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Addressing individual behaviours and living conditions: Four Nordic public health policies

Aims: To identify characteristics of the public health policies of four Nordic countries concerning how they present the causes of ill health, the best ways to deal with these causes, and where to place responsibility; additionally, to investigate whether there is a common Nordic policy. Methods: Analyses of recent public health programmes in Denmark, Finland, Norway, and Sweden. Results: Focus is on either, or both, individual behaviour and living conditions as causes of ill health; the remedies are classical liberal as well as social democratic policies. None of the programmes is consistent with either ideological strand; each has its peculiar combination of interpretations and policies. The Danish programme is the most liberal focusing on behaviours and individual’s choices; the Norwegian programme is the most social democratic or social liberal focusing mostly on the social and physical environment and the politicians’ responsibility to improve the population’s health. The Swedish and the Finnish programmes lie between those of Denmark and Norway. The Finnish and Norwegian governments stress their responsibility for the health of the population. Conclusions: No common Nordic political approach to public health exists. All programmes contain contradictory policies and ideological statements with differences regarding the emphasis on individual behaviour versus choice and living conditions and political responsibility. The policies are not entirely predictable from the political stance of the government; national differences seem to play a role.

Public health policies: a Scandinavian model?

Aim: To identify how public health problems are identified, explained, and addressed in Scandinavian public health programmes. Methods: Recent public health white papers from Denmark, Norway, and Sweden have been studied asking the following questions. How are policies and activities justified? Which problems and causes are identified? What is to be done? To what extent are the interpretations and suggested interventions in accordance with liberal or social democratic political ideals? Results: The programmes studied give similar reasons for dealing with public health, namely the wish to create good lives for citizens and to improve the economy of society. The health problems identified are almost the same: cancer, heart disease, diabetes, musculoskeletal diseases, and mental illness. The Danish programme differs from its Norwegian and Swedish counterparts with regard to explanations and suggested solutions to the problems. It may be characterized as more liberal. While the Danish programme stresses the importance of individual behaviour, responsibility, and autonomy, the two others emphasize social relations, living conditions, and participation in addition to behavioural factors. Political responsibility for the health of the population is emphasized in the Norwegian and Swedish programmes. The Swedish programme, in particular, stresses common values such as equality and equal rights, and the significance of the welfare state. The Norwegian programme underlines the importance of empowering the individual, an ambition that could also be seen as a social liberal ambition to increase the self-determination of citizens. Conclusion: There is not one Scandinavian model in public health policy but several: a Danish model mainly adhering to liberal ideals, a Norwegian one that could tentatively be labelled social liberal, and a Swedish model adhering to more social democratic ideals.

Health inequalities: Political problematizations in Denmark and Sweden

Problematisation is a crucial step in any political process. By defining the nature of a problem, pointing to reasons for dealing with it and identifying its causes as well as its possible solutions, problematisation frames an issue as relevant and accessible to political action. Through a study of political documents in the field of public health policies from Denmark and Sweden published during the previous decades, this article analyses the problematisation of social inequalities in health. The article concludes that, in spite of similarities between Denmark and Sweden, in several social and political issues, politicians in the two countries problematised social inequalities in health differently. There were differences in all aspects of the problematisation: timing, reason for dealing with the issue, descriptions, explanations and suggested solutions. While in Denmark social inequalities in health were predominantly defined as poor health of the disadvantaged caused by their own inappropriate behaviour, in Sweden they were defined as a gradient along income or educational achievements caused by both behaviour and living conditions. In Swedish problematisation, the welfare state played a central role and the citizen was seen as part of the community, dependent on the way society was organised. The Danish approach, on the other hand, implied a more individualistic interpretation of people’s conditions and health plights and the state were accorded a less prominent place. The policies chosen to address social inequalities in health follow the same pattern as the general public health policies in the two countries.

