ABSTRACT: BACKGROUND: In general men tend to drink more alcohol and experience more alcohol-related sickness, injuries and mortality than women. In this paper, the overall hypothesis was that increased gender similarity in the division of parental duties would lead to convergence in alcohol-related harm. The aim was to analyse whether the risk of alcohol harm differs between parents who fit a gender-stereotypical versus those with a less gender-stereotypical division of childcare and paid work. METHODS: The study sample was a retrospective registry-based cohort study of all Swedish couples who had their first child together in 1978 (N=49,120). A less gender-stereotypical parenthood was indicated by paternity leave for fathers (1978-1979) and full-time work for mothers (1980). The outcome was inpatient care and/or death caused by alcohol psychosis, alcoholism, liver disease, or alcohol intoxication in the two decades following (1981-2001). Our main statistical method was multivariate logistic regression with odds ratios used to estimate relative risks. RESULTS: The main results show that fathers who took paternity leave had 18% lower risk of alcohol-related care and/or death than other fathers. Mothers who worked full-time about two years after having a child had 71% higher risk than mothers who were unemployed or worked part-time. CONCLUSIONS: A less gender-stereotypical division of duties between parents in early parenthood may contribute to a long-term decreased gender disparity regarding risky alcohol consumption and alcohol-related harm. In order to know more about the causal direction however, future research has to consider subjects' drinking patterns in the years prior to parenthood.

Despite increasing interest in gender and health,'lay' perceptions of gender differences in mortality have been neglected. Drawing on semi-structured interview data from 45 men and women in two age cohorts (born in the early 1950s and 1970s) in the UK, we investigated lay explanations for women's longer life expectancy. Our data suggest that respondents were aware of women's increased longevity, but found this difficult to explain. While many accounts were multifactorial, socio-cultural explanations were more common, more detailed and less tentative than biological explanations. Different socio-cultural explanations (i.e. gendered social roles,'macho' constraints on men and gender differences in health-related behaviours) were linked by the perception that life expectancy would converge as men and women's lives became more similar. Health behaviours such as going to the doctor or drinking alcohol were often located within wider structural contexts. Female respondents were more likely to focus on women's reproductive and caring roles, while male respondents were more likely to focus on how men were disadvantaged by their 'provider' role. We locate these narratives within academic debates about conceptualising gender: e.g.'gender as structure' versus 'gender as performance','gender as difference' versus 'gender as diversity'.

STUDY OBJECTIVE: Examine the relation between aspects of gender equality and population health based on the premise that sex differences in health are mainly caused by the gender system. Setting/ PARTICIPANTS: All Swedish couples (98 240 people) who had their first child together in 1978. DESIGN: The exposure of gender equality is shown by the parents' division of income and occupational position (public sphere), and parental leave and temporary child care (domestic sphere). People were classified by these indicators during 1978-1980 into different categories; those on an equal footing with their partner and those who were traditionally or untraditionally unequal. Health is measured by the outcomes of death during 1981-2001 and sickness absence during 1986-2000. Data are obtained by linking individual information from various national sources. The statistical method used is multiple logistic regressions with odds ratios as estimates of relative risks. MAIN RESULTS: From the public sphere is shown that traditionally unequal women have decreased health risks compared with equal women, while traditionally unequal men tend to have increased health risks compared with equal men. From the domestic sphere is indicated that both women and men run higher risks of death and sickness when being traditionally unequal compared with equal. CONCLUSIONS: Understanding the relation between gender equality and health, which was found to depend on sex, life sphere, and inequality type, seems to require a combination of the hypotheses of convergence, stress and expansion.

