Swedish Health Services Research Articles

To accept, or not to accept, that is the question: citizen reactions to rationing

The publicly financed health service in Sweden has come under increasing pressure, forcing policy makers to consider restrictions. To describe different perceptions of rationing, in particular, what citizens themselves believe influences their acceptance of having to stand aside for others in a public health service. Qualitative interviews, analysed by phenomenography, describing perceptions by different categories. Purposeful sample of 14 Swedish citizens, based on demographic criteria and attitudes towards allocation in health care. Participants expressed high awareness of limitations in public resources and the necessity of rationing. Acceptance of rationing could increase or decrease, depending on one's (i) awareness that healthcare resources are limited, (ii) endorsement of universal health care, (iii) knowledge and acceptance of the principles guiding rationing and (iv) knowledge about alternatives to public health services. This study suggests that decision makers should be more explicit in describing the dilemma of resource limitations in a publicly funded healthcare system. Openness enables citizens to gain the insight to make informed decisions, i.e. to use public services or to 'opt out' of the public sector solution if they consider rationing decisions unacceptable.

Improving teamwork between students from two professional programmes in dental education

In Sweden, the National Board of Health and Welfare forecasts a decrease in dentists with 26% and an increase in dental hygienists with 47% until the year of 2023. This, together with changes in both epidemiology, especially of dental caries, and political priorities, calls for an effective and well-developed cooperation between dentists and dental hygienists in future dentistry. Hence, the aim of this project was to investigate whether highlighting teamwork during the undergraduate studies of dental students and dental hygiene students could improve the students’ holistic view on patients as well as their knowledge of and insight into each other’s future professions. Thirty-four dental students and 24 dental hygiene students participated in the study. At the beginning of their final year in undergraduate education, a questionnaire testing the level of knowledge of the dental hygienists’ clinical competences was completed by both groups of students. In addition, activities intending to improve teamwork quality included the following: (i) a seminar with a dentist representing the Public Dental Health Services in Sweden, (ii) dental students as supervisors for dental hygiene students, (iii) planning and treatment for shared patients and (iv) students’ presentations of the treatments and their outcomes at a final seminar. The project was ended by the students answering the above-mentioned questionnaire for the second time, followed by an evaluation of the different activities included in the study. The knowledge of dental hygienists’ competences showed higher scores in almost all questions. Both groups of students considered the following aspects important: seminars with external participants, dental students acting as supervisors and planning and treating shared patients. By initiating and encouraging teamwork between dental students and dental hygiene students, it is possible to increase knowledge on dental hygienists’ competence and also to develop and strengthen a holistic view on patients and dental work, thereby preparing both groups of students for their professional life.

Prevalence of footrot in Swedish slaughter lambs

BackgroundFootrot is a world-wide contagious disease in sheep and goats. It is an infection of the epidermis of the interdigital skin, and the germinal layers of the horn tissue of the feet. The first case of footrot in Swedish sheep was diagnosed in 2004. Due to difficulties in distinguishing benign footrot from early cases of virulent footrot and because there is no possibility for virulence testing of strains of Dichelobacter nodosus in Sweden, the diagnosis is based of the presence or absence of clinical signs of footrot in sheep flocks. Ever since the first diagnosed case the Swedish Animal Health Service has worked intensively to stop the spread of infection and control the disease at flock level. However, to continue this work effectively it is important to have knowledge about the distribution of the disease both nationally and regionally. Therefore, the aims of this study were to estimate the prevalence of footrot in Swedish lambs at abattoirs and to assess the geographical distribution of the disease.MethodsA prevalence study on footrot in Swedish lambs was performed by visual examination of 2000 feet from 500 lambs submitted from six slaughter houses. Each foot was scored according to a 0 to 5 scoring system, where feet with score ≥2 were defined as having footrot. Moreover, samples from feet with footrot were examined for Dichelobacter nodosus by culture and PCR.ResultsThe prevalence of footrot at the individual sheep level was 5.8%, and Dichelobacter nodosus was found by culture and PCR in 83% and 97% of the samples from feet with footrot, respectively. Some minor differences in geographical distribution of footrot were found in this study.ConclusionsIn a national context, the findings indicate that footrot is fairly common in Swedish slaughter lambs, and should be regarded seriously.

