Health in Sweden - Sweden´s Public Health Report 2001
Life expectancy continues to increase
The first national Swedish public health report, which was published in 1987, showed that life expectancy in Sweden had increased by one year during the first half of the 1980s - a larger increase than at any other time during the post-war period. Since then men's life expectancy has increased by 3.3 years and women's by 1.9 years. Men's life expectancy, after stagnating during the 1970s, has thus increased more quickly than women's and the difference between men's and women's life expectancy has decreased from 6 years to 4.6 years. Since 1983/84, moreover, infant mortality has halved - in 2000 it was as low as 3.2 deaths during the first year of life per 1 000 live births.
Life expectancy and health unevenly distributed
The 1987 Report early drew attention to the fact that health was unevenly distributed. Even though class differences in material welfare had decreased, blue-collar workers' risk of illness was greater than white-collar workers'. In addition, a number of factors of significance for health development proved to be distributed in such ways as to cause concern that class differences in health were going to increase.
None of the three subsequent public health reports, and not the present one either, the fifth, have found otherwise than that the social differences in health persist. Now as then they are greatest among men. Male upper white-collar workers at age 35 are expected to live 2 years longer than unskilled male blue-collar workers and female upper white-collar workers 0.7 years longer than female unskilled blue-collar workers.
Health differences between social groups, however, appear to have shrunk somewhat among men but instead are increasing among women.
The Report also notes that health development is favouring those aged 45 or older rather than younger adults. Children and young people in Sweden have long had a very favourable health development but among them, too, there are disquieting signs.
Cardiovascular diseases decreasing
Cardiovascular disorders are the group that causes most premature deaths, at the same time as they often entail long-term health problems and functional impairments. During the 1990s the risk of developing coronary diseases, primarily myocardial infarction, decreased by about 20 per cent and the risk of dying from coronary disease decreased even more. This is the most important reason why life expectancy has increased so much in recent years. The risk of dying of stroke has also decreased. The decreased risks of developing cardiovascular disease are due to improvements in the life habits that affect health, predominantly reduced smoking and improved dietary habits, while the reduced risks of dying from them may be ascribed chiefly to medical care efforts. An estimated 3 000 people's lives are saved annually thanks to improved coronary care. Mortality from cardiovascular diseases is considerably higher among men than among women, but it is the men who have gained most in life expectancy as these diseases have become less common and less deadly.
Slower increase in and reduced mortality from cancer
Tumours cause half of all deaths before age 65 among women and one-third among men. Cancer is otherwise a disease of old age and two-thirds of all cancers occur after 65. The risk of developing a cancer disease increased by just over one per cent during the 1980s but the rate of increase fell to half a per cent during the 1990s. Every third cancer case is explained by tobacco, dietary habits and sunbathing habits. Mortality from cancer has decreased by an average of 1.5 per cent per year during the past twenty years.
The two commonest forms -breast cancer among women and prostate cancer among men - constitute a third of all cancer. Both forms increased somewhat during the 1990s but there has been no corresponding increase in mortality.
Both lung cancer and mortality from lung cancer are increasing among women but decreasing among men.
Reduced mortality from accidents
Accidental injuries are the largest cause of death for the ages up to 45 years. Mortality form accidents has declined by 37 per cent for men and almost halved for women since 1980. Two-thirds of those who die of their injuries are men. Traffic predominates as the cause of fatal accidents, causing one-fifth of all accidental deaths. Mortality from accidents is greatest in sparsely-populated areas.
Falls are the commonest cause of accidents for all ages but particularly among the elderly.
The frequency of suicide continues to decrease and during the past two decades suicide mortality has decreased by 38 per cent for both sexes. Suicide is commoner among men: during 1998 three times as many men as women committed suicide. On the other hand, suicide attempts are commoner among women than among men.
Alcohol-related mortality down
Alcohol-related mortality has declined by one-third since the beginning of the 1980s. Changed drinking habits with reduced consumption of spirits have probably contributed to this.
Elderly people healthier but varying development for other ages
Middle-aged and elderly people appear to have had the most favourable health development in Sweden during the past twenty years. People over 45 increasingly consider their health as good. For ages 16-44 the proportion did not change for most of the 1980s and during the 1990s it gradually decreased. Particularly mental ill-health such as anxiety, worry and anguish, and sleep problems, became more common during the 1990s. These problems had decreased for all ages during the 1980s but increased again somewhat during the 1990s except for women over 65, for whom the improvement continued. At the end of the 1990s these problems were otherwise most common among those born abroad, predominantly from countries outside Europe.
