsfors No No Leksand No Yes Danderyd Yes Yes Hultsfred No Mellerud No Rättvik No No Sollentuna Yes Yes Mönsterås No No Lilla Edet Yes Yes Orsa No No Stockholm Emmaboda No Yes Mark No Yes Älvdalen No No Rinkeby-Kista Yes Yes Kalmar No Yes Svenljunga Yes Smedjebacken No Yes Spånga-Tensta No No Nybro Yes Yes Herrljunga Yes Mora No No Hässelby Yes No Oskarshamn No Yes Vara Yes No Falun Yes No Bromma Yes Yes Västervik No No Götene No No Borlänge Yes Kungsholmen Yes No Vimmerby Yes No Tibro Yes Yes Säter Yes No Norrmalm Yes Yes Borgholm No No Töreboda Yes No Hedemora No Östermalm Yes Yes Gotland Yes No Göteborg Avesta No No Södermalm Yes Yes Olofström Yes Yes Angered Yes Yes Ludvika Yes No Enskede-Årsta-Vantör No Yes Karlskrona No Yes Östra Göteborg Yes Yes Ockelbo Yes Yes Skarpnäck Yes No Ronneby Yes Yes Örgryte-Härlanda Yes Yes Hofors No No Farsta No No Karlshamn No Yes Centrum Yes No Ovanåker Yes Yes Älvsjö Yes Sölvesborg No No Majorna-Linné Yes Yes Nordanstig Yes No Hägersten-Liljeholmen No No Svalöv Yes Yes Askim-Frölunda-Högsbo Yes Yes Ljusdal Yes No Skärholmen Yes Yes Staffanstorp Yes No Västra Göteborg No Yes Gävle No No Södertälje No Yes Burlöv No No Västra Hisingen Yes Yes Sandviken Yes Yes Nacka Yes No Vellinge Lundby Yes No Söderhamn Yes No Sundbyberg No Yes Östra Göinge No No Norra Hisingen No Yes Bollnäs No Yes Solna Yes No Örkelljunga Yes Yes Mölndal Yes Yes Hudiksvall Yes Yes Lidingö Yes No Bjuv * Kungälv No Ånge No * Vaxholm No No Kävlinge Yes Yes Lysekil No No Timrå No Yes Norrtälje Yes No Lomma No No Uddevalla Yes Yes Härnösand Yes No Sigtuna Yes Yes Svedala Yes Strömstad Yes Yes Sundsvall Yes No Nynäshamn Yes Yes Skurup Yes Vänersborg Yes Yes Kramfors Yes Yes Håbo Yes No Sjöbo Yes Yes Trollhättan Yes Yes Sollefteå Yes Yes Älvkarleby No No Hörby Yes Yes Alingsås Yes No Örnsköldsvik Yes No Knivsta No No Höör No No Borås Yes Yes Ragunda No No Heby No Tomelilla Yes No Ulricehamn No Yes Bräcke No No Tierp No No Bromölla Yes No Åmål No Yes Krokom No No Uppsala Yes Yes Osby No Yes Mariestad No No Strömsund No No Enköping Yes No Perstorp No No Lidköping Yes Yes Åre No No Östhammar Yes Klippan No Skara No No Berg Yes No Vingåker No Yes Åstorp Yes Yes Skövde No Yes Härjedalen Yes Yes Gnesta Yes Yes Båstad No Yes Hjo No No Östersund Yes Yes Nyköping No Yes Malmö Tidaholm Yes Nordmaling Yes No Oxelösund Yes Yes Innerstaden Yes No Falköping Yes Yes Bjurholm Yes * Flen No No Norr Yes No Kil No No Vindeln No No Katrineholm Yes Yes Söder No No Eda Robertsfors No No Eskilstuna No No Väster No No Torsby No No Norsjö Yes No Strängnäs Yes Yes Öster Yes No Storfors No Malå No Yes Trosa Yes No Lund Yes Yes Hammarö Yes Storuman No Yes Ödeshög No No Landskrona No Munkfors No No Sorsele No Ydre No Helsingborg No Yes Forshaga No Yes Dorotea * Kinda Höganäs Yes Yes Grums Yes Yes Vännäs Yes Yes Boxholm No No Eslöv Yes Årjäng No No Vilhelmina No No Åtvidaberg Yes Yes Ystad Yes Yes Sunne No Åsele No Finspång No Yes Trelleborg No Yes Karlstad Yes Yes Umeå No No Valdemarsvik Kristianstad Yes No Kristinehamn Yes Yes Lycksele No Yes Linköping Yes No Simrishamn Yes No Filipstad No Yes Skellefteå Yes Yes Norrköping No Yes Ängelholm No No Hagfors Yes Yes Arvidsjaur No Yes Söderköping No No Hässleholm Yes Yes Arvika No Yes Arjeplog Yes Motala Yes No Hylte No Säffle No No Jokkmokk Yes No Vadstena No Yes Halmstad Yes No Lekeberg No No Överkalix No Yes Mjölby Yes Laholm Yes Yes Laxå No No Kalix No Yes Aneby No Yes Falkenberg No No Hallsberg No No Övertorneå No Gnosjö Yes Yes Varberg Yes No Degerfors No Yes Pajala Yes Yes Mullsjö Yes Yes Kungsbacka No Yes Hällefors No No Gällivare No No Habo Yes Yes Härryda No Yes Ljusnarsberg No Älvsbyn Yes Gislaved Yes Yes Partille Yes Örebro Yes Yes Luleå Yes Yes Vaggeryd Yes Yes Öckerö No Yes Kumla No No Piteå Yes Yes Jönköping Yes Yes Stenungsund Yes Yes Askersund No No Boden Yes Nässjö No Yes Tjörn No Yes Karlskoga No Yes Haparanda No Värnamo Yes Yes Orust Yes No Nora Yes Kiruna Yes Yes Sävsjö Yes Yes Sotenäs No No Lindesberg Yes No
* Not applicable if the operations are conducted by the same manager. Source: Open comparisons - Crime victim, the National Board of Health and Welfare. 112 Regional Comparisons 2014: Public Health
Lifestyle and living habits
Lifestyle and living habits deals with specific human be- 31 . SEDENTARY LEISURE TIME haviours in everyday activities over which the individual New research shows that being sedentary is in itself a risk themselves has an influence, for example eating habits, factor for several diseases [12]. According to the WHO, physical activity, tobacco and alcohol use and sleeping physical inactivity is the fourth most important risk factor and sexual habits. Society can also create favorable condi- for premature death and plays a major role in the increas- tions in which individuals can themselves influence the ing global incidence of non-infectious diseases [156]. It is choices they make concerning their own lifestyle habits. primarily the level of activity during leisure time and the Lifestyle habits are affected by social conditions and living quality of that leisure time that has been shown to be im- conditions [1, 2]. portant to how people feel with respect not only to physi- cal capacity and general health, but also to general health PHYSICAL ACTIVITY and social capacity, emotional and mental health [157]. A Physical activity is used as a generic term and encompass- common recommendation is 30 minutes of physical activ- es body movements during both work and recreation and ity per day. various forms of physical activity, for example sport, play, gymnastics, exercise and outdoor activities. It can also be said that physical activity is a health factor, while physical 31.1 – : Individuals who stated that they have a inactivity is a risk factor. However, it is entirely possible to sedentary leisure time when asked “How much have you moved about and exerted yourself physically in your leisure time during achieve the recommended minimum of 30 minutes’ mod- the past 12 months?”, 16–84 years old. erate physical exertion at the same time as being highly Per cent sedentary. 25 The “bone bank” that children and adolescents build 20 up in their skeletons has a great deal of importance later in life. The bone bank is built up through physical activ- 15 ity and loading and part of this activity can be made up of
sport. Physical activity in leisure time has become increas- 10 ingly important as our work has become increasingly sed- entary. 5
0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year Total Women Men
Source: Health on Equal Terms, Public Health Agency of Sweden. Lifestyle and living habits 113
31.2 – , : Individuals who stated that 31.3 – : : Individuals who stated that they have a sedentary leisure time when asked “How much have they have a sedentary leisure time when asked “How much have you moved about and exerted yourself physically in your leisure you moved about and exerted yourself physically in your leisure time during the past 12 months?”, 2014. time during the past 12 months?”, 35–74 years old, 2014.
Per cent Per cent 25 25
20 20
15 15
10 10
5 5
0 0 Women Men Women Men 16–29 year 30–44 year 45–64 year 65–84 year Pre-upper-secondary Upper-secondary Post-secondary
Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden. Register of Education (UREG), Statistics Sweden.
It is important to take into account people’s varying cir- Sedentary leisure time is most common among those cumstances when society’s public, private and voluntary with a low educational level stakeholders design environments and organise services The proportion who state they have a sedentary leisure [158]. Promoting older people’s opportunities to take part time has not changed appreciably between the measure- in daily activity and go outdoors is vital. This can be done ment periods 2007 and 2014, but there are regional and by working together with citizens to plan easily acces- local variations. Among women, sedentary leisure time sible green spaces close to housing. Municipalities and is commonest in the oldest age group, while, for men, county councils also have a responsibility as employers the age group 45–64 years contains the highest propor- to encourage opportunities for physical activity among tion who are inactive in their leisure time. The proportion their employees, which may involve activities both dur- whose leisure time is sedentary has been around 12–14 per ing and outside of working hours. The national guidelines cent since 2004. A sedentary leisure time is more com- for methods of preventing disease recommends advisory mon among individuals with a low educational level than discussions and written prescriptions of physical activity among those with a higher educational level. and/or the use of step counters. These measures have been shown to be effective [55, 159]. 114 Regional Comparisons 2014: Public Health
31.4 – , : Individuals who stated that they have a sedentary leisure time when asked “How much have you moved about and exerted yourself physically in your leisure time during the past 12 months?”, 16–84 years old, 2011–2014.
Jämtland 8 Halland 9 Jönköping 10 Värmland 10 Dalarna 10 Västerbotten 11 Gotland 11 Örebro 11 Kalmar 12 Norrbotten 12 Kronoberg 12 Västmanland 12 Uppsala 12 Sörmland 13 SWEDEN 13 Östergötland 13 Västra Götaland 14 Blekinge 14 Stockholm 14 Skåne 14 Gävleborg 15 Västernorrland 15 0 5 10 15 20 25
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
31.5 – , : Individuals who stated that they have a sedentary leisure time when asked “How much have you moved about and exerted yourself physically in your leisure time during the past 12 months?”, 16–84 years old, 2011–2014.
Sörmland 10 Kronoberg 10 Kalmar 11 Gävleborg 11 Västerbotten 12 Gotland 12 Uppsala 12 Skåne 12 Dalarna 13 Halland 13 Värmland 13 Jönköping 14 Västra Götaland 14 SWEDEN 14 Norrbotten 14 Västernorrland 15 Östergötland 15 Örebro 16 Västmanland 16 Stockholm 16 Jämtland 17 Blekinge 18 0 5 10 15 20 25
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. Lifestyle and living habits 115
¡ 31.6 £ ¤¥¦§¨©ª¡«: Individuals who stated that they have a sedentary leisure time when asked “How much have you moved about and exerted yourself physically in your leisure time during the past 12 months?” (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16£84 years old. Skåne (FHS), 18£80 years old.
