Comprehensive Public Health Policy Research Articles

Age, period and cohort effects on body mass index in New Zealand, 1997–2038

Objective:To estimate the effects of age, period and birth cohort on observed trends, and to provide short‐ to medium‐term projections of population BMI in New Zealand. Methods:Data were obtained from New Zealand national health surveys covering the period 1997 to 2015 (n=76,294 individuals). A Hierarchical Age‐Period‐Cohort (HAPC) model and an Age‐Period model with interaction terms were specified for population groups defined by ethnicity and sex. Observed trends were extrapolated to estimate group‐specific BMI projections for the period 2015–2038; these were weighted by projected population sizes to calculate population‐wide BMI projections. Results:Population mean BMI increased from 26.4 kg/m2 (95%CI 26.2–26.5) in 1997 to 28.3 kg/m2 (95%CI 28.2–28.5) in 2015. Both models identified substantial, approximately linear, period trends behind this increase, with no significant cohort effects. Mean BMI was projected to reach 30.6 kg/m2 (95%CI 29.4–31.7; HAPC model) to 30.8 kg/m2 (95%CI 30.2–31.4; Age‐Period model) by 2038. Conclusions:BMI continues to increase in New Zealand. On current trends, population mean BMI will exceed 30 kg/m2 – the clinical cut‐off for obesity – by the early 2030s. Implications for public health:Unless prevented by comprehensive public health policy changes, increasing population obesity is likely to result in unfavourable economic and health impacts.

Addressing the social determinants of health at the local level: Opportunities and challenges.

The gradient in health inequalities reflects a relationship between health and social circumstance, demonstrating that health worsens as you move down the socio-economic scale. For more than a decade, the Norwegian National government has developed policies to reduce social inequalities in health by levelling the social gradient. The adoption of the Public Health Act in 2012 was a further movement towards a comprehensive policy. The main aim of the act is to reduce social health inequalities by adopting a Health in All Policies approach. The municipalities are regarded key in the implementation of the act. The SODEMIFA project aimed to study the development of the new public health policy, with a particular emphasis on its implementation in municipalities. In the SODEMIFA project, a mixed-methods approach was applied, and the data consisted of surveys as well as qualitative interviews. The informants were policymakers at the national and local level. Our findings indicate that the municipalities had a rather vague understanding of the concept of health inequalities, and even more so, the concept of the social gradient in health. The most common understanding was that policy to reduce social inequalities concerned disadvantaged groups. Accordingly, policies and measures would be directed at these groups, rather than addressing the social gradient. A movement towards an increased understanding and adoption of the new, comprehensive public health policy was observed. However, to continue this process, both local and national levels must stay committed to the principles of the act.

Public health policy in a time of change and disaster in South Africa: 1910-1920.

With the establishment of the Union of South Africa in 1910, the central focus of the newly appointed government was to alter and consolidate the policies of the pre-Union colonies that differed materially in many respects and to substitute them with uniform policies that had to be implemented as a consolidated whole for the Union. This central focus was applied to a number of policies, notably those for the black people, immigration, education, labour, national defence and the development and implementation of railway, mining and agricultural policies. However, an omission occurred with regard to the consideration of a comprehensive public health policy by the political parties and the Union Parliament, consisting of white people only. This article examines this omission during the first 10 years of the Union of South Africa (1910–1920), during the three 5-yearly general elections (on 15 September 1910, 20 October 1915 and 10 March 1920), and argues that this lack of consideration of a comprehensive public health policy can be found in the theory of party political responsible government during unification, which was further developed by Kavanagh, that party political manifestos act as the guiding force behind the policy matters that are discussed and decided upon in Parliament. The article confirms that the reason for not establishing a comprehensive public health policy prior to the outbreak of the influenza epidemic in 1918 was the incidental and piecemeal fashion in which expressions on public health appeared in the published party political manifestos, which in turn influenced the proceedings of Parliament. This political negligence was, however, quickly overturned by Parliament immediately after the epidemic, showing the influence of this demographic disaster on political thinking and action.

