Swimming-induced pulmonary edema (SIPE) has gained increasing attention in recent years. However, risk factors for SIPE remain incompletely understood, and existing data are primarily based on small-scale studies. Which individual risk factors are associated with SIPE? We conducted a case-control study based on Sweden's largest open water swimming event, Vansbrosimningen. Data were obtained through interviews with individuals diagnosed with SIPE in 2017 to 2024 and through a web-based survey administered to control participants without SIPE. Individual factors associated with SIPE were identified by using multiple logistic regression. A total of 258 cases diagnosed with SIPE and 2,117 control participants were included. A first logistic regression model identified female sex (OR, 5.3; 95% CI, 3.6-7.7), higher age (OR for age ≥ 61 years, 7.3; 95% CI, 3.8-14.2), hypertension (OR, 1.9; 95% CI, 1.2-3.2), heart disease (OR, 6.0; 95% CI, 2.5-14.2), asthma (OR, 1.7; 95% CI, 1.2-2.6), and low frequency of open water swimming during the current season (OR for never, 3.6; 95% CI, 2.4-5.4) as independently associated with SIPE. A second model found that previous respiratory symptoms during open water swimming (OR, 3.5; 95% CI, 2.3-5.2) and acute respiratory tract infection (OR, 10.2; 95% CI, 5.2-20.2) were also strongly associated with SIPE; however, the association with asthma failed statistical significance in this model. This study confirms previously reported individual risk factors for SIPE and immersion pulmonary edema: female sex, higher age, hypertension, heart disease, respiratory tract infection, and prior SIPE episodes. The data also suggest that asthma and limited experience of open water swimming are associated with an increased risk of SIPE. A comprehensive understanding of the risk factors for SIPE will improve safety during open water swimming and contribute to the development of medical guidelines for SIPE.
We present here a first-of-its-kind survey of field margin flora in Sweden. The survey was carried out in summer 2020 - 2023, covering most of Sweden's major agricultural regions. Volunteer botanists surveyed a 100 × 1 m transect at the edge of the crop, estimating abundances of all non-crop plants growing there. We later cleaned the data by cross-referencing surveyor comments and reports with data on management and soil, and filtered it to only include herbaceous plants growing in the field at the height of the growing season, before harvest. In total, 7364 observations from 442 species found in 294 sites, ranging from Skåne in the south to Västerbotten in the north, were retained in the data. These data offer a unique insight into the present state of Swedish field margin plant communities, from a fine to a large scale. They are useful for community studies, and can aid in making informed decisions on management and conservation of plants growing on, or near, agricultural land.
BACKGROUND: The COVID-19 pandemic was a global public health crisis that affected everyone, including pregnant women and new mothers. Previous research suggests this population adhered well to infection prevention measures, though vaccine uptake was limited due to safety concerns. Sweden’s largely voluntary and less restrictive pandemic response provided a unique context to study adherence and vaccination patterns. This study aimed to examine adherence to infection prevention measures and COVID-19 vaccination among pregnant women, new mothers, and their families. METHODS: We conducted a longitudinal study using data from the prospective population-based NorthPop Birth Cohort Study in Sweden. Repeated questionnaires were distributed between June 2020 and December 2021, enabling assessment of self-reported adherence to infection prevention measures and COVID-19 vaccination uptake. Descriptive statistics were applied, and differences were analysed using Pearson’s chi-square test and independent-samples t-tests. Sensitivity analyses were performed to examine differences in adherence between participants who were pregnant during the pandemic and postpartum participants, and associations with vaccination were examined using univariable logistic regression. RESULTS: Pregnant women and new mothers reported high adherence to infection prevention measures, peaking in December 2020 and declining thereafter for most behaviours. Compared with postpartum participants, women who were pregnant during the pandemic were less likely to limit social contacts (OR = 0.69, 95% CI: 0.49–0.97) and to stay home when experiencing cold symptoms (OR = 0.68, 95% CI: 0.49–0.93). Vaccine uptake was high (94.7%) among all participants. Participants with at least a university degree were more likely to be vaccinated than those with lower educational level (OR = 3.04, 95% CI: 1.87–4.92), and the likelihood of vaccination increased by 9% with each additional year of age (OR = 1.09, 95% CI: 1.03–1.15). CONCLUSIONS: Trust in public authorities and the healthcare system, together with a strong sense of collective responsibility, may partly explain the high adherence to recommendations and COVID-19 vaccine uptake among pregnant women and new mothers during the COVID-19 pandemic in Sweden. Sociodemographic differences in vaccine uptake highlight the need for targeted communication and support. These findings provide insights relevant for future pandemic preparedness and maternal health policy across Europe.
