Per Tillgren

Cervical screening participation and risk among Swedish‐born and immigrant women in Sweden

Cervical cancer is one of the most common cancers among women worldwide, although cervical screening has reduced the incidence in many high‐income countries. Low screening uptake among immigrant women may reflect differences in risk of cervical cancer. We investigated the degree of participation in cervical screening among immigrant and Swedish‐born women and their concurrent risk of cervical cancer based on individual information on Pap smears taken both from organized and opportunistic screening. Mean degree of participation in cervical screening was estimated for women between 23 and 60 years from 1993 to 2005, stratified by birth region and age at migration. In Poisson regression models, we estimated relative risks (RRs), incidence rates and incidence rate ratios of cervical cancer for women adhering or not to the cervical screening program. We also assessed effect of adherence to screening on the risk of cervical cancer among immigrant groups compared to Swedish‐born women. The degree of participation was 62% and 49% among Swedish‐born and immigrant women, respectively, with large variations between immigrant groups. Participation was lowest among those immigrating at older ages. Swedish‐born and immigrant women who where nonadherent to the cervical screening program had a fivefold excess risk of cervical cancer compared to adherent women. After adjustment for screening adherence, excess RRs of cervical cancer were statistically significant only for women from Norway and the Baltic States. Participation to screening is lower among immigrant than Swedish‐born women, and adherence to the recommended screening intervals strongly prevents cervical cancer.

Vision Zero - a road safety policy innovation

The aim of this paper is to examine Swedens Vision Zero road safety policy. In particular, the paper focuses on how safety issues were framed, which decisions were made, and what are the distinctive features of Vision Zero. The analysis reveals that the decision by the Swedish Parliament to adopt Vision Zero as Swedens road safety policy was a radical innovation. The policy is different in kind from traditional traffic safety policy with regard to problem formulation, its view on responsibility, its requirements for the safety of road users, and the ultimate objective of road safety work. The paper briefly examines the implications of these findings for national and global road safety efforts that aspire to achieving innovative road safety policies in line with the Decade of Action for Road Safety 2011–2020, declared by the United Nations General Assembly in March 2010.

Who is a successful quitter? One-year follow-up of a National Tobacco Quit and Win Contest in Sweden

The first nation-wide Quit and Win Contest in Sweden was held in 1988 with 12,840 participants. This corresponds to a participant rate of 6.4 per 1,000 daily tobacco users in Sweden. In order to follow up the long-term effects of cessation and to analyse the determinants for successful cessation, a panel (n = 946) of randomized participants were followed-up at 6 and 12 months with a mailed questionnaire. This gave a complete set of data for 557 (panel) respondents. Available baseline data from the participants’ entry forms included sex, age, occupation, specific tobacco habits, quitting attempts during the previous year, and place of residence. At the 12-month follow-up 21% had been tobacco-free for the whole year. In addition 9% of the participants relapsed into tobacco-use, then quit again and were tobacco-free at the 12-month follow-up. The success rate for those participants (14%) who used smokeless tobacco (oral snuff) was similar to that of smokers. The logistic regression showed a significantly better prognosis for success among those without any earlier quitting attempts during the previous year (OR 2.35), if the subjects participated of their own volition rather than having been recruited by a non-tobacco user (OR 1.74), and if they were married/co-habiting (OR 1.92), the results were also significantly improved. The results also show that as a population-based method, Quit and Win produced many successful tobacco quitters, and one year after the contest one-fifth of the participants were still abstinent.

Aspects of health, physical/leisure activities, work and socio-demographics associated with pet ownership in Sweden

Aims: The aim of the work presented here was to explore differences between pet owners and non-pet-owners concerning aspects of health, physical/leisure activities, work and socio-demographics. Methods: The study was based on nationally representative data from the Swedish population (n = 43,589). Associations between pet ownership and background variables were investigated using logistic regression analysis. Results: A total of 39,995 respondents were included in the analysis (non-pet-owners = 25,006; pet owners = 14,989). Pet ownership was associated with both positive and negative aspects of health, physical/leisure activities and socio-demographics. Pet owners had better general health but suffered more from mental health problems than non-pet-owners. Their leisure activities involved a greater interest in nature life and/or gardening than those of non-pet-owners. The logistic regression analysis showed that people who were self-employed, in the age range 35 to 49, of female sex, and suffering from pain in the head, neck and shoulders were more likely to own a pet than others. People physically active at a level sufficient to have a positive effect on their health more often owned a pet than people who were less active. Conclusions: Pet owners differ from non-pet-owners in aspects of socio-demographics, health, physical/leisure activities and work situation. This study, based on a general regional population in Sweden, showed differences of both a positive and a negative kind between non-pet-owners and pet owners concerning aspects of health, physical and leisure activities, and work situation.