Harm Reduction: When Evidence Should Influence Health Policy

Harm reduction can be thought of as any program or policy designed to reduce drug-related harm without requiring the cessation of drug use. An example of a successful harm reduction strategy is the use of needle exchange programs or syringe exchange programs. Unfortunately, decisions may be made by policy makers that conflict with scientific literature and the abundance of evidence supporting such harm reduction measures. Evidence in favour of harm reduction strategies is robust, and their implementation is required in any comprehensive public health policy attempting to improve the well-being of society as a whole. This article examines the evidence supporting the efficacy of one such harm reduction strategy, namely, needle exchange programs; it also outlines a simple approach for medical students, residents, physicians, and other health care professionals to be involved in change on a global scale by discussing the Vienna Declaration as a tool for influencing evidence-based drug policy.

Beverage intake and obesity in early childhood: evidence form primary health care clients in Northwest Argentina.

Sugar sweetened beverages (SSB) are thought to play an important role in weight gain. We examined the relationship between the intake of caloric and noncaloric beverages (SSB and water) and the nutritional status of children. In 2014, we randomly selected 16 public health clinics in four cities of Northwest Argentina and conducted a survey among mothers of children 0-6 years of age. Children's beverage intake was ascertained by 24-h dietary recall provided by the mothers. Children's weight and height measures were obtained from clinic's registries. We calculated the body mass index using the International Obesity Task Force standards. The analysis included 562 children 25 months to 6 years of age with normal or above normal nutritional status. Children's beverage consumption was as follows, water 81.8%, carbonated soft drinks (CSD) 49.7%, coffee/tea/cocoa 44.0%, artificial fruit drinks 35.6%, flavored water 17.9%, natural fruit juice 14.5%. In multivariate logistic regression models the likelihood of being obese v. being overweight or having normal weight doubled with an intake of one to five glasses of CSD (OR=2.2) and increased by more than three-fold with an intake of more than five glasses (OR=3.5). Drinking more than five glasses of water decreased the likelihood of being obese by less than half (OR=0.3). The percentage of children drinking more than five glasses of other beverages was low (3.3-0.9%) and regression models did not yield significant results. The study contributed evidence for reducing children's CSD intake and for promoting water consumption, together with the implementation of comprehensive regulatory public health policies.

Vaping cannabis (marijuana): parallel concerns to e-cigs?

The proliferation of vaporization ('vaping') as a method for administering cannabis raises many of the same public health issues being debated and investigated in relation to e-cigarettes (e-cigs). Good epidemiological data on the prevalence of vaping cannabis are not yet available, but with current trends towards societal approval of medicinal and recreational use of cannabis, the pros and cons of vaping cannabis warrant study. As with e-cigs, vaping cannabis portends putative health benefits by reducing harm from ingesting toxic smoke. Indeed, vaping is perceived and being sold as a safer way to use cannabis, despite the lack of data on the health effects of chronic vaping. Other perceived benefits include better taste, more efficient and intense effects and greater discretion which allows for use in more places. Unfortunately, these aspects of vaping could prompt an increased likelihood of trying cannabis, earlier age of onset, more positive initial experiences, and more frequent use, thereby increasing the probability of problematic use or addiction. Sales and marketing of vaping devices with no regulatory guidelines, especially related to advertising or product development targeting youth, parallels concerns under debate related to e-cigs and youth. Thus, the quandary of whether or not to promote vaping as a safer method of cannabis administration for those wishing to use cannabis, and how to regulate vaping and vaping devices, necessitates substantial investigation and discussion. Addressing these issues in concert with efforts directed towards e-cigs may save time and energy and result in a more comprehensive and effective public health policy on vaping.

Antenatal and postnatal depression: A public health perspective

Depression is widely prevalent among women in the child-bearing age, especially during the antenatal and postnatal period. Globally, post-partum depression has been reported in almost 10% to 20% of mothers, and it can start from the moment of birth, or may result from depression evolving continuously since pregnancy. The presence of depression among women has gained a lot of attention not only because of the rising incidence or worldwide distribution, but also because of the serious negative impact on personal, family and child developmental outcomes. Realizing the importance of maternal depression on different aspects-personal, child, and familial life, there is a crucial need to design a comprehensive public health policy (including a mental health strategy), to ensure that universal psychosocial assessment in perinatal women is undertaken within the primary health care system. To conclude, depression during pregnancy and in the postnatal period is a serious public health issue, which essentially requires continuous health sector support to eventually benefit not only the woman, but also the family, the community, and health care professionals.

