Socioeconomic Inequalities In Mortality Research Articles

Modelling cost-effective strategies for minimising socioeconomic inequalities in colorectal cancer screening outcomes in England

Colorectal cancer (CRC) incidence and mortality is higher in socioeconomically deprived groups for a variety of reasons, but is exacerbated by poorer screening uptake. However, many strategies for improving screening participation exist. This analysis aimed to model the impact of screening on CRC inequalities in England and then compare different strategies for increasing participation, to determine the most cost-effective methods for reducing screening-induced inequalities. An existing health economic model, Microsimulation Model in Cancer of the Bowel was adapted. Screening-eligible individuals were simulated to investigate the impact of screening on CRC inequalities. Following this, four strategies for promoting screening participation were compared: 1) annual re-invitation of screening non-participants; 2) a national media advertising campaign; 3) text message reminders for non-participants; 4) health promotion in deprived populations. Cost-effectiveness, CRC outcomes, resource impacts and effects on CRC inequalities were assessed. Inequalities analysis was based on age-standardised CRC mortality by socioeconomic group. Screening was found to be highly cost-effective but CRC inequalities increased as screening effectiveness improved. Annual re-invitation of non-participants was most cost-effective for promoting particiption (incremental cost-effectiveness ratio = £4404 per quality-adjusted life-year), reducing CRC mortality (11,129 deaths averted), and reducing screening-induced inequality (slope of inequalities reduced from 20.80 to 19.38), although it required 42% more screening kits to be sent out. Other strategies were cost-effective compared with screening alone, and improved CRC outcomes, but had varying impacts on inequalities. Whilst bowel cancer screening increases socioeconomic inequalities in CRC mortality, effective and cost-effective strategies are available for mitigating screening-induced inequalities.

Socioeconomic inequalities in stillbirth and neonatal mortality rates: evidence on Particularly Vulnerable Tribal Groups in eastern India.

BackgroundTribal peoples are among the most marginalised groups worldwide. Evidence on birth outcomes in these groups is scant. We describe inequalities in Stillbirth Rate (SBR), Neonatal Mortality Rate (NMR), and uptake of maternal and newborn health services between tribal and less disadvantaged groups in eastern India, and examine the contribution of poverty and education to these inequalities.MethodsWe used data from a demographic surveillance system covering a 1 million population in Jharkhand State (March 2017 – August 2019) to describe SBR, NMR, and service uptake. We used logistic regression analysis combined with Stata’s adjrr-command to estimate absolute and relative inequalities by caste/tribe (comparing Particularly Vulnerable Tribal Groups (PVTG) and other Scheduled Tribes (ST) with the less marginalised Other Backward Class (OBC)/none, using the Indian government classification), and by maternal education and household wealth.ResultsPVTGs had a higher NMR (59/1000) than OBC/none (31/1000) (rate ratio (RR): 1.92, 95%CI: 1.55–2.38). This was partly explained by wealth and education, but inequalities remained large after adjustment (adjusted RR: 1.59, 95%CI: 1.28–1.98). NMR was also higher among other STs (44/1000), but disparities were smaller (RR: 1.47, 95%CI: 1.23–1.75). There was a systematic gradient in NMR by maternal education and household wealth. SBRs were only higher in poorer groups (RRpoorest vs. least poor:1.56, 95%CI: 1.14–2.13). Uptake of facility-based services was low among PVTGs (e.g. institutional birth: 25% vs. 69% in OBC/none) and among poorer and less educated women. However, 65% of PVTG women with an institutional birth used a maternity vehicle vs. 34% among OBC/none. Visits from frontline workers (Accredited Social Health Activists [ASHAs]) were similar across groups, and ASHA accompaniment of institutional births was similar across caste/tribe groups, and higher among poorer and less educated women. Attendance in participatory women’s groups was similar across caste/tribe groups, and somewhat higher among richer and better educated women.ConclusionsPVTGs are highly disadvantaged in terms of birth outcomes. Targeted interventions that reduce geographical barriers to facility-based care and address root causes of high poverty and low education in PVTGs are a priority. For population-level impact, they are to be combined with broader policies to reduce socio-economic mortality inequalities. Community-based interventions reach disadvantaged groups and have potential to reduce the mortality gap.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12939-022-01655-y.

