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Humanitarian programming in fragile economies often use unconditional cash transfers (UCTs) to offset food insecurity. However, there is an increasing focus on using cash transfers to boost household incomes beyond the short-term through micro-enterprise start-up and growth. This paper conducts a randomised control trial to measure the impact of three different sizes of business grants against UCT in Somalia. We find that giving the same amount of money as a lump sum business grant results in higher likelihood of business ownership and income compared with UCT in the short run (3-4 months after the transfers). However, the impacts are larger and persist 3 years later only for those who received larger amount of grants. The results indicate our 'medium'-sized grant being more cost-effective. © 2022 The Author(s).

Parenthood can be defined by the contradiction that it is one of the most satisfying yet stressful experiences in life. Many parents experience stress during parenthood, and some to the extent that they display symptoms of parental burnout. Nevertheless, research on parental burnout is scant and many studies have only examined the condition in Western settings. The aim of this study was to examine parental burnout among Somali mothers in Mogadishu, Somalia, and its association with certain psychological, psychosocial, and sociodemographic factors. In this cross-sectional study, questionnaire data were collected through the measurements Parental Burnout Assessment and Patient Health Questionnaire 9, as well as through social and demographic questions. A total of 882 Somali mothers in Mogadishu participated. The analysis methods used were univariate, bivariate, and multiple linear regression analysis. The results revealed that the mean parental burnout score was low in the sample. Additionally, a significant association was found between higher levels of parental burnout and higher levels of depression, perceived lack of social support, being unmarried, having a low monthly household income, and when the youngest child was of school-age.

This study aimed to investigate the patterns of sick leave, as well as factors associated with sick leave due to COVID-19 during one year after the COVID-19 diagnosis, and sex-related aspects on sick leave. This nationwide study involved 11,902 individuals who received sickness benefits for COVID-19 during the first wave of the pandemic. Data from three Swedish registries were analyzed for sick leave that commenced between March 1 and August 31, 2020, with a follow-up period of 12 months. Sick leave due to COVID-19 was counted as the number of days with sickness benefits and required to include at least one registered COVID-19 diagnosis. The median duration of sick leave was 35 days, and 347 (2.9%) individuals continued their sick leave during the entire follow-up period. Furthermore, 1 year later, the cumulative incidence of sick leave was slightly higher in males (3.5%) compared to females (2.7%). Older age, being single with no children, diagnosed with the virus, medium income level, history of sick leave, and need for inpatient care were significantly associated with a higher duration of sick leave due to COVID-19, both in the total population and when stratified by sex. These results indicated that three out of 100 (3%) patients were still on sick leave 1 year after their COVID-19 diagnosis. Aspects regarding the importance of sick leave duration differed between males and females and comprised sociodemographic characteristics and need for inpatient care. The results indicated the complexity of sick leave due to COVID-19.

Background: Today’s older people drink more alcohol than earlier cohorts of older people. Social integration has been identified as an important factor for older people’s drinking, but the association is complex. This study investigates both high and low levels of social integration and their associations with longitudinal patterns of alcohol consumption among older women and men.

Methods: Longitudinal nationally representative data of older Swedish women and men aged over 65 – the Swedish Level of Living Survey (LNU) and Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD) – from 2010/2011 and 2014 (n = 1048). Associations between social contacts and social activities at baseline and longitudinal patterns of drinking frequency were examined with multinomial logistic regression analyses. Results: Men reported drinking alcohol more often than women, but the most common drinking frequency among both women and men was to drink monthly or less. Drinking habits were generally stable over time. People with high levels of social activity at baseline were more likely to have a stable daily or weekly drinking frequency or increased drinking frequency over the four-year follow-up period, particularly women. People with low levels of social contacts and/or social activities were less likely to have a stable daily or weekly drinking frequency, compared to people in the low and stable drinking frequency group.

Conclusions: Alcohol consumption is embedded in a social context, older people drink in social situations and social integration predicts continued drinking patterns.

Background: Covid-19 pandemic have had a major impact on the healthcare system, both globally and nationally. A variety of guidelines and policies from hospitals and governments affected the maternity care. Because of guidelines and policies women have been limited in their options regarding their childbirth, and the opportunity to bring a partner, doula or support person has been uncertain. Aim: The aim of this study was to, from the birthing persons perspective, investigate how the covid-19 pandemic affected their birth experience. Method: Integrative literature review. A systematic search was conducted in the databases PubMed and Cinahl. Inclusion- and exclusion criteria were chosen, quality was assessed, and data was extracted from relevant studies. In the data analysis a qualitative content analysis with a deductive approach was used. Findings: A total of 16 articles were included. Guidelines and policies aiming to protect women led to feelings of loss of autonomy, and disappointment regarding the birth plans and wishes. Women gave birth alone, some women without pain relief, some have been separated from their newborn, and some did not received information or options regarding their birth. Conclusion and clinical implications: Based on the recommendations regarding intrapartum care for a positive birth experience, restrictions during the pandemic have restricted the woman's right to a positive birth experience. Therefore, when guidelines arise during a pandemic, it is important to consider the evidence that already exists to promote a good birth experience.

Background: Sexual and Reproductive Health (SRH) is a cornerstone of overall health, particularly in fragile humanitarian contexts. Despite being recognized as a fundamental human right, access to quality SRH services is often significantly restricted in crisis situations. This limitation can lead to damaging health outcomes for women, children, and marginalized groups. Given this reality, there is an urgent need for an enriched understanding of SRH in area simpacted by conflicts, disasters, and population displacements. With global trends such as increasing forced migration and escalating crises, a thorough re evaluation of the challenges and potential solutions associated with SRH in these contexts is crucial.

Aim: The aim of the integrative review is to describe the current status of sexual and reproductive health (SRH) services and interventions in humanitarian settings and explore key challenges in sexual and reproductive health services in these settings.

Methodology: This integrative literature review analyzed and synthesized 22 research papers through inductive methodology by Elo and Kyngäs (2008).

Results: This in-depth review of studies from a wide range of humanitarian environments worldwide, has unveiled critical insights into the hurdles surrounding Sexual and Reproductive Health (SRH) services. Firstly, barriers to accessibility and awareness prevent individuals from acquiring vital SRH knowledge and services, and this prevention is often intensified by sociocultural stigmas. Educational and language obstacles further amplify these challenges, particularly for migrants. This review also underscores the severe impact of gender-based violence (GBV) and early or forced marriages on SRH outcomes.