Sex differences in health, and the reality of a gender system, are well-known, but we know little about how this connects to opinions on fairness and desired change. This study aims to explore two principal questions: how to compare the position of women and men within-state and how to choose between-states, where a state is defined as a situation in which individuals have a particular set of resources, rights and duties, and if components in the set are altered, a new state for the same individuals appears. Based on various normative rules (monistic view or separate spheres, equity as choice or ethics of care, equity by attainment or shortfall; variants of welfarism, feminism and conservatism), a survey among Swedish public health workers was carried out. The results demonstrate a major rejection of the idea of compensation between health, power, influence and resources, and of considering past processes when judging fairness as to women and men. Moreover, most respondents believe that a biologically based difference in health is fair and reject health maximization as a guiding principle. The support for gender equality is strong when contrasted with the conservative goal, and subsists when contrasted against the Pareto criterion and trading-off health/income as well. Results that call for additional research and exchange of views include that common notions in research and policy-making are rejected by a majority, and that females and males differ considerably when judging change from a societal perspective.

BACKGROUND AND PURPOSE: To prevent new cardiovascular events after stroke, prescribed preventive drugs should be used continuously. This study measures persistent use of preventive drugs after stroke and identifies factors associated with persistence. METHODS: A 1-year cohort (21 077 survivors) from Riks-Stroke, the Swedish Stroke Register, was linked to the Swedish Prescribed Drug Register. RESULTS: The proportion of patients who were persistent users of drugs prescribed at discharge from hospital declined progressively over the first 2 years to reach 74.2% for antihypertensive drugs, 56.1% for statins, 63.7% for antiplatelet drugs, and 45.0% for warfarin. For most drugs, advanced age, comorbidity, good self-perceived health, absence of low mood, acute treatment in a stroke unit, and institutional living at follow-up were independently associated with persistent medication use. CONCLUSIONS: Persistent secondary prevention treatment declines rapidly during the first 2 years after stroke, particularly for statins and warfarin. Effective interventions to improve persistent secondary prevention after stroke need to be developed.

This study combines data at individual and area level to examine interactions between equality within couples and gender equality in the municipality in which individuals live. The research question is whether the context impacts on the association between gender equality and health. The material consists of data on 37,423 men and 37,616 women in 279 Swedish municipalities, who had their first child in 1978. The couples were classified according to indicators of their level of gender equality in 1980 in the public sphere (occupation and income) and private sphere (child care leave and parental leave) compared to that of their municipality. The health outcome is compensated days from sickness insurance during 1986-1999 with a cut-off at the 85% percentile. Data were analysed using logistic regression with the overall odds as reference. The results concerning gender equality in the private sphere show that among fathers, those who are equal in an equal municipality have lower levels of sick leave than the average while laggards (less equal than their municipality) and modest laggards have higher levels. In the public sphere, pioneers (more equal t han their municipality) fare better than the average while laggards fare worse. For mothers, those who are traditional in their roles in the public sphere are protected from high levels of sick leave, while the reverse is true for those who are equal. Traditional mothers in a traditional municipality have the lowest level of sick leave and pioneers the highest. These results show that there are distinct benefits as well as disadvantages to being a gender pioneer and/or a laggard in comparison to your municipality. The associations are markedly different for men and women.

OBJECTIVES: The initial objective is to examine the relationship between paternity leave in 1978-1979 and male mortality during 1981-2001, and the second objective is to calculate the cost-effectiveness of the 1974 parental insurance reform in Sweden. METHODS: Based on a population of all Swedish couples who had their first child together in 1978 (45,801 males), the risk of death for men who took paternity leave, compared with men who did not, was estimated by odds ratios. The cost-effectiveness analysis considered costs for information, administration and production losses, minus savings due to decreased sickness leave and inpatient care, compared to health gains in life-years and quality-adjusted life-years (QALYs). RESULTS: It is demonstrated that fathers who took paternity leave have a statistically significant decreased death risk of 16%. Costs minus savings (discounted values) stretch from a net cost of EUR 19 million to a net saving of EUR 11 million, and the base case cost-effectiveness is EUR 8000 per QALY. CONCLUSIONS: The study indicates that that the right to paternity leave is a desirable reform based on commonly stated public health, economic, and feminist goals. The critical issue in future research should be to examine impact from health-related selection.