Placing a housing lens on neighbourhood disadvantage, socioeconomic position and mortality

Placing a housing lens on neighbourhood disadvantage, socioeconomic position and mortality

Educational Attainment and Lifestyle Risk Factors Associated With All-Cause Mortality in the US

The US has experienced increasing socioeconomic inequalities and stagnating life expectancy. Past studies have not disentangled 2 mechanisms thought to underlie socioeconomic inequalities in health, differential exposure and differential vulnerability, that have different policy implications. To evaluate the extent to which the association between socioeconomic status (SES) and all-cause mortality can be decomposed into a direct effect of SES, indirect effects through lifestyle factors (differential exposure), and joint effects of SES with lifestyle factors (differential vulnerability). This nationwide, population-based cohort study used the cross-sectional US National Health Interview Survey linked to the National Death Index. Civilian, noninstitutionalized US adults aged 25 to 84 years were included from the 1997 to 2014 National Health Interview Survey and were followed up until December 31, 2015. Data were analyzed from May 1 to October 31, 2021. A causal mediation model using an additive hazard and marginal structural approach was used. Both SES (operationalized as educational attainment) and lifestyle risk factors (smoking, alcohol use, obesity, and physical inactivity) were assessed using self-reported questionnaires. Time to all-cause mortality. Participants included 415 764 adults (mean [SD] age, 49.4 [15.8] years; 55% women; 64% non-Hispanic White), of whom 45% had low educational attainment and 27% had high educational attainment. Participants were followed up for a mean (SD) of 8.8 (5.2) years during which 49 096 deaths (12%) were observed. Low educational attainment (compared with high) was associated with 83.6 (men; 95% CI, 81.8-85.5) and 54.8 (women; 95% CI, 53.4-56.2) additional deaths per 10 000 person-years, of which 66% (men) and 80% (women) were explained by lifestyle factors. Inequalities in mortality were primarily a result of greater exposure and clustering of unhealthy lifestyle factors among low SES groups; with some exceptions among women, little evidence of differential vulnerability was identified. In this cohort study, differential exposure to lifestyle risk factors was an important mediator of socioeconomic inequalities in mortality. Public health interventions are needed, particularly among low SES groups, to address smoking, physical inactivity, alcohol use, and the socioenvironmental contexts within which these risk factors develop.

Exposure to Tobacco Smoking in Vehicles, Indoor, and Outdoor Settings in Germany: Prevalence and Associated Factors.

Little is known on whether secondhand smoke (SHS) exposure in vehicles, indoor, and outdoor settings is similarly patterned in terms of different socio-epidemiological indicators in Germany. This study aims to estimate the current national-level prevalence and associated socio-epidemiological indicators of SHS exposure in vehicles, indoor, and outdoor settings in the German population, using current data from a representative household survey. We used cross-sectional data (N = 3928 respondents aged 14–99 years) from two waves of the DEBRA survey (German Study on Tobacco Use), conducted between January and March 2020. The reported prevalence of SHS exposure during the last seven days was 19% in vehicles, 25% in indoor settings, and 43% in outdoor settings. We found that younger age and current smoking were consistently associated with higher SHS exposure. Furthermore, people with low education were more likely to be exposed to SHS in vehicles and indoor settings than people with high education. This study found that the prevalence of SHS exposure in vehicles, indoor, and outdoor settings is a relevant feature of everyday life in Germany, especially for younger people and people with lower education, leading to potentially persistent socioeconomic and tobacco-attributable inequalities in morbidity and mortality.

Socio-economic Inequality in Mortality in Italy

Socio-economic Inequality in Mortality in Italy

Educational differences in alcohol-related mortality and their impact on life expectancy and lifespan variation in Spain (2016–2018): a cross-sectional analysis using multiple causes of death

BackgroundSocioeconomic inequalities in alcohol-related mortality in Spain exists, and are postulated to contribute to inequalities in all-cause mortality. We aim to assess absolute and relative educational inequalities in alcohol-related mortality,...

Decomposition of socioeconomic inequality in COVID-19 mortality in Iran: A retrospective cohort study.

