Background: Revising existing health related-quality of life (HRQoL) instruments used among adults with the intention of making them child-friendly enables the collection of similar HRQoL data in children, adolescents and adults. The aim of this article is to describe and discuss the development process of a Swedish child-friendly pilot version of the EQ-5D instrument. 

Methods: We modified the existing Swedish EQ-5D adult version to make it child-friendly. Within a multidisciplinary research group, we investigated linguistic and interpretation issues by performing face-to-face and group interviews with children and adolescents aged 6–17 years. 

Results: The first modification of the adult language was to change single words into words intelligible to and used by children [e.g. changing ‘depression’ (depression) into ‘ledsen’ (sad)]. The second related to whole expressions (using verb-form in the headings of dimensions).

Conclusion: The advantage of being able to collect much the same data from children and adolescents, for example in population surveys covering all ages and in chronic childhood diseases, as for adults might outweigh possible disadvantages of modifying existing HRQoL instruments. The Swedish child-friendly EQ-5D pilot version resulting from this development process is further tested for feasibility and construct validity in a clinical interview study; initial results are reported in a subsequent paper.

BACKGROUND:

There is an increasing interest in studying health-related quality of life in children and adolescents. A Swedish child-friendly pilot version of the EQ-5D instrument has been developed. The aim of this article is to report on its assessment of feasibility and discriminative validity.

METHODS:

A questionnaire with the child-friendly pilot version was addressed during a clinical examination to 260 children aged 8 years and 230 children aged 12 years. Comprehensibility and acceptability were investigated and feasibility was assessed according to missing and ambiguous answers. Discriminative validity was investigated by determining whether groups that were a priori known to differ in health status (by clinical and socio-demographic characteristics) were distinguished also by the percentage of reported problems on the five health dimensions and by visual analogue scale (VAS) scores.

RESULTS:

Feasibility was supported for self-completion in the presence of an interviewer. Discriminative validity was supported as children with asthma or rhinitis, severe illness or handicap, having consulted health care during the past 3 months, overweight and obesity and children with a parent born outside the Nordic countries reported more problems and had lower VAS scores.

CONCLUSIONS:

The results of the initial testing of the Swedish child-friendly pilot version of the EQ-5D instrument indicate feasibility and discriminative validity. However, further research should explore alternative modes of administration and study design, and be performed in groups with a larger proportion with diseased children.

Background: The importance of resilience factors in the positive adaptation of refugee youth is widely recognised. However, their actual mechanism of impact remains under-researched. The aim of this study was therefore to explore protective and promotive resilience mechanisms on both negative and positive mental health outcomes. Promotive resilience is seen as a direct main effect and protective resilience as a moderating effect.

Methods: Cross-sectional study with 160 Syrian youth aged 13-24 years, who recently resettled in Norway. A multi-dimensional measure for resilience was used to explore the potential impact of resilience factors on pathways between potentially traumatic events from war and flight (PTE), post-migration stress, mental distress and health-related quality of life (HRQoL). Analyses included regression, moderation and moderated mediation using the PROCESS macro for SPSS.

Results: A direct main effect of resilience factors (promotive resilience mechanism) was found for HRQoL and general mental distress, but not for post-traumatic stress disorder (PTSD). No moderating effects of resilience factors (protective resilience mechanism) were found. Post-migration stressors mediated the effects of PTE, and this indirect effect was present at all levels of resilience. Relational and environmental level resilience factors and combined amounts had more impact than individual level factors.

Conclusions: Despite high risk exposure and mental distress, resilience was also high. The direct main effect of resilience factors and less impact on PTSD, suggests universal resilience building interventions may be beneficial, compared to exclusively targeting groups with high symptom levels. These interventions should target relational and environmental resilience factors as well as individual coping techniques. Additionally, reducing current stress and symptoms could increase the efficacy of resilience factors already present.

BACKGROUND: Most refugees and other forced migrants have experienced potentially traumatic events (PTEs). Torture and other traumatic experiences, as well as various daily stressors, impact the mental health and psychosocial well-being of war-affected populations.

METHODS: The study includes two population-based samples of Iranian and Iraqi men living in Finland and Sweden. The Finnish Migrant Health and Well-being Study (Maamu) was conducted in 2010-2012. The Linköping study was conducted in Sweden in 2005. In both samples, health and well-being measures, social and economic outcomes as well as health service utilization were reported.

RESULTS: The final sample for analysis consisted of two groups of males of Iranian or Iraqi origin: 278 residents in Finland and 267 residents in Sweden. Both groups were subdivided according to the reported PTEs: Torture survivors; Other PTEs; No PTEs. Migrants that reported PTEs, torture survivors in particular, had significantly poorer social and health outcomes. Torture survivors also reported lower trust and confidence in authorities and public service providers, as well as more loneliness, social isolation and experiences of discrimination.

