Area-level measures of deprivation in Sweden often rely on limited socio-economic indicators, such as income or education. To address this, we developed the Index of Multiple Deprivation in Sweden (IMDIS) to capture a multitude of explanatory factors for socio-economic inequalities and the distribution across small areas in Sweden. The IMDIS is a compositional index constructed for small areas in Sweden in 2015 and combines 15 indicators across 4 domains (Housing, Employment, Income and Capital, and Education) into an overall deprivation score. Indicators were selected and spatially smoothed to mitigate the effect of small numbers and increase robustness. Domains were constructed using a weighted average of underlying indicators, allowing detailed examination of the significance each domain or indicator has in small areas, and were further combined using explicit weights. All areas were subsequently ranked from the 1st least to 5984th most deprived area. For each area, we generated three key outputs: a score, a rank, and assignment to a deprivation decile. The IMDIS showed high internal consistency and revealed stark geographic inequalities in deprivation. The most deprived areas were concentrated in urban regions, particularly Stockholm, Gothenburg, and Malmö. Housing deprivation was more prominent in urban areas, while educational deprivation was more prevalent in rural and peripheral regions. The IMDIS offers a comprehensive measure of multiple deprivation at the small-area level in Sweden. Its domains and indicators can be used individually or combined to identify inequalities in vulnerable areas and explore geographic patterns, supporting a deeper understanding of social disparities.

Abstract Background Educational inequalities in mortality continue to persist. We aimed to systematically analyse the association between level of education and cervical cancer mortality. Methods We conducted a systematic review and meta-analysis. We systematically searched Pub-Med, Web of Science, Scopus, EMBASE and Global Health (CAB), EconLit and Sociology Source Ultimate databases. A protocol has been registered with PROSPERO (CRD42023411757). We included studies that measured the association between level of education and cervical cancer mortality using individual level data. Included articles were assessed for study quality and risk of bias using the Joanna Briggs Institute critical appraisal checklists. A random-effects meta-analysis was conducted to evaluate the overall and stratified effects of education on mortality. Findings Our literature search resulted in over 47,000 articles. 30 studies mentioned cervical cancer as a cause of death, and of these, 11 were eligible for the meta-analysis. Results showed an overall risk ratio of 2.41 (95% CI 1.81-3.20) for low education (ISCED 0-2) and 1.62 (95% CI 1.18-2.24) for medium education (ISCED 3-4). Those aged 25-64 with low education had more than twice the risk of cervical cancer (RR = 5.73; 95% CI 5.04-6.51) compared to those aged 25 and above (RR = 2.11; 95% CI 1.82-2.45). Besides, the impact of an additional level of education on reducing risk of cervical cancer mortality was higher in Northern Europe, compared to the South. Interpretation Lower educational attainment is associated with an increase in the risk of cervical cancer mortality, with an additional level of education greatly reducing this risk in Northern Europe. Younger cohorts with low education have a higher risk of cervical cancer mortality. This study provides important information for evidence-based policy seeking to reduce health inequities and inequalities in both the health and education sector. Key messages • Lower educational attainment is linked to a higher risk of cervical cancer mortality. • Younger cohorts (aged 25-64) with low education are at a particularly heightened risk compared to those aged 25 and above.

It is still unclear how changes in alcohol control policies may have contributed to changes in overall levels of alcohol-attributed harm between and within the Nordic countries. We modified and applied the Bridging the Gap (BtG)-scale to measure the restrictiveness of a set of alcohol control policies for each Nordic country and each year between 1990 and 2019. Alcohol-attributed harm was measured as total and sex-specific alcohol-attributed disease burden by age-standardized years of life losts (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) per 100 000 population from the Global Burden of Disease Study (GBD). Longitudinal cross-country comparisons with random effects regression analysis were employed to explore associations, within and across countries, differentiated by sex and the time to first effect. Overall, alcohol-attributed YLLs, YLDs, and DALYs decreased over the study period in all countries, except in Iceland. The burden was lower in those countries with restrictive national policies, apart from Finland, and higher in Denmark which had the least restrictive policies. Changes in restrictiveness were negatively associated with DALYs for causes with a longer time to effect, although this effect was stronger for males and varied between countries. The low alcohol attributed disease burden in Sweden, Norway, and Iceland, compared to Denmark, points towards the success of upholding lower levels of harm with strict alcohol policies. However, sex, location and cause-specific associations indicate that the role of formal alcohol policies is highly context dependent and that other factors might influence harm as well.