This study aimed to investigate the relationship between socioeconomic status and COVID‐19 mortality in Iran. We performed a retrospective cohort study on data from the hospitalised COVID‐19 patients in Qazvin. We collected data on education, self‐reported socioeconomic status, and location of residence as a proxy for socioeconomic status (SES). We applied the Blinder‐Oaxaca decomposition approach to assess the role of socioeconomic inequality in COVID‐19 mortality and determine the main contributors to the observed inequality. Overall, 941 patients (48.96%) had low SES, while only 24.87% (n = 478) were classified in the high SES category. The mortality rate was significantly higher in the low SES group, and we spotted a 17.13% gap in COVID‐19 mortality between the high and low SES patients (p < 0.001). Age was the main contributor to the observed inequality, responsible for 6.91% of the gap (p < 0.001). Having co‐morbidities (1.53%) and longer length of stay (LOS) in hospitals (0.95%) in the low SES group were other main determinants of the inequality in COVID‐19 mortality (p < 0.05). In the unexplained part of our model, the effect of increased age (10.61%) and a positive RT‐PCR test result (3.43%) were more substantial in the low SES group compared to the high SES patients (p < 0.05).The low SES people had an increased risk of getting COVID‐19, and the disease has been more severe and fatal among them. Increased age, co‐morbidities, and LOS were identified as the main drivers of this inequality.

The dose-response relationship between socioeconomic deprivation and alcohol-attributable mortality risk\u2014a systematic review and meta-analysis

BackgroundIndividuals with low socioeconomic status (SES) experience a higher risk of mortality, in general, and alcohol-attributable mortality in particular. However, a knowledge gap exists concerning the dose-response relationships between the level of socioeconomic deprivation and the alcohol-attributable mortality risk.MethodsWe conducted a systematic literature search in August of 2020 to update a previous systematic review that included studies published up until February of 2013. Quantitative studies reporting on socioeconomic inequality in alcohol-attributable mortality among the general adult population were included. We used random-effects dose-response meta-analyses to investigate the relationship between the level of socioeconomic deprivation and the relative alcohol-attributable risk (RR), by sex and indicator of SES (education, income, and occupation).ResultsWe identified 25 eligible studies, comprising about 241 million women and 230 million men, among whom there were about 75,200 and 308,400 alcohol-attributable deaths, respectively. A dose-response relationship between the level of socioeconomic deprivation and the RR was found for all indicators of SES. The sharpest and non-linear increase in the RR of dying from an alcohol-attributable cause of death with increasing levels of socioeconomic deprivation was observed for education, where, compared to the most educated individuals, individuals at percentiles with decreasing education had the following RR of dying: women: 25th: 2.09 [95% CI 1.70–2.59], 50th: 3.43 [2.67–4.49], 75th: 4.43 [3.62–5.50], 100th: 4.50 [3.26–6.40]; men: 25th: 2.34 [1.98–2.76], 50th: 4.22 [3.38–5.24], 75th: 5.87 [4.75–7.10], 100th: 6.28 [4.89–8.07].ConclusionsThe findings of this study show that individuals along the entire continuum of SES are exposed to increased alcohol-attributable mortality risk. Differences in the dose-response relationship can guide priorities in targeting public health initiatives.

Socioeconomic Inequalities in Mortality After Age 67: The Contribution of Psychological Factors.

Diverging trends of longer lives and increased inequalities in age-at-death invite to updated research on late-life mortality. Earlier studies have identified health behavior, childhood, psychosocial, and material conditions as key determinants of life expectancy, but the role of psychological factors remains a topic of debate. The current study is framed in a life course developmental perspective and assesses the mediating role of secondary control strategies (subjective age) and primary control capacity (perceived control) to socioeconomic (wealth and education) inequality in mortality after age 67. Data are derived from the second wave of the Norwegian Life Course, Ageing and Generation study (N=1,432 and age 67–85). All in all, 366 deaths were observed over a mean follow-up of 9.6years. Perceived control was measured by the Pearlin and Schooler Mastery Scale. SA was measured with proportional discrepancy scores in felt age and ideal age. Stepwise Cox proportional hazards regression analyses were conducted to analyze the relative contribution of SES (education and accumulated wealth), felt age, and ideal age discrepancies and perceived control on 11-year mortality. Findings show that lower levels of wealth and perceived control independently predict increased elderly mortality over an 11-year period. Feeling younger and smaller ideal age discrepancies are positively associated with perceived control, but do not account for additional variability in longevity among older adults. Findings add to the interdisciplinary field of socioeconomic inequalities in elderly mortality and underline the specific importance of structural conditions (wealth) and the continued importance of (perceived) primary control capacity for longevity also after age 67. Future research may assess in more detail how wealth and perceived control complement each other in contributing to healthy aging and longevity, for example, by longitudinal research including the role of significant life events in the second half of life in different welfare state contexts.