Self-admission models allow patients to directly contact their psychiatric ward for brief inpatient care based on self-assessed need. To ensure equitable access across all psychiatric services, a broadly applicable, transdiagnostic model for self-admission was developed in Region Stockholm - Sweden's largest public healthcare provider. This study aimed to explore patients' experiences of access to self-admission and its impact on everyday life during mental health problems. Sixteen semi-structured interviews were analyzed using thematic analysis. The analysis yielded one overarching theme, From safety to agency, and three themes: Sense of security, Care that supports and Facilitating recovery. The findings illustrate that the self-admission model fostered safety and autonomy and was perceived as facilitating coping strategies, crisis plans, and greater self-awareness and self-management, helping prevent deterioration and reducing emergency care needs. The model also supported maintaining meaningful routines and social connections. Although generally perceived as empowering, some participants struggled with increased autonomy and emphasized the need for greater involvement of relatives. The self-admission model appears to effectively promote person-centred care and personal recovery. The study supports previous research as well as demonstrates that a transdiagnostic self-admission model can assist patients with mental health conditions.
Type 1 diabetes (T1D) is an increasing clinical and economic concern in Sweden, as well as worldwide. Automated insulin delivery (AID) systems, combining continuous glucose monitoring (CGM) with automated insulin dosing to manage glucose levels, have been evaluated for the impact on glycaemic control and quality of life. This study examines the long-term cost-effectiveness of the AID system Control-IQ compared to standard care-defined as multiple daily injections or insulin pump therapy, both using CGM-in Swedish adults with T1D. A cost-utility analysis is performed using the IQVIA Core Diabetes Model, integrating clinical data from randomized trials and real-world sources. The model projects diabetes-related complications, direct medical costs and quality-adjusted life years (QALYs) over a lifetime period, applying Swedish-specific cost and discount rates. Use of Control-IQ results in a gain of 1.080 QALYs and lower projected lifetime rates of severe hypoglycaemia, renal complications, cardiovascular events and ulcer/amputation/neuropathy. Total direct costs are higher, but the incremental cost-utility ratio is 391,705 SEK/QALY, which is below Sweden's commonly accepted threshold of 500,000 SEK/QALY. Sensitivity analyses demonstrate consistent results across different scenarios. The results indicate that Control-IQ is a cost-effective alternative for Swedish adults with T1D and could be considered for broader use in diabetes care.