Conclusions: This analysis reveals key obstacles that obstruct the provision of SRH services in humanitarian settings. Acknowledging these issues enables decision-makers to plan effectivestrategies and interventions to address the SRH needs in these settings. Exploration of each barrier and seeking holistic solutions to overcome these challenges is suggested.

Background: Higher physical capacity is correlated with increased health. Knowledge in this area regarding psychiatric diseases is sparse. 

Purpose: The aim was to study aerobic and several strength capacities in a physical activity project for persons with depression or anxiety.

Methods: Eighty-four persons (56 women and 28 men) with depression or anxiety were recruited from psychiatric out-patient clinics in Stockholm. Their mean age and BMI was 46 (21-80) years and 26 (17-41) kg/m², respectively. 50% were sick-listed. 50% had BMI>25. Aerobic and strength tests were chosen by each subgroup´s project leaders. Directed physical activity was given, in groups 10-15, 1 hour twice/week during 8-12 weeks.

Results: Significant changes (p<0.05, of all n=84) between pre- and post tests were seen in submaximal cycle test (11% enhanced values, n=56) and distance of 6 minutes walk test (16%, n=15) as well as in strength tests for the back for the back (i.e. time in static horizontal belly-back, 40%, n=44), abdominal and hip flexors (i.e. number of hip flexion sit-ups, 45%, n=38), leg (i.e. standing with 90^O in hips and knees, 48%, n=56) and arm with shoulder muscles (i.e. number of raising weights alternately with the arms, 46%, n=32). Hand grip tests, BMI or blood pressure values did not change significantly.

Conclusions: Directed 8-12 weeks physical activity programs can improve physical fitness in individuals with depression or anxiety.

Introduction: Forensic mental health care is hampered by lack of evidence-based treatments. The Swedish forensic mental health population consists of patients suffering from severe illnesses such as schizophrenia and bipolar disorders, similar to populations in international studies. Illness Management and Recovery (IMR) is an intervention for patients with serious mental illness, based on psychoeducational, cognitive-behavioral and motivational components. The purpose is to strengthen participants’ illness management skills and recovery. Objective: To test effectiveness of IMR within forensic mental health by comparing it to treatment as usual. Method: This is a cluster-randomized controlled trial. Patients in forensic mental health inpatient units are randomized to an active (IMR) or a control condition (treatment as usual). Clustering of patients is based on ward-units where inpatients are admitted. Patients in the active condition receive two group and one individual IMR sessions per week. The treatment phase is estimated to last nine months. Outcomes include illness related disability, illness management skills, sense of recovery, hope, mental health and security related problems. Outcomes are measured at baseline, four months into treatment, at treatment completion and at three months follow-up. Staff experiences of implementing IMR will be explored by a self-report measure and semi-structured interview based on Normalization Process Theory. Ethics and dissemination: The study is approved by the Swedish Ethical Review Authority (Registration No. 2020–02046). Participation will be voluntary based on written informed consent. Results will be disseminated through peer-reviewed articles and conferences. The study is registered in the US registry of clinical trials (NCT04695132). 

AIM: The aim was to investigate same-sex mothers' self-assessed experiences of forming a family, and the association between heteronormative information, parental support and parenting stress.

DESIGN: A quantitative, cross-sectional study.

METHODS: In a web survey conducted in Sweden in 2019, same-sex mothers (N = 146) with a child aged 1-3 years answered questions about their experiences of forming a family through assisted reproduction and questions about parenting stress. Descriptive statistics describes the process of forming a family. Pearson's correlation analyses and independent sample t tests were used to test hypotheses about heteronormative information, parental support and parenting stress.

RESULTS: Same-sex mothers experienced going through assisted reproduction treatment as stressful, and parental groups as not being supportive. Heteronormative information correlated with both lower perceived parental support and higher perceived parenting stress. Non-birth mothers experienced less acknowledgement and support than birthmothers.

This study investigated whether strength, balance, body mass index, falls self-efficacy, activity levels, self-rated health, and participation in a multicomponent exercise intervention could predict physical activity levels after 5 months of self-quarantine due to the COVID-19 pandemic. This study included baseline data of 200 community-dwelling older adults (79% women, 21% men) with a mean age of 72 years who participated in a randomized controlled trial investigating a multicomponent exercise program, with 7-month follow-up survey data of their physical activity levels. The results showed significant associations with the activity levels at the 7-month follow-up. The activity levels (odds ratio (OR): 2.83, 95% CI: 1.20-6.71), the self-rated health score (2.80, 1.42-5.53), and being allocated to a specific multicomponent group-based exercise program (2.04, 1.04-4.00) showed a significant association with the activity habits at the 7-month follow-up. As this study suggests, besides the physical activity levels and the self-rated health score, participation in a high challenge multicomponent exercise program was significantly associated with physical activity levels at the 7-month follow-up. This study indicates that a relatively short multicomponent group exercise program (6-9 weeks) can motivate individuals to sustain their own training and activity levels even several months after the program has been paused or terminated. Identifying older adults' physical activity levels and self-rated health scores and prescribing multicomponent group-based exercise programs to promote sustained physical activity habits may be a successful alternative to provide for older adults in the future.

BACKGROUND: A neonatal mortality prediction score can assist clinicians in making timely clinical decisions to save neonates' lives by facilitating earlier admissions where needed. It can also help reduce unnecessary admissions.

OBJECTIVE: The study aimed to develop and validate a prognosis risk score for neonatal mortality within 28 days in public hospitals in the Amhara region, Ethiopia.

METHODS: The model was developed using a validated neonatal near miss assessment scale and a prospective cohort of 365 near-miss neonates in six hospitals between July 2021 and January 2022. The model's accuracy was assessed using the area under the receiver operating characteristics curve, calibration belt, and the optimism statistic. Internal validation was performed using a 500-repeat bootstrapping technique. Decision curve analysis was used to evaluate the model's clinical utility.

RESULTS: In total, 63 of the 365 neonates died, giving a neonatal mortality rate of 17.3% (95% CI: 13.7-21.5). Six potential predictors were identified and included in the model: anemia during pregnancy, pregnancy-induced hypertension, gestational age less than 37 weeks, birth asphyxia, 5 min Apgar score less than 7, and birth weight less than 2500 g. The model's AUC was 84.5% (95% CI: 78.8-90.2). The model's predictive ability while accounting for overfitting via internal validity was 82%. The decision curve analysis showed higher clinical utility performance.

CONCLUSION: The neonatal mortality predictive score could aid in early detection, clinical decision-making, and, most importantly, timely interventions for high-risk neonates, ultimately saving lives in Ethiopia.