Extreme degrees of obesity may occur in association with hypothalamic tumors, usually after surgical intervention. This phenomenon has been reported to occur in as many as 25-75% of children undergoing extensive surgical extirpation of craniopharyngiomas (Cranio). Because less is known about the auxology of children with Cranio with milder alterations in growth, we undertook a 3-yr longitudinal analysis, using the KIGS database (Pfizer International Growth Database), to study their growth patterns and evolution of weight. We compared the effect of GH therapy on height, weight, and body mass index (BMI) in 199 prepubertal children with diagnosed Cranio treated by surgery and/or radiotherapy to two other groups of children with other causes of organic GH deficiency (OGHD): one with postsurgical and/or postirradiated OGHD (OGHD + S/I; n = 92) and the other with OGHD not due to Cranio and not having undergone either surgery or irradiation (OGHD - S/I; n = 85). At the start of GH therapy, 1) mean chronological (P < 0.0001) and bone (P = 0.0002) ages were youngest in OGHD - S/I and oldest in OGHD + S/I; 2) the mean height sd score (SDS) was lowest in OGHD - S/I and comparably higher in the other two groups (P < 0.0001); 3) mean weight and BMI SDS were greatest in Cranio and least in OGHD - S/I (both P < 0.0001); and 4) the mean initial GH dose prescribed was highest in OGHD - S/I and comparable in the other two groups (P < 0.0001). After 3 yr of GH therapy, 1) mean bone age remained youngest in OGHD - S/I and oldest in OGHD + S/I (P < 0.0001); 2) mean height SDS was highest in Cranio and comparably lower in the other two groups (P = 0.0159); 3) mean weight and BMI SDS remained greatest in Cranio and least in OGHD - S/I (P < 0.0001 and P = 0.0003, respectively); and 4) the mean GH dose remained highest in the OGHD - S/I group and least in the Cranio group (P = 0.0082). There were statistically significant increases within each group between the start of treatment and after 3 yr of GH therapy in height and weight, but not in BMI SDS. Lastly, after 3 yr of GH treatment, children in the Cranio group continued to have disproportionately heavier weight and higher BMI (with the greatest values in those with lower stimulated peak GH concentrations) compared with members of the other two groups, with no salutary effect of GH treatment on weight SDS and a mild improvement in BMI SDS. After S/I treatment, children with Cranio are disproportionately prone to varying degrees of weight gain compared with children with other forms of OGHD. In the present cohort of prepubertal children with Cranio, GH therapy induced excellent linear growth, but failed to have an ameliorative effect on weight gain and had only a slight beneficial effect on BMI gain. Because affected children may have resultant significant long-term medical morbidity and diminished quality of life, it is critical that the mechanism of this phenomenon be determined to devise helpful preventive or therapeutic interventions.

Women live longer than men in almost all countries, but men are more privileged in terms of power, influence, resources and probably morbidity. This investigation aims at illustrating how the choice of normative framework affects judgements about the fairness in these sex differences, and about desired societal change. The selected theories are welfare economics, health sector extra-welfarism, justice as fairness and feminist justice. By means of five Swedish proposals aiming at improving the population's health or "sex equity", facts and values are applied to resource allocation. Although we do not claim a specific ethical foundation, it seems to us that the feminist criterion has great potential in public health policy. The overall conclusion is that the normative framework must be explicitly discussed and stated in issues of women's and men's health.

BACKGROUND: Alcohol problems can increase the risk of downward mobility within, or mobility out of, the workforce. The magnitude of this risk has been unclear, as has also been the question whether the risk is different for men and women, for different socio-economic classes, and for single-living compared with co-habiting people. METHODS: The study period was 1970-1980, when unemployment was low in Sweden. Information about socio-economic status from censuses was linked to hospitalization for alcoholism, alcohol psychosis and alcohol intoxication (AAA) over the period 1970-1975 in Stockholm County in persons aged 20-49 years in 1970 and gainfully employed in the same socio-economic category in both 1970 and 1975, and to general population data. The standardized rate ratio for mobility out of the workforce and for downward socio-economic mobility was calculated for those hospitalized with AAA. RESULTS: There was a statistically significant risk of mobility out of the workforce over the period 1976-1980 in both sexes and in all socio-economic groups. The relative risk was 6.63 for male skilled and semi-skilled manual workers and 9.52 for non-manual employees at medium and high level, while the corresponding figures were lower for women. The absolute risk of leaving the workforce was lowest in non-manual employees at medium and high level. The relative risk was reduced in persons who were co-habiting. CONCLUSIONS: Severe alcohol problems are powerful determinants of downward mobility within, or mobility out of, the workforce in both sexes and in all socio-economic categories.