CONCLUSIONS: Torture and other PTEs prevalent in refugee and migrant populations create a wide-ranging and long-term impact in terms of increased risk of various types of adverse social and health conditions. Early identification through systematic and effective screening should be the first step in guiding migrants and refugees suffering from experiences of torture and other PTEs to flexible, multidisciplinary services.

Background: Past exposure to violence has been suggested to have a lasting effect on subjective well being (SWB). Similarly, family conflict is another known predictor of SWB. Research shows that refugee women exposed to gender based violence (GBV) before resettlement may also face post-resettlement family conflicts due to socio-cultural factors, changes in social network and migration-based shifting gender roles. This study examines the role of family conflict as a likely mediator between past exposure to violence and SWB among Syrian refugee women in Sweden.

Methods: A total of 452 women out of a random sample of 1215 Syrian refugee women in Sweden responded to a questionnaire survey in Arabic. Variables include Past violence i.e. exposure to any of torture, physical or sexual violence preflight or during flight before arriving Sweden; Post-resettlement distressing family conflicts i.e. feeling disrespected or unimportant in the family or distressing conflicts; SWB was measured by WHO-5 wellbeing index. Maximum likelihood estimation with Robust standard errors and bias corrected bootstrapped 95% confidence intervals for all estimates.

Results: Total effect of past violence on SWB was significant (Estimate = -6.63; CI = -12.73 - -0.46). Similarly, family conflicts were associated with decreased SWB (Estimate = -3.80; CI = -5.17 - -2.40), and past violence exposure increased family conflicts (Estimate = 0.57; 0.13 - 1.08). The total effect of violence exposure on decreased SWB was decomposed into a direct and an indirect effect (mediated via family conflicts). The indirect effect via family conflicts was significant (M = -2.19; C1 = -4.30 - 0.59), while decomposing rendered the direct effect non-significant (Estimate = -4.44, CI = -10.51 - 1.52).

Conclusions: Post-resettlement distressing family conflicts mediate the effect of prior exposure to violence on reduced SWB among refugee women.

Key messages: Past violence exposure reduces refugee women’s SWB via aggravated family conflicts implying the need for family targeted interventions to improve SWB of female refugees previously exposed to violence. Strategies to improve subjective wellbeing among female refugees should include screening for and addressing all forms of previous and ongoing GBV

Background

Large numbers of refugees have come to Europe in search of safety. For non-refugee migrants, expectations and the extent to which they are met are shown to be integral components of adaptation and wellbeing. This study aims to explore the prevalence of low expectations for labour market, economic and social integration among Syrian refugees recently resettled in Sweden and whether depression is associated with these expectations.

Methods

A random sample of 1215 Syrian refuges of working age recently resettled in Sweden responded to a questionnaire in Arabic. Expectations were assessed by three items developed for this study. Average item score of >1.80 on the depressive symptoms in Hopkins Symptom Checklist indicated depression. Logistic regressions adjusted for demographic factors and social support were conducted. Weighted data was used to produce socio-demographically representative prevalence rates and odds ratios (ORs). Robust standard errors were used to obtain 95% confidence intervals for all estimates.

Results

Prevalence of low economic, social and labour market expectations were 14.1% (95% CI 12.0-16.1), 13.4% (11.3-15.4) and 10.9% (9.1-12.6) respectively. Approximately 40.2% (36.9-43.3) of the participants had depression. Those with depression were about four times more likely to have low economic expectations (OR 3.89, 95% CI 2.66-5.92), three times more likely to have low social (OR 3.1, 2.30-5.24), and labour market (OR 2.83, 1.90-4.47) expectations.

Conclusions

Low expectations, while not widespread, exist among Syrian refugees in Sweden. Notable proportions had depression which was also significantly associated with low expectations. The association between depression and low expectations in keys areas necessary for adaptation and wellbeing in a new land, indicates the need to address mental health issues in current societal level efforts aimed at boosting labour market participation and social inclusion.

Key messages:

• Notable proportions of Syrian refugees in Sweden have low expectations in domains vital for adaptation and wellbeing in a new land. Depression is significantly associated with low expectations.

• Low expectation among Syrian refugees in domains vital for adaptation and wellbeing and the association with depression indicate need to address mental health in social and labour market interventions.