Background: Sexual Reproductive Health and Rights (SRHR) can be best achieved by providing access to comprehensive information about sex practices and sexuality, accessible, acceptable and affordable sexual health care and promotion. Progress on SRHR requires addressing barriers in laws, policies, economics, and social norms that impede the achievement of sexual and reproductive health.

Aim: To explore international students' experiences and perceptions about studying sensitive issues within SRHR in a master’s degree program in Sweden.

Methodology: A qualitative research method was used. A total of 9 participants were recruited through convenience sampling. Interviews were carried out via zoom and audio-recorder. The data corpus was analyzed using qualitative thematic analysis according to Braun and Clarke, and the theoretical perspective for the thesis was the Socio Ecological Model.

Results: Two main themes and eight subthemes emerged during analysis. The first main theme was diversity in what was perceived as sensitive topics with three subthemes namely the international mix matters, personal experience and beliefs and religious affiliation/practices and cultural background. The second main theme was discussion of sensitive issues in the classroom with five subthemes namely lack of a warning from lecturers about potentially sensitive topics ahead, Classroom settings as a haven for discussing potentially sensitive topics, Respect among students themselves and from lecturers, Participants’ choice not to engage insensitive discussions and the presentation of the lecturer's opinions and views on potential sensitive issues.

Conclusions: This thesis highlights the importance of discussions in an international classroom that include sensitive topics and how that can aide the progress of SRHR in the future. 

BACKGROUND: Previous population-based studies investigating the relationship between physical activity and the gut microbiota have relied on self-reported activity, prone to reporting bias. Here, we investigated the associations of accelerometer-based sedentary (SED), moderate-intensity (MPA), and vigorous-intensity (VPA) physical activity with the gut microbiota using cross-sectional data from the Swedish CArdioPulmonary bioImage Study.

METHODS: In 8416 participants aged 50-65, time in SED, MPA, and VPA were estimated with hip-worn accelerometer. Gut microbiota was profiled using shotgun metagenomics of faecal samples. We applied multivariable regression models, adjusting for sociodemographic, lifestyle, and technical covariates, and accounted for multiple testing.

FINDINGS: Overall, associations between time in SED and microbiota species abundance were in opposite direction to those for MPA or VPA. For example, MPA was associated with lower, while SED with higher abundance of Escherichia coli. MPA and VPA were associated with higher abundance of the butyrate-producers Faecalibacterium prausnitzii and Roseburia spp. We observed discrepancies between specific VPA and MPA associations, such as a positive association between MPA and Prevotella copri, while no association was detected for VPA. Additionally, SED, MPA and VPA were associated with the functional potential of the microbiome. For instance, MPA was associated with higher capacity for acetate synthesis and SED with lower carbohydrate degradation capacity.

INTERPRETATION: Our findings suggest that sedentary and physical activity are associated with a similar set of gut microbiota species but in opposite directions. Furthermore, the intensity of physical activity may have specific effects on certain gut microbiota species.

FUNDING: European Research Council, Swedish Heart-Lung Foundation, Swedish Research Council, Knut and Alice Wallenberg Foundation.

Background: WHO guidelines' clarity on evidence-based quality midwifery practice emphasizes that knowledge should be translated into practice with adherence to recommended quality of midwifery care. The MIDWIZE Capacity Building Training Program was established to build the capacity of public health officials by ensuring that midwifery and maternal health care is consistent with international guidelines. The Capacity Building Training Program ensures that public health officials are trained in the field of reproductive, maternal, newborn, child, and adolescent health by following a MIDWIZE care model which adheres to the WHO guidelines' clarity on evidence-based quality midwifery practice. However, there is a gap in knowledge on what facilitates and sustains change and what inhibits change when quality improvement interventions are made in maternal and child health.

Aim: To examine what brings change, what inhibits change, and what sustains change in Maternal and Child Health from the views of public health officials in five East African Countries.

Methodology: Qualitative content analysis with a deductive research approach.

Ethical Considerations: No ethical approval was needed to conduct this study.

Result: The authors identified the government as being the central mandatory authority to facilitate and sustain change. The results emphasized the importance of evidence-based practice and using a multi-sectoral approach to facilitate change. An inhibitor to change was found to be an inadequate skilled workforce.

Conclusion: The strategies mentioned by the participants in what facilitates and sustains change have been backed up by previous research and they are key to attaining positive outcomes in maternal and child health. 

Background: WHO guidelines' clarity on evidence-based quality midwifery practice emphasizes that knowledge should be translated into practice with adherence to recommended quality of midwifery care. The MIDWIZE Capacity Building Training Program was established to build the capacity of public health officials by ensuring that midwifery and maternal health care is consistent with international guidelines. The Capacity Building Training Program ensures that public health officials are trained in the field of reproductive, maternal, newborn, child, and adolescent health by following a MIDWIZE care model which adheres to the WHO guidelines' clarity on evidence-based quality midwifery practice. However, there is a gap in knowledge on what facilitates and sustains change and what inhibits change when quality improvement interventions are made in maternal and child health. Aim: To examine what brings change, what inhibits change, and what sustains change in Maternal and Child Health from the views of public health officials in five East African Countries. Methodology: Qualitative content analysis with a deductive research approach. Ethical Considerations: No ethical approval was needed to conduct this study. Result: The authors identified the government as being the central mandatory authority to facilitate and sustain change. The results emphasized the importance of evidence-based practice and using a multi-sectoral approach to facilitate change. An inhibitor to change was found to be an inadequate skilled workforce. Conclusion: The strategies mentioned by the participants in what facilitates and sustains change have been backed up by previous research and they are key to attaining positive outcomes in maternal and child health.

The emergence of COVID-19 has changed the world as we know it, arguably none more so than for older people. In Sweden, the majority of COVID-19-related fatalities have been among people aged ⩾70 years, many of whom were receiving health and social care services. The pandemic has illuminated aspects within the care continuum requiring evaluative research, such as decision-making processes, the structure and organisation of care, and interventions within the complex public-health system. This short communication highlights several key areas for future interdisciplinary and multi-sectorial collaboration to improve health and social care services in Sweden. It also underlines that a valid, reliable and experiential evidence base is the sine qua non for evaluative research and effective public-health systems.

INTRODUCTION: Migrant women are a heterogenous group with both higher and lower risk for pregnancy complications and adverse birth outcomes compared with women in the receiving countries. This study aimed to investigate women's use of Swedish healthcare postpartum, in terms of hospital stay >48 h, readmission to hospital, and specialized out-patient clinic visits, in relation to maternal country of birth.