Arvika Gullspång Surahammar Klippan Österåker Laholm Vindeln Helsingborg Lomma Lycksele Mjölby Högsby Borgholm Valdemarsvik Askersund Mönsterås Växjö Älmhult Sandviken Ludvika Krokom Vilhelmina Motala Lilla Edet Karlstad Västerås Åmål Haparanda Kalmar Tranemo Håbo Heby Lund Älvdalen Dorotea Gislaved Rättvik Tjörn Lessebo Finspång Tibro Stenungsund Skurup Borås Åre Oskarshamn Osby Ale Höganäs Sundsvall Arboga Kumla Vallentuna Kungälv Piteå Jokkmokk Öckerö Gävle Mölndal Övertorneå Ängelholm Tierp Härnösand Norberg Falun Mark Uppvidinge Eslöv Västervik Orust Markaryd Nordanstig Alingsås Örebro Skara Örkelljunga Kungsbacka Strömsund Landskrona Sollefteå Båstad Enköping Höör Sjöbo Emmaboda Svenljunga Sölvesborg Hallsberg Norsjö Katrineholm Dals-Ed Sala Uppsala Strömstad Östra Göinge Eskilstuna Lidköping Vårgårda Berg Tingsryd Trosa Herrljunga Ronneby Skinnskatteberg Mora Vimmerby Arjeplog Smedjebacken Fagersta Kävlinge Karlskoga Trollhättan Flen Karlsborg Danderyd Gagnef Hudiksvall Ljungby Lekeberg Lysekil Olofström Ystad Ljusnarsberg Nybro Åsele Leksand Vingåker Laxå Åstorp Östhammar Överkalix Köping Perstorp Lerum Skellefteå Malå Arvidsjaur Götene Örnsköldsvik Torsås Burlöv Ulricehamn Hjo Boden Upplands Väsby Falköping Ovanåker Svalöv Tomelilla Umeå Borlänge Mellerud Kungsör Vadstena Östersund Sollentuna Huddinge Knivsta Vännäs Ånge Sundbyberg Värmdö Hallstahammar Kiruna Södertälje Tyresö Partille Bengtsfors Bjuv Mariestad Bromölla Ekerö Botkyrka Hylte Lindesberg Vara Upplands-Bro Hultsfred Gotland Avesta Aneby Härjedalen Orsa Simrishamn Boxholm Halmstad Härryda Haninge Eda Säter Sotenäs Ockelbo Eksjö Tranås Tidaholm Malmö Filipstad Lidingö Hällefors Ragunda Forshaga Uddevalla Hedemora Älvsbyn Gnosjö Vetlanda Luleå Kramfors Grums Värnamo Nacka Norrtälje Habo Karlshamn Bräcke Vansbro Hagfors Gnesta Trelleborg Pajala Hammarö Tanum Munkedal Ljusdal Kil Sorsele Töreboda Alvesta Kristinehamn Sigtuna Åtvidaberg Älvkarleby Mullsjö Mörbylånga Nordmaling Norrköping Munkfors Söderköping Stockholm Degerfors Nykvarn Vänersborg Storuman Järfälla Nynäshamn Jönköping Bjurholm Essunga Salem Falkenberg Karlskrona Kalix Storfors Nässjö Bollnäs Göteborg Sunne Linköping Söderhamn Hofors Vellinge Kristianstad Svedala Sävsjö Nyköping Strängnäs Gällivare Torsby Solna Kinda Oxelösund Vaggeryd Täby Grästorp Hörby Vaxholm Bollebygd Nora Hässleholm Ydre Skövde Robertsfors Malung-Sälen Årjäng Varberg Färgelanda Timrå Ödeshög 0 10 20 30 40 0 10 20 30 40 0 10 20 30 40 0 10 20 20 40 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008
Values with less than 100 respondents are not presented. Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne. 116 Regional Comparisons 2014: Public Health
32 . REGULAR PHYSICAL ACTIVITY FOR AT [160]. FaR® has also been shown to have the same degree LEAST HALF AN HOUR PER DAY of compliance among patients as other long-term treat- Regular physical activity is a health factor and has been ments, but there needs to be support and interventions in shown to combat the emergence of a large number of a number of areas in the FaR® concept. For example, this diseases such as cardiovascular disease, type 2 diabetes, involves expanding the training of qualified staff, develop- hypertension, high cholesterol, bowel cancer and also de- ing information and discussion techniques for prescribers pression [53]. Physical activity also has a major importance and stimulating the monitoring of FaR® patients. The tar- in combating overweight and obesity, strengthening the get group for this assignment is broad as the entire chain muscles, joints and immune system, as well as relieving of FaR® is to be illuminated. The care chain encompasses anxiety, worry and sleep disturbances. Physical activity such groups as prescribers within the county council, dis- also reduces the risk of death [55, 160]. Physical activity trict sports associations, activity organisers and patients should be undertaken regularly and feel mildly strenuous [160]. [157]. It is primarily the level of activity during leisure time and the quality of that leisure time that has been shown to be important to how people feel with respect to not 32.1 – : Regular physical activity – individuals who answers two questions, how much they estimate to be only physical capacity and general health, but also general engaged in 30 minutes of moderately strenuous activity a day health and social capacity, emotional and mental health. (3.5 hours per week), 16–84 years old. A common recommendation is 30 minutes of physical Per cent activity per day [158]. Specially adapted conditions can be 80 created for daily physical activity through dialogue with citizens, for example in childcare services and schools. It 70 is important to design school playgrounds and play parks
so that they are safe environments that encourage play and 60 movement. Schools have to encourage their pupils to be healthy and school health services are responsible for pre- 50 ventative work that takes place in schools [161]. FYSS 2008 is a source of information summarising the
extent to which physical activity can be used to prevent 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 and treat various illnesses. Research indicates that pre- Year scribing physical activity on prescription (fysisk aktiv- Total Women Men itet på recept, FaR®) increases patients’ physical activity Source: Health on Equal Terms, Public Health Agency of Sweden. Lifestyle and living habits 117
Municipalities and county councils also have a respon- 32.3 – : : Regular physical activity – sibility as employers to encourage opportunities for physi- individuals who answers two questions, how much they estimate to be engaged in 30 minutes of moderately strenuous activity a cal activity among their employees. It is also possible to day (3.5 hours per week), 35–74 years old, 2014. read about this in the national guidelines for methods of Per cent preventing disease [55] in the section on physical activity 80 and sedentary lifestyle habits. 70 It is difficult to estimate the degree of physical activity 60 in a population. The indicator shows an estimate, based 50 on responses to two questions, of the proportion who achieve an average of 30 minutes’ moderately strenuous 40 physical activity per day, in line with what is commonly 30 recommended. However, it is not possible on the basis 20 of the response options available to draw an exact limit 10 as these contain a mixture of intensity, volume and fre- 0 quency. The assessment of the response options available Women Men is consistent, but there is the potential for individuals to Pre-upper-secondary Upper-secondary Post-secondary be assigned to the wrong categories. Source: Health on Equal Terms, Public Health Agency of Sweden. Register of Education (UREG), Statistics Sweden.
Men with a high educational level exercise most 32.2 – , : Regular physical activity – individuals who answers two questions, how much they estimate The proportion who state that they are physically active to be engaged in 30 minutes of moderately strenuous activity a (measured as at least 30 minutes per day) is basically un- day (3.5 hours per week). changed over the course of the period 2007 to 2014, but Per cent 80 there are regional and local variations. The proportion who are physically active has been around 65 per cent since 2004 among both women and men. The lowest 70 proportion is found among women with only pre-upper- secondary education. The proportion who state they are 60 physically active is highest in the younger age groups and then declines. There are differences between the educa-
50 tional groups to the advantage of those who have a high educational level.
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year 16–29 year 30–44 year 45–64 år 65–84 year
Source: Health on Equal Terms, Public Health Agency of Sweden. 118 Regional Comparisons 2014: Public Health
32.4 – , : Regular physical activity – individuals who answers two questions, how much they estimate to be engaged in 30 minutes of moderately strenuous activity a day (3.5 hours per week), 16–84 years old, 2011–2014.
Kalmar 70 Jämtland 69 Halland 68 Kronoberg 67 Gotland 66 Västmanland 66 Västerbotten 66 Dalarna 65 Värmland 65 Stockholm 65 Jönköping 65 Östergötland 64 SWEDEN 64 Skåne 64 Uppsala 64 Västra Götaland 63 Norrbotten 63 Gävleborg 62 Sörmland 62 Örebro 61 Blekinge 61 Västernorrland 61 0 20 40 60 80 100
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
32.5 – , : Regular physical activity – individuals who answers two questions, how much they estimate to be engaged in 30 minutes of moderately strenuous activity a day (3.5 hours per week), 16–84 years old, 2011–2014.
Halland 70 Kronoberg 70 Skåne 69 Sörmland 69 Gotland 68 Kalmar 68 Dalarna 68 Västerbotten 68 Blekinge 68 Norrbotten 67 Västra Götaland 67 SWEDEN 67 Stockholm 66 Värmland 66 Östergötland 65 Jämtland 65 Västmanland 65 Uppsala 65 Gävleborg 65 Jönköping 64 Västernorrland 64 Örebro 64 0 20 40 60 80 100
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. Lifestyle and living habits 119
F¡ 32.6 £ ¤¥¦§¨©ª¡«: Regular physical activity £ individuals who answers two questions, how much they estimate to be engaged in 30 minutes of moderately strenuous activity a day (3.5 hours per week), (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16£84 years old. Skåne (FHS), 18£80 years old.
Växjö Karlsborg Hässleholm Vellinge Hjo Mariestad Arboga Kävlinge Halmstad Norsjö Hallsberg Värmdö Borlänge Haninge Ånge Lomma Eslöv Vara Smedjebacken Ystad Kristianstad Trollhättan Gällivare Borgholm Storuman Tranås Gislaved Östra Göinge Östersund Hultsfred Sjöbo Kalmar Sorsele Tierp Grästorp Knivsta Mölndal Bollnäs Lilla Edet Höganäs Tjörn Landskrona Vaggeryd Åre Stockholm Kiruna Robertsfors Vetlanda Båstad Karlskoga Söderhamn Lund Höör Vimmerby Nordanstig Kungsbacka Västervik Piteå Perstorp Valdemarsvik Ulricehamn Ale Sollefteå Lerum Bollebygd Nora Mönsterås Härryda Falkenberg Oskarshamn Åstorp Leksand Härnösand Säter Ovanåker Falun Burlöv Skövde Älvsbyn Öckerö Askersund Sollentuna Upplands Väsby Arvika Flen Nordmaling Fagersta Berg Värnamo Borås Kramfors Rättvik Mörbylånga Boden Haparanda Solna Lessebo Tyresö Mjölby Ängelholm Luleå Torsås Osby Hallstahammar Bromölla Västerås Heby Övertorneå Huddinge Vallentuna Uddevalla Ljusnarsberg Ludvika Sundbyberg Karlskrona Degerfors Åtvidaberg Uppsala Vindeln Tibro Malå Lidingö Strängnäs Tidaholm Oxelösund Markaryd Simrishamn Älvdalen Åsele Tanum Mark Nybro Ragunda Helsingborg Ockelbo Gullspång Surahammar Mora Sigtuna Lindesberg Hudiksvall Hällefors Härjedalen Enköping Norberg Laholm Sölvesborg Jokkmokk Kumla Falköping Färgelanda Svedala Laxå Tranemo Gävle Gagnef Timrå Kungälv Arjeplog Lysekil Söderköping Varberg Vilhelmina Nyköping Dals-Ed Östhammar Motala Essunga Bjuv Nacka Stenungsund Överkalix Arvidsjaur Älmhult Karlshamn Lekeberg Älvkarleby Kristinehamn Österåker Sandviken Botkyrka Vansbro Uppvidinge Skara Upplands-Bro Vingåker Alvesta Kungsör Aneby Svalöv Sala Trelleborg Boxholm Täby Håbo Finspång Eda Karlstad Norrtälje Strömsund Eksjö Hedemora Malung-Sälen Olofström Filipstad Sundsvall Åmål Katrineholm Forshaga Gotland Sotenäs Högsby Gnosjö Svenljunga Nässjö Hofors Grums Ekerö Hylte Avesta Habo Järfälla Lidköping Töreboda Hagfors Orsa Örebro Bräcke Hammarö Krokom Munkedal Mellerud Kil Malmö Skellefteå Kalix Mullsjö Emmaboda Ronneby Herrljunga Munkfors Bjurholm Köping Örnsköldsvik Nykvarn Klippan Göteborg Skurup Nynäshamn Tingsryd Gnesta Eskilstuna Salem Orust Götene Pajala Storfors Kinda Danderyd Ljusdal Sunne Trosa Jönköping Strömstad Partille Norrköping Dorotea Sävsjö Umeå Vänersborg Södertälje Torsby Vårgårda Vadstena Lycksele Vaxholm Linköping Bengtsfors Vännäs Ydre Ljungby Örkelljunga Skinnskatteberg Årjäng Alingsås Tomelilla Hörby Ödeshög 40 50 60 70 80 40 50 60 70 80 40 50 60 70 80 40 50 60 70 80 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008
Values with fewer than 100 respondents are not presented.
Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne. 120 Regional Comparisons 2014: Public Health
33 . PARTICIPATION IN ACTIVITIES and young people aged 7 to 20. Several studies show a de- ARRANGED BY SPORTS CLUBS cline in physical activity [166] and the activities of sports Children and young people who are physically active build clubs in the teenage years [165–168]. The age group 13–20 up their skeleton and their muscles at the same time as is therefore of great interest. In addition, adult-led struc- they develop their movement capability. If they are not tured activities are important and can prevent the use of sufficiently physically active, they are at a greater risk of ill- alcohol and drugs [169]. health [162]. Physical activity also has a relatively positive The indicator shows the number of instances of partici- impact on young people’s perceived physical expertise. pation per inhabitant aged 13–20 in the sports clubs that The potential of physical activity to prevent young people were eligible for LOK over the course of the year. The meas- smoking is relatively underutilised [163]. A review of the ure shows the average number of instances of participa- literature on children’s physical activity reports the results tion, which means that some individuals may account for of a measurement using step counters. The results show many instances, while others for none. In addition to LOK, that Swedish children and adolescents aged 7–18 are the municipalities also often provide local grants to instances most physically active in comparison with those in other of participation, but this information is not included here. countries [164]. Nonetheless, self-reported physical activ- The results for instances of participation in sports clubs ity among 11–15-year olds is low according to an interna- at the national level in 2013 are 36 instances for boys and tional comparison that investigated the proportion who 23 instances for girls in the age group. The number of in- state that they achieve the Public Health Agency of Swe- stances has decreased over the course of a ten-year period den’s recommended amount of physical activity per day, for both boys and girls. The results are also lower at the which is 60 minutes for children and adolescents. Physi- municipal level in the majority of municipalities and in cal activity decreases during the teenage years; a trend almost all counties when comparing 2013 and 2009. that continues in adult life [162]. Boys are more physically The figures for instances of participation vary a lot be- active at all ages. Those who stop participating in team tween municipalities – overall between 3 and 71 instances sports often do so because they do not believe they are suf- (girls 1–49 and boys 4–92 instances of participation). These ficiently good at them and they do not get to play enough. vary between 23 and 39 at the county level. If the results In order to prevent people stopping an activity, it has to be are broken down into different ages in the group, you can sufficiently fun. This factor is of great importance when see that the instances of participation halve among 17–20- someone begins taking part in a sport, but then gradually year olds, compared with 13–16-year olds. Football, horse- stops [165]. riding and floorball are the sports that have more partici- There are many ways for children and adolescents to be pation among 7–20-year olds [170]. The number of sports physically active in their leisure time, for example play, clubs in the country increased up until the year 2000, but cycling to and from school or practising a sport or sport- has been decreasing ever since. The density of sports clubs ing activity. There are statistics at the local level on pay- is highest in Jämtland, Härjedalen and Dalarna [170]. ments of central government grants for local activities Many stakeholders can contribute to improving the situ- (statligt lokalt aktivitetsstöd, LOK), the intention of which ation. The central government contributes to reducing the is to support the activities of sports clubs for children cost of participation through LOK grants, something that Lifestyle and living habits 121
can be complemented by financial support from munici- of alcohol, narcotics, doping and tobacco (ANDT). Activi- palities. This can contribute to additional families having ties are presumed to reinforce the bond between people the financial opportunity to participate in sports clubs’ and create clear rules of behaviour [169]. Leisure activities activities. Some municipalities use the socioeconomic are one of many important constituents of the preventa- perspective as the basis of their work to review the guide- tive work against ANDT, particularly in the age groups 6–12 lines for calculating assistance with respect to children and 13–18 [169]. and young people’s leisure activities. Work to improve the situation should be directed not just at involving and re- taining the involvement in sporting activities of as many young people as possible, but can also be combined with other things. These can be supervised spontaneous sport- 33.1 – : Individuals in the age group 13–20 who participate during a year in sports associations that qualify for ing activities for both boys and girls, e.g. drive-in-sports, municipal local activity support, divided by the number of which do not require much equipment or focus on com- inhabitants aged 13–20. petition, etc. Municipalities can also contribute by pro- Number per inhabitant viding attractive local environments in residential areas, 50 around preschools and schools and invest in building safe 40 routes to schools. Furthermore, voluntary organisations are important stakeholders in sport and in cultural and 30 other activities. Such organisations can reach out to and engage with different groups of children and young peo- 20 ple based on the different desires, financial circumstances and diversity of boys and girls. In addition, this involves 10 the content and format of sporting activities such as the 0 group climate, the level of attention regardless of ability, 02 03 04 05 06 07 08 09 10 11 12 13 the importance of reinforcing social skills and good con- Year Total Women Men tact with adults and other young people [163]. Supervised Source: The Swedish Sports Confederation. activities are also a protective factor that reduces the use 122 Regional Comparisons 2014: Public Health
33.2 – , : Individuals in the age group 13–20 who participate during a year in sports associations that qualify for municipal local activity support, divided by the number of inhabitants aged 13–20, 2013.
Västerbotten 34.6 Västernorrland 29.2 Norrbotten 28.1 Värmland 26.9 Gotland 25.5 Gävleborg 25.4 Blekinge 24.8 Halland 24.5 Västmanland 24.2 Dalarna 24.0 Västra Götaland 23.2 SWEDEN 23.1 Jönköping 23.0 Skåne 22.6 Stockholm 22.5 Kalmar 22.1 Kronoberg 21.3 Jämtland 20.6 Östergötland 19.3 Sörmland 18.5 Uppsala 18.4 Örebro 17.9 0 10 20 30 40 50
Number per inhabitant Source: The Swedish Sports Confederation. 2013 2009
33.3 – , : Individuals in the age group 13–20 who participate during a year in sports associations that qualify for municipal local activity support, divided by the number of inhabitants aged 13–20, 2013.
Västerbotten 43.0 Västernorrland 40.8 Stockholm 38.9 Jönköping 38.7 Västmanland 38.3 Kronoberg 37.2 Västra Götaland 37.0 Dalarna 37.0 Norrbotten 36.7 Gävleborg 36.6 SWEDEN 36.3 Halland 35.8 Skåne 35.6 Örebro 35.2 Värmland 34.1 Gotland 32.4 Blekinge 32.3 Uppsala 31.1 Östergötland 31.0 Kalmar 30.4 Jämtland 29.4 Sörmland 29.1 0 10 20 30 40 50
Number per inhabitant Source: The Swedish Sports Confederation. 2013 2009 Lifestyle and living habits 123
33.4 ¢ £¤¥¦§¨©ª: Individuals in the age group 13¢20 who participate during a year in sports associations that qualify for municipal local activity support, divided by the number of inhabitants aged 13¢20, 2013.
Solna Borås Nora Tierp Grums Degerfors Norrköping Vallentuna Umeå Järfälla Nyköping Ånge Leksand Karlshamn Robertsfors Älmhult Vellinge Kramfors Smedjebacken Östra Göinge Härnösand Lessebo Torsby Boxholm Lomma Nacka Uppsala Burlöv Mora Nybro Alvesta Götene Partille Osby Malung-Sälen Haninge Täby Sundbyberg Mark Höör Kungälv Säter Tidaholm Karlsborg Hammarö Tranås Torsås Nynäshamn Luleå Ulricehamn Tranemo Orust Danderyd Vindeln Vadstena Perstorp Kalix Avesta Värmdö Trosa Sölvesborg Bollnäs Åmål Vansbro Tibro Gotland Arvidsjaur Ödeshög Upplands Väsby Karlskrona Bollebygd Essunga Skellefteå Kävlinge Botkyrka Gullspång Värnamo Motala Dorotea Kinda Hagfors Nässjö Hallsberg Mellerud Mölndal Olofström Katrineholm Norrtälje Ovanåker Rättvik Lindesberg Sotenäs Svalöv Sundsvall Sävsjö Mullsjö Nykvarn Tanum Västerås Söderhamn Strömstad Åre Ystad Arvika Tjörn Berg Ängelholm Eksjö Älvsbyn Borgholm Örnsköldsvik Emmaboda Ale Härjedalen Gävle Enköping Eslöv Högsby Karlstad Eskilstuna Herrljunga Hörby Landskrona Falkenberg Håbo Knivsta Stockholm Filipstad Hällefors Nordanstig Grästorp Gislaved Jokkmokk Salem Höganäs Hedemora Klippan Skurup Jönköping Härryda Kungsör Vilhelmina Kiruna Lidingö Norsjö Lilla Edet Timrå Mjölby Storfors Pajala Östersund Munkfors Sunne Simrishamn Borlänge Skara Svedala Sjöbo Falun Sollentuna Vaggeryd Skinnskatteberg Forshaga Sorsele Vara Strömsund Göteborg Vårgårda Vaxholm Halmstad Töreboda Åsele Älvdalen Haparanda Uppvidinge Åstorp Eda Hofors Varberg Österåker Malå Lidköping Vetlanda Östhammar Valdemarsvik Tingsryd Älvkarleby Bromölla Gnosjö Trelleborg Båstad Ekerö Hjo Helsingborg Falköping Finspång Orsa Piteå Habo Gällivare Söderköping Stenungsund Kalmar Hallstahammar Upplands-Bro Uddevalla Karlskoga Hultsfred Örkelljunga Alingsås Köping Kristinehamn Askersund Hudiksvall Lerum Krokom Bjuv Hässleholm Lycksele Markaryd Dals-Ed Kil Lysekil Ockelbo Flen Kristianstad Malmö Ronneby Gagnef Skövde Mörbylånga Södertälje Norberg Tyresö Sandviken Tomelilla Oxelösund Växjö Sigtuna Trollhättan Laxå Åtvidaberg Sollefteå Övertorneå Nordmaling Fagersta Surahammar Aneby Svenljunga Huddinge Vimmerby Bengtsfors Arjeplog Kungsbacka Vänersborg Bjurholm Bräcke Ljungby Västervik Färgelanda Vingåker Lund Öckerö Gnesta Årjäng Mariestad Hylte Heby Storuman Oskarshamn Kumla Ljusdal Ydre Vännäs Laholm Mönsterås Överkalix Örebro Linköping Sala Ragunda Arboga Ludvika Strängnäs Lekeberg Boden Munkedal Ljusnarsberg 0 25 50 75 0 25 50 75 0 25 50 75 0 25 50 75 Number per inhabitant SWEDEN 2013 2009
Source: The Swedish Sports Confederation. 124 Regional Comparisons 2014: Public Health
EATING HABITS mission has included a specific focus on individuals with Good eating habits and safe food are prerequisites if the intellectual disabilities. Municipalities, county councils, population’s health is to develop in a positive direction, regions, voluntary organisations and private stakeholders and these together constitute one of the objective domains will collaborate in this work. For 2014, Friskvården i Värm- of public health policy [18]. Good eating habits in the form land, has been responsible for the administration and co- of the intake of fruit, vegetables and fats has been shown ordination of “A Healthier Sweden”. to be linked to, for example, a decreased risk of cardiovas- The healthcare system should work to ensure that food cular disease and certain forms of cancer. Diet and eating is good and nutritious and provide information and indi- habits are also of considerable importance to type 2 diabe- vidual advice about diet and breastfeeding. This applies tes, overweight and tooth decay [55, 160]. both within the scope of its work with patients and also to prevention, for example in maternal and paediatric health 34 . CONSUMPTION OF FRUIT AND services. The national guidelines for methods of prevent- VEGETABLES ing disease recommends that patients with unhealthy eat- A well-composed and nutritious diet promotes health. ing habits be offered a qualified advisory discussion. Wholemeal cereal products, fish, fruit and vegetables are The National Board of Health and Welfare assesses that foods with a good nutritional content that we eat too lit- eating habits is the lifestyle habit that the healthcare sys- tle of. Educational level, accessibility, price and values are tem has so far devoted the least effort to tackling. Accord- some factors that have an impact on consumption. Heart ingly, there is room for improvement [55]. disease, high blood pressure and some types of cancer are examples of diseases and conditions linked to low intake of fruit and vegetables. The Swedish National Food Agen- cy’s recommendations to eat more vegetables and fruit are 34.1 – : Individuals who states that they eat fruit supported by major international health studies. The rec- and/or vegetables more than 3 times per day, 16–84 years old. ommendation is to eat at least 500 grams per day. Barely 10 Per cent 50 per cent are estimated to achieve the recommended level
[171, 172]. 40 Schools and health and social care organisations, in- cluding the healthcare system, have a responsibility to 30 serve good, nutritious food to pupils, service users and pa- tients. Offering a good range of nutritious products in chil- 20 dren’s environments is particularly important. Schools have a responsibility to educate pupils and promote a 10 good diet [173]. 0 The government commission “A Healthier Sweden” 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year aims to give people inspiration and knowledge about eat- Total Women Men ing well and taking exercise by taking note of concrete Source: Health on Equal Terms, Public Health Agency of Sweden. examples from throughout the entire country. This com- Lifestyle and living habits 125
34.2 – , : Individuals who states that 34.3 – : : Individuals who states that they eat fruit and/or vegetables more than 3 times per day, they eat fruit and/or vegetables more than 3 times per day, 16–84 years old, 2014. 35–74 years old, 2014.
Per cent Per cent 50 50
40 40
30 30
20 20
10 10
0 0 Women Men Women Men 16–29 year 30–44 year 45–64 year 65–84 year Pre-upper-secondary Upper-secondary Post-secondary Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden. Register of Education (UREG), Statistics Sweden.