Background Refugee women are at more risk of a continuum of violence, pre, during and post flight. After resettlement, increased family conflicts are likely, due to shifts in gender roles and changing family structures. Prevalence estimates, however, remain scarce especially for Syrian refugee women in Europe. Given that exposure to violence is a substantial risk factor for ill health and poor adaptation, this study aims to estimate the prevalence of violence in different phases of flight and associated sociodemographic factors. Methods The study is based on a random sample of 452 Syrian refugee women resettled in Sweden. Exposure to violence was operationalised as having been a victim of torture, physical or sexual violence, pre and during flight; witnessing violence was operationalised as experiencing war at close quarters, witnessing physical violence, or forced separation from loved ones, pre and during flight; family conflicts was operationalised as experiencing distressing conflicts in the family since resettlement. Descriptive analysis were conducted to estimate prevalence and logistic regression to assess associations. Weighted data produced socio-demographically representative estimates. Robust standard errors were used to obtain 95% confidence intervals for all estimates. Results About 25.1% (95% 20.9 – 29.4) of the women were exposed to violence preflight, 7.8% (95% 5.2 – 10.4) were victims during flight. Up to 93.3% (95% 90.7 – 95.9) witnessed violence preflight, 67.2% (95% 62.6 – 71.8) during flight. About 34.2% (95% 29.7 – 38.7) are experiencing distressing family conflicts.Logistic regressions showed no significant difference after controlling for age, education and marital status. Conclusions The magnitude of violence and ongoing family conflicts calls for a closer look at the plight of refugee women.Violence is widespread and not specific to any sociodemographic group, an important finding for healthcare and public health workforce to take note of. 

In response to the increased demand from the public health labour market, various bachelor and master programmes have been developed in recent years throughout Europe. As an example, in the European ASPHER survey 18 Schools and Departments of Public Health delivered 977 bachelor degrees per year (2011/12) with a median of 55 per institution. The expectations of – present and potential - employers of professionals, trained in public health, are largely unknown. However, in comparison to the attention paid and the knowledge generated around postgraduate/master education in public health, still relatively little is known about the provision of bachelor degrees. Furthermore, while real efforts have and are made to define professional and academic frameworks, including accreditation schemes for master programmes, the roles, practices and competences for bachelor programmes are somehow blur. This presentation will report on the work of the ASPHER's Working Group on Undergraduate Public Health Education in Europe aiming to promote collaboration initiatives on bachelor programmes across Europe among academic institutions, share best practices and generate knowledge on employability and career progression of public health bachelor graduates. In particular, the results of the survey carried out by ASPHER across over 100 schools of public health in early 2014 will be presented bringing up the current and full picture as regards the undergraduate education in Public Health in Europe.

BACKGROUND: Despite common mental disorders (CMDs) being a main reason for preterm exit from the labour market, there is limited knowledge regarding healthcare use around the time of being granted disability pension (DP) due to CMD. The aim was to study specialized healthcare use before and after being granted DP due to CMD and whether these trajectories differed before and after changes in DP granting criteria in Sweden in 2008.

METHODS: Included individuals lived in Sweden, aged 19-64 years with incident DP due to CMD before (wave 1, 2005-06, n = 24 298) or after (wave 2, 2009-10, n = 4056) the changes in 2008. Healthcare trajectories during a 7-year window were assessed by generalized estimating equations. Between- and within-wave differences were examined by interaction models.

RESULTS: Psychiatric healthcare increased until the year preceding DP and declined thereafter, with one exception; such outpatient care kept increasing in wave 1 following DP. In the year preceding DP, 4.6 and 19.2% of the individuals in wave 1 had psychiatric in- and specialized outpatient care, respectively, compared with 7.9 and 46.6% in wave 2. No clear pattern was observed regarding somatic healthcare. The slopes of the different DP waves differed mainly during DP granting years (1 year prior to 1 year after), showing a sharper decline in wave 2.

CONCLUSION: Transition to DP due to CMD seems to be associated with changes in psychiatric healthcare use, with higher rates in the year preceding DP. Outpatient healthcare patterns somewhat differed among those granted DP after stricter rules were introduced.

The current protracted economic crisis is giving rise to the scarcity of public health resources across Europe. In response to budgetary pressures and the Eurozone public debt crisis, decision-makers resort to a short-term solution: the introduction of austerity measures in diverse policy fields. Health and social policy tend to be easy targets in this regard and budget cuts often include a reduction of healthcare expenditure or social welfare benefits. We suggest incorporating discussions from the field of ethics in policy making processes and in the academic debate on austerity. This includes recognising procedural justice as a social value. On the road to economic recovery, governments are compelled to resort to fiscal consolidation and austerity packages but decisions taken to save our European ships in crisis should be anchored in values such as (procedural) justice, equity and solidarity.