MATERIAL AND METHODS: A population-based register study including 278 219 primiparous and 367 776 multiparous women in Sweden (2014-2019) using data from Swedish Pregnancy Register, National Patient Register and Statistics Sweden. Multivariable logistic regression analyses were used to estimate associations between maternal country of birth and outcomes, adjusting for year of birth, maternal age, education, pre-gestational hypertension and diabetes, and healthcare region, presented as crude and adjusted odds ratios (aOR) with 95% confidence interval (CI) with Swedish-born women as reference.

RESULTS: Subgroups of migrant women had higher odds of postpartum hospital stays > 48 h, particularly women from Eritrea (primiparous aOR 2.80, CI 2.49-3.15; multiparous aOR 2.78, CI 2.59-2.98), Somalia (primiparous aOR 2.61, CI 2.34-2.92; multiparous aOR 1.87, CI 1.79-1.97), and India (primiparous aOR 2.52, CI 2.14-2.97; multiparous aOR 2.61, CI 2.33-2.93), compared to Swedish-born women. Primiparous women from Afghanistan (aOR 1.32, CI 1.08-1.6), Iraq (aOR 1.30, CI 1.16-1.46), and Iran (aOR 1.23, CI 1.04-1.45) had slightly higher odds of hospital readmission, along with multiparous women from India (aOR 1.34, CI 1.02-1.76) and Somalia (aOR 1.24, CI 1.11-1.38). Specialized out-patient clinic visits were most common in primiparous women from Somalia (aOR 1.47, CI 1.35-1.59), Iran (aOR 1.31, CI 1.22-1.42) and Afghanistan (aOR 1.31, CI 1.18-1.46), and in multiparous women from Iran (aOR 1.30, CI 1.20-1.41) and Iraq (aOR 1.15, CI 1.11-1.20), however less common in women from some other countries.

CONCLUSIONS: The use of Swedish health care during the postpartum period varied among women, depending on their country of birth. Women from certain countries had particularly high odds of postpartum hospital stays exceeding 48 h, compared to Swedish-born women, regardless of parity and pre-gestational medical disorders. Further studies are needed to determine whether the individual needs of migrant women are being met during the postpartum period or not.

BACKGROUND: Universal coverage of evidence-based interventions for perinatal health, often part of evidence-based guidelines, could prevent most perinatal deaths, particularly if entire communities were engaged in the implementation. Social innovations may provide creative solutions to the implementation of evidence-based guidelines, but successful use of social innovations relies on the engagement of communities and health system actors. This proof-of-concept study aimed to assess whether an earlier successful social innovation for improved neonatal survival that employed regular facilitated Plan-Do-Study-Act meetings on the commune level was feasible and acceptable when implemented on multiple levels of the health system (52 health units) and resulted in actions with plausibly favourable effects on perinatal health and survival in Cao Bang province, northern Vietnam.

METHODS: The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework guided the implementation and evaluation of the Perinatal Knowledge-Into-Practice (PeriKIP) project. Data collection included facilitators' diaries, health workers' knowledge on perinatal care, structured observations of antenatal care, focus group discussions with facilitators, their mentors and representatives of different actors of the initiated stakeholder groups and an individual interview with the Reproductive Health Centre director. Clinical experts assessed the relevance of the identified problems and actions taken based on facilitators' diaries. Descriptive statistics included proportions, means, and t-tests for the knowledge assessment and observations. Qualitative data were analysed by content analysis.

RESULTS: The social innovation resulted in the identification of about 500 relevant problems. Also, 75% of planned actions to overcome prioritised problems were undertaken, results presented and a plan for new actions to achieve the group's goals to enhance perinatal health. The facilitators had significant roles, ensuring that the stakeholder groups were established based on principles of mutual respect. Overall, the knowledge of perinatal health and performance of antenatal care improved over the intervention period.

CONCLUSIONS: The establishment of facilitated local stakeholder groups can remedy the need for tailored interventions and grassroots involvement in perinatal health and provide a scalable structure for focused efforts to reduce preventable deaths and promote health and well-being.

INTRODUCTION: Highly effective long-acting reversible contraceptive (LARC) methods reduce unintended pregnancy rates; however, these methods are underutilized. The LOWE trial intervention provided structured contraceptive counseling resulting in increased uptake of LARC. This longitudinal follow up of the LOWE study assessed the long-term impact of the intervention by investigating the contraceptive use at 12 months with a focus on continued use of LARC.

MATERIAL AND METHODS: In the cluster randomized LOWE trial, abortion, youth, and maternal health clinics were randomized to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of an educational video on contraceptive methods, key questions asked by the health care provider, a tiered effectiveness chart and a box of contraceptive models. Women ≥ age 18, who were sexually active or planned to be in the upcoming 6 months, could participate in the study. We assessed self-reported contraceptive use at three, six and 12 months. Contraceptive choice and switches were analyzed with descriptive statistics. Contraceptive use at 12 months and continued use of LARC were analyzed using mixed logistic regressions, with clinic included as a random effect. Analysis with imputed values were performed for missing data to test the robustness of results.

RESULTS: Overall, at 12 months, women in the intervention group were more likely to be using a LARC method (aOR 1.90, 95% CI: 1.31-2.76) and less likely to be using a short-acting reversible contraceptive (SARC) method (aOR 0.66, 95% CI: 0.46-0.93) compared to the control group. Women counseled at abortion (aOR 2.97, 95% CI: 1.36-6.75) and youth clinics (aOR 1.81, 95% CI: 1.08-3.03) were more likely to be using a LARC method, while no significant difference was seen in maternal health clinics (aOR 1.84, 95% CI: 0.96-3.66). Among women initiating LARC, continuation rates at 12 months did not differ between study groups (63.9% vs. 63.7%). The most common reasons for contraceptive discontinuation were wish for pregnancy, followed by irregular bleeding, and mood changes.

CONCLUSIONS: The LOWE trial intervention resulted in increased LARC use also at 12 months. Strategies on how to sustain LARC use needs to be further investigated.

INTRODUCTION: Since early 2020, the COVID-19 pandemic has challenged societies and revealed the built-in fragility and dependencies in complex adaptive systems, such as healthcare. The pandemic has placed healthcare providers and systems under unprecedented amounts of strain with potential consequences that have not yet been fully elucidated. This multilevel project aims to explore resilient performance with the purpose of improving the understanding of how healthcare has adapted during the pandemic's rampage, the processes involved and the consequences on working conditions, ethics and patient safety.