To evaluate the impact of the 2018 switch from PCV13 to PCV10 in Sweden's childhood immunisation programme on the serotype distribution of Streptococcus pneumoniae. Respiratory tract (RT) S. pneumoniae isolates (n=1615; 2020-2023) were serotyped, tested for antimicrobial susceptibility and compared with invasive pneumococcal disease (IPD) isolates (n=397) and PCV13-era data (2016-2018). Predominant serotypes were 3 (13%), 19A (11%), 23B (10%), and 11A (7.5%). PCV10 coverage was low (4.1%), but increased with PCV13 (29%), PCV15 (30%), PCV20 (47%) and PCV21 (71%). After reintroduction of PCV10, the proportions of serotypes 3 (8.7% to 13%) and 19A (4.5% to 11%) increased (p<0.001), and an increase in serotype 19A was also observed in IPD (5.6% to 19%, p<0.001). Serotype 8 dominated IPD (21%) but was uncommon in RT isolates (2.8%). Among RT isolates, reduced benzylpenicillin susceptibility was observed in 11%. Resistance was highest to trimethoprim/sulfamethoxazole (13%), followed by erythromycin (9.3%), tetracycline (8.5%), and clindamycin (6.9%). Multidrug- and extensively drug-resistant isolates were uncommon (7.9% and 1.1%) and were predominantly serotypes 15A and 19A. Serotypes 19A and 3 re-emerged as predominant, indicating the need for continued surveillance. Our study emphasises the risk of rapid serotype resurgence when lower-valency vaccines are reintroduced.
BACKGROUND: The COVID-19 pandemic accelerated a large-scale shift toward remote work, raising important public health questions about how changes in daily routines affect physical activity. While many studies have reported short-term declines in activity during the pandemic, fewer have examined long-term patterns using objective data, particularly in contexts with relatively soft public health restrictions such as Sweden. METHODS: We conducted a longitudinal descriptive study using step count data from 1,529 Swedish participants collected via a custom-built smartphone app between March 2019 and March 2021. The app accessed one year of historical step data before and after Sweden’s March 2020 recommendation to work from home. Participants ranged in age from 18 to 75 years, and 55% were women. We combined demographic variation with detailed temporal analyses across months, weekdays, and hours to examine sustained and routine-specific changes in physical activity. RESULTS: Participants took 16.2% fewer daily steps during the remote work period compared to the previous year, with the sharpest decline on weekdays (− 23.9%) and during morning hours. Weekend activity showed a modest increase (+ 2.9%), indicating partial compensation. The overall change was most dramatic in younger men (− 24.1%) and smallest in women aged 55 years and older. Temporal analyses revealed that the morning peak in step activity largely disappeared, consistent with the loss of commuting routines, while lunch and afternoon peaks remained visible. These changes persisted across several months and could not be explained by seasonal variation. CONCLUSIONS: Our results suggest that even in a country with less strict COVID-19 regulations, such as Sweden, everyday physical activity was affected. The data indicate that governmental policies advising, but not enforcing, work from home were followed. Remote work conditions may be associated with a substantial reduction in everyday physical activity, particularly during typical commuting hours. As hybrid and remote work remain prevalent in post-pandemic life, these behavioral patterns warrant attention in public health planning. The use of passively collected smartphone data provides a scalable approach to understanding the health consequences of long-term shifts in work routines.
Post-glacial recolonisation of Fennoscandia created secondary contact zones in many species, offering opportunities to study how gene flow and selection contribute to their establishment and maintenance. Here, we analyse genomic data from three boreal tree species-Picea abies, Betula pendula and Pinus sylvestris-sampled along a latitudinal gradient in Sweden. Despite differences in colonisation timing and dispersal ecology, all three species exhibit north-south genetic structuring aligned with environmental gradients. Most notably, the two main genetic clusters within each species overlap in a shared contact zone, corresponding to the climatic transition between Sweden's two major environmental zones. The extent and structure of the contact zone differ among species: P. abies shows stronger genetic structure and moderate gene flow, B. pendula exhibits intermediate differentiation and gene flow, and P. sylvestris displays the weakest structure with stronger gene flow. All three species also show genomic signatures of local adaptation, with distinct underlying architectures. In P. abies, adaptive loci are broadly distributed across the genome, while, strikingly, they are mostly found within an inversion on chromosome 1 in B. pendula. In P. sylvestris, local adaptation likely relies on subtle allele frequency shifts across many loci with weak signals. These patterns align with theoretical expectations for polygenic local adaptation under varying migration regimes. Our comparative approach demonstrates how gene flow and selection jointly shape genomic landscapes in shared environments and contribute to understanding local adaptation in forest trees, with implications for predicting species' responses to climate change.