Cardiovascular Disease Risk Factors in the Hispanic/Latino Population: Lessons From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Cardiovascular disease (CVD) is one of the leading causes of mortality among Hispanics/Latinos residing in the United States (US), yet despite the rapid growth of this diverse population, there has been a dearth of objective, comprehensive data on prevalence of risk factors for CVD and other chronic diseases. The Hispanic Community Health Study/SOL) is the largest and most comprehensive cohort study to date/SOL) was initiated to address this gap in knowledge. This article reviews existing research on CVD risk factors among Hispanic/Latino adults of diverse background residing in the US, compares findings from HCHS/SOL with other representative samples on prevalence of major CVD risk factors in this population, and discusses the lessons learned thus far from HCHS/SOL. Baseline findings from this study demonstrate that sizeable burdens in CVD risk exist among all major Hispanic/Latino background groups in the US. At the same time, there are marked variations in rates of individual risk factors by Hispanic/Latino background groups. Comprehensive public health policies to lower CVD risk among those who have adverse levels of one or more risk factors, and to prevent development of CVD risk factors in the small proportion free of CVD risk are urgently needed to lower the future burden of CVD among the US Hispanic/Latino population.

Ethnic Disparities in Cardiovascular Risk Factors in Children and Adolescents

The pathogenesis of coronary atherosclerosis originates as early as childhood, and disparities in rates of cardiovascular disease (CVD) risk factors among children have been previously documented. This review of recently published studies on race/ethnicity-specific burden of risk factors among US children/adolescents highlights the persistent racial/ethnic variations in prevalence of CVD risk factors, with sizeable burdens of CVD risk among all race/ethnic groups. Non-Hispanic Black children had the highest rates of high blood pressure and obesity, while Mexican American children had higher diabetes rates and lowest rates of ideal fasting glucose levels. Non-Hispanic White children had lower rates of high blood pressure and higher rates of physical activity, but they experienced higher burdens of adverse lipid levels and cigarette smoking than others. Comprehensive public health policies addressing CVD risk in childhood are needed to lower the future burden of CVD.

Dietary Bioactives and Health: The Road Ahead

Dietary and nutritional guidelines are integral to creating comprehensive public health policies. Research on dietary bioactives that may promote human health has generated dramatic conceptual shifts in recent years due to the emergence of at least two key scientific paradigms: the role of epigenetics in nutrient–gene interactions and the influence of the gut microbiome. Dietary bioactives are an important component of public health research; however, because some areas of research are still in their infancy, the profound biological influences of underlying genetic, environmental (including the gut microbiome), and epigenetic events on public health frequently have been neglected. Some possible implications of our current understanding of the role of dietary bioactives are highlighted.

Abnormality of risk factors for atherosclerotic disease among young Japanese aged 19–39 years old: an evaluation of health checkup data

Japanese public health policies on the prevention of atherosclerotic diseases have focused on controlling obesity. The aim of this study was to assess the prevalence of abnormality in risk factors for atherosclerotic disease among young Japanese classified according to body mass index (BMI). Data were obtained from 359 men (mean age 32±5years) and 1,108 women (mean age 33±4years) between 2005 and 2010. Abnormal levels of aspartate aminotransferase, alanine aminotransferase, and/or gamma-glutamyltranspeptidase were considered to indicate liver dysfunction, and abnormal levels of low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, and/or triglycerides were considered to indicate dyslipidemia. The cutoff points for high blood pressure (HBP) and hyperglycemia were set as a reference in the high-normal range. No significant difference was observed in both sexes in all items among each year. In men, HBP (12.9%), liver dysfunction (33.9%), dyslipidemia (29.9%), and hyperglycemia (2.7%) were observed in the normal BMI group (18.5<BMI≤25kg/m(2)). In women, these abnormalities were observed in both the normal BMI group and lean group. Asymptomatic abnormalities, particularly liver dysfunction and dyslipidemia, were observed in a substantial percentage of subjects without obesity. Therefore, we recommend that the comprehensive public health policy should be directed at all individuals, including the non-obese group, for the early prevention/detection against atherosclerotic diseases.

