Global folkhälsa befinner sig idag vid en brytpunkt med nedskärningar i internationellt bistånd, trots att det humanitära behovet är större än någonsin. Globala framsteg hotas nu när det globala hälsosystemet tvingas omorganisera när dess största biståndsgivare USA lämnar WHO, lägger ner sin biståndsmyndighet USAID och avbryter utländskt bistånd. Detta riskerar att få förödande konsekvenser med miljontals döda människor och hotar de framsteg som gjorts för de tre globala infektionssjukdomar som leder till flest dödsfall globalt: tuberkulos, hiv och malaria, sjukdomar som dessutom går att förebygga och behandla. Samtidigt är demokratin på tillbakagång och befinner sig på den lägsta nivån på över 50 år där istället allt fler människor bor i autokratier. Den negativa utvecklingen av mänskliga och demokratiska rättigheter har ett tydligt samband med ökningen av socioekonomiska klyftor världen över.

Introduction Although climate change has been consistently identified as one of the greatest threats to humans, many clinicians do not feel prepared to address climate change with patients and medical school curricula still have very little coverage of its health consequences. At the same time, health care providers have been shown to be trusted voices and are therefore well suited to help build the public and political necessary to enact policies that effectively address climate change and protect human health in equitable ways. Nevertheless, teaching climate, health and sustainable healthcare to medical colleagues, students and healthcare leaders can be challenging for various reasons. It is therefore essential to provide health care providers and leaders with the appropriate tools and communication skills to facilitate a more sustainable and greener healthcare. Case presentation In this case report, we describe how we developed a sustainability guide for clinicians with examples of how to reduce unnecessary environmental and climate impact, without compromising patient safety, highlighting potential co-benefits for public health, healthcare efficiency, financial aspects and to the occupational environment. Discussion The sustainability guide has been appreciated by medical specialties as a tool to illustrate concrete ways of working with sustainable healthcare in Sweden. It has also been used to introduce the field into the medical curriculum at Swedish universities and teach students in sustainability. Conclusion Our sustainability guide highlights the potential value of providing health care personnel and leaders with the appropriate tools and communication skills to facilitate a more sustainable and green healthcare.

The medical profession plays a crucial role in tackling the health impacts of climate change and in promoting a green transition of society and the health sector. Despite this, opportunities for action are still quite unknown within the profession, and no mandatory education is required in interns' or residents' education. Medical schools, on the contrary, both in Sweden (due to legislation) and abroad, have started integrating climate, health and sustainable healthcare into the medical curricula in line with international educational recommendations, thus preparing future generation physicians for the task. The following overview presents concrete and relevant pedagogical initiatives currently used in Sweden and abroad to enhance education and clinical implementation of climate medicine and sustainable healthcare for medical students and physicians. Furthermore, the significance of strong leadership and mandatory education is emphasized.

The purpose of this case-control study was to investigate the associations between maternal serum concentrations of vitamin D early in pregnancy and the occurrence of preterm birth. The study included 269 women (cases) whose children were born preterm (< 37 gestational weeks [gw]) and 332 women (controls) whose children were born term (≥ 37 gw). Among the cases, 59 were extreme preterm (< 28 gw), 74 severe preterm (28‒32 gw), and 136 late preterm (33‒36 gw). All women gave birth in Scania, the most Southern County of Sweden. Concentrations of 25-hydroxyvitamin D3 (vitamin D) in maternal serum collected early in pregnancy were analyzed using liquid chromatography-tandem-mass-spectrometry (LC/MS/MS). The serum concentrations of vitamin D were trichotomized based on the distributions among the controls (≤ 44.9; 45.0‒68.8; and ≥ 68.9 nmol/L) as well as dichotomized at a predefined cut-off (< 50 and ≥ 50 nmol/L). Logistic regression was used to estimate the associations between vitamin D and preterm births, partly when all cases were included in the analyses, and partly when the three different case groups were included separately. The category with the highest vitamin D concentration was used as a reference in the regression analyzes. The analyses were performed without as well as with adjustments for potential confounders. When the category with the lowest vitamin D concentrations were compared with the reference category in the analyses where the vitamin D concentrations were trichotomized, no statistically significant associations were observed. However, among the extreme preterm an adjusted odds ratio of 1.93 (95