Pediatric in-hospital cardiac arrest is a rare event. Despite Sweden's extensive national health registries, data describing pediatric in-hospital cardiac arrest are limited. In 2018, pediatric-specific variables were introduced into the Swedish Registry for Cardiopulmonary Resuscitation. This study aimed to identify the characteristics and outcomes of pediatric IHCA at a Swedish tertiary pediatric referral hospital following implementation of these variables. This observational cohort study included all pediatric in-hospital cardiac arrest events with initiated cardiopulmonary resuscitation (CPR) recorded at Queen Silvia Children's Hospital between 2018 and 2025. Demographic characteristics, arrest location, resuscitation variables, and survival outcomes were analyzed. Survival was assessed using Kaplan-Meier methods and Cox proportional hazard regression. A total of 125 in-hospital cardiac arrest events were included. Infants (< 1 year) represented 65.6% of cases and 57% of patients had congenital heart disease. Most arrests occurred in the intensive care unit (56.8%), followed by hospital wards (21.6%) and the operating room (16.0%). CPR was initiated within the first minute in 81.3% of cases. Return of spontaneous circulation was achieved in 90% of patients. Survival was 82% at 30 days and 68% at 1 year. Pediatric in-hospital cardiac arrest occurring in highly monitored tertiary care environments has a very high rate of return of spontaneous circulation as well as survival. This study also highlights the importance of systematic registry data collection to improve understanding of pediatric in-hospital cardiac arrest and to support future benchmarking and quality improvement. In-hospital cardiac arrest is rare for pediatric patients. This retrospective cohort analysis, from one tertiary care pediatric hospital which includes a large pediatric cardiac surgery activity, presents pediatric cardiac arrest events in the hospital, along with case factors.
As in many other countries, Swedish defense during the Cold War was primarily organized around the perceived threat of war, including the potential use of nuclear weapons. This article shifts attention from such scenarios to the ways in which civil contingencies and natural disasters were conceptualized as knowledge objects within the emerging field of defense and disaster medicine. Their incorporation into Sweden's preparedness agenda signaled a broader and more multifaceted understanding of protection and security within the scientific advisory system of the Swedish defense. By centering medical knowledge production on these hazards, the article offers new insights into the role of medical expertise in Swedish preparedness, while simultaneously shifting focus away from a war-centered narrative of Cold War defense investments. The empirical exploration spans the period from the late 1950s, when a comprehensive governmental inquiry into Swedish defense medicine led to the establishment of the Delegation for Applied Medical Defense Research [Försvarsmedicinska forskningsdelegationen] and subsequently the Organizing Committee for Disaster Medicine [Katastrofmedicinska organisationskommittén] (Kamedo) in the first half of the 1960s. The study concludes in the mid-1970s, when the Delegation was incorporated into the Swedish Defense Research Establishment [Försvarets forskningsanstalt] (FOA).
Oral administration of peptide therapeutics is limited by gastrointestinal degradation and poor epithelial permeability. Here, water-in-oil-in-water (W/O/W) double emulsions produced by microfluidics were designed to co-entrap octreotide and medium-chain triglycerides, enabling digestion-triggered generation of permeation-enhancing medium chain fatty acids. Synthesis parameters were systematically optimized to obtain stable, monodisperse droplets with defined core-shell morphology. The emulsions comprised an inner aqueous phase containing the payload, encapsulated within a Miglyol® 812 N oil phase stabilized by polyglycerol polyricinoleate (PGPR), and dispersed in an external aqueous phase stabilized by Tween® 80. The produced double emulsion had droplets of ∼190 μm in diameter with a single inner aqueous core of ∼78 μm. Lipolysis studies confirmed minimal fatty acid release under gastric conditions, but substantial release of caprylic (C8) and capric (C10) acids following small intestinal digestion, accompanied by release of payload. In Caco-2 monolayers, digested emulsions increased the apparent permeability (Papp) of fluorescein isothiocyanate-dextran (FD-4) and octreotide in a fatty acid concentration-dependent manner. Immunostaining showed occludin redistribution under permeation-enhancing conditions. Ex vivo studies with rat colonic mucosae mounted in Ussing chambers demonstrated a ∼ 4-fold increase in FD-4 permeability for the digested emulsions, comparable to matched concentrations of free fatty acids, while octreotide permeability remained unchanged. Coarse-grained molecular dynamics simulations revealed strong association of octreotide with mixed bile salt-fatty acid micelles, limiting its freely dissolved fraction, whereas FD-4 remained predominantly solvated, consistent with the experimental findings. This study demonstrates that digestion of structured double emulsions enables in situ generation of permeation enhancers while simultaneously releasing hydrophilic cargo, providing a formulation strategy for oral delivery of peptide therapeutics.