The potential impact of co-residence structures on socio-demographic inequalities in COVID-19 mortality

During the COVID-19 pandemic, confinement measures were adopted across the world to limit the spread of the virus. In France, these measures were applied between March 17 and May 10. Using high-quality population census data and focusing on co-residence structures on French territory, this article analyzes how co-residence patterns unevenly put different socio-demographic groups at risk of being infected and dying from COVID-19. The research ambition is to quantify the possible impact of co-residence structures heterogeneity on socio-economic inequalities in mortality stemming from within-household transmission of the virus. Using a simulation approach, the article highlights the existence of theoretical pronounced inequalities of vulnerability to COVID-19 related to cohabitation structures as well as a reversal of the social gradient of vulnerability when the age of the infected person increases. Among young age categories, infection is simulated to lead to more deaths in the less educated or foreign-born populations. Among the older ones, the inverse holds with infections having a greater potential to provoke deaths through the transmission of the virus within households headed by a highly educated or a native-born person. Demographic patterns such as the cohabitation of multiple generations and the survival of both partners of a couple help to explain these results. Even though inter-generational co-residence and large households are more common among the lower educated and foreign born in general, the higher educated are more likely to still live with their partner at higher ages.

Socioeconomic Inequalities in Chronic Liver Diseases and Cirrhosis Mortality in European Urban Areas before and after the Onset of the 2008 Economic Recession.

Objective: To analyse the trends in chronic liver diseases and cirrhosis mortality, and the associated socioeconomic inequalities, in nine European cities and urban areas before and after the onset of the 2008 financial crisis. Methods: This is an ecological study of trends in three periods of time: two before (2000–2003 and 2004–2008), and one after (2009–2014) the onset of the economic crisis. The units of analysis were the geographical areas of nine cities or urban areas in Europe. We analysed chronic liver diseases and cirrhosis standardised mortality ratios, smoothing them with a hierarchical Bayesian model by each city, area, and sex. An ecological regression model was fitted to analyse the trends in socioeconomic inequalities, and included the socioeconomic deprivation index, the period, and their interaction. Results: In general, chronic liver diseases and cirrhosis mortality rates were higher in men than in women. These rates decreased in all cities during the financial crisis, except among men in Athens (rates increased from 8.50 per 100,000 inhabitants during the second period to 9.42 during the third). Socioeconomic inequalities in chronic liver diseases and cirrhosis mortality were found in six cities/metropolitan areas among men, and in four among women. Finally, in the periods studied, such inequalities did not significantly change. However, among men they increased in Turin and Barcelona and among women, several cities had lower inequalities in the third period. Conclusions: There are geographical socioeconomic inequalities in chronic liver diseases and cirrhosis mortality, mainly among men, that did not change during the 2008 financial crisis. These results should be monitored in the long term.

Cancer mortality 1981–2016 and contribution of specific cancers to current socioeconomic inequalities in all cancer mortality: A population-based study

BackgroundIn many high-income countries cancer mortality rates have declined, however, socioeconomic inequalities in cancer mortality have widened over time with those in the most deprived areas bearing the greatest burden. Less is known about the contribution of specific cancers to inequalities in total cancer mortality. MethodsUsing high-quality routinely collected population and mortality records we examine long-term trends in cancer mortality rates in Scotland by age group, sex, and area deprivation. We use the decomposed slope and relative indices of inequality to identify the specific cancers that contribute most to absolute and relative inequalities, respectively, in total cancer mortality. ResultsCancer mortality rates fell by 24 % for males and 10 % for females over the last 35 years; declining across all age groups except females aged 75+ where rates rose by 14 %. Lung cancer remains the most common cause of cancer death. Mortality rates of lung cancer have more than halved for males since 1981, while rates among females have almost doubled over the same period. ConclusionCurrent relative inequalities in total cancer mortality are dominated by inequalities in lung cancer mortality, but with contributions from other cancer sites including liver, and head and neck (males); and breast (females), stomach and cervical (younger females). An understanding of which cancer sites contribute most to inequalities in total cancer mortality is crucial for improving cancer health and care, and for reducing preventable cancer deaths.