METHODS: An emerging explorative multilevel design based on grounded theory methodology is applied. Open and theoretical sampling is performed. Empirical data are gathered over time from written narratives and qualitative interviews with staff with different positions in healthcare organisations in two Swedish regions. The participants' first-person stories are complemented with data from the healthcare organisations' internal documents and national and international official documents.

ANALYSIS: Experiences and expressions of resilient performance at different system levels and times, existing influencing risk and success factors at the microlevels, mesolevels and macrolevels and inter-relationships and consequences in different healthcare contexts, are explored using constant comparative analysis. Finally, the data are complemented with the current literature to develop a substantive theory of resilient performance during the pandemic.

ETHICS AND DISSEMINATION: This project is ethically approved and recognises the ongoing strain on the healthcare system when gathering data. The ongoing pandemic provides unique possibilities to study system-wide adaptive capacity across different system levels and times, which can create an important basis for designing interventions focusing on preparedness to manage current and future challenges in healthcare. Feedback is provided to the settings to enable pressing improvements. The findings will also be disseminated through scientific journals and conferences.

OBJECTIVE: To identify and examine barriers to midwife-led care in Eastern Africa and how these barriers can be reduced DESIGN: A qualitative inductive study with online focus group discussions and semi-structured interviews using content analysis SETTING: The study examines midwife-led care in Ethiopia, Malawi, Kenya, Somalia, and Uganda -five African countries with an unmet need for midwives and a need to improve maternal and neonatal health outcomes.

PARTICIPANTS: Twenty-five participants with a health care profession background and current position as a maternal and child health leader from one of the five study countries.

FINDINGS: The findings demonstrate barriers to midwife-led care connected to organisational structures, traditional hierarchies, gender disparities, and inadequate leadership. Societal and gendered norms, organisational traditions, and differences in power and authority between professions are some factors explaining why the barriers persist. A focus on intra- and multisectoral collaborations, the inclusion of midwife leaders, and providing midwives with role models to leverage their empowerment are examples of how to reduce the barriers.

KEY CONCLUSIONS: This study provides new knowledge on midwife-led care from the perspectives of health leaders in five African countries. Transforming outdated structures to ensure midwives are empowered to deliver midwife-led care at all healthcare system levels is crucial to moving forward.

IMPLICATIONS FOR PRACTISE: This knowledge is important as enhancing the midwife-led care provision is associated with substantially improved maternal and neonatal health outcomes, higher satisfaction of care, and enhanced utilisation of health system resources. Nevertheless, the model of care is not adequately integrated into the five countries' health systems. Future studies are warranted to further explore how reducing barriers to midwife-led care can be adapted at a broader level.

Objectives Long-duration activity-limiting neck/back pain is common, but the knowledge of what work and lifestyle factors that influence the prognosis is sparse. The objective was therefore to evaluate if two factors, good self-perceived work ability and no daily smoking, are associated with a favourable prognosis of long-duration activity-limiting neck/back pain in a working population, and if these exposures have a synergistic prognostic effect.

Design A prospective cohort study based on three subsamples from the Stockholm Public Health Cohort.

Settings A working population in Stockholm County, Sweden.

Participants Individuals, 18–61 years old, reporting long-duration activity-limiting neck/back pain the previous 6 months at baseline in 2010 (n=5177).

Measures The exposures were: self-perceived work ability (categorised into good, moderate and poor) and daily smoking (no/yes). The outcome in 2014 was ‘absence of long-duration activity-limiting neck/back pain’ the previous 6 months representing a favourable prognosis of reported problems at baseline in 2010. Risk ratios (RRs) and risk differences (RDs) with 95% CI was estimated by general linear regressions, and the synergistic effect was estimated by the synergy index (SI) with 95% CI.

Results Participants with moderate or good work ability, respectively, had an adjusted RR for a favourable prognosis of 1.37 (95% CI 1.11 to 1.69), and 1.80 (1.49 to 2.17) in comparison with participants with poor work ability. The corresponding adjusted RD were 0.07 (0.02 to 0.11) and 0.17 (0.12 to 0.22). Participants not smoking on daily basis had an adjusted RR of 1.21 (1.02 to 1.42), and an adjusted RD of 0.05 (0.01 to 0.10) for a favourable outcome compared with daily smokers. The adjusted SI was 0.92 (0.60 to 1.43).

Conclusion For participants with long-duration activity-limiting neck/back pain, moderate or good self-perceived work ability and not being a daily smoker were associated with a favourable prognosis but having both exposures seemed to have no synergistic prognostic effect.

Purpose: In response to the need for hearing aids in low-income countries, an approach to provide hearing aids through trained community workers was developed. This study compares the effectiveness of the community-based approach with that of a centre-based approach. Methods: One hundred and forty adolescents (56% girls; 12-18 years; mean: 15 years) from eleven sub-districts participated in a cluster-randomized trial comparing a community-based service (n = 75) with a centre-based service (n = 65) in Bangladesh. The International Outcome Inventory for Hearing Aids (IOI-HA) was administered to the participants six weeks after fitting of a hearing aid, and its scores were analyzed by Mann-Whitney U-tests and an ordinal regression model. Results: The community-based approach performed as well as the centre-based approach on five out of seven outcome measures. The latter approach performed statistically significantly better on Residual participation restrictions (p = .007) and Impact on others (p = .012), but the effect sizes were small. Controlling for sex, age, hearing loss, place of living and proxy responses did not change the results. Conclusions: The community-based approach is a viable and effective option for hearing aid delivery in low-resourced settings. The approach needs to be adapted to particular contexts, and possible down-sides may need to be counteracted by special interventions.

Objectives People affected by leprosy and their families face social and economic problems. The focus of interventions is often on prevention of disabilities and socioeconomic rehabilitation. The objective of this study was to explore to what extent the potential of assistive devices to facilitate activities and participation of people affected by leprosy has been utilised. Design Published literature was reviewed and the findings analysed. Results Considerable attention has been given to the protecting role of assistive devices. The focus of assistive devices facilitating functioning has been on mobility aspects of self-care and domestic life. Conclusions The findings indicate that the potential of assistive devices to facilitate activities and participation in life areas such as work and employment is still waiting to be utilised on a broad scale.