Since the 1990s, mental ill-health among children and adolescents in Sweden has risen steadily, now ranking among the highest in Europe. Despite this, general practitioners' and resident physicians' education in primary healthcare in child and adolescent psychiatry is limited. Nevertheless, these professionals are expected to possess broad competence in managing mental ill-health in young patients. This study of general practitioners and resident physicians in primary healthcare regarding children and adolescents with mental ill-health aims to map (1) the self-assessed amount of education in child and adolescent psychiatry, (2) self-perceived competence in different types of symptoms, and 3) self-perceived competence when prescribing psychiatric medications. A cross-sectional study was conducted using web-based questionnaires completed by 184 general practitioners and 144 resident physicians in Sweden's second-largest region. Data were analysed using Pearson's Chi-squared test, Fisher's exact test, Spearman's correlation test, and the Holm-Bonferroni method. Most participants reported limited education in child and adolescent psychiatry. Further, they reported lower competence in managing mental ill-health and prescribing drugs for children (6-12 years) compared to adolescents (13-17 years). Particularly low competence was reported in self-harm, eating disorders, and substance-related disorders. The growing prevalence of mental ill-health among children and adolescents is increasing pressure on primary care, with more young patients seeking help and higher expectations on providers. This study reveals that general practitioners and resident physicians often feel insufficiently prepared to manage these cases, highlighting gaps in medical training and emphasizing the need for strengthened medical school curricula, residency programs, and continuing medical education.
Sweden’s health system is increasingly exposed to strategic vulnerabilities arising from globalised pharmaceutical supply chains, medicine shortages, antimicrobial resistance, and hybrid geopolitical threats. In a period of heightened international tension, safeguarding health security has become an urgent policy concern. While the securitisation of health diplomacy raises ethical and political challenges, this article argues that health diplomacy should be understood not only as a cooperative instrument but also as a form of deterrence that operates through governance integration, transparency, and strategic interdependence, strengthening national resilience. In this context, deterrence refers to reducing the incentives and opportunities for adversarial actors to exploit health-system vulnerabilities, such as pharmaceutical shortages or supply-chain disruptions, to generate societal disruption, undermine public trust, or exert political pressure. Focusing on Sweden, the article shows how deeper Nordic and European Union coordination enhances anticipatory capacity, stabilises access to critical medicines, particularly antibiotics, and reinforces crisis communication and public trust. Positioning health diplomacy within broader security architectures can support continuity of care during systemic stress while remaining anchored in civilian governance and global health norms.