The indicator is measured using data gathered from the Women with a high educational level eat the most fruit national public health survey. Two questions measure the and vegetables frequency of consumption of fruit and vegetables, respec- More than 30 per cent of women and only about 15 per tively. This report sets out the proportion who consume cent of men state that they consume fruit and vegetables fruit and vegetables more than three times per day. Five more than three times per day. Over the course of the two times per day is said to be equivalent to the recommended measurement periods, we can see a tendency for men to consumption of 500 grams. A lower limit is used because increase their consumption, while women are eating less only 25 per cent of the population achieve this level of con- fruit and vegetables. There are local and regional differ- sumption. Validation studies have shown that the ques- ences. There is also a difference between groups with dif- tions about fruit and vegetables have a strong association ferent educational levels; women with a high educational with other good eating habits [127]. level more frequently eat fruit and vegetables, compared When the indicator was presented in 2009, the limit for with women with a low educational level. The pattern is eating fruit and vegetables was five times per day, rather similar for men, but not as distinct. than more than three times per day as is measured now. 126 Regional Comparisons 2014: Public Health
34.4 – . : Individuals who states that they eat fruit and/or vegetables more than 3 times per day, 16–84 years old, 2011–2014.
Halland 35 Västerbotten 34 Stockholm 33 Gotland 32 Skåne 32 Kalmar 32 Värmland 31 Östergötland 31 SWEDEN 31 Västra Götaland 31 Dalarna 30 Sörmland 29 Jämtland 29 Kronoberg 29 Gävleborg 29 Uppsala 29 Blekinge 28 Örebro 28 Jönköping 28 Norrbotten 27 Västernorrland 27 Västmanland 26 0 10 20 30 40
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
34.5 – . : Individuals who states that they eat fruit and/or vegetables more than 3 times per day, 16–84 years old, 2011–2014.
Stockholm 19 Kronoberg 18 Skåne 17 Västmanland 17 Sörmland 17 Halland 17 Örebro 17 Uppsala 17 SWEDEN 16 Västra Götaland 16 Östergötland 15 Gotland 15 Jönköping 15 Kalmar 15 Västerbotten 14 Norrbotten 14 Dalarna 14 Blekinge 14 Gävleborg 13 Värmland 13 Jämtland 11 Västernorrland 11 0 10 20 30 40
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. Lifestyle and living habits 127
F¡¢£¤ 34.6 ¦ §¢¨©ª«¬®¤¯: Individuals who states that they eat fruit and/or vegetables more than 3 times per day. (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16¦84 years old. Skåne (FHS), 18¦80 years old.
Lund Mölndal Dorotea Nybro Skurup Luleå Lerum Ljusdal Höganäs Halmstad Vänersborg Värnamo Bromölla Gnesta Strömstad Ljusnarsberg Örkelljunga Enköping Ockelbo Vansbro Sigtuna Falköping Borlänge Gällivare Båstad Gotland Oskarshamn Töreboda Eslöv Norrtälje Sundsvall Lilla Edet Ystad Vindeln Lessebo Färgelanda Höör Österåker Markaryd Vimmerby Lomma Partille Tanum Tibro Malmö Åre Torsås Hultsfred Vellinge Älmhult Hjo Tidaholm Östra Göinge Mark Säter Kiruna Burlöv Åtvidaberg Avesta Ovanåker Ängelholm Ronneby Tranås Vaggeryd Simrishamn Gagnef Uppvidinge Piteå Värmdö Laholm Vallentuna Skinnskatteberg Svalöv Ekerö Härnösand Timrå Helsingborg Nyköping Robertsfors Vadstena Lidingö Kalmar Åmål Ludvika Kristianstad Perstorp Nora Jokkmokk Landskrona Bollebygd Boden Sollefteå Klippan Linköping Rättvik Storuman Trelleborg Köping Härjedalen Bengtsfors Sollentuna Karlskrona Degerfors Älvdalen Karlskoga Solna Bräcke Kalix Ale Norberg Upplands-Bro Ulricehamn Mora Ånge Falkenberg Söderhamn Kungsör Knivsta Kristinehamn Hylte Fagersta Hörby Upplands Väsby Krokom Älvkarleby Stockholm Trosa Orsa Mellerud Emmaboda Borås Hallsberg Överkalix Danderyd Uddevalla Sorsele Ragunda Härryda Arvika Sandviken Haparanda Kävlinge Lysekil Bollnäs Dals-Ed Växjö Karlshamn Malung-Sälen Strömsund Nacka Skara Mjölby Heby Hässleholm Flen Lidköping Älvsbyn Umeå Arboga Tierp Åsele Mörbylånga Öckerö Surahammar Norsjö Uppsala Gislaved Vingåker Östhammar Tomelilla Kungälv Mariestad Malå Gävle Järfälla Övertorneå Arjeplog Tyresö Kungsbacka Tjörn Arvidsjaur Osby Nässjö Lycksele Pajala Falun Herrljunga Västervik Aneby Finspång Hallstahammar Gullspång Boxholm Svedala Borgholm Sala Eda Sjöbo Motala Skellefteå Eksjö Göteborg Strängnäs Berg Filipstad Jönköping Hedemora Tranemo Forshaga Alingsås Stenungsund Örnsköldsvik Gnosjö Ljungby Karlstad Söderköping Grums Sundbyberg Vara Karlsborg Habo Sölvesborg Olofström Kramfors Hagfors Vännäs Botkyrka Nordmaling Hammarö Södertälje Eskilstuna Nordanstig Kil Leksand Valdemarsvik Bjurholm Mullsjö Varberg Svenljunga Kumla Munkfors Huddinge Katrineholm Orust Nykvarn Täby Skövde Munkedal Nynäshamn Håbo Smedjebacken Lekeberg Salem Åstorp Alvesta Kinda Storfors Örebro Östersund Vetlanda Sunne Mönsterås Högsby Hällefors Bjuv Lindesberg Essunga Sävsjö Norrköping Hudiksvall Grästorp Torsby Västerås Trollhättan Vilhelmina Vaxholm Oxelösund Askersund Götene Ydre Tingsryd Vårgårda Hofors Årjäng Sotenäs Haninge Laxå Ödeshög 0 15 30 45 0 15 30 45 0 15 30 45 0 15 30 45 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008
Values with fewer than 100 respondents are not presented. Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne. 128 Regional Comparisons 2014: Public Health
TOBACCO USE 35.1 – : Daily smoking – individuals who reported Smoking has been decreasing in Sweden since the middle that they smoke daily, 16–84 years old. of the 1980s. This reduction is presumed to be due to fac- Per cent 25 tors such as increased tobacco taxes and new legislation
concerning smoke-free environments. Smoking is still 20 estimated to be the single greatest risk factor for disease
and premature death [18]. 15
35 . DAILY SMOKING 10 About 12 000 people in Sweden die each year from dis- eases related to smoking. In the future, we should see a 5 more positive trend as the number of smokers decreases 0 [175]. Smoking carries a considerable cost for the Swedish 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year economy as a whole. The costs of healthcare, absence from Total Women Men work due to illness and loss of production have been esti - Source: Health on Equal Terms, Public Health Agency of Sweden. mated at SEK 30 billion per year [176]. Many of those who stop smoking start using snus instead (a Swedish moist powder tobacco product consumed by placing a small wad under the upper lip). Using snus increases the risk of gum damage and doubles the risk of pancreatic cancer, on smoking in schoolyards [177]. Many people still smoke although this disease is uncommon. Mortality from stroke in schoolyards, despite this having been prohibited since and myocardial infarction also appears to be higher among 1994 and supervision of the ban needs to be given a higher those who use snus than those who do not use tobacco, priority in the majority of municipalities [178]. although the incidence of these diseases is not higher [55]. Three quarters of adult smokers want to stop and many The municipalities are responsible for the supervision want professional help with this [176]. Research shows that of retailers with respect to tobacco products. However, it is possible to prevent tobacco use among young people half of the municipalities only allocate 10 per cent or less through collective support from schools and parents [179]. of one full-time equivalent employee to this supervision It is also unusual for young people to begin smoking after and 6 per cent do not devote any resources to this at all. the age of 19. Accordingly, it is of the utmost importance to Some municipalities provide a good service in this area, implement smoking prevention efforts at an early stage, but generally there needs to be improvement. Municipali- for example in childcare and schools. The healthcare sys- ties have an important role in the prevention of tobacco tem’s role in prevention is also important, not least within use, for example supervising age limits in the retail sector maternal and paediatric health services, guidance centres and smoke-free schoolyards. Better collaboration with the for young people, student health and occupational health police and improvements to self-regulation are also re- services. There are many interventions that help in the quired in the retail sector. The Government’s ANDT strat- work to prevent tobacco use, for example establishing mu- egy specifically emphasises the importance of initiatives nicipal action plans and collaborating with other stake- that increase the likelihood of compliance with the ban holders such as educational associations, sports clubs Lifestyle and living habits 129
35.2 – , : Daily smoking – 35.3 – : : Daily smoking – individuals individuals who reported that they smoke daily. who reported that they smoke daily, 35–74 years old, 2014.
Per cent Per cent 25 25
20 20
15 15
10 10
5 5
0 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Women Men Year Pre-upper-secondary Upper-secondary Post-secondary 16–29 year 30–44 year 45–64 year 65–84 year Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden. Register of Education (UREG), Statistics Sweden.
and voluntary organisations [180, 181]. Tobacco Endgame Daily smoking is most common among those with a low – Smoke-free Sweden 2025 is an opinion-building project. educational level The aim is to get a political decision in 2015 to set a target The proportion of daily smokers has decreased over the for Sweden to be smoke-free in 2025 [181]. course of this period in the majority of counties and mu- The national guidelines for methods of preventing nicipalities, with the exception of women in the oldest age disease recommends that patients who are daily smok- group. However, there are major local differences in the ers should be offered a qualified advisory discussion. -Al incidence of both smoking and the use of snus. The high- though the use of nicotine replacement therapy can have est proportion of smokers is in the 45–65 age group and a number of side-effects, prescription of these medica- the proportion of daily smokers is still considerably higher tions is given a relatively high priority as daily smoking is among individuals with a low educational level. Daily use judged to be much more dangerous. For pregnant women, of snus among men has decreased somewhat, but not to legal guardians and individuals who are to have surgery, the same extent as daily smoking. the interventions have an even higher priority and also Smoking is sometimes also monitored in the national encompass those who smoke more infrequently. There public health survey and this data is necessary in order to are also recommended interventions for pregnant and get an impression of the extent and development of the breastfeeding women who use snus. County councils and problem. The proportion who responded that they smoke municipalities are also working towards smoke-free work- sometimes is most notable among the younger age group places. and has not decreased in the same way as the proportion who are daily smokers. 130 Regional Comparisons 2014: Public Health
35.4 – , : Daily smoking – individuals who reported that they smoke daily, 16–84 years old, 2011–2014.
Västerbotten 8 Uppsala 9 Halland 10 Västernorrland 11 Jönköping 11 Västra Götaland 11 Stockholm 11 Kalmar 12 Blekinge 12 SWEDEN 12 Gävleborg 12 Norrbotten 12 Kronoberg 12 Örebro 12 Dalarna 13 Västmanland 13 Jämtland 13 Gotland 13 Värmland 13 Skåne 13 Östergötland 14 Sörmland 14 0 5 10 15 20 25
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
35.5 – , : Daily smoking – individuals who reported that they smoke daily, 16–84 years old, 2011–2014.
Gävleborg 7 Västerbotten 7 Halland 7 Kronoberg 8 Värmland 8 Uppsala 8 Västernorrland 8 Västmanland 9 Jönköping 10 Västra Götaland 10 Dalarna 10 Örebro 10 SWEDEN 10 Stockholm 11 Skåne 11 Sörmland 12 Blekinge 12 Gotland 12 Kalmar 12 Jämtland 13 Östergötland 13 Norrbotten 13 0 5 10 15 20 25
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. Lifestyle and living habits 131
¡¢£ 35.6 § ¨¡©ª«¬®¯£°: Daily smoking - individuals who reported that they smoke daily (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16§84 years old. Skåne (FHS), 18§80 years old. Värmland (LH), 18+ years old.