Why the concept ‘‘lifestyle diseases’’ should be avoided

The concept lifestyle disease is used about a number of different diseases such as coronary heart disease, diabetes, lung cancer etc. The concept indicates that people’s behaviours cause the diseases. This is only partly true. All diseases, both so-called lifestyle diseases and infectious diseases, have multiple causes. Singling out only one type of causes, such as is implied in the concept of lifestyle diseases can lead prevention to focus only on changing people s behaviours or lifestyles, and thus to neglect other possibilities to improve health. Mortality due to chronic diseases has increased during the last century and the main cause behind this is the decrease in the mortality in infectious diseases among younger people. More people live long enough to develop the chronic diseases. The concept lifestyle disease gives a too narrow picture of causes death and should be abandoned and give place for a broader understanding of causes and preventive options.

Is old age necessarily connected with high hospital admission rates

The proportion of old people in a population is often taken as an indicator of the perceived need for and utilization of health services. What is the relation between age and hospital admission rates, and has it changed over time? These questions are investigated by a study of hospital statistics. In 1930 hospitalization rates were approximately the same for all age groups. In 1950 there was an increase with increasing age for men, but not for women, who had experienced a general increase in all age groups. In 1979 there was a pronounced increase in hospitalization rates in the high age groups for both sexes; this increase has been even more marked in the decades since. The number of admissions per 1,000 inhabitants over 64 years of age increased from 296 in 1979 to 418 in 1993. Changes in diagnoses and operation patterns for old patients during the last decade illustrate marginal changes in disease patterns and a slight increase in some types of surgery. An increase in readmission rates contributes substantially to the overall increase. The proportion of old people in a population tells us very little about perceived need for health services and cannot be used to predict hospital admission rates.

Ethics, equality and evidence in health promotion Danish guidelines for municipalities

Aim: The Danish National Board of Health has expressed its commitment to social equality in health, evidence-informed health promotion and public health ethics, and has issued guidelines for municipalities on health promotion, in Danish named prevention packages. The aim of this article is to analyse whether the Board of Health adheres to ideals of equality, evidence and ethics in these guidelines. Methods: An analysis to detect statements about equity, evidence and ethics in 10 health promotion packages directed at municipalities with the aim of guiding the municipalities towards evidence-informed disease prevention and health promotion. Results: Despite declared intentions of prioritizing social equality in health, these intentions are largely absent from most of the packages. When health inequalities are mentioned, focus is on the disadvantaged or the marginalized. Several interventions are recommended, where there is no evidence to support them, notwithstanding the ambition of interventions being evidence-informed. Ethical considerations are scanty, scattered and unsystematically integrated. Further, although some packages mention the importance of avoiding stigmatization, there is little indicating how this could be done. Conclusions: Including reduction of health inequalities and evidence-informed and ethically defendable interventions in health promotion is a challenge, which is not yet fully met by the National Board of Health. When judged from liberal ethical principles, only few of the suggested interventions are acceptable, i.e., those concerning information, but from a paternalistic view, all interventions that may actually benefit the citizens are justified.

Appeals to autonomy and obedience: continuity and change in governing technologies in Danish and Swedish health promotion.

The increasingly used concept new public health indicates that a fundamental change has occurred in the goals and methods of disease prevention and health promotion. The change is often said to imply less expert-driven governing of citizens. In this article, governing technologies in the field of public health in Denmark and Sweden are analysed to investigate whether substantial changes have taken place in the governing efforts. In the endeavours unfolded in relation to health examinations for children and pregnant women during the last eighty years, no apparent evidence exists of a significant change in governing technologies. Regulatory, expert-driven and empowering technologies have been used during the whole period; additionally, appeals to autonomy, responsibility and obedience as well as to trust in authorities co-exist throughout the period. The fundamental change is the huge increase in the health authorities’ governing ambitions.