Chronic musculoskeletal pain is reported by 1 of 4 adolescents worldwide. Pain-related functioning is negatively affected by pain itself but also related to depressive symptoms. Although the association between pain-related functioning and depressive symptoms is established, there is a lack of longitudinal studies that establish the direction of the association. The aim was to analyse the temporal association between depressive symptoms and pain-related functioning among adolescents with recurrent musculoskeletal pain. This longitudinal sample comprised 604 adolescents in seventh and eighth grade (M = 13.7 y) who reported recurrent musculoskeletal pain at baseline, defined as occurring at least every week over the previous 6 months. The adolescents were followed yearly for 2 consecutive years (T1, T2, and T3). Temporal associations of self-reported pain-related functioning and depressive symptoms were analysed. Using cross-lagged panel modelling, 4 models were estimated: autoregressive; depressive symptoms predicting pain-related functioning; pain-related functioning predicting depressive symptoms; and a bidirectional model. Pain intensity was entered as a covariate. The results indicate high stability of depressive symptoms and pain-related functioning over time. Although the strength of the prediction was strongest in the autoregressive paths, cross-lagged paths revealed that depressive symptoms at T1 and T2 significantly predicted pain-related functioning at T2 and T3, respectively. Conversely, pain-related functioning at T1 and T2 did not predict depressive symptoms at T2 and T3, respectively. The model where depressive symptoms predict pain-related functioning provided the best model fit and thus, in this general population sample, depressive symptoms drive pain-related functioning more than vice versa. Screening for and targeting depressive symptoms might be essential in affecting the functional consequences of pain.
Operational efficiency in the emergency department (ED) is crucial for minimizing patient wait times, preventing overcrowding, and optimizing resource utilization. Although systemic inefficiencies in ED operations have been extensively studied, the understanding of individual physician-level work practices that support high productivity is limited. This study aimed to explore how productive emergency physicians structure their work in order to provide insights into physician-level practices that may support clinical workflow and overall departmental efficiency. This study employed a thematic analysis informed by Braun and Clarke's reflexive approach to analyze semi-structured interviews with eight high-throughput emergency physicians at Stockholm South General Hospital (Södersjukhuset) in Stockholm, one of Sweden's largest emergency hospitals, between March and May 2021. Five predefined topic areas (prioritization, communication, examination, laboratory and imaging modalities and medical record management), guided data collection and the initial organization of the dataset, after which themes were developed inductively through an iterative and collaborative analytic process. Thematic analysis developed six themes characterizing how productive emergency physicians structured their workflow: initial situational awareness, parallel progression, cognitive offloading, anticipatory communication, selective resource utilization and pragmatic responsiveness. This study provides insights into work practices that may enhance productivity in emergency medicine, with the potential to be reinforced through targeted training. Integrating these approaches into physician education could help reduce patient wait times, prevent overcrowding, and optimize resource utilization, thereby improving overall workflow. Further research is needed to explore their broader implications for clinical decision-making, healthcare efficiency, and patient safety.
Peroneal tendon pathologies are frequently associated with ankle sprains. However, the incidence and demographics of peroneal tendon pathology remain undetermined. This study aims to present surgeon- and patient-reported data of patients undergoing first-time surgery for peroneal tendon pathology with data extracted from the Swedish Foot and Ankle Register (Swefoot). Data from 719 patients between December 2015 and November 2022 underwent analysis. The data included patient characteristics, surgeon-reported findings and preoperative Self-Reported Foot and Ankle Score (SEFAS) and EuroQol 5-Dimension 3-Levels (EQ-5D-3L) assessments. The mean age at surgery was 49 years. Peroneal tendon rupture is the most frequent diagnosis. A higher prevalence of peroneal tendon pathology, specifically peroneus brevis rupture and tendinosis, was observed in women compared to men. Pre-operatively, patients exhibited moderate functional impairment and diminished health-related quality of life compared with normative values. This is Sweden's first large-scale demographic study of peroneal tendon pathologies. Further research is required to comprehensively elucidate demographic patterns. Observational study, Level 3.