Climate change is already impacting our environment and health, with rising sea levels, extreme weather, and higher temperatures. Greenhouse gas levels are at their highest in three million years, making climate-related health risks increasingly urgent. Heatwaves, wildfires, and floods lead to mortality, trauma, and non-communicable diseases both in the short and long term. Climate change also alters the spread of infectious diseases in Sweden, increasing cases of Vibrio bacteria infections in brackish water and expanding the range of disease-carrying vectors like ticks and mosquitoes. Vulnerable populations, such as outdoor workers, children, elderly, and people with chronic illnesses, face higher risks. Addressing these challenges requires multidisciplinary research, proactive policy measures, and healthcare system adaptation. Additionally, the healthcare sector must reduce its own carbon footprint to mitigate climate change impacts.

PURPOSE:Given the paucity of data regarding workplace risk of COVID-19, particularly from countries with limited lockdowns, we aimed to quantify the occupational risks of COVID-19-related hospital admission among workers in Sweden. METHODS:We identified 607,179 employed individuals, 20-69 years of age, in Skåne, Sweden. From December 31st, 2019-December 31st 2021, 2,633 incident COVID-19-related admissions were identified. Using a job exposure matrix for risk of becoming infected with the SARS-CoV-2 virus in an occupational setting we delineated occupations with low work-related risk. Based on these reference occupations, incidence rate ratios (IRR) and 95% confidence intervals (CI) were computed by Poisson regression for four-digit occupations defined by the International Standard Classification of Occupations job codes (ISCO-08). RESULTS:After adjusting for various sociodemographic characteristics, risk compared to reference occupations was elevated among healthcare occupations as a group (IRR 1.31; 95% CI: 1.13-1.51), with nurses, healthcare assistants, and nursing aids having the highest IRRs (ranging from 1.28-1.54). In the educational sector, no apparent elevated overall risk was observed (IRR 1.03; 95% CI: 0.86-1.23). For the transportation sector, an overall excess risk was observed (IRR 1.34; 95% CI: 1.10-1.65), with bus and tram drivers having the highest risks. IRRs < 1 were observed among electricians, some builders, and software developers. CONCLUSION:Excess risk of COVID-19-related hospital admission was observed in many patient-facing occupations across the healthcare sector and in multiple occupations within the transportation sector. However, despite limited lockdowns and legislation, no apparent increased risks were observed in the educational or retail sales sectors.

OBJECTIVE:This systematic scoping review aimed to map the literature on the use of various nudging strategies to influence prescriber behavior toward reducing opioid prescriptions across diverse healthcare settings. METHODS:A systematic database search was conducted using seven electronic databases. Only articles published in English were included. A total of 2234 articles were identified, 35 of which met the inclusion criteria. Two independent dimensions were used to describe nudging strategies according to user action and the timing of their implementation. RESULTS:Six nudging strategies were identified. The most common strategy was default choices, followed by increasing salience of information or incentives and providing feedback. Moreover, 32 studies used the electronic health record as an implementation method, and 29 reported significant results. Most of the effective interventions were multicomponent interventions (i.e., combining nudge strategies and non-nudge components). CONCLUSIONS:Most nudging strategies used a passive approach, such as defaulting prescriptions to generics and requiring no action from the prescriber. Although reported as effective, this approach often operates under the prescriber's radar. Future research should explore the ethical implications of nudging strategies.INPLASY registration number: 202420082.