Danderyd Älvsbyn Munkfors Vara Lomma Piteå Köping Sotenäs Lidingö Solna Alvesta Ljusnarsberg Ekerö Tjörn Tibro Eslöv Umeå Nordmaling Trosa Strängnäs Bjurholm Falkenberg Ragunda Ludvika Vallentuna Kungälv Laxå Sjöbo Leksand Karlskrona Partille Skurup Arvika Hofors Orsa Svalöv Sunne Järfälla Karlskoga Simrishamn Gagnef Alingsås Stockholm Motala Bräcke Essunga Heby Båstad Gällivare Östra Göinge Mönsterås Lund Älvdalen Hylte Bjuv Täby Falköping Askersund Botkyrka Sundsvall Östhammar Oskarshamn Bengtsfors Åre Växjö Håbo Södertälje Vellinge Härjedalen Sollefteå Huddinge Kinda Kalmar Söderköping Borås Hammarö Finspång Kumla Degerfors Norsjö Hallstahammar Töreboda Östersund Kalix Vänersborg Haninge Ängelholm Torsby Örebro Eskilstuna Härryda Bollnäs Nyköping Norrköping Upplands Väsby Timrå Sölvesborg Västervik Vännäs Nacka Vadstena Tierp Vimmerby Knivsta Uppvidinge Osby Mjölby Nora Värnamo Luleå Katrineholm Hässleholm Dorotea Halmstad Emmaboda Hörby Krokom Gislaved Högsby Sigtuna Rättvik Västerås Fagersta Överkalix Jönköping Laholm Valdemarsvik Flen Värmdö Ånge Götene Svenljunga Skellefteå Nässjö Grästorp Malmö Tranås Vindeln Mark Norrtälje Ovanåker Vetlanda Vingåker Gnesta Strömsund Filipstad Ulricehamn Ockelbo Lycksele Sandviken Kristianstad Hultsfred Örnsköldsvik Mariestad Karlshamn Perstorp Nordanstig Boden Hällefors Surahammar Sundbyberg Berg Klippan Trelleborg Linköping Hjo Avesta Lilla Edet Sorsele Lysekil Åsele Sala Vilhelmina Karlstad Ljusdal Skara Säter Kungsbacka Hagfors Gullspång Mörbylånga Kramfors Tyresö Eda Upplands-Bro Karlsborg Skövde Haparanda Robertsfors Vårgårda Gotland Älvkarleby Härnösand Lindesberg Tomelilla Norberg Arboga Forshaga Göteborg Bromölla Uppsala Herrljunga Arjeplog Strömstad Mora Storfors Trollhättan Kungsör Hudiksvall Stenungsund Tidaholm Arvidsjaur Kil Uddevalla Markaryd Åstorp Älmhult Borlänge Höör Burlöv Lerum Hedemora Orust Skinnskatteberg Malå Smedjebacken Åmål Oxelösund Varberg Vansbro Tingsryd Örkelljunga Höganäs Hallsberg Munkedal Aneby Malung-Sälen Lekeberg Tanum Boxholm Storuman Nybro Dals-Ed Eksjö Öckerö Kiruna Färgelanda Gnosjö Ystad Söderhamn Övertorneå Habo Ljungby Svedala Landskrona Mullsjö Sollentuna Enköping Bollebygd Nykvarn Lidköping Olofström Ronneby Nynäshamn Falun Lessebo Helsingborg Salem Österåker Årjäng Torsås Sävsjö Pajala Borgholm Mellerud Vaggeryd Grums Åtvidaberg Ale Vaxholm Gävle Kristinehamn Tranemo Ydre Mölndal Kävlinge Jokkmokk Ödeshög 0 5 10 15 20 25 0 5 10 15 20 25 0 5 10 15 20 25 0 5 10 15 20 25 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008 LH - Värmland 2012 LH - Värmland 2008
Values with fewer than 100 respondents are not presented Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne; Liv och Hälsa (LH) [Life and Health], County Council of Värmland. 132 Regional Comparisons 2014: Public Health
36 . TOBACCO USE DURING PREGNANCY The positive trend among pregnant women may be due Smoking when pregnant is serious as it involves greater to Sweden having been early to adopt a preventative strat- health risks for the foetus and the expectant mother. These egy to get the population to stop smoking. This involves risks include placental abruption, premature labour, im- smokers who are expecting children being offered advice paired foetal growth and sudden infant death. There are and help with smoking cessation (such as motivational also studies that show an increased risk of lower birth discussions) [55, 176, 183]. Maternal and paediatric health weight and an increased risk of stillbirth and sudden in- services and family health centres have a great opportuni- fant death [182]. The effects are clear during the pregnancy ty to influence pregnant women’s tobacco habits as almost itself, but children of mothers who have smoked also all expectant parents make use of the healthcare system appear to be at risk of later problems such as lower lung repeatedly during pregnancy. During pregnancy there are capacity, wheezy breathing, ear inflammation and colic in plentiful opportunities to provide information and have the first year. discussions about such aspects as the negative effects of Research also indicates that tobacco use is linked to smoking and to offer help with smoking cessation. Mu- asthma, allergies, an increased risk of behavioural prob- nicipalities also have the opportunity to offer information lems, delayed cognitive development and difficulties and education and to draw up action plans for tobacco- reading and writing. In addition, there is an increased risk free environments, not least around childcare facilities that the child will suffer from cancer and cardiovascular and schools. In addition, municipalities can reach many disease later in life. Snus can have a detrimental impact people in their capacity as employers. In recent years, on the foetus and pregnancy in the same way as smoking. work on the national guidelines has reinforced prevention However, there are major differences between counties, at the regional and local levels [55]. which indicates that prevention can be improved region- Large regional and local differences ally [55, 176, 183].
It is important to provide early interventions to 36.1 – : Women who smoke or use snus during pregnant teenagers early pregnancy week 8–12.
Around 15 per cent of women who gave birth in 2012 Per cent smoked three months before they became pregnant. The 15 proportion of pregnant women who smoke at the time they are registered with maternal health services has de- 12 creased from about 31 per cent in 1983 to just under 6 per 9 cent in 2012. Smoking has decreased in all age groups, but is still most common among the youngest women who 6 give birth. Just under 22 per cent of the teenagers who
gave birth in 2012 smoked during pregnancy, while this 3 proportion was 12 per cent among women aged 20–24. The proportion who smoked late in pregnancy was about 18 0 00 01 02 03 04 05 06 07 08 09 10 11 12 per cent among teenagers and 9 per cent in the 20–24 age Year Total group. Pregnant women under the age of 19 are five times Source: The Swedish Medical Birth Register, the National Board of more likely to smoke late in pregnancy than those aged Health and Welfare. over 30 [184]. Lifestyle and living habits 133
The proportion of pregnant women who use tobacco early use of snus is more common than smoking in Västerbot- in pregnancy varies between counties, but there are con- ten and Jämtland and in some other northern counties. siderably larger differences at the municipal level. How- Tobacco use is more common among individuals with a ever, the local variations may be due to a small population. low educational level than those with a high educational This means that relatively minor changes in the numbers level. can result in relatively large changes to the statistics. The
36.2 – . : Women who smoke or use snus during early pregnancy week 8–12, 2012.
Stockholm 5.65 Uppsala 5.68 Kronoberg 6.12 Jönköping 6.34 Östergötland 6.60 Örebro 6.77 Halland 6.99 SWEDEN1 7.04 Norrbotten 7.36 Västra Götaland 7.37 Västerbotten 7.37 Blekinge 7.64 Skåne 7.86 Dalarna 7.94 Västmanland 8.40 Sörmland 8.47 Kalmar 8.91 Gotland 9.23 Gävleborg 9.30 Västernorrland 9.35 Jämtland 9.63 Värmland2 0 3 6 9 12 15 1 For estimating the country's value for 2012, data for Värmland in 2011 has been used. 2 Data is missing Per cent 2012 2008 Source: The Swedish Medical Birth Register, the National Board of Health and Welfare. 134 Regional Comparisons 2014: Public Health
¡¢£¤ 36.3 ¦ §¢¨©ª«¬®¤¯: Women who smoke or use snus during early pregnancy week 8–12, 2010–2012.
Danderyd Sävsjö Ljungby Strömsund Lomma Kalmar Haninge Gällivare Vaxholm Säter Ale Forshaga Täby Tjörn Nässjö Höör Knivsta Skara Falköping Ludvika Habo Pajala Bjurholm Nordanstig Arjeplog Tyresö Eskilstuna Torsås Öckerö Gnosjö Grästorp Norberg Stockholm Alingsås Bollebygd Älvkarleby Storuman Karlshamn Orust Ödeshög Sundbyberg Tingsryd Kalix Valdemarsvik Ragunda Alvesta Tranemo Sollentuna Vilhelmina Botkyrka Herrljunga Malung-Sälen Östersund Köping Mark Växjö Båstad Motala Dals-Ed Uppsala Värnamo Osby Övertorneå Solna Halmstad Sunne Ronneby Lund Ånge Lindesberg Nynäshamn Vellinge Uddevalla Strängnäs Sjöbo Nacka Sundsvall Falkenberg Mellerud Linköping Piteå Burlöv Bromölla Vännäs Munkfors Söderhamn Kristinehamn Vallentuna Kristianstad Västervik Skurup Jönköping Boxholm Åsele Landskrona Umeå Emmaboda Södertälje Flen Tierp Arvidsjaur Hammarö Robertsfors Tibro Älvsbyn Sotenäs Uppvidinge Ydre Trelleborg Lidingö Kumla Katrineholm Arboga Lidköping Enköping Mullsjö Grums Kungsbacka Vansbro Håbo Sollefteå Skövde Sölvesborg Ulricehamn Timrå Ängelholm Munkedal Olofström Tranås Kinda Skellefteå Åmål Haparanda Mölndal Bollnäs Hörby Tomelilla Ekerö Mora Ljusnarsberg Åstorp Lerum Karlskoga Vingåker Degerfors Borgholm Vindeln Askersund Kungsör Kävlinge Vetlanda Hässleholm Bjuv Upplands-Bro Nora Färgelanda Klippan Gagnef Trollhättan Fagersta Storfors Härryda Borlänge Smedjebacken Hallsberg Höganäs Eksjö Härnösand Gullspång Ystad Österåker Sandviken Surahammar Mariestad Varberg Finspång Vadstena Nyköping Falun Mönsterås Tidaholm Söderköping Järfälla Kil Heby Laxå Upplands Väsby Hedemora Torsby Leksand Arvika Ovanåker Lycksele Värmdö Oskarshamn Älvdalen Hylte Örebro Vimmerby Aneby Vaggeryd Norrköping Svalöv Härjedalen Malmö Borås Jokkmokk Årjäng Strömstad Rättvik Vänersborg Bengtsfors Götene Norsjö Krokom Svenljunga Göteborg Salem Hultsfred Östra Göinge Karlskrona Gotland Laholm Lilla Edet Karlsborg Kiruna Eslöv Markaryd Karlstad Gävle Lekeberg Hofors Svedala Hagfors Oxelösund Högsby Trosa Gnesta Boden Örkelljunga Huddinge Östhammar Nybro Hällefors Hjo Sigtuna Berg Dorotea Lessebo Ljusdal Sala Eda Luleå Åtvidaberg Kramfors Tanum Mörbylånga Åre Norrtälje Filipstad Västerås Lysekil Essunga Bräcke Kungälv Stenungsund Orsa Töreboda Partille Simrishamn Vara Perstorp Avesta Vårgårda Gislaved Skinnskatteberg Älmhult Mjölby Hallstahammar Malå Helsingborg Nordmaling Ockelbo Sorsele Örnsköldsvik Nykvarn Hudiksvall Överkalix 0 15 30 45 0 15 30 45 0 15 30 45 0 15 30 45 Per cent SWEDEN 2010–2012 2007–2009 1 Data is missing for Värmland for 2012. 2 Numbers lower than 4 for people smoking/using snus are not presented.