Background The positive effect of education on reducing all-cause adult mortality is known; however, the relative magnitude of this effect has not been systematically quantified. The aim of our study was to estimate the reduction in all-cause adult mortality associated with each year of schooling at a global level. Methods In this systematic review and meta-analysis, we assessed the effect of education on all-cause adult mortality. We searched PubMed, Web of Science, Scopus, Embase, Global Health (CAB), EconLit, and Sociology Source Ultimate databases from Jan 1, 1980, to May 31, 2023. Reviewers (LD, TM, HDV, CW, IG, AG, CD, DS, KB, KE, and AA) assessed each record for individual-level data on educational attainment and mortality. Data were extracted by a single reviewer into a standard template from the Global Burden of Diseases, Injuries, and Risk Factors Study. We excluded studies that relied on case-crossover or ecological study designs to reduce the risk of bias from unlinked data and studies that did not report key measures of interest (all-cause adult mortality). Mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among studies and to adjust for study-level covariates. This study was registered with PROSPERO (CRD42020183923). Findings 17 094 unique records were identified, 603 of which were eligible for analysis and included data from 70 locations in 59 countries, producing a final dataset of 10 355 observations. Education showed a dose-response relationship with all-cause adult mortality, with an average reduction in mortality risk of 19% (95% uncertainty interval 18-20) per additional year of education. The effect was greater in younger age groups than in older age groups, with an average reduction in mortality risk of 29% (28-30) associated with each additional year of education for adults aged 18-49 years, compared with a 08% (06-10) reduction for adults older than 70 years. We found no differential effect of education on all-cause mortality by sex or Socio-demographic Index level. We identified publication bias (p<00001) and identified and reported estimates of between-study heterogeneity. Interpretation To our knowledge, this is the first systematic review and meta-analysis to quantify the importance of years of schooling in reducing adult mortality, the benefits of which extend into older age and are substantial across sexes and economic contexts. This work provides compelling evidence of the importance of education in improving life expectancy and supports calls for increased investment in education as a crucial pathway for reducing global inequities in mortality. Funding Research Council of Norway and the Bill & Melinda Gates Foundation. Copyright (c) 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Objectives: Cervical cancer screening (CCS) is an important public health measure for early detection of cervical cancer and prevents a large proportion of cervical cancer deaths. However, participation in CCS is relatively low and varies substantially by country and socio-economic position. This study aimed to provide up-to-date participation rates and estimates on educational inequalities in CCS participation in 24 European countries with population-based CCS programmes. Study design: This was a cross-sectional study. Methods: Using data from the European Health Interview Survey (EHIS) conducted in 2019, 80,479 women aged 25-64 years were included in the analyses. First, standardized participation rates and standardized participation rates by educational attainment were calculated for all 24 countries based on each country-specific screening programme organization. Second, a series of generalized logistic models was applied to assess the effect of education on CCS participation. Results: Screening participation rates ranged from 34.1% among low-educated women in Romania to 97.1% among high-educated women in Finland. We observed that lower-educated women were less likely to attend CCS than their higher-educated counterparts. Largest educational gaps were found in Sweden (odds ratio [OR] = 6.36, 95% confidence interval [CI] = 3.89-10.35) and Poland (odds ratio = 5.80, 95% CI = 4.34-7.75). Conclusion: Population-based screening initiatives have successfully reduced participation differences between women with medium and high educational attainment in some countries; however, persistent disparities still exist between women with low and high levels of education. There is an urgent need to increase participation rates of CCS, especially among lower-educated women. (c) 2024 The Authors. Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Abstract Background Cycles of school closure and reopening during the COVID-19 pandemic, coupled with remote learning, led to concerns about increasing inequality in education that persist in 2024. The aim of this abstract, within a wider study of safe school reopening, is to explore health and education professionals’ perceptions of inequalities among students during the pandemic. Methods In 2021, online semi-structured interviews were conducted in 6 languages with education and health professionals. They explored the: 1-effect of the pandemic on schools/pupils/teachers; 2-reorganisation of schools; 3-experience of implementing infection control measures in schools; 4-intersectoral working; 5-important resources for keeping schools open. Interviews were transcribed verbatim and translated into English where needed. A deductive qualitative analysis was undertaken using the conceptual framework developed by the United Nations H6+ Technical Working Group on Adolescent Health and Well-Being. Domain 3 (safety and supportive environment) includes consideration of equality. Results 62 interviews were included in the analysis (22 health and 40 education professionals from 28 countries). Professionals perceived greater negative impact on education for specific groups of students. Those with chronic illness stayed out of school for longer than others. Good access to distance learning was difficult for students from rural areas (lack of internet/electricity), disadvantaged families (lack of electronic equipment) or larger families (less learning space at home). Conclusions Professionals perceived that school closures intensified the disadvantage experienced by certain groups of students, exacerbating inequalities in education. Targeted catch-up strategies are still needed. Key messages • School closure during the COVID-19 pandemic have exacerbated inequalities in education. • In future health crisis impacting schooling, targeted catch-up strategies would be needed for certain groups of students.