AIMS: This study was undertaken to examine the association between short stature and acute non-fatal myocardial infarction and to analyse causal mechanisms related to height with a focus on childhood risk factors. METHOD: The SHEEP (Stockholm Heart Epidemiology Program) is a population-based case-referent study. The outcome was incident first events of myocardial infarction. The study base included all Swedish citizens aged 45 to 70, who lived in Stockholm County during 1992-94. This analysis is based on 967 male cases, 412 female cases and 1696 referents. Exposure information was obtained through questionnaires, interviews, health examinations, and obstetric records. RESULTS: Adult height was inversely related to myocardial infarction. The odds ratio for men in the shortest quartile (< 173 cm) compared with the tallest was 1.78 (95% CI: 1.39, 2.28). For women the corresponding odds ratio in the shortest quartile (<159 cm) was 1.86 (95% CI: 1.28, 2.71). Height was also inversely associated with fetal growth and indicators of material resources during childhood. Within each social class of origin short stature was associated with number of siblings, lack of higher education, and absence of upward social mobility. Adjustment for childhood risk factors decreased the excess relative risk of short stature with around 25%. Adult social, behavioural, and biological risk factors could not explain the association. The findings were similar for men and women. CONCLUSION: Height is associated with many risk factors of myocardial infarction, which increase the risk of disease through many different causal pathways. Childhood exposures have no dominant role in explaining the association between short stature and myocardial infarction.

The main aim of the Swedish Women's Peace reform in 1998 was to enhance criminal legal protection for women exposed to violence in heterosexual relationships and to promote gender equality. However, these ambitions risk being contravened in a masculinist criminal legal system. One problem concerns how the victim is constructed in criminal legal cases. The author argues that moral balancing and discourses of responsibility and guilt in Swedish cases constrain the agency possible for women and suggest that a more comprehensive policy in Sweden must be developed to include violent men, their agency, and their responsibility for the violence.

Engaging men in work towards gender equality is a critical aspect of gender and development. However, there are few documented grassroots-level approaches to undertaking such work. This paper argues that context specific stresses on local constructions of masculinity, such as unemployment, poverty and high HIV prevalence, may provide useful entry points for work with men towards gender equality. While these stresses may act to undermine men's ability to 'achieve' the requirements of traditional constructions of masculinity, particularly the role of men as providers, they simultaneously create spaces for change. In this research, land-use provided a basis from which to engage with a group of older men (45-75 years) around a range of issues, including HIV and AIDS and health. Increases in levels of communication around HIV, household resources and health are used as indicative of the men's moves towards gender-equal behaviour. The paper argues that this was achieved by supporting positive aspects of traditional masculine identities, particularly the role of men as breadwinners, in a social and economic context where these roles are threatened or placed under pressure, while simultaneously working around 'sensitive' issues.