Mobility among the elderly has been improving for some time. This is probably partly an effect of knee and hip arthroplasty.
The proportion of elderly people with impaired vision is shrinking, almost certainly due to the large number of cataract operations.
Locomotive pain - a problem for many
During the 1990s disorders of the locomotive organs increased among female lower white-collar workers up to pensionable age and among male aged 45-64 years. For male blue-collar workers, however, they declined. Aches and pains in the locomotive organs are very common: half of men and 70 per cent of women have back, neck, shoulder, elbow, leg or knee pain. Various types of ache have become more common since the beginning of the 1980s, notably among women. These problems are also more widespread among those born abroad than among native Swedes, particularly women from non-European countries.
Allergies continue to increase
Other major health problems are asthma, allergies and other hypersensitivity - complaints that have grown enormously during the past few decades and which afflict children and young people in particular.
Diabetes increasing among children
The incidence of juvenile diabetes (type 1) increased during the 1990s particularly in the younger age groups. The causes have not been established, but the shift towards an increase at younger ages indicates that environmental factors and/or life style factors play a part.
Infectious diseases still a great social problem
In days gone by infectious diseases were a dominating cause of death but during the twentieth century they declined drastically. Recently, however, resistant bacteria and antibiotics resistance have made it harder to treat infections. Through travel, there is a continual import of resistant bacteria from other parts of the world. A particular problem is resistant tuberculosis, for which in some cases there is no treatment.
Sexually transmissible diseases increasing again
Chlamydia is now the largest sexually transmissible disease in Sweden. A disquieting increase in reported cases was seen at the end of the 1990s chiefly among young people; but gonorrhoea in the large cities, and syphilis and HIV, both mainly among homosexual men, are increasing. In Sweden HIV and syphilis present a relatively limited problem but the increasing frequencies may be a signal that prevention is not fully functioning.
Social differences in dental health still large
Dental health has improved appreciably during the past 25 years, particularly for children and those over 65. The social differences in dental health are still large and are not decreasing. More and more people visit a dentist during a two-year period, except for fairly young people and male white-collar workers at middle and upper levels.
Heavy manual labour still a health risk
Formerly, many people worked in very unhealthy workplaces. Blue-collar workers, in particular, risked accidents or were exposed to hazardous substances. For decades, efforts to improve the work environment have had a high priority in Sweden and work-environment risks no longer affect public health to the same extent as earlier. The work environment now plays a relatively small part in, among other things, the occurrence of cancer. However, heavy manual labour and monotonous work tasks are still causing a great deal of back and neck complaints and disorders of the locomotive organs. The latter underlay almost half women's and a third of men's newly-granted disability pensions in 1999. Computer work is increasing continuously and between 60 and 70 per cent of both sexes are now using computers in their jobs. This may be one explanation of why complaints in the neck and other parts of the back have increased.
Stress - a growing work-environment problem
Awareness of the psychosocial work environment is growing. Working tempo and time pressure continue to increase. Stressed work increased continuously in the 1990s, specially for women. The proportion who work overtime also grew during the late 1990s and the proportion who feel reluctant to go to work has also increased. The health lead enjoyed by gainfully-employed is shortening: the proportion who judge their health as good has decreased more since 1993 among those who are in work than among those who are without gainful employment.
Stress both good and bad
It may be hard to decide whether stress at work is positive for health or negative. A number of research results show that negative stress - e.g. in work that makes heavy demands on getting the job done but allows little opportunity for affecting how it is organised - increases the risk of e.g. myocardial infarction. Positive stress, i.e. heavy demands on performance but with much opportunity of affecting one's work situation, is not considered equally dangerous, or is perhaps even a protective factor. Economic stress, however, may be more negative for people who have no paid work, than the demands and loads to which the gainfully-employed are subjected.
Even though developments in working life are most frequently described as negative, almost three-quarters of gainfully-employed people in Sweden are in general very content with their work. Where time pressure and overtime increase, however, opportunities of combining working life and private life shrink, and this can in the long run entail both health problems and social problems.
Negative development for care staff and teachers
Health development during the 1990s appears to have been specially negative for municipal and county-council employees, mainly women. Particularly in the nursing and educational sector, both work environment and well-being seem to have deteriorated. Reorganisations and cutbacks have increased the load on people working in these sectors, who are predominantly women.