Abstract Background Health inequalities have been linked to reduced life expectations. This study aimed to investigate regional variations in all-cause years of life lost (YLLs) in European Economic Area (EEA) countries prior to the COVID-19 pandemic. Methods Demographic data were extracted from Eurostat for 1390 small regions 32 EEA countries. Age-standardised sex specific YLL rates per 100,000 population in 2019 were estimated for EEA regions (Eurostat NUTS level 3) using methodologies derived from the Global Burden of Disease study. Relative spatial disparities were evaluated using the Gini coefficient (GC) and absolute spatial disparities assessed using the slope index of inequality (SII). Results Between EEA countries, relative geographical inequality in age-standardized YLL rates was higher than within them, slightly more so for males (GC = 16.96% [95% CI = 16.26-17.65]) than females (14.22% [13.62-14.82]). Among females, the UK (11.21% [95% CI 10.11-12.30]), Greece, and Croatia had the highest relative spatial inequality, while Ireland (3.37% [2.26-4.48]), Slovakia, and the Netherlands had the lowest. For males, Belgium (10.76% [9.34-12.17]), the UK, and Croatia exhibited the highest relative spatial inequality, while Ireland (1.99% [1.18-2.81]), Lithuania, and Slovakia had the lowest. Germany had the largest absolute geographical inequality in YLLs among females (SII=16.86% [16.28 to 17.44]), followed by Estonia and the UK. Among males, Estonia had the largest absolute spatial inequality (36.60% [-10.88 to 84.07]), followed by Latvia and Hungary. Ireland had the lowest absolute spatial inequality for both females and males. Conclusions Relative and absolute disparities in premature mortality rates are evident across regions of the EEA, both within countries and across the entire region. These findings offer insights for national and local stakeholders, aiding them in customising public health interventions to target spatial health disparities.

BACKGROUND:Health inequalities have been associated with shorter lifespans. We aimed to investigate subnational geographical inequalities in all-cause years of life lost (YLLs) and the association between YLLs and socioeconomic factors, such as household income, risk of poverty, and educational attainment, in countries within the European Economic Area (EEA) before the COVID-19 pandemic.METHODS:In this ecological study, we extracted demographic and socioeconomic data from Eurostat for 1390 small regions and 285 basic regions for 32 countries in the EEA, which was complemented by a time-trend analysis of subnational regions within the EEA. Age-standardised YLL rates per 100 000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease study. Geographical inequalities were assessed using the Gini coefficient and slope index of inequality. Socioeconomic inequalities were assessed by investigating the association between socioeconomic factors (educational attainment, household income, and risk of poverty) and YLLs in 2019 using negative binomial mixed models.FINDINGS:Between Jan 1, 2009, and Dec 31, 2019, YLLs lowered in almost all subnational regions. The Gini coefficient of YLLs across all EEA regions was 14·2% (95% CI 13·6-14·8) for females and 17·0% (16·3 to 17·7) for males. Relative geographical inequalities in YLLs among women were highest in the UK (Gini coefficient 11·2% [95% CI 10·1-12·3]) and among men were highest in Belgium (10·8% [9·3-12·2]). The highest YLLs were observed in subnational regions with the lowest levels of educational attainment (incident rate ratio [IRR] 1·19 [1·13-1·26] for females; 1·22 [1·16-1·28] for males), household income (1·35 [95% CI 1·19-1·53]), and the highest poverty risk (1·25 [1·18-1·34]).INTERPRETATION:Differences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA.FUNDING:Research Council of Norway; Development, and Innovation Fund of Hungary; Norwegian Institute of Public Medicine; and COST Action 18218 European Burden of Disease Network.

The Nordic countries share similarities in many social and welfare domains, but drug policies have varied over time and between countries. We wanted to compare differences in mortality and disease burden attributed to drug use over time. Using results from the Global Burden of Disease (GBD) study, we extracted age-standardized estimates of deaths, DALYs, YLLs and YLDs per 100 000 population for Denmark, Finland, Iceland, Norway, and Sweden during the years 1990 to 2019. Among males, DALY rates in 2019 were highest in Finland and lowest in Iceland. Among females, DALY rates in 2019 were highest in Iceland and lowest in Sweden. Sweden have had the highest increase in burden since 1990, from 252 DALYs to 694 among males, and from 111 to 193 among females. Norway had a peak with highest level of all countries in 2001–2004 and thereafter a strong decline. Denmark have had the most constant burden over time, 566–600 DALYs among males from 1990 to 2010 and 210–240 DALYs among females. Strict drug policies in Nordic countries have not prevented an increase in some countries, so policies need to be reviewed.