Background Due to health effects from participating in physical activity (PA) it is from a public health perspective important to study how participation PA may change over a lifetime and how different life events impact on the participation. Although studies in the field are sparse, parenthood has been found to be a life event associated with decreased PA, especially among women. We studied physical activities performed among women and men with and without children. Methods This study includes data for from parents-to-be, 224 women and 208 men, from Karlskrona municipality, situated in the south eastern part of Sweden. Data collection was carried out during 2008–2009. When contacting the antenatal clinics in the municipality all expectant parents were asked by the midwife about participation in the study. Respondents completed a questionnaire about age, socioeconomic status, level of education, previous children, smoking and alcohol habits, Body Mass Index, self estimated health, and participation in different kinds of outdoor and indoor recreational PA. We measured the self-reported amount of outdoor recreational PA undertaken during the last year. Results Both women and men without children performed more outdoor and indoor PA compared to those who had children. Women walked significantly more (p = 0.017) than men irrespective of whether or not they had children. Women with children participated in significantly more gardening (p = 0.009) and winter sports (p = 0.013) than women without children, and women without children participated in significantly more PA indoors (p = 0.001) than women with children. Men with children participated in significantly more gardening (p = 0.001) than men without children, and men without children participated in significantly more PA indoors (p = 0.006). Conclusions Becoming a parent is a life event that affects participation in PA, both concerning duration and the kind of activities performed. To gain deeper understanding and more insight about reasons for these changed patterns of PA as well as the effects on the outcome of the parents health in a short- and long term would be important to follow prospectively.

Background. In 2002, 2 cases of tick-borne encephalitis were diagnosed among inhabitants living in a tick endemic area on the island of Aspö in south-eastern Sweden. During the previous 25 years, only 2 additional cases had been diagnosed in that region of Sweden. To study presence and evolution of seroprevalence of antibodies to the tick-borne encephalitis virus we carried out a follow-up study, comparing inhabitants´ immunoglobulin G antibody levels against the virus in blood samples drawn in 1991 and 2002. Method. The island of Aspö is located in the south-eastern archipelago by the Baltic Sea in the county of Blekinge, Sweden. Due to the confirmed cases of tick-borne encephalitis, permanent and part-time residents were offered tick-borne encephalitis vaccination in the autumn of 2002. Blood samples were collected and analyzed by the two-step enzyme-linked immunosorbent assay to detect immunoglobulin G antibodies against tick-borne encephalitis virus. Also, questionnaires including questions about sex, age, earlier history of and previous vaccination against tick-borne encephalitis, residency on Aspö, history of observed tick-bites and earlier history of Lyme borreliosis and human granulocytic erhlichiosis, was filled in. All those individuals who had participated in a study on LB performed in 1991, and where available blood samples made it possible to compare tick-borne encephalitis immunoglobulin G seroprevalence, were included in the follow-up. Results. A significant increase in immunoglobulin G levels was seen during the follow-up with 24 (12.0%) of 200 blood samples being seropositive in 2002 versus 7 (3,5%) of 200 blood samples in 1991. However, only five participants converted from seronegative level during the 11 y follow-up and one of these participants had been vaccinated against tick-borne encephalitis during the observation period. In only four of all positive sera from 2002 and in no sera from 1991, were neutralizing antibodies against tick-borne encephalitis virus demonstrated. Compared with women, significantly more men were seropositive. In comparison with other age groups the greatest increase was seen in the age group 20 to 29 years. However, most seropostive levels were seen among those >50 years. Conclusion. Although we found seropositive blood samples in this area already in 1991, the existence of tick-borne encephalitis virus at that time is doubtful since no neutralizing antibodies against tick-borne encephalitis virus were demonstrated. During the 11 years follow-up an obvious increase of tick-borne encephalitis immunoglobulin G seropositive levels in humans was seen. Recommending preventing measures, including vaccination against tick-borne encephalitis is of importance for people regularly staying in this endemic area.

Background: Mental health service use has increased among the young.Trends in psychiatric hospitalizations might lend clues as to underlying causes influencing young peoples’ growing use ofpsychiatric services.

Methods: We calculated population-adjusted rates for seven broadcategories of ICD-10 psychiatric diagnoses for Swedishinpatients discharged 1997- 2011. We computed rates forages 13-74 overall, as well as six age strata: 13-17, 18-24, 25-29,30-44, 45-64 and 65-74 years, utilizing data from nationalregisters.

Results: The overall population-standardized rate of psychiatric hospitalizations did not change significantly over the 15-year period. Yet, children and young adults under age 30 sawnotable increases in inpatient psychiatric care, with ratesroughly doubling over the time period. Affective and anxietydisorders accounted for much of these increases, with curvi-linear increases in developmental and childhood behavioral disorders. Rates among older age groups were more stable,though all age groups saw increases in hospitalizations for anxiety disorders. Declines were seen for adults ages 30-44 for psychotic disorders. Adults ages 65-74 declined in hospitalizations for affective disorders while rising for all other age groupsduring this time.

Conclusions: Young adults ages 18-29 years have become the age group withthe greatest proportion hospitalized for psychiatric care. Adolescents and young adults under age 30 saw rises in ratesof psychiatric inpatient care, while at the same time, older age groups did not. A large portion of this increase is due to affective and anxiety disorders, warranting investigation into changes in outpatient care practices, severity, or perceivedseverity of these disorders among this age group.