Swedish health care system – some trends of its reforming

The constant increase in public health expenditure, which is being observed from the 60s, initiated research into way to optimize it. The aim the article is to show concepts of the health reforms which have been applied in the Swedish health service. In the article are presented main proposals of changes in the system financing and service provision. Article characterizes patient participation in costs of services, private health insurance, privatisation of health care facilities, purchase-provider split and providers reimbursement. The articles begins with the overview of concepts related to health care system reform. Next, the health system in Sweden is shortly presented. The main part of the article presents the reforms which has been implemented in the financing and services provision. Patients’ participation in financing of the health system has been extended by fees for service. The importance of private medical insurance is marginal. Purchaser-provider split has been introduced in most of counties. In general primary care facilities have been privatised. In regard to service providers reimbursement is generally used global budgeting, feed for service or diagnosis-related groups.

The Study on the Decentralization of the Swedish Health Service System and its Cost ontainment

The Study on the Decentralization of the Swedish Health Service System and its Cost ontainment

The cost-effectiveness of somatropin treatment for short children born small for gestational age (SGA) and children with growth hormone deficiency (GHD) in Sweden

Objective: Reduction in health-related quality of life is common in children born small for gestational age (SGA) or children with growth hormone deficiency (GHD). Growth hormone treatment with somatropin in these children leads to normalisation of height. The aim of this study was to determine whether somatropin is a cost-effective treatment option for short children born SGA and GHD children in Sweden.Methods: A Markov decision-tree model was used to calculate the relative costs and health benefits associated with somatropin treatment over the lifetime of SGA and GHD children, compared with no treatment. The analysis was undertaken from a Swedish Health Service perspective. As quality-adjusted life-year (QALY) data were not obtained directly in the clinical studies, a degree of uncertainty is related to these results. Sensitivity analyses assessed the degree of uncertainty surrounding central parameters.Results: For short children born SGA, somatropin treatment was associated with an additional 3.29 QALYs at an incremental cost of 792,489 SEK (Swedish Krona), compared with no treatment. For GHD, somatropin treatment resulted in 3.25 additional QALYs at an incremental cost of 391,291 SEK. This equates to an incremental cost per QALY of 240,831 SEK and 120,494 SEK for SGA and GHD, respectively, below a cost-effectiveness threshold of 500,000–600,000 SEK/QALY.Conclusions: Somatropin is a cost-effective treatment strategy in Sweden for children with GHD and SGA. To overcome present study limitations future clinical research should incorporate appropriate quality of life questionnaires.

"If we only got a chance.” Barriers to and possibilities for a more health-promoting health service

With the overall objective to develop future strategies for a more health-promoting health service in Sweden, the aim of this paper was to describe how health personnel view barriers and possibilities for having a health-promoting role in practice. Seven focus group discussions were carried out with a total of 34 informants from both hospital and primary health care settings in Sweden. The informants represented seven professional groups; counselors, occupational therapists, assistant nurses, midwives, nurses, physicians, and physiotherapists. The data were analyzed using qualitative content analysis. The analysis resulted in one major theme "If we only got a chance". The theme captures the health professionals' positive view about, and their willingness to, develop a health-promoting and/or preventive role, while at the same time feeling limited by existing values, structures, and resources. The four categories, "organizational commitment to a paradigm shift", "recognition of staff as health-promoting instruments", "a balance between resources and tasks", and "freedom of action" capture what is needed for implementing and increasing health promotion and preventive efforts in the health services. The study indicates that an organizational setting that support health promotion is still to be developed. There is a need for a more explicit leadership with a clear direction towards the goal of "a more health-promoting health service" and with enough resources for achieving this goal.