The association of demographic and socioeconomic determinants and self-perceived health

Inequalities in health are evident in the whole world and present an important and consistent public health issue. The highest contribution to the inequality in heath is attributable to the demographic and socioeconomic determinants of health. The aim of this study was to analyse the association between the demographic (gender, age, marital status and type of settlement) and socioeconomic determinants of health (education and Wealth Index), and self-perceived health. In the study the data from 2006 National Health Survey of the population of Serbia were used. The interview involved 14,522 adults aged >20 years. The association between the demographic and socioeconomic determinants of health as independent variables, and self-perceived health as dependent variable were examined using bivariate and multivariate logistic regression analyses. The minimum level of significance was p < 0.05. According to our study, the elderly and females significantly more often perceived their health as poor. Respondents living in rural settings were less likely to perceive their health as poor compared to those living in urban settings (odds ratio was 0.82 in males and 0.75 in females). Males with low education were three times more likely to perceive their health as poor (odds ratio was 3.46) in relation to males with high education. This association was more pronounced in females (odds ratio was 5.37). The same pattern was observed for Wealth Index. This study showed that demographic and socioeconomic inequalities in self-perceived health are present in Serbia. Comprehensive public health policies and interventions for reducing these inequalities are urgently needed with the primarily focus on the most disadvantaged socioeconomic groups.

Guest Editorial — Novel Insights into the Pathology of Stachybotrys chartarum

The adverse health effects of indoor mold exposure gained much public attention in recent years. Although many studies support the involvement of fungi in building-related illnesses and emphasize the importance of mold exposure as an emerging public health issue, the role of toxigenic species such as Stachybotrys chartarum (SC) remains highly controversial [1]. Widespread litigation is making it more contentious, and the existing scientific information does not offer sufficient evidence that could lead to a better understanding of the problem and development of comprehensive public health policies. The article by Nagayoshi et al. [2] published in this issue of Mycopathologia describing for the first time the remodeling of pulmonary arteries in mice as a result of inhalation exposure to the spores of S. chartarum significantly extends our knowledge of the pathologic effects of this fungus. The ability to produce potent trichothecene mycotoxins became a source of great concern about S. chartarum. Approximately one-third of the isolates from the United States and Europe represent a chemotype that synthesizes macrocyclic trichothecenes [3]. Macrocyclic trichothecenes are not found in SC isolates belonging to the second chemotype which produces atranones. However, both chemotypes can synthesize much less potent simple trichothecenes. Molds can affect human health through mycotoxicosis, infection, allergy, and inflammation. The first category is often disputed, especially in the context of residential indoor air exposure [1, 4]. Arguments against the role of S. chartarum in building-related diseases are mostly based on the projection that the relatively low concentrations of the SC spores found in most indoor environments are insufficient to cause severe systemic toxicoses. Such opinions do not take into account local toxic effects at the site of deposition of fungal particles where the toxins can reach millimolar concentrations. Reports focusing on mycotoxins tend to present the ‘‘toxic black mold,’’ as S. chartarum is known to the public, as a species with unique properties compared with other fungi. While its high toxigenic potential clearly sets it apart, the effects of different fungal compounds common to all fungi such as b-D-glucan, proteins including hemolysin and proteases or various low-molecular-weight metabolites are likely to play a significant role in pathophysiology of this species [5–9]. In recent years, a number of animal studies of pulmonary effects of S. chartarum have been published, utilizing different animals/strains, different fungal isolates, and experimental protocols. The common finding was lung injury and inflammation. Some of those effects were paralleled in the experiments conducted with pure trichothecene toxins or atranones but toxin-independent mechanisms were also postulated [1, 10, 11]. It is I. Yike (&) D. Dearborn Department of Environmental Health Sciences, Case Western Reserve University, School of Medicine, Location Code 4940, Room WG19, 2109 Adelbert Rd., Cleveland, OH 44106, USA e-mail: ixy@case.edu

Natural disasters and public health: hurricanes Katrina, Rita, and Wilma

The events of Hurricane Katrina have been seared into our collective consciousness, revealing a glaring discrepancy between the experiences of privileged whites and those of low-income blacks. The latter faced a scale of physical danger and mental trauma that the former largely escaped. While residents with resources evacuated in cars, poor residents were left to fend for themselves-without food, water, medicine, shelter, or safety. Many poor African Americans died; many more lost loved ones and all of their material belongings. Natural Disasters and Public Health analyzes the public health effects of Hurricanes Katrina, Rita, and Wilma on minorities in New Orleans and along the Gulf Coast. The contributors assess the overall health policy and public health implications of these three natural disasters. While most of the current literature on disaster relief focuses on FEMA, race, urban planning, and the environment, Natural Disasters and Public Health takes a broader perspective, advocating the inclusion of comprehensive public health policy in future disaster relief programs. Unflinching photographs-many from the Astrodome in Houston after the evacuation of New Orleans and including the triage clinic set up there by the Baylor School of Medicine-illustrate the poor conditions under which health care professionals and aid workers ministered to the sick and injured. Reports from the field by disaster relief professionals and research articles by scholars present lessons learned and offer tools and guidance for future planning. This volume is a valuable resource for public policymakers, health care agencies, providers who plan for large-scale emergencies, academics teaching disaster relief courses, and professionals working in this field.