An Undergraduate Nurse Employment Demonstration Project (UNDP) was implemented in four Health Service Areas in British Columbia with a concurrent evaluation study. This demonstration project comprised the development and implementation of a new position in the BC healthcare system. The position enabled third- and fourth-year nursing students to be employed at their level of education. The purposes of the evaluation were to explore the feasibility and outcomes of this type of paid undergraduate student nurse employment. The three-year project and evaluation included both implementation and outcome analysis. The implementation evaluation design was descriptive and prospective, involving multiple data sources. The outcome evaluation design was quasi-experimental, with intervention and comparison groups. Learning outcomes for undergraduate nurses were increased confidence, organizational ability, competency and ability to work with a team. Workplace outcomes were increased unit morale, help with workload and improved patient care. New graduates with undergraduate nurse experience reported less time required for orientation and transition than other graduates who did not have this experience, and workplace nurses viewed these new graduates as more job-ready than other new graduates. After 21 months, new graduates with undergraduate nurse experience were less likely to move to other employment than other new graduates. Results from the four Health Service Areas indicated that the paid undergraduate nurse position was feasible and that outcomes benefited students, new graduates and workplaces. The undergraduate nurse position is now being implemented throughout all Health Service Areas in British Columbia.By 2000, concerns in British Columbia about the nursing workforce, workplace and patient safety had escalated to the point where diverse stakeholder groups were prepared to work together in new ways to prepare nursing graduates to be more job-ready, to recruit and retain new graduates and to retain existing nurses. Stakeholder groups were administrators, labour organizations, professional associations, educators and government. One idea to support job readiness and retention focussed on the feasibility of implementing cooperative education for nursing students. The effort was unsuccessful owing to lack of funding, but resulted in a review of the literature on cooperative education and other work-study programs. Cooperative education connects classroom learning with paid work experience for the purpose of enhancing students' education (Fitt and Heverly 1990; Heinemann and De Falco 1992; Ryder 1987). Reported benefits for students were improved job preparation and graduate retention (Ishida et al. 1998), additional staffing and reduction in orientation time (Cusack 1990; Ishida et al. 1998), increased practice judgment (Cusack 1990; Siedenberg 1989) and better workload management (Ross and Marriner 1985). A work-study model reported in the literature offered benefits similar to those of cooperative education, with greater flexibility in design. An example was the University of Texas Health Science Center at Houston's collaborative work-study scholarship program with local hospitals (Kee and Ryser 2001). Students in second clinical semesters were employed as unlicensed personnel by hospitals. The students, as unlicensed personnel, worked to the level of their nursing preparation. Reported benefits for students were academic credit, financial assistance, interaction with multidisciplinary teams, opportunity to refine clinical skills, understanding of nurses' roles and guaranteed interview for positions on graduation (Kee and Ryser 2001). Benefits for practice organizations were skilled help, the opportunity to recruit new nurses and increased interaction with a university nursing program. While nurse education stakeholders in British Columbia were exploring options, the concept of undergraduate student nurse employment was initiated by a group of fourth-year students at the University of Victoria who were completing the course "Nurses Influencing Change." The students were concerned about having enough practice experience to meet increasing nursing competency requirements and their survival as new graduates given workplace realities. Debt load also was a concern because extensive student practicum time limited opportunities for paid employment during the nursing education program. Students found that the idea of paid undergraduate nurse positions, based on the student employment model in Alberta, was supported by nurse leaders, many practising nurses and nursing faculty who also were concerned about meeting patient care standards and adequately preparing nursing students. In 2000, the BC Ministry of Health Services funded an Undergraduate Nurse Demonstration Project (UNDP)- one type of paid employment for undergraduate student nurses - in four Health Service Areas linked with four schools of nursing. A concurrent three-year evaluation study examined the feasibility and outcomes of the UNDP (Gamroth et al. 2004). This paper summarizes the findings of the evaluation. Evaluation Research An Undergraduate Nurse Employment Demonstration Project (UNDP) was implemented in four Health Service Areas in British Columbia with a concurrent evaluation study. This demonstration project comprised the development and implementation of a new position in the BC healthcare system. The position enabled third- and fourth-year nursing students to be employed at their level of education. The purposes of the evaluation were to explore the feasibility and outcomes of this type of paid undergraduate student nurse employment. The three-year