The attitudes of patients and staff towards aspects of health promotion interventions in mental health services in Sweden

The present study investigates attitudes towards aspects of health promotion in mental health services, as rated by patients and staff. The aim of the study was to investigate similarities and differences in attitudes towards health promotion interventions among patients and staff in mental health services, using a newly developed questionnaire, the Health Promotion Intervention Questionnaire (HPIQ). The study has a cross-sectional design and a sample of 141 patients and 140 staff were recruited to the study. The response rate was 59% for the patients and 50% for the staff. The participants were asked to rate the attitudes of the 19 items included in the HPIQ. The result showed that patients and staff in some cases share similar attitudes regarding aspects of health promotion intervention. According to both groups, empowerment is the most important intervention in health promotion. Significant differences between the ratings of patients and staff appeared regarding all subscales of HPIQ. Patients rated alliance and educational support significantly higher than staff and staff-rated empowerment and practical support significantly higher than patients. Based on these findings, it is of importance to meet patients' desire for information and knowledge in an interactive manner with an empowerment approach to promote health in mental health services.

Fluorescence-guided transurethral resection of bladder cancer using hexaminolevulinate: analysis of health economic impact in Sweden

A decision analytic model was established to estimate the budget impact on the Swedish health service of using hexaminolevulinate (HAL) in conjunction with white light cystoscopy (WLC) in the management of bladder cancer for 1 year following initial diagnosis. Flowcharts were developed to represent the diagnostic and treatment pathways for each of four risk groups for non-muscle-invasive bladder cancer (NMIBC), as defined by risk of tumour recurrence and progression. Flowcharts were based on European Association of Urology Guidelines and adjusted to current Swedish clinical practice. The model covers the use of HAL cystoscopy in the operating room to guide transurethral resection of the bladder (TURB) in all patients. HAL cystoscopy as an adjunct to WLC allows for more accurate and complete resection of tumours compared with WLC alone, and the model assumed a consequent reduction in recurrence of 40%. The model projects that compared with WLC alone, use of HAL cystoscopy in the first TURB of all patients and for all TURBs due to recurrence in the first year after diagnosis, leads to a reduction of 23 cystectomies and 180 TURBs in a population of 2032 newly diagnosed bladder cancer patients. Avoidance of these procedures would result in a saving of SEK1 321 716 to the Swedish health service. HAL cystoscopy, used as an adjunct to white light in guiding TURB in NMIBC patients, may result in reduction of invasive, time-intensive and high-cost procedures such as cystectomy and TURB, compared with WLC alone.

Alcohol prevention activity in Swedish primary health care and occupational health services. Asking patients about their drinking

Aims To investigate the alcohol preventive activity in Swedish Occupational health services (OHS) and Primary health care (PHC) in relation to education in handling risky drinking, perceived skill ...

Towards Increased Alcohol Intervention Activity in Swedish Occupational Health Services

To investigate the extent to which Swedish occupational physicians and nurses discuss alcohol issues with their patients, their reasons for and against addressing these issues, their amount of education in handling risky drinking, and factors that they believe could facilitate increased alcohol intervention activity in OHS. All Swedish physicians and nurses in OHS were surveyed with a postal questionnaire. The questionnaire was returned by 313 physicians (response rate 54%) and 759 nurses (response rate 69%). As much as 70% of the physicians and 85% of the nurses reported that they "frequently" discussed alcohol problems with their patients. The majority of both physicians (81%) and nurses (69%) admitted participating in a maximum of a half-day training in handling risky drinking. Among the physicians, the most common reason for asking patients about their alcohol consumption was the clinical relevance (57%). Seventy-three per cent of the nurses initiated discussions about alcohol on the basis of questionnaire responses. Both the physicians (72%) and nurses (90%) said that the knowledge about counselling techniques to use when alcohol-related symptoms are evident was the most important facilitator to increased intervention activity. OHS professionals usually discuss alcohol-related issues with their patients. Nonetheless, they are interested in gaining further education and knowledge in this respect. The study results indicate that OHS is an important setting for alcohol prevention.