Socioeconomic inequalities associated with mortality for COVID-19 in Colombia: a cohort nationwide study

BackgroundAfter 8 months of the COVID-19 pandemic, Latin American countries have some of the highest rates in COVID-19 mortality. Despite being one of the most unequal regions of the world,...

Social inequality in incidence and mortality of malignant neoplasms of lip, oral cavity and pharynx: Is Costa Rica an international paradox?

Low socioeconomic position (SEP) has been associated with higher incidences and mortality of lip, oral cavity and pharynx (LOP) cancers in the vast majority of countries with available data. The origins of health inequalities in cancer are socioeconomic, although they vary by time and country. Evidence from Low-and Middle-income Countries (LMICs) remains scarce. This study aims to identify and describe socioeconomic inequalities in LOP cancers incidence and mortality in Costa Rica. The hypothesis tested is that people leaving in low-SEP districts in Costa Rica have greater incidence and mortality rates of lip, oral cavity and pharynx cancers. The 10th revision of the InternationalClassification of Diseases (ICD-10) was used to define cancer sites. Data come from a national population-based Cancer Registry with 100% completeness to study incidence. Incidence rate included all new cases of LOP cancer diagnosed from January 1, 2011, and December 31, 2015, for a total of 2798517 individuals, 13832524years of follow-up and 601 LOP cases. Mortality rate was extracted from the National Death Index, including 2739733 individuals, 23950240 person-years of follow-up and 586 LOP cancer deaths, from January 1, 2010, to December 31, 2018. The 2011 Census (with 94% of Costa Rican inhabitants) was used to characterize the urbanicity and wealth of 477 districts. Survival models were performed for both incidence and mortality, allowing to consider existing competitive risks. Cox models were used for incidence, and parametric survival models based on a Gompertz distribution for mortality. The study found that people who lived in the most socioeconomically disadvantaged areas had lower probabilities of developing LOP cancers than people in the richest districts. The same pattern for mortality, however, was not significant. The hypothesis that incidence and mortality of LOP cancers will show a positive social gradient was not confirmed in this study, contradicting the existing literature. This could be explained by the social distribution of risky health behaviours, more frequent in socially advantaged populations.

Socioeconomic Inequalities in Premature Cancer Mortality Among U.S. Counties During 1999 to 2018.

This study investigated socioeconomic inequalities in premature cancer mortality by cancer types, and evaluated the associations between socioeconomic status (SES) and premature cancer mortality by cancer types. Using multiple databases, cancer mortality was linked to SES and other county characteristics. The outcome measure was cancer mortality among adults ages 25-64 years in 3,028 U.S. counties, from 1999 to 2018. Socioeconomic inequalities in mortality were calculated as a concentration index (CI) by income (annual median household income), educational attainment (% with bachelor's degree or higher), and unemployment rate. A hierarchical linear mixed model and dominance analyses were used to investigate SES associated with county-level mortality. The analyses were also conducted by cancer types. CIs of SES factors varied by cancer types. Low-SES counties showed increasing trends in mortality, while high-SES counties showed decreasing trends. Socioeconomic inequalities in mortality among high-SES counties were larger than those among low-SES counties. SES explained 25.73% of the mortality. County-level cancer mortality was associated with income, educational attainment, and unemployment rate, at -0.24 [95% (CI): -0.36 to -0.12], -0.68 (95% CI: -0.87 to -0.50), and 1.50 (95% CI: 0.92-2.07) deaths per 100,000 population with one-unit SES factors increase, respectively, after controlling for health care environment and population health. SES acts as a key driver of premature cancer mortality, and socioeconomic inequalities differ by cancer types. Focused efforts that target socioeconomic drivers of mortalities and inequalities are warranted for designing cancer-prevention implementation strategies and control programs and policies for socioeconomically underprivileged groups.

Area-level indicators of income and total mortality during the COVID-19 pandemic.