Background Pandemics are linked with declining birth rates, but little is known about how the COVID-19 pandemic has influenced childbearing decisions. We aimed to investigate the associations between the COVID-19 pandemic and reproductive decisions, specifically to identify potential changes in the frequency of deliveries and induced abortions in Skåne, Sweden. Methods Using the Skåne Healthcare Register, we identified women aged 15–45 years who had at least one pregnancy-related care visit registered between 1 January 2013 and 11 November 11 2021. Deliveries and induced abortions were identified, and changes in weekly delivery and abortion counts were assessed using an interrupted time series design. Relative risks (RRs) and 95% confidence intervals (CIs) were estimated from a Poisson regression model. Results During the study period we identified 129 131 deliveries and 38 591 abortions. Compared with the counterfactual (exposed interval assuming COVID-19 had not occurred), pandemic exposure was associated with fewer deliveries (RR 0.93; 95% CI 0.89 to 0.98). For abortions, pandemic exposure appeared to be associated with fewer abortions (RR 0.95; 95% CI 0.90 to 1.00); however, age-related differences were found. Among women aged 25 years and over, pandemic exposure was more strongly associated with fewer abortions. Contrastingly, among women aged under 25 years, abortions appeared to increase. Conclusions The COVID-19 pandemic seemed to have contributed to a decline in births in Southern Sweden. During the same period, abortions declined in women in the older age range, but contrastingly increased among younger women.

Objective To investigate whether maternal paracetamol use in early pregnancy is associated with cerebral palsy (CP) in offspring. Study design We conducted a registry and biobank-based case-control study with mother-child pairs. We identified CP cases (n = 322) born between 1995 and 2014 from a nationwide CP-registry. Randomly selected controls (n = 343) and extra preterm controls (n = 258) were obtained from a birth registry. For each mother, a single serum sample from early pregnancy (gestation weeks 10-14) was retrieved from a biobank and analyzed for serum concentrations of paracetamol, categorized into unexposed (<1 ng/ml), mildly exposed (1-100 ng/ml), and highly exposed (>100 ng/ml), and in quartiles. Analyses were performed using logistic regression and adjusted for potential confounders. Separate analyses were conducted including only those children born preterm and only those born term. Results Of the 923 participants, 36.8% were unexposed, 53.2% mildly exposed, and 10% highly exposed to paracetamol. Overall, prenatal exposure to paracetamol was not associated with CP. Sensitivity and subgroup analyses showed no clear associations between paracetamol and CP across strata of term/preterm birth as well as subtypes of CP. Conclusions The present study does not support an association between intrauterine exposure to paracetamol in early pregnancy and the risk of CP. However, it is important to stress that the exposure estimate is based on a single serum sample.

Small for gestational age (SGA) is considered an adverse birth outcome. Per- and polyfluoralkyl substances (PFAS) have become increasingly investigated as contributing environmental factors, thus far with inconclusive results. The current study aimed to investigate the hypothesized association between increased maternal PFAS levels in early pregnancy and an increased risk for SGA birth. This population-based study used data from a sample of children born in Scania, Southern Sweden, between 1995 and 2009. Two groups were compared: cases born with SGA (n = 298) and non-SGA controls (n = 580). The cases consisted of two subgroups: one included women whose children’s growth in late pregnancy was in the lowest quartile, and another included women from the remaining growth quartiles. Corresponding maternal serum samples were collected from a biobank and analyzed for concentrations of four types of PFAS: perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluorohexane sulfonic acid (PFHxS), and perfluorooctane sulfonic acid (PFOS) using liquid chromatography–tandem mass spectrometry (LC/MS/MS). The results were combined with information from birth registers and analyzed using Mann–Whitney U-tests and logistic regression—unadjusted as well as adjusted for potential confounders. In conclusion, elevated maternal concentrations of PFAS were not associated with an increased risk of SGA birth. However, significant ORs were observed in a subgroup analysis restricted to women of Nordic origin (unadjusted OR 3.2 and adjusted OR 2.4) for PFHxS.

Despite the end of the Cold War, the world still has thousands of nuclear weapons and adversarial relations between the countries that possess them. A nuclear war could cause large and abrupt global environmental change known as nuclear winter, with potentially devastating public health consequences. A significant line of natural science research characterizes nuclear winter and its potential effect on global food security, but less has been done on the human impacts and policy implications. Therefore, this Viewpoint proposes an interdisciplinary research and policy agenda to understand and address the public health implications of nuclear winter. Public health research can apply existing tools developed for the study of other environmental and military issues. Public health policy institutions can help build preparedness and community resilience to nuclear winter. Given the extreme potential severity of nuclear winter, it should be treated as a major global public health challenge to be addressed by public health institutions and researchers.