Inpatient and emergency child and adolescent psychiatry units in Sweden do not use restraint and seclusion: what we have learned

The Swedish Health and Medical Services Act states that health and medical care for all children, youth and adults shall: Be of a high standard and satisfy the patients need for security; Be easily accessible; Be based respect for the patients right to self-determination and integrity; Promote good communication between the patient and health and medical care personnel. The use of restraint and seclusion in psychiatric care is regulated by the same law compulsory psychiatric care (the current version was passed in 1991) for all ages. It states that coercive measures should be used only when there were no other alternatives. A court decision is needed and compulsory care includes: Compulsory medication; To be held with force; Isolation; Ban of visitors; Forbidden objects can be taken into custody. A caring attitude at wards based upon the UN Declaration of the Rights of the Child together with the paragraphs from above on respect for the patients right to self-determination and integrity and to promote good communication between the patient and health and medical care personnel including the child and his/her parents/legal guardians has minimized the use of restraint and seclusion in child and adolescent psychiatric care. Quiet rooms do not exist and the needs to use compulsory medication and to hold children with force have been rare occasions. To create a caring attitude of this kind is essentially depending how the staff is selected and their awareness and education.

Middle Eastern mothers in Sweden, their experiences of the maternal health service and their partner's involvement

BackgroundTraditional patterns relating to how to handle pregnancy and birth are often challenged due to migration. The purpose of this study was to describe Middle Eastern mothers' experiences of the maternal health care services in Sweden and the involvement of their male partner.MethodsThirteen immigrant mothers from the Middle East who had used the maternal health services in Sweden were interviewed using focus group discussions and individual interviews. These were taped, transcribed and analysed according to Content analysis.ResultsThe four main categories that developed were:• Access to the professional midwife• Useful counselling• Stable motherhood in transition• Being a family living in a different cultureConclusionAccording to the respondents in this study, understanding the woman's native language or her culture was not vital to develop a good relationship with the midwife. Instead the immigrant woman developed trust in the midwife based on the knowledge and the empathy the midwife imparted.Increasing the amount of first trimester antenatal visits could avoid spontaneous visits to the emergency clinic. There was a greater need for involvement and support by the father during the perinatal period, such as caring for older children and carrying out household chores since the mothers' earlier female network was often lost.Clinical implicationsThere is a need to involve immigrant parents in the available parental education in order to prepare them for parenthood in their new country as well as to explore their altered family situation. Collecting immigrant women and their partner's, experiences of maternal health care services offers a possibility to improve the existing care, both in content, access and availability where the timing of visits and content require further evaluation.

Screening for postnatal depression in Swedish child health care

To investigate how postnatal depressive mood was identified by child health nurses and which factors were associated with the implementation of screening for postnatal depression and with offering supportive listening visits. A random sample of all 2580 nurses in child health services in Sweden, 499 nurses, were asked to complete a postal questionnaire. A response rate of 70% was achieved. Half of the nurses in the study used the Edinburgh Postnatal Depression Scale (EPDS) and at least another 7% were going to begin. Having the appropriate training, access to regular supervision and pathways to care were essential, and increased the likelihood of using the EPDS. The odds of using the EPDS were six times greater for nurses with access to supervision as compared with nurses without supervision. Most of the nurses who used the EPDS included a follow-up interview on the same occasion as the mother completed the scale, and four out of five nurses allowed extra time for the EPDS. More than half of these allowed half an hour or more. The significance of factors associated with the implementation of routine screening is discussed. Training, supervision and pathways to care were essential for the implementation of routine screening with the EPDS.

Occupational Health Services in Sweden

(2007). Occupational Health Services in Sweden. Policy and Practice in Health and Safety: Vol. 5, No. sup1, pp. 113-123.