BackgroundThere is mounting evidence that socioeconomic inequalities in mortality have widened during the COVID-19 pandemic. This study aimed at evaluating the relationship between area-level indicators of income and total mortality during the first phase of COVID-19 pandemic in the most hit Italian region.MethodsWe conducted an ecological study based on the number of deaths registered in the municipalities of the Lombardy region (Italy) between January 2019 and June 2020. Municipalities were grouped according to quintiles of average income and pension of their resident population. Monthly age-standardized mortality ratios (MRs) between the poorest and the richest municipalities and the corresponding 95% CI were computed to evaluate whether the pre-existing socioeconomic inequalities widened during the pandemic.ResultsOver the study period, 175 853 deaths were registered. During the pre-pandemic period (January 2019 to February 2020) the MR between the poorest and the richest municipalities ranged between 1.12 (95% CI: 1.00–1.25) and 1.33 (95% CI: 1.20–1.47). In March 2020, when the pandemic began to rapidly spread in the region, it raised up to 1.61 (95% CI: 1.51–1.72) and decreased thereafter, reaching the pre-pandemic values in April 2020. Similar results were observed in the analysis of the mortality at ages 65 and over in municipalities grouped according to average pension, where the MR increased up to 1.82 (95% CI: 1.70–1.94) in March 2020.ConclusionsThe socioeconomic inequalities in mortality widened in Lombardy, the Italian region most severely hit during the first phase of the COVID-19 pandemic.

Commentary on Peña et al.: The broader public health relevance of understanding and addressing the alcohol harm paradox.

Socio-economic inequalities in alcohol-attributable mortality make an important contribution to socio-economic health inequalities overall. A comprehensive approach to reducing socio-economic inequalities in alcohol-related health requires combining the implementation of evidence-based, cost-effective alcohol control policies with broader policy measures that act upon the structural, economic and social root causes of socioeconomic inequalities.

Geographical and socioeconomic inequalities in female breast cancer incidence and mortality in Iran: A Bayesian spatial analysis of registry data.

BackgroundIn Iran, trends in breast cancer incidence and mortality have generally been monitored at national level. The purpose of this study is to examine province-level disparities in age-standardised breast cancer incidence versus mortality from 2000 to 2010 and their association with socioeconomic status.MethodsIn this study, data from Iran’s national cancer and death registry systems, and covariates from census and household expenditure surveys were used. We estimated the age-standardised incidence and mortality rates in women aged more than 30 years for all 31 provinces in the consecutive time intervals 2000–2003, 2004–2007 and 2008–2010 using a Bayesian spatial model.ResultsMean age-standardised breast cancer incidence across provinces increased over time from 15.0 per 100,000 people (95% credible interval 12.0,18.3) in 2000–2003 to 39.6 (34.5,45.1) in 2008–2010. The mean breast cancer mortality rate declined from 10.9 (8.3,13.8) to 9.9 (7.5,12.5) deaths per 100,000 people in the same period. When grouped by wealth index quintiles, provinces in the highest quintile had higher levels of incidence and mortality. In the wealthiest quintile, reductions in mortality over time were larger than those observed among provinces in the poorest quintile. Relative breast cancer mortality decreased by 16.7% in the highest quintile compared to 10.8% in the lowest quintile.ConclusionsBreast cancer incidence has increased over time, with lower incidence in the poorest provinces likely driven by underdiagnoses or late-stage diagnosis. Although the reported mortality rate is still higher in wealthier provinces, the larger decline over time in these provinces indicates a possible future reversal, with the most deprived provinces having higher mortality rates. Ongoing analysis of incidence and mortality at sub-national level is crucial in addressing inequalities in healthcare systems and public health both in Iran and elsewhere.

How did Sweden Fail the Pandemic?

Sweden has since the start of the pandemic a COVID-19 mortality rate that is 4 to 10 times higher than in the other Nordic countries. Also, measured as age-standardized all-cause excess mortality in the first half of 2020 compared to previous years Sweden failed in comparison with the other Nordic countries, but only among the elderly. Sweden has large socioeconomic and ethnic inequalities in COVID-19 mortality. Geographical, ethnic, and socioeconomic inequalities in mortality can be due to differential exposure to the virus, differential immunity, and differential survival. Most of the country differences are due to differential exposure, but the socioeconomic disparities are mainly driven by differential survival due to an unequal burden of comorbidity. Sweden suffered from an unfortunate timing of tourists returning from virus hotspots in the Alps and Sweden's government response came later and was much more limited than elsewhere. The government had an explicit priority to protect the elderly in nursing and care homes but failed to do so. The staff in elderly care are less qualified and have harder working conditions in Sweden, and they lacked adequate care for the clients. Sweden has in recent years diverged from the Scandinavian welfare model by strong commercialization of primary care and elderly care.