Risk of cervical cancer among immigrants by age at immigration and follow-up time in Sweden, from 1968 to 2004

Because of great variation in the prevalence of human papilloma virus infection and other risk factors of cervical cancer worldwide, migrant studies may help further the understanding of the aetiology and improve prevention of cervical cancer. Our aim was to study the risk of invasive cervical cancer among immigrant women. We followed 758,002 immigrants from different countries who resided in Sweden between 1968 and 2004. Age‐standardised incidence rates (ASRs) of immigrants were compared with that in their countries of origin. Poisson regression models estimated the relative risks of cervical cancer among immigrants, overall and stratified by age at migration and follow‐up time, compared to Swedish‐born women. Overall 1,991 of 19,542 observed cases of cervical cancer occurred among immigrants. Generally they had lower ASRs than in their countries of origin, with the exception of Nordic immigrants. Compared to Swedish‐born women, we observed a higher relative risk of cervical cancer among immigrants overall (RR = 1.13, 95% CI 1.08–1.18), and particularly among women from Denmark (RR = 1.8, 95% CI 1.6–2.1), Norway (RR = 1.7, 95% CI 1.5–1.9) and Central America (RR = 2.5, 95% CI 1.3–4.9), while the relative risks were lower in immigrants from Eastern Africa (RR = 0.2, 95% CI 0.1–0.6), South Central Asia (RR = 0.4, 95% CI 0.2–0.6) and South Western Asia (RR = 0.5, 95% CI 0.4–0.7). Follow‐up time and age at migration were important effect modifiers for cervical cancer risks. We suggest targeted prevention toward high‐risk immigrants, specifically older women, in the first 10 years after arrival into their new homeland.

Comparison of a high and a low intensity smoking cessation intervention in a dentistry setting in Sweden: a randomized trial

BackgroundTobacco is still the number one life style risk factor for ill health and premature death and also one of the major contributors to oral problems and diseases. Dentistry may be a potential setting for several aspects of clinical public health interventions and there is a growing interest in several countries to develop tobacco cessation support in dentistry setting. The aim of the present study was to assess the relative effectiveness of a high intensity intervention compared with a low intensity intervention for smoking cessation support in a dental clinic setting.Methods300 smokers attending dental or general health care were randomly assigned to two arms and referred to the local dental clinic for smoking cessation support. One arm received support with low intensity treatment (LIT), whereas the other group was assigned to high intensity treatment (HIT) support. The main outcome measures included self-reported point prevalence and continuous abstinence (≥ 183 days) at the 12-month follow-up.ResultsFollow-up questionnaires were returned from 86% of the participants. People in the HIT-arm were twice as likely to report continuous abstinence compared with the LIT-arm (18% vs. 9%, p = 0.02). There was a difference (not significant) between the arms in point prevalence abstinence in favour of the HIT-protocol (23% vs. 16%). However, point prevalence cessation rates in the LIT-arm reporting additional support were relatively high (23%) compared with available data assessing abstinence in smokers trying to quit without professional support.ConclusionScreening for willingness to quit smoking within the health care system and offering smoking cessation support within dentistry may be an effective model for smoking cessation support in Sweden. The LIT approach is less expensive and time consuming and may be appropriate as a first treatment option, but should be integrated with other forms of available support in the community. The more extensive and expensive HIT-protocol should be offered to those who are unable to quit with the LIT approach in combination with other support.Trial RegistrationTrial registration number: NCT00670514

A cost-effectiveness analysis of a community-based diabetes prevention program in Sweden.

OBJECTIVES Lifestyle changes to prevent type 2 diabetes among high-risk persons have been shown to be cost-effective. This study investigates the cost-effectiveness of a community-based program promoting general population lifestyle changes to prevent diabetes. METHODS The 10-year program was implemented in three municipalities in Sweden. Effectiveness was measured with a quasiexperimental cohort design, that is, risk factor levels in a population group aged 36-56 years at baseline and 8-10 years later (2,149 men; 3,092 women) in the program municipalities and a control area were compared. The incremental cost-utility analysis included future diabetes and cardiovascular disease-related health effects and societal costs (discounted 3 percent), estimated by a Markov model. RESULTS In all areas, risk factor levels increased during follow-up, leading to increased societal costs of between SEK40,000 and 90,000 (1 Euro 2004 = SEK9.13; 1 US

Non-pharmaceutical prevention of hip fractures – a cost-effectiveness analysis of a community-based elderly safety promotion program in Sweden

= SEK 7.35) and quality-adjusted life-year (QALY) losses between 0.12 and 0.48 per individual. Compared with the control area, the cost increases and QALY losses for women were more favorable in two program areas but less favorable in one, and less favorable for men in both areas (data unavailable for one municipality). The findings indicate that the program was cost-effective in only two female study groups. CONCLUSIONS Conflicting results on the cost-effectiveness of the program were obtained. As several potentially valuable aspects of the program are not included in the cost-effectiveness analysis, the societal value of the program might not be adequately reflected.