Source: The Swedish Medical Birth Register, the National Board of Health and Welfare. Lifestyle and living habits 135
ALCOHOL USE strategy) for the first time. Municipalities’ role in alcohol Alcohol consumption causes many diseases in the popula- prevention is to ensure compliance with age limits in tion, for example cancer, cardiovascular disease and liver shops, approving alcohol licences for restaurants and car- disease. The WHO calculates that risky alcohol consump- rying out preventative work in schools. It is also important tion is one of the five biggest risk factors for lost healthy that they are able to offer drug-free recreational activities life years [185]. for young people. Teenagers’ parents are important and the effort to achieve the overall goal of reducing the avail- 37 . RISKY CONSUMPTION OF ALCOHOL ability of alcohol to teenagers is assisted by getting parents Risky consumption of alcohol can contribute to an in- and young adults to refrain from purchasing alcohol for creased risk of harmful physical, mental and social seque- young people under the age of 20 years [193]. lae. Several different measures of what is considered risky The healthcare system’s role in prevention is also im- consumption are used and there is no nationally accepted portant, not least within maternal and paediatric health measure currently in use. A measure for risky consump- services, guidance centres for young people, student tion of alcohol that is often used in healthcare is that more health and occupational health services. Prevention is to than 14 standard glasses per week for men and more than be incorporated into both encounters with patients and in 9 glasses per week for women can be considered risky con- work involving the population at the county council level sumption. Lower limits for risky consumption also exist, [194]. for example prior to surgical procedures [186]. The national guidelines for methods of preventing dis- According to the WHO’s calculations, alcohol consump- ease recommends that advisory discussions and online tion is among the most common risk factors for lost health and computer-based advice should be offered to patients life years and is also the greatest risk factor for individu- whose use of alcohol is risky. Pregnant women, parents of als in the 15–49 age groups in both the EU and Sweden. small children and people who are to undergo surgery are Risky consumption of alcohol is estimated to cost society priority groups in this work. For pregnant women, all alco- at least SEK 66 billion per year [187]. Risky consumption of hol use is considered risky use [55]. alcohol can have serious long-term medical consequences and can result in other diseases such as high blood pres- sure, liver disease and cancer. In addition, it increases the 37.1 – : Indivudals identied as risk consumers risk of mental ill-health, alcohol psychosis and suicide. after their responses to three questions on alcohol consumption, Drowning, injuries in traffic and violent crime are also 16–84 years old. linked to alcohol consumption [188]. Per cent Alcohol consumption during pregnancy can result in 25 foetal injuries and in the child having learning difficul- 20 ties, behavioural disorders and deformities [189, 190]. The risk of foetal injuries as a result of low to moderate alco- 15 hol consumption is affected by both the mother’s and the child’s genes, which is an indication that the only option 10 that is entirely free of risk is to refrain from alcohol during pregnancy [191]. It is estimated that one in five children 5 grows up in a household with at least one adult who con- 0 sumes alcohol in a way that is judged to put their health at 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year risk, which is also a risk factor for the child’s health [192]. Total Women Men In 2010, the Government adopted an overall strategy for Source: Health on Equal Terms, Public Health Agency of Sweden. its alcohol, narcotics, doping and tobacco policy (ANDT 136 Regional Comparisons 2014: Public Health
37.2 – . : Indivudals identied as risk 37.3 – . : Indivudals identied as risk consumers after their responses to three questions on alcohol consumers after their responses to three questions on alcohol consumption. consumption.
Per cent Per cent 45 45
30 30
15 15
0 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year Year 16–29 year 30–44 year 45–64 year 65–84 year 16–29 year 30–44 year 45–64 year 65–84 year Source: Health on Equal Terms, Public Health Agency of Sweden. Source: Health on Equal Terms, Public Health Agency of Sweden.
Data from the national public health survey is used as 37.4 – : : Indivudals identied as risk the indicator of risky alcohol habits. The indicator shows consumers after their responses to three questions on alcohol the proportion who are estimated to have risky alcohol consumption, 35–74 years old, 2014. habits based on how they responded to three questions. Per cent The questions concern how often the respondent drinks, 25 how much they drink and how often they drink a large 20 amount. The responses are assigned points and the re-
spondent is classified as a risky consumer if they achieve 15 a certain number of points. The limit is lower for women than for men. The method used to calculate the indicator 10 has changed since 2009 and the Public Health Agency of Sweden publishes follow-ups of the ANDT strategy each 5 year. 0 Reduced risky consumption among younger people Women Men Risky alcohol consumption in the population varies con- Pre-upper-secondary Upper-secondary Post-secondary Source: Health on Equal Terms, Public Health Agency of Sweden. siderably throughout the country, both regionally and Register of Education (UREG), Statistics Sweden. locally. In general, young people in Sweden drink less alcohol than young people in other European countries and young people’s consumption has decreased more in In Sweden, risky alcohol consumption is more common Sweden than in other places in recent years. There is an among young people (in the age 16–29) than in other age association between young people’s alcohol consumption groups. Nevertheless, a clear downward trend can be seen and alcohol consumption among adults. among younger men, while the development for younger In countries where adults consume a lot of alcohol, women has not been as positive. In the younger age group, young people normally do so as well. Adults in Sweden are the proportion of women whose alcohol consumption is still among those who drink the least in Europe, despite risky is also just as high as for men in the same age group. levels of alcohol consumption becoming increasingly similar in countries within the EU [185]. Lifestyle and living habits 137
37.5 – , : Indivudals identied as risk consumers after their responses to three questions on alcohol consumption, 16–84 years old, 2011–2014.
Västernorrland 8 Kronoberg 9 Dalarna 10 Västerbotten 11 Jönköping 11 Kalmar 11 Sörmland 11 Uppsala 11 Värmland 12 Norrbotten 12 Gotland 12 Västmanland 12 Skåne 12 Östergötland 12 Västra Götaland 12 Örebro 12 Blekinge 13 SWEDEN 13 Halland 13 Gävleborg 14 Jämtland 15 Stockholm 16 0 5 10 15 20 25 30
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden.
37.6 – , : Indivudals identied as risk consumers after their responses to three questions on alcohol consumption, 16–84 years old, 2011–2014.
Västerbotten 15 Blekinge 15 Örebro 17 Västmanland 18 Skåne 18 Gotland 18 Gävleborg 18 Norrbotten 18 Jämtland 19 Västernorrland 19 Dalarna 19 Jönköping 19 Kronoberg 19 Västra Götaland 20 SWEDEN 20 Halland 20 Kalmar 21 Östergötland 21 Värmland 21 Stockholm 22 Uppsala 22 Sörmland 25 0 5 10 15 20 25 30
2011–2014 2007–2010 Per cent Source: Health on Equal Terms, Public Health Agency of Sweden. 138 Regional Comparisons 2014: Public Health
¡¢£¤ 37.7 ¥ ¦¢§¨©ª«¬¤®: Indivudals identi±ed as risk consumers after their responses to three questions on alcohol consumption (see explanation below for measurement period). Age demarcation: National Public Health Survey (HLV), 16¥84 years old. Skåne (FHS), 18¥80 years old. Värmland (LH), 18+ years old.
Valdemarsvik Järfälla Malung-Sälen Tranemo Kalix Kumla Härnösand Umeå Norsjö Vårgårda Åsele Hagfors Övertorneå Karlskrona Uddevalla Ljusdal Överkalix Örkelljunga Gotland Svenljunga Burlöv Ulricehamn Nybro Vellinge Markaryd Hudiksvall Gullspång Åmål Pajala Karlshamn Åstorp Essunga Ragunda Nässjö Ljusnarsberg Sollentuna Lindesberg Skinnskatteberg Lekeberg Botkyrka Skara Emmaboda Strömstad Sölvesborg Rättvik Söderhamn Håbo Leksand Arboga Sandviken Härjedalen Ronneby Östersund Arvika Haninge Götene Dals-Ed Vallentuna Karlskoga Olofström Hultsfred Mellerud Mora Gällivare Jönköping Orust Älvdalen Ljungby Torsås Gnesta Svedala Ekerö Hofors Perstorp Varberg Laxå Osby Norrköping Svalöv Hässleholm Båstad Tjörn Orsa Heby Lysekil Vimmerby Partille Krokom Kiruna Värnamo Flen Vetlanda Finspång Växjö Kungsbacka Grästorp Trelleborg Hedemora Gävle Karlsborg Lidköping Tierp Norrtälje Åtvidaberg Bjuv Sigtuna Enköping Kil Upplands-Bro Lycksele Oxelösund Nora Sollefteå Malå Munkfors Tyresö Uppvidinge Sorsele Storfors Årjäng Ånge Södertälje Bengtsfors Strängnäs Arvidsjaur Östhammar Skurup Linköping Motala Säter Bollebygd Östra Göinge Nordmaling Ystad Högsby Härryda Älvsbyn Bromölla Alingsås Stenungsund Gagnef Örnsköldsvik Kristinehamn Malmö Kungsör Lerum Torsby Köping Munkedal Tingsryd Ludvika Vadstena Degerfors Vara Nacka Simrishamn Avesta Kramfors Tidaholm Sotenäs Hylte Töreboda Hammarö Grums Sjöbo Filipstad Mölndal Landskrona Storuman Hörby Täby Danderyd Dorotea Borgholm Kungälv Göteborg Skövde Askersund Västervik Kalmar Tibro Kinda Mjölby Uppsala Falköping Knivsta Hjo Åre Ockelbo Arjeplog Kristianstad Lund Mariestad Klippan Eskilstuna Värmdö Alvesta Fagersta Bollnäs Huddinge Nordanstig Laholm Öckerö Karlstad Jokkmokk Skellefteå Falkenberg Trosa Mörbylånga Smedjebacken Sunne Österåker Eslöv Tomelilla Borås Sundbyberg Piteå Falun Söderköping Stockholm Bjurholm Borlänge Halmstad Höganäs Boden Sala Höör Solna Bräcke Mönsterås Timrå Tranås Strömsund Sundsvall Lessebo Aneby Vansbro Surahammar Ängelholm Boxholm Katrineholm Lomma Västerås Eksjö Upplands Väsby Mark Haparanda Gnosjö Vilhelmina Lidingö Älvkarleby Habo Berg Gislaved Örebro Mullsjö Vännäs Vänersborg Lilla Edet Nykvarn Vindeln Luleå Hällefors Nynäshamn Ovanåker Oskarshamn Helsingborg Salem Eda Hallsberg Vingåker Sävsjö Hallstahammar Färgelanda Forshaga Vaggeryd Älmhult Tanum Kävlinge Vaxholm Herrljunga Norberg Ale Ydre Robertsfors Trollhättan Nyköping Ödeshög 0 10 20 30 0 10 20 30 0 10 20 30 0 10 20 30 Per cent SWEDEN (HLV) HLV 2011–2014 HLV 2007–2010 FHS - Skåne 2012 FHS - Skåne 2008 LH - Värmland 2012 LH - Värmland 2008
Values with fewer than 100 respondents are not presented. Source: Health on Equal Terms, including supplementary sample (HLV), Public Health Agency of Sweden; Public Health Survey Skåne (FHS), Region Skåne; Liv och Hälsa (LH) [Life and Health], County Council of Värmland. Lifestyle and living habits 139
PATIENT-REPORTED EXPERIENCES those patients who need to make lifestyle changes. There Patient-reported experiences are used in various types is currently insufficient data to measure how the health- of monitoring and evaluation. This type of indicator or care system works with living habits. What there is at the measure is based on question from surveys that patients moment are a number of questions in the national patient respond to in conjunction with receiving care and treat- survey that can demonstrate patients’ experiences of the ment from the healthcare system, social services or other extent to which the healthcare system works with lifestyle organisations. The patient-reported measures can be habits during patient encounters. divided into two categories. The first is PROM (patient-re- In addition, the National Board of Health and Welfare ported outcome measures) that measure outcomes before plans to publish an evaluation of the national guidelines and after an intervention and they are designed as results for methods of preventing disease in order to answer the measures. The second category is PREM (patient-reported question of how the healthcare system uses advice or experience measures) that measure patient-reported ex- discussions in order to help patients change their living periences. PREMs are often designed as structural or pro- habits. Primary care is a large part of the healthcare system cess measures, but also exist as results measures. PROMs and its role includes monitoring the population’s health measure results in care, for example functional capacity, and undertaking health promotion and disease preven- quality of life and health-related quality of life, via the pa- tion. tients’ own reports following treatment. Unhealthy living habits are unevenly distributed The report Regional Comparisons 2013 – Healthcare pre- throughout the population and are more common among sented indicators that are based on general PROMs. The those with a low educational level, for example. In addi- national patient survey highlights patients’ experiences tion there is covariance between them and other socioeco- and can be defined as PREM indicators. In this report, a nomic background factors. Living habits are established question has been chosen that deals with whether the pa- early in life and healthy habits should begin in childhood. tients have had a discussion about lifestyle and living hab- Aside from the home, schools and leisure activities also its during their most recent appointment with a general play an important role in creating a healthy lifestyle. practitioner. The results are shown at the county coun- The indicator measures how many patients who have a cil level and for the country as a whole. This report uses discussion about at least one living habit in conjunction measurements from primary care from 2011 and 2013. with an appointment with a general practitioner. Such dis- cussions may be about smoking, which is the habit that 38 . PATIENTS IN PRIMARY CARE – contributes most to early death. It is also vital that patients DISCUSSING LIFESTYLE AND LIVING who are to undergo surgery or already have a smoking- HABITS related disease receive help to stop smoking in order not The burden of disease is a measure drawn up by the WHO to worsen their health further. The report A National Can- in order to compare and monitor the diseases that lead to cer Strategy for the Future (SOU 2009:11) indicates that the most ill-health and the risk factors that are of considerable number of cancers may double by 2030 and proposes that importance to the development of disease. According to one of the targets for cancer prevention should focus on, National Guidelines for Methods of Preventing Disease 2011, for example, primary care facilities offering smoking ces- a large proportion of the total burden of disease can be sation [195]. ascribed to four living habits: tobacco use, insufficient As indicated in the diagrams, the figures for the major- physical activity, risky use of alcohol and unhealthy eat- ity of county councils are largely unchanged between the ing habits [55]. These habits should be taken into account two measurement periods. The outcome also shows that in the healthcare system’s contact with people seeking the variations between county councils are smaller among care and the National Board of Health and Welfare recom- women than among men. mends offering advice or discussion in order to support 140 Regional Comparisons 2014: Public Health
38.1 – , : Patients who answered “Yes” to the question: Did the doctor or another member of sta¡ discuss any of the following living habits with you: tobacco, alcohol, exercise or eating habits?, 2013.