Background: Most cerebral palsy (CP) cases have an unexplained etiology, but a role for environmental exposures has been suggested. One purported environmental risk factor is exposure to endocrine-disrupting pollutants specifically per- and polyfluoroalkyl substances (PFAS).Objectives: We investigated the association between prenatal PFAS exposures and CP in Swedish children. Methods: In this case-control study, 322 CP cases, 343 population controls, and 258 preterm controls were identified from a birth registry in combination with a CP follow-up program from 1995 to 2014 and linked to a biobank which contains serum samples from week 10-14 of pregnancy. Maternal serum concentrations of four PFAS compounds: perfluorohexane sulfonate (PFHxS), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), and perfluorooctane sulfonate (PFOS) were analyzed using liquid chromatography-tandem-massspectrometry. We estimated odds ratios (ORs) and 95 % confidence intervals (CIs) for CP and each PFAS in quartiles and as continuous variables controlling for various sociodemographic and lifestyle factors.Results: In crude and adjusted analyses, we did not find consistent evidence of associations between serum PFHxS, PFOA, PFNA, PFOS and concentrations in early pregnancy and CP, except in preterm infants. The ORs comparing the highest PFAS quartiles to the lowest were 1.05 (95 % CI: 0.63-1.76), 0.96 (95 % CI: 0.55-1.68), 0.71 (95 % CI: 0.41-1.25), and 1.17 (95 % CI: 0.61-2.26), for PFHxS, PFOA, PFNA, and PFOS, respectively. Some positive associations were observed for preterm infants, but the results were imprecise. Similar patterns were observed in analyses treating PFAS as continuous variables. Conclusions: In this study, we found little evidence that early pregnancy prenatal exposure to PFHxS, PFOA, PFNA, or PFOS increases the risk of CP. However, some positive associations were observed for preterm cases and warrant further investigation.

Objective This study aimed to quantify the risk of COVID-19-related hospital admission in spouses living with partners in at-risk occupations in Denmark during 2020-21.Methods Within a registry-based cohort of all Danish employees (N=2 451 542), we identified cohabiting couples, in which at least one member (spouse) held a job that according to a job exposure matrix entailed low risk of occupational exposure to SARS-CoV-2 (N=192 807 employees, 316 COVID-19 hospital admissions). Risk of COVID-19-related hospital admission in such spouses was assessed according to whether their partners were in jobs with low, intermediate or high risk for infection. Overall and sex-specific incidence rate ratios (IRR) of COVID-19-related hospital admission were computed by Poisson regression with adjustment for relevant covariates.Results The risk of COVID-19-related hospital admission was increased among spouses with partners in highrisk occupations [adjusted IRR (IRRadj)1.59, 95% confidence interval (CI) 1.1-2.2], but not intermediate-risk occupations (IRRadj 0.97 95% 0.8-1.3). IRR for having a partner in a high-risk job was elevated during the first three pandemic waves but not in the fourth (IRRadj 0.48 95% CI 0.2-1.5). Sex did not modify the risk of hospital admission.Conclusions SARS-CoV-2 transmission at the workplace may pose an increased risk of severe COVID-19 among spouses in low-risk jobs living with partners in high-risk jobs, which emphasizes the need for preventive measures at the workplace in future outbreaks of epidemic contagious disease. When available, effective vaccines seem essential.

Objective To map the risk of work-related SARS-CoV-2 across occupations and pandemic waves and investigate its impact on morbidity and partner-risk. Methods The cohort includes 2,4 million employees aged 20–69 with follow-up from 2020 through 2021. During this period, 261,203 employees had a positive SARS-CoV-2 test and 4416 were admitted to hospital with Covid-19 (HA). At-risk occupations defined at the 4-digit DISCO-08 level were identified using a reference population of mainly office-workers defined a priory by a job-exposure matrix (JEM). Incidence rate ratios (IRR) and effect modification by pandemic wave were computed by Poisson regression. We adjusted for demographic, social and health characteristics including household size, completed Covid-19 vaccination and occupation-specific frequency of testing. Results In addition to eight specific occupations in the healthcare sector, we found increased risk of Covid-19 related HA in bus drivers, kindergarten teachers, domestic helpers, and operators in food production (IRR from 1.5–3) and modestly increased risk of SARS-CoV-2 infection in numerous occupations outside the healthcare sector including police and security guards, supermarket attendants, receptionists, cooks, and waiters. After the first year of the pandemic, the risk fell to background levels among healthcare workers but not in other occupations. The risk of Covid-19 related HA was increased in spouses with partners in high-risk occupations (IRR 1.54, 95% CI 1.1–2.2). Employees born in low-income countries and male employees from Eastern Europe more often worked in at-risk occupations. Being foreign-born modified the risk of PCR test positivity, primarily because of higher risk among men born in Eastern Europe working in at-risk occupations (IRR 2.39, 95% CI 2.09–2.72 versus IRR 1.19 (95% CI 1.14–1.23) in native-born men). Conclusion SARS-Cov2 transmission at the workplace was common during the Covid-pandemic in spite of temporary lock-downs which emphasizes the need for improved safety measures during future epidemics.