project and evaluation included both implementation and outcome analysis. The implementation evaluation design was descriptive and prospective, involving multiple data sources. The outcome evaluation design was quasi-experimental, with intervention and comparison groups. Learning outcomes for undergraduate nurses were increased confidence, organizational ability, competency and ability to work with a team. Workplace outcomes were increased unit morale, help with workload and improved patient care. New graduates with undergraduate nurse experience reported less time required for orientation and transition than other graduates who did not have this experience, and workplace nurses viewed these new graduates as more job-ready than other new graduates. After 21 months, new graduates with undergraduate nurse experience were less likely to move to other employment than other new graduates. Results from the four Health Service Areas indicated that the paid undergraduate nurse position was feasible and that outcomes benefited students, new graduates and workplaces. The undergraduate nurse position is now being implemented throughout all Health Service Areas in British Columbia. By 2000, concerns in British Columbia about the nursing workforce, workplace and patient safety had escalated to the point where diverse stakeholder groups were prepared to work together in new ways to prepare nursing graduates to be more job-ready, to recruit and retain new graduates and to retain existing nurses. Stakeholder groups were administrators, labour organizations, professional associations, educators and government. One idea to support job readiness and retention focussed on the feasibility of implementing cooperative education for nursing students. The effort was unsuccessful owing to lack of funding, but resulted in a review of the literature on cooperative education and other work-study programs. Cooperative education connects classroom learning with paid work experience for the purpose of enhancing students' education (Fitt and Heverly 1990; Heinemann and De Falco 1992; Ryder 1987). Reported benefits for students were improved job preparation and graduate retention (Ishida et al. 1998), additional staffing and reduction in orientation time (Cusack 1990; Ishida et al. 1998), increased practice judgment (Cusack 1990; Siedenberg 1989) and better workload management (Ross and Marriner 1985). A work-study model reported in the literature offered benefits similar to those of cooperative education, with greater flexibility in design. An example was the University of Texas Health Science Center at Houston's collaborative work-study scholarship program with local hospitals (Kee and Ryser 2001). Students in second clinical semesters were employed as unlicensed personnel by hospitals. The students, as unlicensed personnel, worked to the level of their nursing preparation. Reported benefits for students were academic credit, financial assistance, interaction with multidisciplinary teams, opportunity to refine clinical skills, understanding of nurses' roles and guaranteed interview for positions on graduation (Kee and Ryser 2001). Benefits for practice organizations were skilled help, the opportunity to recruit new nurses and increased interaction with a university nursing program. While nurse education stakeholders in British Columbia were exploring options, the concept of undergraduate student nurse employment was initiated by a group of fourth-year students at the University of Victoria who were completing the course "Nurses Influencing Change." The students were concerned about having enough practice experience to meet increasing nursing competency requirements and their survival as new graduates given workplace realities. Debt load also was a concern because extensive student practicum time limited opportunities for paid employment during the nursing education program. Students found that the idea of paid undergraduate nurse positions, based on the student employment model in Alberta, was supported by nurse leaders, many practising nurses and nursing faculty who also were concerned about meeting patient care standards and adequately preparing nursing students.

The moral philosopher Dan Brock has argued that equality of health outcomes "even if achievable" is problematic as a goal in its own right-because it is open to the levelling down objection. The levelling down objection to egalitarianism has received surprisingly little attention in the bioethics literature on distribution of health and healthcare and deserves more attention. This paper discusses and accepts an example given by Brock showing that prioritarianism and egalitarianism may judge distributions of health outcomes differently. We should accept that levelling down is never a good thing, all things considered, but that equality often is. By discussing variants of Brock's example, it is demonstrated that if equality, prioritarianism and aggregation are combined, as in a population-wide summary measure of health, such as the health achievement index, this combined set of principles is not open to levelling down. The paper suggests-although a more thorough investigation of the properties of the achievement index is needed-that this measure (a) is always sensitive to inequality in health,(b) is always sensitive to average health,(c) can assign priority to those with lowest health outcomes and (d) is not sensitive to levelling down. Levelling down is not an embarrassment for egalitarians if they adopt a pluralist theory that integrates fairness with goodness. Equality is not the only value egalitarians promote. But equality is so important that we should not reject it.