Dalarna 43 Jönköping 43 Stockholm 43 Sörmland 43 Gotland 42 Gävleborg 42 Uppsala 42 SWEDEN 41 Västernorrland 41 Blekinge 40 Kronoberg 40 Värmland 40 Västra Götaland 40 Halland 39 Skåne 39 Jämtland 38 Kalmar 38 Västmanland 38 Örebro 38 Norrbotten 37 Västerbotten 36 Östergötland 36 0 10 20 30 40 50 60
2013 2011 Per cent Source: National Patient Survey, the Swedish Association of Local Authorities and Regions.
38.2 – , : Patients who answered “Yes” to the question: Did the doctor or another member of sta discuss any of the following living habits with you: tobacco, alcohol, exercise or eating habits?, 2013.
Gotland 50 Stockholm 49 Sörmland 49 Uppsala 49 Dalarna 48 Jönköping 47 Kronoberg 47 Skåne 47 Västernorrland 47 SWEDEN 46 Västra Götaland 45 Gävleborg 44 Kalmar 44 Värmland 44 Örebro 44 Halland 43 Jämtland 43 Blekinge 42 Norrbotten 41 Västmanland 41 Östergötland 41 Västerbotten 40 0 10 20 30 40 50 60
2013 2011 Per cent Source: National Patient Survey, the Swedish Association of Local Authorities and Regions. Lifestyle and living habits 141
SEXUAL AND REPRODUCTIVE HEALTH having decreased by more than 50 per cent since screen- AND RIGHTS ing was introduced in the 1960s. The reason for this is In Sweden, sexuality and reproductive health is one of the that early detection and treatment increases the chances objective domains of public health policy. This domain of successfully treating cell changes. In countries where covers the entire population and people’s entire life cycle, few women participate in screening, cervical cancer is which has a major importance to everyone’s self-esteem, the most common form of cancer and usually affects rel- close relationships and well-being [196]. The term sexual atively young women aged 40–50. The majority of those and reproductive health and rights is used in both Sweden women who develop cervical cancer in Sweden have not and abroad. Reproductive health is a state of complete participated in screening in accordance with the recom- physical, mental and social well-being concerning the mendations [57]. reproductive system and all its functions, not simply the The national quality register for cervical cancer preven- absence of disease. Sexual health deals with quality of life tion covers several interventions with a proven effect on and personal relationships, with advice and healthcare, increasing the screening rate. The invitation should in- while sexual rights encompasses everyone’s right to deter- clude a pre-booked time, but it should also be simple to mination over their own body and sexuality. Reproductive change this time, with plenty of options in terms of time rights encompass the individual’s right to determine the and place. The screening rate increases if it is possible for number of children they will have and the length of time screening to be conducted in conjunction with a gynae- between each child. One of the determinants in sexual and cological examination in some other context, but there reproductive health is unprotected sex. Unprotected sex then needs to be access to information about the previous can lead to unwanted pregnancies and sexually transmit- screening in order to avoid screening taking place too fre- ted infections [196]. quently. Women who have not taken part in screening for some 39 . CERVICAL CANCER SCREENING time should be sent reminders, with the next step being to Human papilloma virus (HPV) is the most common sexu- make contact by telephone to encourage them to attend. ally transmitted infection in Sweden and the rest of the In some places there is also the opportunity to perform world. In most cases, HPV infection has no symptoms and screening in the home, which has been shown to increase is self-limiting. However, this infection can also give rise the screening rate. Previous experience of poor treatment to genital warts or gynaecological cell changes that may by the healthcare system can lead to women not partici- lead to cervical cancer [197]. pating in screening. Condoms are a relatively secure form of protection Other interventions that are effective are informa- against sexually transmitted HPV, but the infection can tion initiatives targeting areas with a low screening rate also be transmitted through skin contact. It is therefore through local information channels and established in- important that the condom covers the whole area of skin stitutions, as well as general information and marketing. where an infected person has genital warts. Free screening and invitations containing information in There are two vaccines against HPV, but they are not able to cure an existing infection and are thus preferably given prior to the commencement of sexual activity. Since 1 January 2010, vaccination against HPV has been included 39.1 – : Women aged 23–60 who have undergone in the childhood vaccination programme and is offered by gynecological cervical screening within recommended intervals. school health services to girls in years 5–6. Per cent However, it is important that the women who are vac- 90 cinated also participate in regular cervical cancer screen- ing as the vaccine does not protect against all types of HPV 85 that can cause cancer. Consequently, screening will con- tinue to be a very important complement to vaccination 80 in the defence against this disease. In Sweden, all women aged 23–50 are invited to participate in cervical cancer screening once every three years. Screening takes place 75 every five years for women aged 50–60. Women who have both been vaccinated and are screened regularly are very 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 well protected against cervical cancer. Year Total Screening is an effective way of detecting cell changes and preventing cervical cancer; with the number of cases Source: National Quality Register for Cervical Cancer Prevention. 142 Regional Comparisons 2014: Public Health
languages other than Swedish can also be effective, even taken in the same way as before and then analysed for HPV. if these interventions have not been verified in the same If the HPV test is positive, a cytological analysis (cell ex- way as others [198]. amination) of the sample is performed. A new recommen- HPV vaccination is a good indicator, but data are not dation is expected to come at the beginning of 2015 once currently available because this only became an obliga- the evidence concerning the HPV test has been reviewed tory part of the childhood vaccination programme in 2011. and the National Board of Health and Welfare’s national In addition, not all those involved began this work at the screening council has adopted a position on this matter. same time. The hope is that it will soon be possible to monitor the HPV vaccination rate at the local and regional Two out of ten women do not participate in screening level. The screening rate varies between county councils and in The cervical cancer screening rate has been chosen as general it is lower in the major cities and higher in north- an indicator. The screening rate is the proportion of wom- ern than southern Sweden. The cervical cancer screening en in the population in the age groups in question who rate in the ages 23–60 was about 80 per cent for the whole have participated in one instance of screening within the of Sweden in 2013 and this has largely remained constant. recommended interval. The National Board of Health and No clear trend can be seen between the years compared Welfare is reviewing the recommendations for cervical for different county councils. The screening rate has de- cancer screening because a new method is now available creased in some county councils and has increased in that involves the sample being analysed initially using an others. HPV test. There is no difference to the woman, a sample is
39.2 – , : Women aged 23–60 who have undergone gynecological cervical screening within recommended intervals, 2013.
Halland 90.5 Dalarna 89.9 Värmland 89.1 Västra Götaland 87.6 Gävleborg 86.5 Jämtland 85.9 Kalmar 85.7 Västernorrland 85.6 Jönköping 85.6 Norrbotten 83.9 Blekinge 82.5 Västerbotten 81.7 Västmanland 81.2 Sörmland 80.5 SWEDEN 80.5 Örebro 79.4 Östergötland 76.9 Gotland 76.4 Skåne 76.2 Stockholm 74.8 Kronoberg 70.0 Uppsala 66.4 0 20 40 60 80 100
2013 2009 Per cent Source: National Quality Register for Cervical Cancer Prevention. Lifestyle and living habits 143
40 . UNPROTECTED SEX – CHLAMYDIA There are differences between county councils in the Klamydia Chlamydia is caused by a bacterium, Chlamydia rate of testing and the number of cases of chlamydia, trachomatis, which is found in the urethra and in the va- which indicates that there are opportunities to improve gina and cervix in women. It can also be found in the rec- prevention. As more women than men are tested in all tum and/or throat and is transmitted through unprotected county councils, more women are also diagnosed with intercourse and other sexual acts. The disease usually chlamydia than men. The majority of cases of chlamydia has no symptoms and can therefore be difficult to detect. in men are discovered via contact tracing, which clearly Any symptoms primarily appear in the form of burning indicates that there needs to be more effective ways to and irritation when urinating due to an inflammation in reach men than those used today [202]. the urethra [199]. A chlamydia infection can lead to com- Chlamydia infection is classified by the Communicable plications that reduce fertility [200–203]. Early diagnosis Diseases Act as a disease that is harmful to public health and treatment of chlamydia reduces the risk of complica- and cases that are detected are reported using anonymised tions, future ill-health and the cost to society related to data to the communicable diseases doctor in the county the infection [204]. It is difficult to conduct international council and the Public Health Agency of Sweden. In addi- comparisons of the incidence of chlamydia as relatively tion, there is an obligation to trace the infection in cases few countries have classified it as an infection that must of chlamydia. be reported. In addition, the infection is seriously under- Since 2007, the chlamydia trend has been unchanged at reported in some countries. Sweden, Norway, Denmark, the national level, but with large variations between coun- Finland, the Netherlands and the United Kingdom have ties. The biggest reduction has taken place in the 15–19 age good, reliable reporting systems for diagnosed cases of group. The results show a higher incidence of chlamydia chlamydia and these countries thus account for 95 per among women. As described above, however, more wom- cent of all reported cases in the EU [205]. en get tested and this explains why fewer men are diag- In 2013, a total of 35 885 cases of chlamydia were re- nosed with chlamydia. This means that the actual epide- ported in Sweden, which was a reduction of 4.7 per cent on miological situation may involve small or no differences the figure for 2012. Just over half (57 per cent) of the cases between the sexes, which should be taken into account were women and their median age was 21. The median age when interpreting these results. As chlamydia is reported among men was 23. In 2013, 22 cases of lymphogranuloma using anonymised data, it is not possible to conduct any venerum (LVG) were reported. This is a particularly serious analysis relative to educational level. However, there is a form of chlamydia infection. All those who contracted LVG large study of Swedish young people about self-reported were men who have sex with men [206]. knowledge, attitudes and behaviours [207] that shows a Unprotected sex and having multiple partners increas- link between sexual risk-taking and social vulnerability es the spread of infection. Currently, about 24 per cent of and general risk-taking lifestyle. young people (15–24) state that they always use a condom. Just under four in ten say that they rarely or never use a condom and condom use has decreased in recent years. Younger men are those who are most likely to state that they always use a condom [207]. Young people’s propen- sity for using condoms generally decreases with advanc- 40.1 – : Cases of chlamydia infection per 100 ing age [207, 208]. 000 inhabitants, 15–29 years old. The national action plan for chlamydia prevention is an Number per 100 000 inhabitants important governance document that supports a goal-ori- 4 000 ented approach and the coordination of interventions at various levels in society [209, 210]. It is meant to help those 3 000 involved see which interventions they need to implement and prioritise. Communicating information about health 2 000 promotion and improved education for young people in schools are among the most important preventative in- 1 000 terventions in the action plan. Municipalities are also re- sponsible for various services for young people and share 0 responsibility for guidance centres for young people with 2008 2009 2010 2011 2012 2013 county councils. County councils are also responsible for Year Total Women Men the control of infectious diseases and for contraceptive ad- Source: Public Health Agency of Sweden. vice [210]. 144 Regional Comparisons 2014: Public Health
40.2 – , : Cases of chlamydia infection per 100 000 inhabitants, 15–29 years old, 2013.
Kronoberg 1 700 Skåne 1 754 Kalmar 1 766 Jönköping 1 783 Västerbotten 1 800 Västra Götaland 1 837 SWEDEN 2 018 Uppsala 2 025 Östergötland 2 050 Blekinge 2 054 Stockholm 2 060 Halland 2 167 Norrbotten 2 192 Västmanland 2 223 Västernorrland 2 230 Dalarna 2 245 Örebro 2 267 Sörmland 2 344 Värmland 2 382 Gävleborg 2 473 Jämtland 2 930 Gotland 3 442 0 1 000 2 000 3 000 4 000
Number per 100 000 inhabitants Source: Public Health Agency of Sweden. 2013 2009
40.3 – , : Cases of chlamydia infection per 100 000 inhabitants, 15–29 years old, 2013.