ABSTRACTObjectivesMost earlier studies on occupational risk of Covid-19 covering the entire workforce are based on relatively rare outcomes such as hospital admission and mortality. This study examines the incidence of SARS-CoV-2 infection by occupational group based upon real-time polymerase chain reaction tests (RT-PCR).MethodsThe cohort includes 2.4 million Danish employees, 20-69 years of age. All data were retrieved from public registries. The sex-specific incidence rate ratios (IRR) of first-occurring positive RT-PCR test from week 8 of 2020 through week 50 of 2021 were computed by Poisson regression for each 4-digit DISCO-08 job code with more than 100 employees (337 in men; 297 in women). Occupational groups with low risk of workplace infection according to a job exposure matrix constituted the reference group. Risk estimates were adjusted by demographic, social and health characteristics including household size, completed Covid-19 vaccination, pandemic wave and occupation-specific frequency of testing.ResultsIRR’s of SARS-CoV-2 infection were elevated in 34 occupations comprising 12 % of male employees and 45 occupations comprising 41 % of female employees. All IRR estimates were below 2.0. Decreased IRRs were observed in 85 occupations in men but none in women.DiscussionWe observed a modestly increased risk of SARS-CoV-2 infection among employees in numerous occupations indicating a large potential for preventive actions, especially in the female workforce. Cautious interpretation of observed risk in specific occupations is needed because of methodological issues inherent in analyses of RT-PCR-test results and because of multiple statistical tests.WHAT IS ALREADY KNOW ABOUT THIS TOPIC?Epidemiological studies suggest that the workplace contribute to the Covid-19 pandemicResults are mostly based upon studies of less frequent outcomes as Covid-19 morbidity or mortality which limits inference about risk in specific occupationsWHAT THIS STUDY ADDSThe risk of Covid-19 infection was increased in 34 of 337 occupations in men and in 45 of 297 occupations in womenSome 12% of the Danish male workforce and 41% of the female workforce are at increased risk of Covid-19 infectionHOW THIS RESEARCH MIGHT AFFECT RESEARCH, PRACTICE OR POLICY?Preventive actions targeting the workplace may contribute substantially to alleviate disease occurrence in the ongoing Covid-19 and similar future pandemics.

The Swedish approach to managing the COVID-19 pandemic has received significant attention in international scholarly work and the press. For this dataset, we have reviewed governmental and media archives to build a detailed timeline that chronicles significant policies, interventions, and events in the Swedish management of COVID-19. The dataset contains summary descriptions of what took place, when it happened, and who the principal actors involved were. Links to primary sources are provided for each entry. Because of the level of detail and saturation, the dataset offers a detailed account of Swedish pandemic governance and will benefit anyone working on Swedish pandemic management or doing comparative work between Sweden and other jurisdictions. The dataset contains details on the date an event took place (column 1), tags to facilitate navigation (column 2), details on the principal actors involved in the event (column 3), a summary description of what took place and who was involved (column 4), and links to primary materials (e.g., archival entries) (columns 4-12). Through a structured and detailed outline, the dataset provides a saturated account of policy interventions and events in Sweden during the COVID-19 pandemic for the period 2020-2023 until it was no longer considered a public health emergency of international concern by the WHO and complements existing and less detailed timelines published at earlier points in the period.