This study aimed to investigate whether ultrasound (US)-detected features preceding Doppler-active synovitis are associated with progression to clinical arthritis in anticitrullinated protein antibody (ACPA)-positive individuals with musculoskeletal (MSK) symptoms. In this prospective cohort study, 309 ACPA-positive individuals with MSK symptoms but without clinical arthritis and Doppler-active synovitis were included. US assessments evaluated minimal US findings, including synovial thickening, tendon sheath involvement, bursal effusions, and bone surface cortical irregularities. Longitudinal within-individual trajectories of US findings were analysed over time. Anticyclic citrullinated peptide 2 immunoglobulin G (IgG) and IgM rheumatoid factor (IgM RF) were measured at inclusion. The primary outcome was development of clinical arthritis over 3 years. Associations were analysed using Cox regression and logistic regression models. During a median follow-up of 13 months (IQR 7-22), 117 of 309 participants (38%) developed clinical arthritis, of whom 97 of 117 (83%) fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism rhematoid arthritis classification criteria. Any US finding at baseline (75/309) was associated with a 3-fold increased risk of arthritis development (51/117 progressors vs 24/192 nonprogressors; hazard ratio [HR] 3.3, 95% CI 2.3-4.8). Among these, tendon sheath involvement showed the strongest association (HR 3.6, 95% CI 2.4-5.4), especially in combination with IgM RF positivity (HR 4.2, 95% CI 2.7-6.4). Longitudinal trajectories demonstrated progressive accumulation of US findings prior to arthritis onset, whereas such findings remained infrequent among nonprogressors. Tendon involvement frequently preceded synovial changes. Minimal US findings preceding Doppler-active synovitis, particularly tendon involvement, were strongly associated with progression to clinical arthritis in ACPA-positive individuals and support an US-identified 'presynovitis' phase of rheumatoid arthritis development and early risk stratification.
Adverse childhood experiences (ACEs) are key risk factors for major depressive disorder (MDD), but their associations with treatment-resistant depression (TRD) remain unclear, particularly after accounting for unmeasured confounding, such as shared genetic and familial environmental factors. To examine the association between ACEs and TRD while accounting for unmeasured confounding within families. This cohort study used a co-twin control design and was based on 2 Swedish Twin Registry cohorts: the Study of Twin Adults: Genes and Environment (STAGE) and the Young Adult Twins in Sweden Study (YATSS). The sample included twins born from 1959 to 1992 who completed surveys in 2005 to 2006 (for the STAGE cohort) or in 2013 to 2014 (for the YATSS cohort). Both cohorts were linked to Sweden's National Patient Register and Prescribed Drug Register for follow-up until the end of 2016. Data analysis was conducted from September to November 2024. ACEs, which were assessed using 7 yes or no items adapted from the Life Stressor Checklist-Revised: emotional neglect or abuse, physical neglect, physical abuse, sexual abuse, rape, hate crime, and witnessing family violence before age 19 years. TRD, which was defined as MDD diagnosed clinically or meeting the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria based on self-reported symptoms and having had at least 2 antidepressant switches of adequate duration (≥6 weeks) with no more than 14 weeks between consecutive prescriptions. The full cohort included 21 192 twins, among whom 17 814 (10 205 females [57.3%]; mean [SD] age, 32.10 [7.82] years) were included in the main analysis. A total of 5558 individuals (31.2%) reported exposure to at least 1 ACE, and 996 (5.6%) reported 3 or more ACEs. The prevalence of TRD was 1.3% (n = 230) overall. Each additional ACE exposure was associated with increased odds of TRD (odds ratio [OR], 1.69; 95% CI, 1.56-1.84). In co-twin control analyses, the association remained within monozygotic and dizygotic twins (OR, 2.23; 95% CI, 1.30-3.83). Among ACE types, physical neglect (OR, 5.73; 95% CI, 3.75-8.75) and sexual abuse (OR, 5.01; 95% CI, 3.47-7.23) showed the greatest magnitude of associations with TRD. In this cohort study, ACE exposure was associated with an increased risk of TRD even after accounting for unmeasured familial confounding. The findings highlight the importance of preventing ACEs and incorporating ACE history into clinical assessment to identify individuals with MDD who may be at elevated risk for treatment resistance.