Experiences from the Swedish Determinants-Based Public Health Policy

A comprehensive Swedish public health policy was adopted by the Swedish Parliament, the Riksdag, in April 2003. It pushes health up on the political agenda and affords equity in health high priority. The first phase of implementation of the policy, 2003-5, is described in the 2005 Public Health Policy Report published by the Swedish National Institute of Public Health (SNIPH). For the purpose of investigating the implementation, SNIPH has monitored the development of 42 determinants and used reports from 22 central agencies and eight county administrative boards together with interviews with all Sweden's county councils (21) and a questionnaire sent out to all municipalities (290). The experiences from the implementation of the policy are that: the determinants approach-focusing on structural factors in society, people's living conditions, and health behaviors that affect health-is in general well understood and emphasizes the role of other sectors in public health; the use of indicators to follow up exposures to determinants is of key importance; the support to actors outside the health service is needed to identify their public health role; a continuous steering from the government and other political bodies is of vital importance; public health promotion on the regional level needs a higher level of coordination; municipalities need more skills development. Sweden has a new government that was elected in September 2006; the new government has retracted the former government's public health policy communication submitted to the Riksdag in the spring of 2006, but does not intend to change the public health policy.

Experiences from the Swedish determinants-based public health policy

A comprehensive Swedish public health policy was adopted by the Swedish Parliament, the Riksdag, in April 2003. It pushes health up on the political agenda and affords equity in health high priority. The first phase of implementation of the policy, 2003-5, is described in the 2005 Public Health Policy Report published by the Swedish National Institute of Public Health (SNIPH). For the purpose of investigating the implementation, SNIPH has monitored the development of 42 determinants and used reports from 22 central agencies and eight county administrative boards together with interviews with all Sweden's county councils (21) and a questionnaire sent out to all municipalities (290). The experiences from the implementation of the policy are that: the determinants approach - focusing on structural factors in society, people's living conditions and health behaviours that affect health - is in general well understood and emphasises the role of other sectors in public health; the use of indicators to follow up exposures to determinants is of key importance; the support to actors outside the health service is needed to identify their public health role; a continuous steering from the government and other political bodies is of vital importance; public health promotion on the regional level needs a higher level of co-ordination; municipalities need more skills development; Sweden has a new government that was elected in September 2006; the new government has retracted the former government's public health policy communication submitted to the Riksdag in the spring of 2006, but does not intend to change the public health policy.

Breaking the Deadlock: Public Health Policy Coordination as the Next Step

Recent public health crises have revealed the extent to which coordinated government activity is crucial for ensuring the efficacy of public policies aimed at protecting, maintaining and improving the health of the population. The need for coherent and effective interventions in many areas of human activity always comes up against the challenges related to the division of responsibilities, power and jurisdictions inherent in public administration. The recently initiated renewal of public health structures in Canada opens up new possibilities for public health and could foster better coordination of public health efforts. This paper shows, however, that the eventual broadening of the traditional mandate of Canadian public health to include the social (non-medical) aspects of health and the articulation of healthy public policies requires intervention at the central policy level. We offer practical observations about the need to foster better policy coordination across sectors of governments, with a view to contributing to the emergence of a comprehensive public health policy in Canada.