The Pathway to Meeting Need for Mental Health Services in Sweden

Mental health problems are often underrecognized and undertreated. Knowledge of the characteristics associated with the pathway to having a need for mental health care by appropriate treatment (met need) can help to correct this deficit. This study used data from a population-based study to determine the characteristics of persons whose needs were meetable, who were aware of the need for mental health care, who requested care, and whose needs were met. A total of 10,443 randomly selected persons in Stockholm, Sweden, aged 20 to 64 years answered a survey that included questions about mental health problems. A subsample of 1,093 persons was then interviewed by psychiatrists, who determined whether the respondents had a psychiatric disorder according to DSM-IV criteria. The interview also assessed need for care, service use, and whether an evidence-based treatment was available for the mental health problem. Among the 1,093 persons interviewed 462 were found to have a mental health problem for which psychiatric treatment was available (meetable need for care). Among the 462 persons with a meetable need for care, 70 percent fulfilled the DSM-IV diagnostic criteria for having a psychiatric disorder; the rest had various symptoms, mostly depressive. Among the persons with a meetable need for care, 84 percent were aware of this need, 37 percent had requested care, and 17 percent had their needs met by evidence-based treatment. Persons whose needs were met tended to be female, have more education, and have good social support. Also, they were less likely to report that feelings of shame would prevent them from requesting psychiatric care. The characteristics associated with unmet need suggest that strategies that focus on specific groups (for example, males and persons with less education) could increase the percentage of persons whose needs are met.

Appraisal of caregiving, burden and psychological distress in relatives of psychiatric inpatients

Appraisal of caregiving and its relationship to family burden and experienced mental health problems in the relatives were investigated as part of a multi-centre study of the quality of mental health services in Sweden performed in 1997. The sample was drawn from relatives of involuntarily and voluntarily admitted patients to acute psychiatric wards. The instrument used was a semi-structured questionnaire, interviewing relatives about the burden, experience of mental health problems and appraisal of the caregiving situation. The results showed a high proportion of relatives engaged in caregiving activities on a daily basis the month before the patient's admission to hospital and a high proportion of relatives appraising the caregiving activities negatively. The burden was more extensive if the relative and the patient were living together, had a longer duration of their relationship, if the relative was rendering caregiving on a daily basis and if the relative appraised caregiving negatively. The relatives' psychological distress was not related to their negative appraisal of caregiving, nor was patient characteristics, such as diagnosis and level of psychosocial functioning. The only factor found to influence the relatives' psychological distress was the duration of relationship to the patient. Interventions reducing psychological distress for relatives who have known the patients for more than 20 years, who live with the patient, who give care on a daily basis and who appraise their caregiving negatively are suggested.

Children in families with a severely mentally ill member. Prevalence and needs for support.

The prevalence of minor children in families with a severely mentally ill member, these children's needs for support and the situation of the spouses were investigated as part of a multi-centre study of the quality of the mental health services in Sweden performed in 1986, 1991 and 1997. The sample was drawn from relatives of compulsorily and voluntarily admitted inpatients to acute psychiatric wards. The instrument used was a semi-structured questionnaire, interviewing relatives about the burden of relatives, their needs for support and participation in care and items concerning the situation of the under-aged children in these families. The results over the years investigated showed the same proportion of patients admitted to hospital who were also parents to minor children and a decreasing proportion of patients who had the custody of their children. Female patients were more often a parent and also more often had the custody of the children. The majority of the children had needs for support caused by their parent's illness and these needs were met in half of the cases. The healthy spouses in families with minor children more often had to give up their own occupation and to a higher extent experienced own needs for care and support from psychiatric services compared to spouses without minor children. The study supports that there is an urgent need for the psychiatric services to initiate parental issues in programmes for treatment and rehabilitation to ensure that the specific needs of minor children are met.