Better habits of life
While smoking is still perhaps the greatest health risk, it has declined in all socioeconomic groups and both sexes since the beginning of the 1980s. For men, the decline has been more rapid than for women. Note, however, that men born abroad smoke to a considerably larger extent than men born in Sweden. A study showed that young male immigrants from Chile, Iran and Turkey smoked more than older. Among native-born Swedish men the pattern is the opposite. Snuff-taking, however, is commoner among younger men than among older. In international terms, the proportion of daily smokers among men is low in Sweden, where men and boys smoke the least in Europe.
For women, the proportion of smokers started to decline considerably later than for men. This is why lung cancer, now decreasing among men, is increasing among women and will continue to do so for 10-20 years. Smoking underlies four-fifths of all lung cancer. Four hundred cases of lung cancer occur annually as a consequence of radon. To 80 per cent, however, it is the combined effect of radon and smoking that counts.
We are eating better
Eating habits have developed positively. We are eating more fruit and vegetables, more fibre food and less fat. This applies to men and women, young people and old people.
More people taking exercise but still too few
Exercise in free time is also becoming more common. Yet only one-fifth of the population may be considered sufficiently active in their free time to give a positive effect on health.
Alcohol problems may be going to increase
Changes in alcohol policy towards increased availability and lower prices may be expected to lead to alcohol consumption increasing. This may partly be countered by changes in drinking habits towards increased consumption of wine and less of spirits, which may reduce the risk of alcohol-related diseases.
Young people's habits disquieting
Recent increases in young people trying drugs and regularly drinking alcohol, together with increased frequencies of teenage abortions and more cases of chlamydia, are causes for concern. Not the least serious is the fact that the proportion of overweight young people is increasing at the same time as more and more appear to move about less and less in their daily lives and are choosing sedentary free-time activities.
Swedish children and young people in international interview surveys in European countries normally appear as the most healthy and the most contented with life. Nonetheless, psychosomatic symptoms such as stomach ache, headache and sleep disturbances have been increasing continuously among schoolchildren since the middle of the 1980s.
Excess weight more common, specially among young adults
The proportion of overweight people of all ages is increasing but particularly among fairly young adults. The increase is probably because we are moving about too little in relation to how much we eat.
The proportion of overweight people has increased in all socioeconomic groups since the beginning of the 1980s. Regarding obesity the social differences have increased somewhat for both sexes, with greater differences women than among men. Obesity increases the risk of disorders and complaints of the locomotive organs and - where there is belly fat - high blood pressure, cardiovascular disease and type 2 diabetes.
Greater health risks in socially vulnerable groups
Single people's health should be noted. Among them there are groups with considerable health risks. This often applies to people with low incomes and poor education. Single-parent children also run greater risks of becoming ill or being injured than children in families with two adults. During the 1990s the social and economic problems of single parents with children increased. Just over 40 per cent of single mothers smoke, which is double the proportion among women in general. This suggests among other things a need to review the living conditions of single people, not least those of single parents.
Children of mentally-ill parents and children of drug abusers also run greater risks of illness or injury than other children do.
That the risks are greater in certain groups does not mean that everybody in them has health problems. On the contrary, even in groups with a serious excess risk it may be a matter of a few individuals with greater-than-average problems. Children of mentally-ill parents, for example, run a greater risk than children in general of dying, or of institutional psychiatric care, drug-dependence or accidents. It is thus important to know that not more than 2 per cent of the children with a mentally-ill parent received a psychiatric diagnosis during a studied four-year period. Even for children of drug-abusing parents, who also had demonstrably great excess risks, only a very small proportion are taken into care.
Having simultaneous problems increases the risk of ill-health
The risks are greatest for those who have several adverse circumstances at the same time. To be a single parent does not perhaps itself increase the risk particularly. But if one also has a poor education and a low income, opportunities for a good life are hampered. Perhaps also, unhealthy habits of life tend to accumulate in groups that are socially vulnerable in other ways. The risk of ill-health then increases for parents and children alike.
The future burden of disease
It seems that the disease panorama of the future will be dominated by the health problems of ageing. As the risk of serious illness or premature death from serious disease declines, more and more people are living to higher ages.
The present Report shows that old people's health is continuing to improve. Their vision and mobility are getting better, as is their dental health. There is nothing to demonstrate any lengthening of the period of illness normally entered in the final phase of life.
But even if the individual risk of falling ill at a given age is decreasing for many conditions such as cardiovascular disease, there is much to indicate that the prevalence of disease will grow as a consequence of more people surviving the diseases they do get. Many of those who now survive a myocardial infarction will get other diseases later in life such as heart failure or cancer. For this reason we must anticipate that the diseases of the elderly are going to place an increased burden upon the community and upon the health and medical care services.
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