A Watershed, Not a Waterloo

WHEN I WAS first asked to write this commentary for Frontiers of Health Services Management, knowing that I would be contributing with the likes of Emily Friedman, I must admit I was a bit intimidated. But after reflection, I realized that I was able to offer comments on a subject I know all too well-the uninsured and the lack of a comprehensive national public health policy. While I do not profess to be either an economist or an expert on the subject of the uninsured, I do live with this situation every day, as I manage a hospital in the Greater Houston area of Texas and I previously was the chief executive officer at a large hospital in Florida. The problems discussed in these articles are especially acute in both of these states. Hospital executives, and hospitals themselves, are at the center of the public policy debate on the uninsured and of the economic pressures that come to bear in a society that expects perfection, demands access, and requires that care be provided but in essence does not want to pay the bill. Deborah Chollet does an admirable job describing the different options available to provide coverage for those who are uninsured. But after reviewing the options she details, I am struck by the overwhelming feeling that we as a country-and as an industry for that matter-do not yet have the will, nor do the politicians have the mandate, to bring any of these approaches to fruition. That being said, I believe that Chollet has concluded her article correctly. She states that our future system-our solution-to this matter will lie in parallel realms of public and private coverage. It seems improbable that a government-sponsored system could or would be enough to remedy this complex challenge. A public-private approach that includes the best of what each has to offer, coupled with a more seamless and coordinated effort between the two segments, as Chollet suggests, seems more practical, more doable, and certainly more palatable to the industry and our political leaders alike. I would also like to echo Chollet's call for improved efficiencies in the system, through reduction in errors, more homogeneity in treating patients' illnesses, and information sharing among providers and between providers and patients. These improvements will both empower providers and patients and improve their decision making. I would broaden this assertion to also include the potential for significant reduction of the administrative costs of the system. The amount of cost in the system related to the silos that exist among consumers, providers, insurers, and the government is staggering and feeds bureaucracies that add no value, provide no care, and cause endless frustration to patients and hospitals alike. Moreover, we as providers must step up and embrace quality practice and eliminate the waste and inefficiencies that exist in our own delivery systems. And at some point in the not-too-distant future, we must be able to prove to ourselves and to our consumers that we do in fact do the right thing at the right time with the appropriate resources, without fail. Friedman's article describes the collision course on which we find ourselves. I am certain the readers will recognize the dilemma that healthcare leaders face daily: too many want what too few are willing or able to pay for. If we indeed are at a watershed moment in our industry, as Friedman contends, then she has eloquently described the situation that has led to this moment. …

The new Swedish national public health policy

By international comparison, Swedish public health public sector and a restructuring of Swedish welfare policy. The labour market underwent transformations work has been successful. The age-standardized mortality ® gures are low in most age groups. Although and there was a signi® cant decrease in the total employment rate. Furthermore there was an increase in job inequity in health is considerable in relative terms, the number of excess deaths in lower social classes is strain, especially in the care sector. These changes took place without any governmental agency taking responssmaller than in most other countries. In spite of this rather positive picture, Sweden has ibility for an analysis of the health consequences. In 1994 the new social democratic government no comprehensive public health policy. It has been recognized that politics is a health determinant in declared that public health was a central political issue. In 1997 a public health committee with a broad parliadiVerent sectors of society but there has not been any eVort to coordinate diVerent governmental oYces in mentary base was formed. The major objective was to propose a national strategy and speci® c goals for public order to promote public health. The problem of how to implement a public health health that would guide governmental oYces, regional and local public authorities, and NGOs. The committee policy has been discussed for more than a decade. In 1987 the Swedish government appointed a task group at comprised members from all major political parties and a number of experts, representing governmental high administrative level with the participation of oYcials and scientists in the ® eld of public health. The aim authorities, scienti® c institutions, labour-market organizations, and representatives for immigrants and was to outline a national public health strategy. An allembracing objective was to promote increased equity in retired persons. The committee worked openly and in dialogue health. Another important issue was how to integrate public health with the general welfare policy system. with public health activists. Two preliminary reports were published and distributed to several hundred The task group proposed a new governmental authority, the National Institute of Public Health. The authorities and voluntary organizations. In the end of 2000 a green paper was published with purpose of the institute was to direct health promotion and disease prevention activities at a national level and proposals for 18 national public health goals. All goals were formulated in terms of health determinants and to cooperate with other national authorities and NGOs in health matters. fundamental infrastructure for preventive work. The goals related to structural and environmental determinThe National Institute of Public Health was established in 1992. At that time there had been a change ants of health as well as lifestyles. All goals are broken down into a number of sub-goals and quantitative of government, which may have contributed to the fact that the institute did not take on its intended strategic indicators have been constructed. It is presumed that the targets will be achieved in 2010. It is also proposed role in the Swedish public health work. Instead its activities focused on programmes directed towards that each respective public sector will be accountable for contributing to the achievement of the goals. speci® c health problems such as alcohol, illicit drugs, HIV/AIDS, injuries, allergic disorders and tobacco use. At present the government is revising the goals and a governmental bill will be put forward to the Swedish There was a quite strong emphasis on information directly to the public. parliament in the end of 2001. There are a number of advantages in expressing the In the 1990s there were considerable cutbacks in the