Objectives The credit market has expanded rapidly, increasing the risk of over-indebtedness among those who lack secure employment or adequate income, an issue of concern in the COVID-19 aftermath. We investigated the role of over-indebtedness for developing poor mental health, and whether this impact is modified by age, gender, educational level or being in precarious employment.Methods This is a cohort study using data from the Swedish Scania Public Health Cohort, based on individuals randomly selected from the general adult population in Scania, southern Sweden, initiated in 1999/2000 (response rate 58%) with follow-ups in 2005 and 2010. Over-indebtedness was assessed by combining information on cash margin and difficulty in paying household bills. Mental health was assessed by General Health Questionnaire-12. Those with poor mental health at baseline were excluded, and the analyses were further restricted to vocationally active individuals with complete data on main variables, resulting in 1256 men and 1539 women.Results Over-indebtedness was more common among women, among persons with a low educational level, born abroad and with a precarious employment at baseline. The age-adjusted incidence rate ratio (IRR) for poor mental health in 2010 among individuals exposed to over-indebtedness in 1999/2000 or 2005 was 2.2 (95% CI 1.7 to 2.8). Adjusting for educational level, country of origin and precarious employment in 1999/2000 or 2005, yielded an IRR of 2.0 (95% CI 1.6 to 2.6). An interaction analysis indicated that a high level of education may act synergistically with over-indebtedness, regarding poor mental health among men.Conclusions Over-indebtedness was related to unfavourable societal power relations, regarding social class, gender and foreign birth. Precarious employment was independently linked to poor mental health and may also mediate the effect by over-indebtedness. The COVID-19 pandemic might entail increased over-indebtedness, which should be acknowledged in policies aiming at buffering social effects of the pandemic.

INTRODUCTION:Postpartum depression is considered a major public health problem, which immigrant mothers are at particular risk of being affected by, but it can also have long-lasting traumatic effects on the child's health and development. The Edinburgh Postnatal Depression Scale is the world's most commonly employed screening instrument for postpartum depression, used in connection with a clinical interview to screen for symptoms of postpartum depression. The aim of this study was to synthesize health care professionals (HCPs) experiences of identifying signs of postpartum depression and performing screening on immigrant mothers, since previous research suggested that this task might be challenging. METHODS:The databases CINAHL, PubMed, PsycINFO, SocINDEX, Embase and Cochrane were searched for papers published January 2000-December 2020, reporting qualitative data on immigrants, postpartum depression and the Edinburgh Postnatal Depression Scale. Eight papers representing eight studies from four countries were included and the Critical Appraisal Skills Program was used to assess their quality. The synthesis of studies was guided by Noblit & Hare's seven-step method based on meta-ethnography. FINDINGS:The synthesis resulted in two final themes: "I do my best, but I doubt that it's enough" and "I can find no way forward". The themes convey the fear and frustration that health care professionals experienced; fear of missing mothers with signs of postpartum depression, related to feeling uncomfortable in the cross-cultural setting and frustration in handling difficulties associated with communication, translated versions of the Edinburgh Postnatal Depression Scale and cultural implications of postpartum depression. CONCLUSIONS AND CLINICAL IMPLICATION:By supporting HCPs' self-efficacy in handling cultural implications of postpartum depression and by developing evidence-based clinical guidelines for the use of interpreters and translated versions of the Edinburgh Postnatal Depression Scale the screening of immigrant mothers may be facilitated.

Several suggestions have been made as to why Sweden's approach to managing the COVID-19 pandemic came to rely on a strategy based on voluntary measures. Two of the most prominent explanations for why the country chose a different strategy than many other countries have focused on micro-and macro-level factors, explaining the strategy either in terms of the psychologies of prominent actors or by pointing to particularities in Swedish constitutional law. Supported by a qualitative analysis using interviews and text analysis, we argue that the Swedish strategy cannot be understood without paying attention to the meso-level and the organizations that produced the strategy. Moreover, we argue that to understand why one of the central organizations in Swedish pandemic management, the Public Health Agency, came to favor certain interventions, one must investigate the culture of production inside the organization and how it created precedents that led the Agency to approach pandemic management with a focus on balancing current and future health risks.