Impact of Direct Mail as a Method to Recruit Smoking Mothers into a "Quit and Win" Contest

BackgroundElderly injuries are a recognized public health concern and are due to two factors; osteoporosis and accidental falls. Several osteoporosis pharmaceuticals are considered cost-effective, but intervention programs aiming at preventing falls should also be subjected to economic evaluations. This study presents a cost-effectiveness analysis of a community-based elderly safety promotion program.MethodsA five-year elderly safety promotion program combining environmental structural changes with individually based measures was implemented in a community in the metropolitan area of Stockholm, Sweden. The community had around 5,500 inhabitants aged 65+ years and a first hip fracture incidence of 10.7 per 1,000 in pre-intervention years 1990–1995. The intervention outcome was measured as avoided hip fractures, obtained from a register-based quasi-experimental longitudinal analysis with several control areas. The long-term consequences in societal costs and health effects due to the avoided hip fractures, conservatively assumed to be avoided for one year, were estimated with a Markov model based on Swedish data. The analysis holds the societal perspective and conforms to recommendations for pharmaceutical cost-effectiveness analyses.ResultsTotal societal intervention costs amounted to 6.45 million SEK (in Swedish krona 2004; 1 Euro = 9.13 SEK). The number of avoided hip fractures during the six-year post-intervention period was estimated to 14 (0.44 per 1,000 person-years). The Markov model estimated a difference in societal costs between an individual that experiences a first year hip fracture and an individual that avoids a first year hip fracture ranging from 280,000 to 550,000 SEK, and between 1.1 and 3.2 QALYs (quality-adjusted life-years, discounted 3%), for males and females aged 65–79 years and 80+ years. The cost-effectiveness analysis resulted in zero net costs and a gain of 35 QALYs, and the do-nothing alternative was thus dominated.ConclusionThe community-based elderly safety promotion program aiming at preventing accidental falls seems as cost-effective as osteoporosis pharmaceuticals.

National public health policy in a local context--implementation in two Swedish municipalities.

In the early 1980s the concept of a Quit and Win (Q&W) contest was developed in the Minnesota Heart Health Program (MHHP) as a population-based smoking cessation strategy. The Q&W model has since spread and been applied in many countries around the world. Different communication strategies have been applied for recruiting participants for Q&W. In the Q&W contest in 1995 in Stockholm County, Sweden, direct mail was used as the main recruitment strategy among daily smoking mothers with children aged 0-6 years. Two additional strategies were employed to recruit participants, that is, ads in a local newspaper and personal communication. The target group was estimated to be approximately 4,300 women. In total 5.5% of the target group was recruited, and of those, 4.3% were recruited by direct mail. After 12 months, 14.3% of the women were sustained smoke-free, and the corresponding percentage for those women who were recruited by direct mail was 15.5%. In comparison with several other Q&W contests employing other strategies, the direct-mail technique seems not only to have been successful in recruiting participants, but also in aiding remained sustained smoke-free women after 12 months. To optimize recruitment for Q&W contests, a combination of recruiting strategies should be applied.In the early 1980s the concept of a Quit and Win (Q&W) contest was developed in the Minnesota Heart Health Program (MHHP) as a population-based smoking cessation strategy. The Q&W model has since spread and been applied in many countries around the world. Different communication strategies have been applied for recruiting participants for Q&W. In the Q&W contest in 1995 in Stockholm County, Sweden, direct mail was used as the main recruitment strategy among daily smoking mothers with children aged 0-6 years. Two additional strategies were employed to recruit participants, that is, ads in a local newspaper and personal communication. The target group was estimated to be approximately 4,300 women. In total 5.5% of the target group was recruited, and of those, 4.3% were recruited by direct mail. After 12 months, 14.3% of the women were sustained smoke-free, and the corresponding percentage for those women who were recruited by direct mail was 15.5%. In comparison with several other Q&W contests employing other strategies, the direct-mail technique seems not only to have been successful in recruiting participants, but also in aiding remained sustained smoke-free women after 12 months. To optimize recruitment for Q&W contests, a combination of recruiting strategies should be applied.