Skåne 1 110 Kalmar 1 171 Uppsala 1 190 Jönköping 1 214 Kronoberg 1 218 Östergötland 1 240 Västra Götaland 1 263 Halland 1 277 SWEDEN 1 305 Västerbotten 1 316 Stockholm 1 317 Värmland 1 349 Blekinge 1 362 Västmanland 1 370 Dalarna 1 391 Norrbotten 1 436 Västernorrland 1 485 Sörmland 1 517 Örebro 1 534 Gävleborg 1 578 Jämtland 1 942 Gotland 2 148 0 1 000 2 000 3 000 4 000
Number per 100 000 inhabitants. Source: Public Health Agency of Sweden. 2013 2009 Lifestyle and living habits 145
41 . UNPROTECTED SEX – TEENAGE and advice in conjunction with the abortion is therefore ABORTIONS important [223]. Studies show that the use of a coil fol- The public health policy includes reducing unwanted lowing an abortion reduces the risk of repeated abortions teenage pregnancies as there is a link between becoming a [224, 225]. teenage mother and socioeconomic vulnerability. Having The services provided by guidance centres for young children in your teens can also have a detrimental impact people vary across the country and the county councils on the health of both the mother and the child [211–215]. have different policies with respect to financial subsidies However, not all teenage mothers and their children suf- for contraceptives [196]. However, national efforts are un- fer from ill-health, although the risk is greater for these derway to coordinate these interventions and even out groups as a whole. The overall aim is for all children who unfair inequalities within this area. The National Board of are born to be wanted. Health and Welfare and the Public Health Agency of Swe- About 110 000 children are born and 35 000–38 000 den submitted a final report on a government commission abortions are carried out in Sweden each year. Women can in September 2014; a proposal for a national strategy for choose to terminate a pregnancy because they do not want sexual and reproductive health and rights. In addition, to or are unable to take care of (more) children, because the the National Agency for Education is working to improve timing is unsuitable or because the relationship with their teaching about sex and relationships in schools [226]. partner is problematic [217, 218]. An abortion is regarded as In prevention involving teenagers who have become a human right in Sweden and one that is protected by law. pregnant, it is also important to ensure that support is This means that the primary aim is not to prevent abor- provided to those who choose to go through with their tions, but to prevent unwanted pregnancies. Sweden has pregnancy. Research shows that teenage mothers feel they a higher rate of teenage abortions than the other Nordic receive less support from those around them, have lower countries. Abortion legislation and the practicalities of self-esteem and report more depressive symptoms that prevention vary between countries [219]. older mothers, which is a factor that can have a detrimen- The average age of women having their first child in tal impact on their parenthood. Consequently, researchers Sweden has increased from around 24 in 1975 to around believe that early interventions are important to pregnant 28 in 2012. The birth rate among teenagers has remained teenagers, for example psychosocial support and lifestyle at the same level for the past ten years having previously interventions [215]. been decreasing for many years. In 2012, almost 6 chil- dren were born per 1 000 women aged 15–19. The number of teenage abortions is decreasing in Sweden. In 2012, the abortion rate was 18.8 per 1 000 women aged 15–19. This 41.1 – : Abortions among women under 19 years is a reduction of 5.1 per cent, compared with the previous of age per 1 000 women 15–19 years old, 2012. year, when the abortion rate was 19.8 per cent. Abortions Number per 100 000 inhabitants 30 were more common in the 20–24 age group, followed by
25–29 and 30–34, than in the teenage group 15–19 [215]. 25 Since the 1970s, Sweden has been working to prevent 20 unwanted pregnancies, but there is no national action plan that takes into account interventions for different 15 target groups [196]. Today there is obligatory teaching about sex and relationships, good access to advice and a 10 wide range of contraception; despite this, about one third 5 of women seeking abortions have not used any form of 0 contraception [220, 221]. However, many women are moti- 86 88 90 92 94 96 98 00 02 04 06 08 10 12 vated to use an effective method of contraception follow- Year Total ing an abortion [217, 222]. Increased use of contraception is Source: Abortion Statistics, the National Board of Health and Welfare. required to prevent unwanted pregnancy and discussions 146 Regional Comparisons 2014: Public Health
It is difficult to measure the number of unwanted pregnan- local changes can be the result of a small population, with cies, but many of these lead to an abortion. The proportion small changes in the number of abortions leading to rela- of abortions carried out is therefore seen as an indicator tively large changes in the statistics. In Sweden, there are of the incidence of unwanted pregnancies. Pregnancies limited register data about women seeking abortions and among women younger than 15 are included, but the aver- there is also a lack of knowledge about the men who are age population in the age group 15–19 has been used as the involved in pregnancies that end in an abortion. Several denominator. research studies do, however, show that there is an asso- ciation between socioeconomic factors and repeated abor- Abortions and socioeconomic factors tions [221, 227–230]. Similar results exist for men who have The results show that the proportion of abortions among been involved in pregnancies that have ended in abor- teenagers has decreased between the measurement peri- tions [231, 232]. The proportion of those teenagers seeking ods, but there are large variations between counties and abortions who have previously had an abortion has been between municipalities. It is important to emphasise that around 16–17 per cent in recent years..
41.2 – , : Abortions among women under 19 years of age per 1 000 women 15–19 years old, 2012.
Jönköping 13.4 Halland 13.7 Örebro 15.2 Östergötland 15.3 Blekinge 15.4 Kronoberg 15.5 Skåne 15.8 Uppsala 17.2 Västerbotten 17.5 Kalmar 17.6 Västra Götaland 17.9 Västmanland 18.5 Norrbotten 18.7 SWEDEN 18.8 Jämtland 19.4 Dalarna 19.5 Västernorrland 21.6 Stockholm 21.7 Sörmland 23.4 Värmland 23.6 Gotland 24.6 Gävleborg 26.5 0 10 20 30 40
2012 2008 Number per 100 000 inhabitants. Source: Abortion Statistics, the National Board of Health and Welfare. Lifestyle and living habits 147
¡¢£ 41.3 ¤ ¥¡¦§¨©ª«£¬: Abortions among women under 19 years of age per 1 000 women 15¤19 years old, 2010¤2012.
Alingsås Skinnskatteberg Malung-Sälen Ale Habo Klippan Ånge Norrtälje Bollebygd Härryda Katrineholm Östhammar Gnosjö Vindeln Helsingborg Årjäng Vårgårda Gnesta Pajala Avesta Mullsjö Öckerö Fagersta Nykvarn Örkelljunga Partille Oskarshamn Mellerud Orsa Växjö Strömsund Karlsborg Lekeberg Värnamo Falun Lessebo Lomma Mariestad Kumla Kramfors Linköping Bromölla Vännäs Säter Ovanåker Överkalix Osby Älvdalen Ljungby Karlskrona Tanum Huddinge Kävlinge Uppsala Enköping Håbo Svalöv Lysekil Österåker Boden Ödeshög Storuman Hjo Hudiksvall Munkedal Ronneby Arvidsjaur Åre Jokkmokk Örebro Söderhamn Sollefteå Vetlanda Hallstahammar Götene Skurup Essunga Smedjebacken Vallentuna Hällefors Kungsör Sollentuna Trollhättan Sundsvall Hammarö Alvesta Åmål Bengtsfors Knivsta Övertorneå Degerfors Stockholm Tranemo Hässleholm Kinda Dals-Ed Borgholm Sjöbo Södertälje Flen Grästorp Eslöv Ljusdal Uppvidinge Tomelilla Mjölby Torsås Vansbro Eskilstuna Arboga Köping Vingåker Falköping Botkyrka Mönsterås Kungsbacka Nordmaling Gävle Ulricehamn Nora Vänersborg Trosa Herrljunga Lidköping Nacka Sorsele Heby Orust Valdemarsvik Tyresö Höganäs Skövde Borås Krokom Vellinge Falkenberg Robertsfors Nordanstig Malå Strömstad Sigtuna Åstorp Gislaved Skellefteå Järfälla Emmaboda Nässjö Båstad Älvsbyn Hultsfred Rättvik Tjörn Göteborg Arvika Eksjö Perstorp Hallsberg Filipstad Ystad Varberg Värmdö Bjuv Åtvidaberg Karlstad Motala Åsele Markaryd Bollnäs Nyköping Oxelösund Boxholm Svenljunga Mörbylånga Strängnäs Sävsjö Landskrona Färgelanda Älmhult Kristianstad Bräcke Salem Örnsköldsvik Mölndal Kalix Hofors Sotenäs Töreboda Tidaholm Borlänge Tingsryd Aneby Umeå Bjurholm Vara Halmstad Tierp Vaxholm Höör Sala Luleå Kiruna Söderköping Mark Mora Gotland Lund Jönköping Västervik Kil Olofström Lidingö Hylte Solna Tranås Östersund Burlöv Dorotea Danderyd Ekerö Norsjö Berg Norberg Vadstena Hedemora Haparanda Vaggeryd Lerum Östra Göinge Lilla Edet Ängelholm Laxå Vimmerby Sundbyberg Simrishamn Piteå Hörby Kristinehamn Gullspång Trelleborg Sandviken Upplands Väsby Leksand Svedala Ludvika Torsby Kalmar Härnösand Kungälv Nynäshamn Sölvesborg Ockelbo Ljusnarsberg Storfors Finspång Tibro Norrköping Täby Västerås Malmö Forshaga Karlshamn Laholm Upplands-Bro Haninge Högsby Nybro Gällivare Timrå Gagnef Vilhelmina Karlskoga Grums Stenungsund Lycksele Sunne Ragunda Askersund Hagfors Älvkarleby Arjeplog Lindesberg Eda Härjedalen Munkfors Skara Uddevalla Surahammar Ydre 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 Number per 100 000 inhabitants SWEDEN 2010–2012 2007–2009 1 Numbers lower than 4 abortions are not presented.
Source: Abortion Statistics, the National Board of Health and Welfare.
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Appendix 1 Processing data from public health surveys
The government commission states that the report should be based to the greatest possible extent on indicators and The national selection alone is used for comparisons results from the national public health survey (HLV), but at the county council level. In this case the dataset is suf- also other sources of data. ficiently large and does not need to be supplemented with The national selection from the HLV is not sufficiently data from supplementary selections or regional surveys, large to be reported at the municipal level; therefore, the which means that the figures are more comparable. Conse- complementary selections provided by municipalities and quently, data used in regional syntheses differs from those county councils, which order and fund these themselves, that appear in the report. In the regional context, it is pos- are used. However, these supplementary selections are not sible to use a broader and better dataset that can be used made each year and they also vary in size between county advantageously for break-downs, analyses and point esti- councils, making the process of breaking down this data mates. complex. Nevertheless, when reporting at the municipal In conjunction with the municipal and county council level, the benefit of the supplementary selections is judged comparisons, average values that are calculated for four-year to outweigh the problems involved in using them. How- periods are used in order to get a sufficiently large dataset. A ever, some municipalities only provide very small supple- one-year period is used for the regional surveys as these are mentary selections or none at all. This applies primarily to not performed as frequently. Data from public health sur- municipalities that have regional public health surveys. In veys is presented in the report without age standardisation order to get as many municipalities as possible into the re- as the standardisation that was used previously can affect port, data from these regional public health surveys is also the individual values, making them misleading. This is also used, provided the questions are identical or judged to be consistent with the Public Health Agency of Sweden’s con- equivalent and that there are data available in the measure- tinuous reporting of the results of the HLV. Consequently, ment period 2011–2014. These municipalities have been all indicators from the HLV are divided up into a number of marked in the presentations in order to show that the data different age groups in order to support the interpretation comes from a source other than the HLV. The measure- of the influence age has on outcome. A limit has also been ments differ in several ways aside from the construction of chosen, requiring there to be a minimum of 100 responses the question. In this project, no analysis of other factors that to the survey for the data to be reported. This is consistent disrupt comparisons has been performed, for example dif- with the reporting of the HLV by the Public Health Agency ferences in the order of questions, the response options in of Sweden. Other assessments have been made for other in- the survey or differences in measurement periods and age dicators with other data sources. One reason for choosing a groups. Accordingly, the comparisons are primarily limited higher limit here is that a larger dataset is required for the to each survey itself. calibration carried out to compensate for drop-out.
REGIONAL COMPARISONS 2014 Public Health
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NATIONAL BOARD OF HEALTH AND AND HEALTH OF BOARD NATIONAL WELFARE www.socialstyrelsen.se/publikationer Article number: 2015-9-2 978-91-7555-336-8 ISBN: [email protected]: 75 29Fax: +46(0)35-19 Regional Comparisons 2014: Public Health can be Health downloaded Public 2014: or Comparisons ordered from:Regional The aim of this report is to contribute to systematic, long-term improvements improvements long-term systematic, to contribute to report is this of The aim health. public improving to thus and level local and regional the at services in Public Health Public lifestyle and health population’s the concerning results report presents This indica new several with been expanded, report also has year’s This habits. indicators 41 total, In conditions. living and conditions social concerning tors example, for concerning, outcomes various highlight that presented are education, disease and mortalityhealth, the and for population’s outcomes improvement an show indicators Many relationships. social and life working 2009. year, comparison previous the with compared level, national the at For the second time, the National Board of Health and Welfare, the Public Public the Welfare, and Health of Board National the time, second the For Authorities Local of Association Swedish the and Sweden Agency of Health The health. public of field the in comparison a regional present Regions and 2009. in was published comparison previous Regional Comparisons 2014 Comparisons Regional