Despite its facilitating role in creating opportunities for people with disabilities to exercise human rights, access to assistive technology is limited in many countries. It is therefore promising that the Convention on Rights of Persons with Disabilities (CRPD) addresses this area. The purpose of this study was to analyse the assistive technology content of the CRPD from a basic human rights perspective in order to clarify its limitations and opportunities for formulation of policies and implementation strategies. Data were collected through a content analysis of the CRPD. It is concluded that a non-discriminatory interpretation of the provisions entitles all people with disabilities to a right to demand available and affordable assistive technology. Ensuring this right is a national as well as an international responsibility.

Purpose. To develop a model of the dynamics of functioning, disability and contextual factors which harmonises with the International Classification of Functioning, Disability and Health (ICF). Method. Model parts based on ICF were identified and a model drawing from engineering concepts was developed. The conceptual and practical applicability of the model was discussed. Results. The so called Friction Model was created, which incorporates the ICF entities capacity, performance, environmental factors, health condition, body functions and structures, and personal factors. Friction describes the interaction between a person and his or her environment. The coefficient of friction is defined as the ratio between capacity and performance. Conclusion. Carrying conceptual strengths and limitations, the Friction Model appears to offer opportunities for practical applications, including ICF-based alternatives to health-economic analyses. Harmonising with the ICF model and terminology, the model uses friction to describe the interaction between a person and the environment. The coefficient of friction can be used as a simple measure of how facilitating an environment is. The applicability is not limited to functioning of people with impairments.

Background: About half a billion people with disabilities in developing countries have limited access to assistive technology. The Convention on the Rights of persons with Disabilities requires governments to take measures to ensure provision of such technologies. To guide implementation of these measures there is a need for understanding health outcomes from a human rights perspective. The objective of this study was therefore to explore the relation between assistive technology use and enjoyment of human rights in a low-income country. Methods: Data was collected in eight districts of Bangladesh through interviews of people with hearing impairments using and not using hearings aids, and people with ambulatory impairments using and not using manual wheelchairs (N = 583). Using logistic regression, self-reported outcomes on standard of living, health, education, work, receiving information and movement were analyzed. Results: The adjusted likelihood of reporting greater enjoyment of human rights was significantly higher among people using hearing aids compared to non-users for all outcomes except working status. Compared to non-users, users of wheelchairs reported a significantly higher adjusted likelihood of good ambulatory performance and a significantly lower adjusted likelihood of reporting a positive working status. Further analyses indicated that physical accessibility to working places and duration of wheelchair use had a statistically significant impact on the likelihood of reporting positive work outcomes. Conclusions: The findings support the notion that assistive technology use increases the likelihood of human rights enjoyment, particularly hearing aid use. Physical accessibility should always be addressed in wheelchair provision.

Background: Knowledge about the relation between user involvement in the provision of assistive technology and outcomes of assistive technology use is a prerequisite for the development of efficient service delivery strategies. However, current knowledge is limited, particularly from low-income countries where affordability is an issue. The objective was therefore to explore the relation between outcomes of assistive technology use and user involvement in the service delivery process in Bangladesh. Methods: Using structured interviews, data from 136 users of hearing aids and 149 users of manual wheelchairs were collected. Outcomes were measured using the International Outcome Inventory for Hearing Aids (IOI-HA), which was adapted for wheelchair users. Predictors of user involvement included preference, measurement and training. Results: Users reported outcomes comparable to those found in other high- and low-income countries. User involvement increased the likelihood for reporting better outcomes except for measurement among hearing aid users. Conclusions: The findings support the provision of assistive technology as a strategy to improve the participation of people with disabilities in society. They also support current policies and guidelines for user-involvement in the service delivery process. Simplified strategies for provision of hearing aids may be explored.

Background: The ‘Convention on the Rights of Persons with Disabilities’ (CRPD) requires governments to meet the assistive technology needs of citizens. However, the access to assistive technology in developing countries is severely limited, which is aggravated by a lack of related services. Objectives: To summarize current knowledge on assistive technology for low- and lower-middle-income countries published in 1995 or later, and to provide recommendations that facilitate implementation of the CRPD. Study design: Literature review. Methods: Literature was searched in web-based databases and reference lists. Studies carried out in low- and lower-middle-income countries, or addressing assistive technology for such countries, were included. Results: The 52 included articles are dominated by product oriented research on leg prostheses and manual wheelchairs. Less has been published on hearing aids and virtually nothing on the broad range of other types of assistive technology. Conclusions: To support effective implementation of the CRPD in these countries, there is a need for actions and research related particularly to policies, service delivery, outcomes and international cooperation, but also to product development and production.

Purpose: The purpose of this work was to contribute to a better understanding of challenges and solutions to equitable provision of assistive technologies in resource limited environments by (i) describing sources of awareness, types of providers and costs of assistive technologies; (ii) describing common reasons for not possessing assistive technologies; and (iii) comparing these sources, providers, costs and reasons among younger and older men and women living in urban and rural settings. Methods: Descriptive and analytic statistics were used to analyze crosssectional data from a total sample of 581 hearing aid users, wheelchair users, individuals with hearing impairments not using hearing aids and individuals with ambulatory impairments not using wheelchairs living in eight districts of Bangladesh. Results: Major sources of awareness, types of providers and costs paid varied between users of different types of assistive technology. Lack of affordability was the main reason for not possessing assistive technology. Outcome differences were found between younger and older groups, men and women, and literate and illiterate respondents, while no differences related to place of living were identified. Conclusions: Age, gender, type of impairment and socioeconomic status need to be considered when planning and implementing equitable provision of assistive technologies.

The objective of this study was to explore the relationship between assistive technology system elements and access to assistive products. Data on assistive technology system elements and self-reported survey data on access to assistive products from 20 countries were analyzed using multivariate statistical methods, including orthogonal partial least squares analyses. Access to assistive products was primarily associated with the geographic coverage of assistive technology services in a country, followed by system elements related to policy and personnel. To achieve universal access to assistive technology, geographic coverage of assistive technology services is an instrumental system element. However, it requires the implementation of appropriate policies along with sufficient funding, recruitment of adequately trained personnel, and availability of assistive products in need.

The objective of the study was to estimate the prevalence of needs for and use of assistive products, and experiences of assistive technology among adults under COVID-19 pandemic circumstances in Sweden. Mainly during June 2021, a nationally representative telephone survey was conducted to collect data through an adapted version of the WHO rapid Assistive Technology Assessment (rATA) questionnaire. Including spectacles, the prevalence of needing at least one assistive product was 68.9% and the prevalence of using at least one assistive product was 68.1%. Excluding spectacles, these prevalence rates were 17.1% and 15.8%, respectively. The access rate was 89.7% including spectacles and 83.2% excluding spectacles. The impact of the pandemic on assistive technology provision appeared to be relatively small.