Social policies can influence and redistribute the social determinants of health and may therefore be effective in contributing to reducing health inequalities. This chapter focuses on the role of Social Protection (SP) policies in reducing health inequalities from a global perspective. Starting with a description of SP and the pathways through which they can influence health, the links between SP policies and health are situated in a life-course perspective. Childhood is emphasized as a crucial phase in life in which SP policies that improve the conditions of the parents can have a positive impact on child health now and later in life. Evidence on how SP targeted at adults can contribute to child health equality is provided. Finally, drawing on research evidence, the effectiveness of parental leave policies in reducing child health inequalities is discussed.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

It is estimated that at least one out of 10 people who contracted COVID-19 continue to experience health problems long after the clearance of the acute infection. These belong to the growing group of people who have post-acute sequelae of SARS CoV-2 infection or long COVID, a multifaceted condition involving multiple organ systems. Given the lack of clear definition and diagnosis, this marked increase in the number of people who have long COVID might not be fully reflected in data on population health in the years to come. In this editorial, we argue that the use of self-reported health measures is vital for fully assessing the long-term impact of the COVID-19 pandemic on health and health inequalities. After briefly introducing self-reported health measures, we discuss strengths and limitations of specific measures that capture direct self-reports of long COVID. We then outline how the impact of long COVID may also be reflected in response patterns to more general self-reported health measures and give suggestions on how these can be used to examine the long-term health impact of the COVID-19 pandemic.

AbstractObjectiveTo investigate the associations between low education and risk of mental disorders, substance use disorders and self‐harm in different age‐groups.MethodsAll subjects in Stockholm born between 1931 and 1990 were linked to their own or their parent's highest education in 2000 and followed‐up for these disorders in health care registers 2001–2016. Subjects were stratified into four age‐groups: 10–18, 19–27, 28–50, and 51–70 years. Hazard Ratios with 95% Confidence Intervals (CIs) were estimated with Cox proportional hazard models.ResultsLow education increased the risk of substance use disorders and self‐harm in all age‐groups. Males aged 10–18 with low education had increased risks of ADHD and conduct disorders, and females a decreased risk of anorexia, bulimia and autism. Those aged 19–27 years had increased risks of anxiety and depression, and those aged 28–50 had increased risks of all mental disorders except anorexia and bulimia in males with Hazard Ratios ranging from 1.2 (95% CIs 1.0–1.3) for bipolar disorder to 5.4 (95% CIs 5.1–5.7) for drug use disorder. Females aged 51–70 years had increased risks of schizophrenia and autism.ConclusionLow education is associated with risk of most mental disorders, substance use disorders and self‐harm in all age‐groups, but especially among those aged 28–50 years.

In this issue of the Scandinavian Journal of Public Health (SJPH), we present the 2022 Pandemics, Diversity and Social Inequality Declaration from Bergen, Norway (Bernadette N Kumar, Gro Jamtvedt & and Esperanza Diaz, this issue), hereafter referred to as the Pandemic Declaration. The main aim of the Pandemic declaration is to ensure that the legacy of the participants of the Norwegian National Conference on Pandemics, Diversity and Social Inequalities, held in Bergen October 2022, was not lost after the conference. The declaration summarizes and reiterates salient exchanges, research and experiences that encompassed the main purpose of the conference. These included lessons learned as to how the covid pandemic exposed and reinforced health inequalities and how they can be reduced, including the integration of diversity into contingency plans. A working group put together a draft based on the abstracts received and the main messages from the keynotes, which was presented and agreed upon among the participants during the conference closing ceremony. The Pandemic declaration has three sections. The first presents the state of the art in terms of updated information that can be used to improve health care for all, including migrants. Second, it highlights key issues discussed during the conference, including what has been achieved in terms of innovations and challenges. The final part of the Pandemic Declaration consists of a section on what is the remaining unfinished agenda, including a list of recommendations for the way forward. The Pandemic Declaration and the accompanying articles published in this issue of the SJPH indicate that the growth of migration and health data and research has been exponential. The momentum achieved so far must be continued and in doing so it is time to address the unfinished agenda by moving beyond researcher driven ‘cherry picking’ of migrant groups and topics to unmet needs of services and user groups. Recent literature, including landmark studies indicate a mismatch between public perception and current evidence about migration health [1,2]. For this narrative to change, relevant and appropriate evidence must be generated and applied. The articles published in this issue examine pressing public health issues among migrant groups categorized according to age, country of origin, sub-population groups (including the Roma population), duration of stay and reasons for migration. Furthermore, a large proportion of the articles focus on young people, which concurs with the recommendations of the Pandemic Declaration. According to the scoping review published by Laue J, Diaz E, Eriksen L, et al in this issue [3] migration research is dominated by quantitative research. The articles published in this issue, follow the trend of articles submitted to SJPH, predominantly applying quantitative methods (80 %). Among these, a greater proportion analyzed register data within the clinical disciplines of reproductive health, mental health, infectious diseases and cardiovascular diseases, or on Migration and Health: Time for a new research agenda