Chapter 10. The Importance of Health and Medical Care for Public Health

Health and medical care are of great signi® cance for of medical knowledge (1, 2). Others have pointed out that mortality from infectious diseases sank long before public health. Estimations indicate that health and medical care contribute several years to life expectancy. antibiotics and vaccination became generally available (3, 4). In their view it was chie y better housing and They also contribute perhaps even more to improving many people’ s functional ability and quality of life. sanitary conditions, and improved social and economic conditions, that underlay the improvements in life This chapter focuses on the contributions of health and medical care during the 1990s. The conclusion is that expectancy. In these circumstances a clash of interests easily the Swedish health services are maintaining a high international standard and made great progress during arises between those who adopt a population perspective with prevention in focus and those who work with the 1990s, primarily in areas concerning cardiovascular care but also because many more people are being patients every day. The former view it as self-evident that contributions directed towards the large majority spared problems with their hip and knee joints or are regaining their sight. Had the risks and treatment poshave greater chances of giving eVects at population level. For those who work with patients it seems unfair sibilities for coronary heart disease been the same during the whole of the 1990s as they are today, the to hear that the eVects of their contributions are not noticed at population level. Cut-backs in resources in lives of rather more than 3,000 persons would have been saved each year. Every year 60,000 cataract operathe public sector unfortunately reinforce this clash of interests. But it is not normally a matter of ` either-or’ ’ tions are performed, a doubling compared with the previous decade. Most have considerably improved but of ` both-and’ ’ . The 1997 Public Health Report included a review of studies of the contribution of vision after the operation. But the picture is not entirely positive. During the early 1990s there were clear signs medical care to public health (6, 7). The basis for that presentation was a broad American study by Bunker that care was not being distributed equably. Towards the end of the decade it appears that care once more and co-workers (5). The study is brie y summarised below. became more equal although disquieting signs remain. Dental care diVers from medical care in its clearly uneven distribution. In addition, patients are aZicted Longer life by injuries caused by medical or surgical treatment. It is reasonable that the heavy staV cutbacks in care According to Bunker’ s calculations medical care proshould lead to a worsening in quality of caring but the longed life expectancy in the USA by about ® ve years eVect on public health is hard to judge. (Table 10:1). The ® gure of 5 years should be interpreted with great caution. It refers to American circumstances and all contributions historically made by A matter of dispute medical care. Smallpox, for example, no longer exists, but it was thanks to health and medical care that the The importance of health and medical care for public health has been debated for decades (1± 5). Some disease could be eradicated. Without these eVorts, smallpox could still have been a major public health people have maintained that the greatly increased life expectancy during the twentieth century can be problem. The greatest gains in life expectancy were ascribed to treatment of cardiovascular diseases (about ascribed largely to medical care and the development

A prospective study of the use of chemotherapy in Sweden and assessment of the use in relation to scientific evidence.

A prospective study on total utilisation of cytotoxic drugs for selected cancers was carried out in two Swedish health service regions, during four weeks in the autumn of 1997. The study included 1,590 patients; 1,169 with solid tumours and 421 with haematological malignancies. The majority of patients (75% to 80%) were treated at university/regional hospitals, often at oncology or haematology departments, and most received treatment as outpatients. Furthermore, most were treated according to recommendations in regional or national clinical guidelines, so-called care programmes, although the percentage varied by diagnosis. Only 10% were participants in a clinical trial. In approximately 40% of the patients, treatment was aimed at cure. However, this percentage varied between 0% and 94% depending on tumour type. At the population level, a comparison of the scientific evidence according to a literature review (Acta Oncol, this issue) with the survey showed that treatment with cytotoxic drugs in Sweden was largely evidence-based. A high percentage of patients received cytotoxic drugs for diseases where recommendations to treat were strong, i.e. outcomes were well-documented in the literature. A low percentage of patients received chemotherapy in disease settings with little or no scientific documentation. The percentage of patients treated was also limited in cases where the effects of chemotherapy are relatively small, although scientifically well-documented. For methodological reasons, one cannot exclude the possibility that cytotoxic drugs may be overutilised at the individual level for palliative purposes, e.g. by not discontinuing treatment despite the absence of clinical benefits. Likewise, one cannot exclude the possibility of underutilisation, e.g. by patients declining treatment because they were not informed about the potential benefits.