The aim of this study was to investigate sexual behavior, contraceptive use, risk factors as well as sources of sex information among first-year high-school students in Sweden. Secondly, to assess differences between genders and study programs as well as changes over a 40-year period. A repeated cross-sectional survey was conducted in two cities. A questionnaire comprising 77 items was used. The study population consisted of 415 students (63.4% females). The median age of sexual intercourse was 15 years. In total, 37% had had sexual intercourse, compared to 56.3% in 2009 and 45% in 1999 (p < 0.001), and the proportion of students who had their first sexual intercourse was not influenced by gender. More students in vocational programs (46.3%), compared to theoretical (33.3%), had experience of at least one sexual intercourse (p = 0.019). The same extend of contraception use at first and latest intercourse was reported, compared to previous studies. Forty-nine percent were mostly informed about sex from the internet, while in previous years, magazines, family and youth clinics were the main information sources. Comparing over time, students were in general less sexually experienced and less engaged in non-penetrative sex and physical intimacy. These findings call for a new approach, when designing sex and relationship education and health-care counseling in adolescents.

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions. Funding: Bill & Melinda Gates Foundation. © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

Sammanfattning

Ett sammanfattande porträtt av den nyantagna lärarstudenten vid GIH med utgångspunkt från enkätsvaren ger vid handen en bild av en person, som är ca 21 år gammal, född i Sverige och uppvuxen i en medelstor stad i Mellansverige. Studenten trivdes mycket bra i skolan och var som elev något över medel med MVG i idrott och hälsa.

Valet av yrkesutbildning grundade sig på ett stort intresse för idrott, samt en önskan att få jobba med barn och ungdom. Studievalet hade för många påverkats av en tidigare idrotts-lärare, kompisar och familj. En bra lärare i idrott och hälsa är enligt studenten positiv, engagerad, rättvis, bestämd och kunnig.

Lärarstudenten ser sig behärska bollspel väl. Störst kunskap och färdighet uppges i fot-boll och alpin skidåkning. Minst kunskap och färdighet skattades i softboll, baseboll, bergsklättring, långfärdsskridskoåkning och i konsten att kunna valla skidor. Många ser sig ha god kunskap om sambandet mellan hälsa, livsstil och miljö, men mindre god om hur en idrottsaktivitet har betydelse för kulturarvet, samband mellan miljö och männi-skans hälsa i ett historiskt och nutidsperspektiv samt i ergonomi.

På sin fritid går lärarstudenten ofta på idrottsevenemang, café, tittar på TV och video eller umgås med vänner och familj. Lärarstudenten går sällan på bio och nästan aldrig på tea-ter, museum eller vernissager. "Vad är vernissage?" undrar en student.

Hälsan, både fysiskt och psykiskt, skattas som tillfredsställande och man känner ofta hopp, glädje och meningsfullhet. Emellertid finner man sig även ofta stressad på grund av tidsbrist och alla krav. Många kvinnliga studenter (41%) rapporterade ryggont och många, både kvinnor och män, beskrev att de har besvär från en skadad fotled eller knä. De flesta lärarstudenterna är regelbundet fysiskt aktiva och de finner att mängden motion delvis är tillfredsställande.

Förväntningarna är höga på utbildningen både att den är mångsidig och kommer att ge ökad kunskap inom olika områden. Under studietiden förväntar man sig att utvecklas och förbättra sin egen fysiska status och hälsa. En student uttrycker det med orden: "Mitt nya liv startar idag". Den sammanfattande bilden av lärarstudenten på GIH liknar den som tidigare har redovisats av Meckbach och Wedman i en liknande studie från maj 2005. Deras studie genomfördes på studenter efter ett års studier på GIH (Meckbach & Wed-man, 2007).

Background: Mental health (MH) has until recently been a neglected subject which is gradually being recognized from the governments worldwide. Although women are increasingly seeking for emotional support during the pregnancy period and the first year after birth, the main attention and studies remain focused on the medical aspects of those periods. leaving the various health policies and intervention plans addressing perinatal MH, insufficient and/or incomplete.

Aim: This Scoping Review aims to present a worldwide Policy Mapping of the latest maternal mental health (MMH) policies from government agencies and major non-governmental organizations (NGOs), and a more in-depth view of recurrent influential factors across a few of the policies that acknowledge the MH of various vulnerable groups of women.

Methodology: A Policy Mapping and a Scoping Review were chosen as the appropriate designs to present the percentage of countries that show awareness of MMH issues globally. A deductive Content Analysis identified recurrent categories in seven selected interrelated policies and provided a qualitative description of the findings.

Results: The results of the quantitative research identified 103 countries that raise awareness on MMH in their latest policies, and 89 of them were from governmental sources. The study revealed 139 countries that had either no reachable data or did not address the issue in their policies. The Content Analysis of the seven selected policies identified a main category entitled ‘Influential socio-economic factors’ and two generic categories ‘Socio-cultural behaviors’ and ‘Socio-education inequalities’ with subcategories which highlight the family and individualism as both a strength and a burden for MMH. A holistic view of individuals in their specific context and the importance of speaking a common language is essential for appropriate mental healthcare. In low socio-economic groups more stigma and less identification of mental health issues is described.

Conclusions: This study provides a global overview of the current awareness on MMH and supports world policy makers in strengthening the plans proposed on MMH issues. It sheds light on the need for contextualization and reflects the common needs and challenges for vulnerable groups of women.

Background: Violence against women is associated with serious health problems, including adverse maternal and child health. Antenatal care (ANC) midwives are increasingly expected to implement the routine of identifying exposure to violence. An increase of Somali born refugee women in Sweden, their reported adverse childbearing health and possible links to violence pose a challenge to the Swedish maternity health care system. Thus, the aim was to explore ways ANC midwives in Sweden work with Somali born women and the questions of exposure to violence.

Methods: Qualitative individual interviews with 17 midwives working with Somali-born women in nine ANC clinics in Sweden were analyzed using thematic analysis.

Results: The midwives strived to focus on the individual woman beyond ethnicity and cultural differences. In relation to the Somali born women, they navigated between different definitions of violence, ways of handling adversities in life and social contexts, guided by experience based knowledge and collegial support. Seldom was ongoing violence encountered. The Somali-born women’s’ strengths and contentment were highlighted, however, language skills were considered central for a Somali-born woman’s access to rights and support in the Swedish society. Shared language, trustful relationships, patience, and networking were important aspects in the work with violence among Somali-born women.