Why did the stillbirth rate decline in Denmark after 1940

Stillbirth rates began declining in several industrialized countries simultaneously at the beginning of the 1940s. The reasons for this sudden decline have been discussed ever since. Changes in obstetric care, in risk factors, and in the composition of the population at risk have been suggested. One hypothesis is that it reflects a cohort effect of improved reproductive health status among women born during the first decades of the twentieth century arising from the decline in fertility. Other hypotheses point towards improved antenatal and obstetric care and changes in the prevalence of different risk factors. In this study, all death certificates for the stillborn in Denmark during 1938, 1941, 1945, and 1949 were used to investigate the different hypotheses. As possible contributing factors, the results suggest improvements in relation to the course of the delivery, changed parity distribution, and a cohort effect.

Widening the scope, targeting interventions, creating risk groups: maternal and child health in Denmark and Sweden from 1930s and onwards

The subject of this article is the health checks for pregnant women and children in Denmark and Sweden introduced in the 1930s and 1940s. It focuses on how political goals and means have changed up until today. The questions addressed are: Which health issues did the politicians and authorities find relevant to deal with? How should they be dealt with? Who were the interventions targeted towards? It is shown that from the 1970s changes gradually took place in two respects. (1) The scope widened inasmuch as increasingly more aspects were to be included in the examinations and guidance. Not only did they come to comprise the physical, social and mental wellbeing of the children but also the life of the entire family, including efforts to improve the parents’ social networks and their ability to handle their relationship with each other. (2) Interventions became increasingly targeted towards those categorised as being in need, either for medical reasons or because they were seen as less capable of caring for their children. Thus, this implied that the universal model of welfare provision was partly abandoned. The categorisations necessitated definitions of normality in more aspects and more surveillance in order to assess whether women and children lived up to the criteria of normality. These two changes were probably inter-related since the urge to target and therefore identify risk groups increased when more resources were invested as a consequence of the widening scope of the activities.

Book Review: Care and coercion: medical knowledge, social policy and patients with venereal disease in Sweden 1785–1903.

Anna Lundbergs book covers a number of topics related to venereal disease in nineteenth-century Sweden such as political ideas, legislation, medical knowledge and practice, social characteristics of patients treated at hospitals, and the social and health consequences of being hospitalized for a venereal disease. Lundberg has undertaken a huge task in analysing a wide variety of material in order to tell the story of venereal disease in Sweden. The sources studied include transcripts of parliamentary debates, laws, medical journals, patient records, records from parish meetings, etc. The reader is presented with many interesting stories about both doctors and patients. It sometimes seems as if the author wants to share with us most of what she has gathered together. The amount of information sometimes overshadows important findings, such as the change from the view of venereal disease as connected with poverty to that of its being connected with immoral behaviour. The most interesting findings result from Lundbergs analysis of the demographic life-course of patients from one hospital during 1814–44 and from another during the following forty-five years. She shows that the majority of patients with a venereal disease did not suffer serious social or health consequences from being hospitalized. That is to say, they got married like others. One important exception is that mortality among the patients discharged from the first hospital was higher than that among the control group. Children born to former female patients also had a high mortality rate at the first hospital. Patients discharged from the second hospital investigated had hardly any excess mortality as compared to the control group and the difference in infant mortality was smaller than among patients from the first hospital. There are some problems with the study. The patients are compared to a control group, described as “similar men and women”. This, however, is not a satisfactory description of the control group sampling. There was no infant mortality at all in the offspring of the control group of the first hospital. This gives the impression that the control group was neither representative in terms of the rest of the population nor comparable to the patient group, because the general level of infant mortality was so high (around 15 per cent) at the time that one would expect at least some mortality also in the control group. When the geographical distribution of patients is studied, it is not calculated in relation to the population, hence we do not know if the high numbers are due to a big population in the area or a high frequency of venereal disease and therefore if it is of special interest to study the areas with many patients. The author also gives some surprising interpretations of her results, as when she says that there was no significant gender difference between the patients at the department of venereal disease and the general hospital, in spite of the fact that the women constituted 61 per cent of the patients at venereal departments and only 43 per cent at the general wards. The book would have gained from a clearer focus from a more selective use of the extensive information, and especially from more careful work with the analyses of the demographic data. The book does, however, have the merit of presenting a lot of interesting information and references to sources on venereal disease in Sweden which will be of great help for scholars in the field.