BACKGROUND: Sweden allocated SEK 354.5 million (approximately EUR 31.5 million) between 2018 and 2022 to extend home visiting services for families in socioeconomically disadvantaged areas. This initiative operationalises proportionate universalism within a decentralised welfare system where 21 regional governments hold authority over healthcare delivery. We examined whether program resources reached areas of greatest need and how targeting varied across regions and over time. METHODS: We analysed Swedish administrative register data aggregated to 12,258 small statistical area-year observations across four implementing regions during each region’s post-rollout period. Program dosage was measured as probability-weighted exposure based on patient registration patterns between areas and child health centres. Socioeconomic need was measured using the Care Need Index (CNI). We estimated targeting associations using linear regressions with year fixed effects and standard errors clustered at the area level. We assessed equity using the Concentration Index and a proportional allocation benchmark, and evaluated within-area heterogeneity in household vulnerability. RESULTS: Program resources were positively associated with area-level need (beta = 0.101, 95% CI: 0.091–0.111, p < 0.001). Where the program operated, targeting exceeded proportional benchmarks (proportionality ratio = 1.33) and the Concentration Index was positive (CI = 0.074), indicating pro-poor allocation. However, only 47% of high-need areas had any program presence, and regional variation was substantial: Stockholm’s targeting association was over three times stronger than Skåne’s (beta = 0.145 vs. 0.043). Within-area analysis revealed that more heterogeneous areas received slightly lower dosage, suggesting area-based allocation partially misses within-neighbourhood inequalities. CONCLUSIONS: Sweden directed resources toward higher-need areas, with targeting that exceeded proportional benchmarks where the program was implemented. The primary equity challenge was not targeting accuracy but coverage: more than half of high-need areas lacked any program presence. Achieving equitable outcomes through proportionate universalism requires both accurate allocation formulas and sufficient implementation capacity to reach all areas of need.
Sexual and reproductive health and rights (SRHR) are central to health equity, yet migrants in Sweden, especially from low-income countries, experience linguistic, cultural, and structural barriers to SRHR information and services. Although migrants are prioritised in Sweden's national strategy for SRHR, no evaluation has examined SRHR education embedded within language programmes, limiting culturally responsive and scalable interventions. This protocol describes a study evaluating an SRHR programme integrated into Swedish for Immigrants (SFI), the national language programme for newly arrived adults.The study explores implementation processes, experiences of participants and implementers, and changes in SRHR knowledge, attitudes, behaviours, and healthcare navigation. Guided by implementation research principles and the UK Medical Research Council process evaluation framework, four qualitative sub-studies will be conducted across participating SFI sites. Semi-structured interviews and ethnographic fieldwork will involve midwives, SFI teachers, municipal stakeholders, and adult migrant learners. Data will be analysed using a combination of deductive and inductive qualitative content analysis and an ethnographic - hermeneutic approach, with process evaluation examining fidelity, adaptations, mechanisms of impact, and contextual determinants.The study is expected to identify key facilitators and barriers influencing programme delivery, acceptability, and relevance. Findings will inform evidence-based recommendations to strengthen cultural adaptation, implementation strategies, and learner engagement. Anticipated impacts include improved individual SRHR knowledge and health literacy, enhanced institutional capacity for inclusive SRHR promotion, and more equitable public service delivery at the societal level.Trial registration: ISRCTN 63,513,002 (registered 27 November 2025). Main findings: This study examines the implementation and anticipated impact of a culturally adapted sexual and reproductive health and rights education programme embedded within Swedish for Immigrants education.Added knowledge: The study provides new knowledge on how sexual and reproductive health and rights education can be structurally integrated into adult language education, using an ecological perspective combined with implementation science.Global health impact for policy and action: The findings may inform policymakers and practitioners about scalable and equity-oriented approaches to integrate sexual and reproductive health and rights education into adult education systems in migrant-receiving countries.