Conclusion: Focus on the individual woman and skills in inter-cultural communication increases possibilities of overcoming social distances. This enhances midwives’ ability to identify Somali born woman’s resources and needs regarding violence disclosure and support. Although routine use of professional interpretation is implemented, it might not fully provide nuances and social safety needed for violence disclosure. Thus, patience and trusting relationships are fundamental in work with violence among Somali born women. In collaboration with social networks and other health care and social work professions, the midwife can be a bridge and contribute to increased awareness of rights and support for Somali-born women in a new society.

Perceptions and experiences of war, violence and migration and related sexual and reproductive health among Somali refugee women in Sweden.

Background and objectives: Sweden has during the latest six years experienced a twofold increase of Somali born refugees. Elevated levels of pregnancy related morbidity and perinatal complications are seen among Somali born refugee women.  Research has shown links between a mother´s prenatal stress and anxiety and the health of the child the first year. Furthermore, violence towards a mother-to-be has negative health effects and increases the neonatal mortality The specific aim in the current study was to explore perceptions and experiences of war, violence and migration among Somali refugee women in Sweden. This in order to find strategies in caring for birth giving Somali refugee women, with possible experiences of violence, which would benefit the woman and society at large.

Material and methods: Qualitative individual audio-recorded interviews were conducted with Somali born refugee women in fertile ages. Interviews were held in three steps: 1) personal narratives by newly arrived Somali born women, 2) perceptions and views out of a depersonalized case and 3) reflections upon emerging themes by female key persons of Somali origin. Thematic analysis according to Clarke and Braun was applied.

Preliminary results: The analysis resulted in two main themes: Lives controlled by the presence of violence and Sacrificing for the sake of a future. Access to education, livelihood opportunities and health facilities has been strictly limited by the long-lasting civil war. Escalated violations of sexual and reproductive health and rights were a common triggering factor for finalizing escape. Lives have been extensively marked by family separations. Patience created by war and a pragmatic orientation in life have made survival possible.

Conclusions: To be presented at the congress

Implications for practice: The results will provide increased evidence based knowledge useful to midwives when caring and supporting birth giving refugee women.

Background: Political violence is a push factors for migration and social determinants of health among migrants. The Somali migration to Sweden has increased threefold during the latest six years, now comprising refugees with more than 20 years of war experiences. Adverse childbearing health and outcomes are reported among Somali born refugees in high income countries. Health is influenced by earlier life experiences and a link between adverse sexual and reproductive health, violence and mental distress is described in research. Therefore, the aim was to explore experiences and perceptions on war, violence and sexual and reproductive health before migration among Somali born women in Sweden.

Method: Qualitative semi-structured individual interviews with Somali born refugee women living in Sweden were conducted, based on personal narratives and a hypothetical case. Thematic analysis was applied.

Results: Escalating violence and power based restrictions permeated gradually all aspect of life and limited both access to and quality of reproductive health services in pre-migration Somalia. Formal societal support for women exposed to violence was absent. This reinforced shame and stigma connected to war related and community based sexual violence and the silence surrounding sexual and intimate partner violence. Women expressed survival strategies in the context of war based on social networks, pragmatism, strength and faith.

Conclusions: Lack of formal structures on community levels has together with collective violence negatively impacted the whole spectra of women’s lives which have undermined the sexual and reproductive and health and rights. Several factors reinforce non-disclosure of violence exposure and can thus hamper health care seeking for violence related illness in the receiving country. Survival strategies shaped by war contain resources for resilience and enhancement of mental, sexual and reproductive health in receiving country.

Keywords: Somalia, war, violence, refugee, sexual and reproductive health and rights, qualitative method, thematic analysis

Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378-521), affecting 3·40 billion (3·20-3·62) individuals (43·1%, 40·5-45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7-26·7) between 1990 and 2021. Age-standardised rates of deaths per 100000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6-38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5-32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7-2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed.Bill & Melinda Gates Foundation.

OBJECTIVE: Somalia has high rates of maternal mortality, fertility and pregnancy among young women. Factors contributing to this situation are a lack of knowledge regarding sexual and reproductive health, early marriages, cultural norms and the unmet need for or use of contraceptives. This study aimed to explore the perceptions of family planning among young men and women with tertiary education in Mogadishu.

METHODS: A purposeful and convenience strategy using snowballing was used to recruit participants. Four focus group discussions were held online with 26 young women and men aged 19-25 years old. All participants were studying at five different universities in Mogadishu, and only one participant was married. The data were analysed using thematic analysis.

FINDINGS: The findings showed that participants objected to the concept of family planning but supported the concept of child spacing. They highlighted that people of their generation with tertiary education practise child spacing to combine careers with family life. Although all the participants knew of the benefits of child spacing, they had different opinions on whether modern contraceptive methods were an option for them. They were more comfortable with traditional contraceptive methods and believed that the quality of the modern contraceptive medicine available in the country was unreliable.

CONCLUSION: Our findings suggest that it is crucial not only to include young people in family planning awareness initiatives and implementation but also to give them a voice to advocate family planning and start dialogues within their own communities.

Several factors associated with loneliness are also considered indicators of social exclusion. While loneliness has been proposed as an outcome of social exclusion, there is limited empirical evidence of a link. This study examines the associations between social exclusion indicators and loneliness in older adults (60+ years) in four Nordic countries. Data from four waves of the European Social Survey were pooled, providing a total of 7755 respondents (Denmark n = 1647; Finland n = 2501, Norway n = 1540; Sweden n = 2067). Measures of loneliness, demographic characteristics, health, and eight indicators of social exclusion were selected from the survey for analysis. Country-specific and total sample hierarchical logistic regression models of loneliness were developed. Significant model improvement occurred for all models after social exclusion indicators were added to models containing only demographic and health variables. Country models explained between 15.1 (Finland) and 21.5% (Sweden) of the variance in loneliness. Lower frequency of social contacts and living alone compared to in a two-person household was associated with a higher probability of loneliness in all countries, while other indicators were associated with loneliness in specific countries: lower neighbourhood safety (Sweden and Denmark); income concern (Sweden and Finland); and no emotional support (Denmark, Finland, and Sweden). A robust relationship was apparent between indicators of social exclusion and loneliness with the direction of associations being highly consistent across countries, even if their strength and statistical significance varied. Social exclusion has considerable potential for understanding and addressing risk factors for loneliness.