Introduction During the global pandemic, the elderly, foreign-born and socioeconomically deprived experienced disproportionately higher rates of COVID-19 morbidity and mortality than general populations. However, these groups have typically been analysed in isolation, without considering how social factors jointly influenced COVID-19-related health. Thus, the aim of this study is to quantify intersectional inequalities in COVID-19 morbidity and mortality in Sweden.Methods In this retrospective cohort study, national registers were used to identify 35-to-100-year-old residents of Sweden in January 2020 (n=6 014 164), tracking COVID-19 hospitalisations and deaths (International Classification of Diseases-10 Codes U07.1/U07.2, plus B34.2 for deaths) until December 2022. Intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy was applied with logistic regression, nesting individuals within intersectional strata based on age, gender, migrant status and region of origin, and income. Measures of discriminatory accuracy (area under the receiver operating characteristic curve or AUC), predicted probabilities and random effects were calculated.Results During follow-up, 77 844 (1.29%) individuals were hospitalised and 18 126 (0.30%) died due to COVID-19. Intersectional models explained 2.22% of the variation in mortality (AUC=0.835) vs 0.60% in hospitalisations (AUC=0.728). Predicted probabilities were lowest in 35-44-year-old Swedish-born women with high income at 0.19% (95% CI 0.16% to 0.21%) for hospitalisations, and 0.01% (95% CI 0.01% to 0.02%) for mortality; and highest among 85-100-year-old foreign-born men from the Global South with low income at 14.85% (95% CI 12.84% to 17.10%) for hospitalisations, and 8.25% (95% CI 6.32% to 10.70%) for mortality. Random effects indicated wider income inequalities in both outcomes in the youngest and narrower in the oldest, native-born and foreign-born groups from the Global North.Conclusions Intersectional inequalities in COVID-19 outcomes consistently increased with age, decreased with income and were higher for men and foreign-born individuals. The results emphasise the need to consider universal public health strategies to reach vulnerable populations during a pandemic.

Strong social protections are essential for reducing health inequalities in society. Sweden has long been recognised for having one of the world’s most generous social welfare systems, which to date has been available to all residents regardless of their length of residency or citizenship status, but even this system has not been immune to political change.1The Swedish government has proposed a reform that would introduce new residence-based rules for accessing social security benefits. Although framed as a way to incentivise employment and reduce long-term benefit dependency, the reform is expected to disproportionately affect migrant residents by excluding them from core welfare protections. As a result, these rules are likely to exacerbate the well-documented health and social inequalities between people with and without migrant backgrounds in Sweden. By conditioning access to social protection on duration of residence or prior income, the reform introduces mechanisms of selective inclusion and exclusion that disproportionately affect individuals in more precarious socioeconomic positions.

Literature reviews constitute a core competence for public health professionals. Many public health graduate students thus choose to conduct a literature review for their thesis, but may face challenges delivering a high-quality systematic review due to time and resource constraints. Informed by the principle of constructive alignment, this article thus provides guidelines for conducting a systematized literature review on quantitative studies within the scope of a master’s thesis in public health, incorporating key elements of a systematic review (i.e., transparency, reproducibility) in a pedagogical context. Based on the authors’ research and supervision experience with the methodology at Stockholm University, this description of best practice presents 12 steps for successfully completing a quantitative systematized literature review, including formulating research questions, conducting searches, extracting and synthesizing findings, and thesis writing, while outlining the tasks of students, supervisors, and examiners in alignment with different learning outcomes. This guide can be used by postgraduate educators to effectively enhance the skills of future public health professionals.

Introduction: Sweden, with its history of restrictive alcohol policies and a large and diverse migrant population, constitutes an interesting context for studies on alcohol consumption patterns in migrant groups. This study examines how hazardous drinking among migrants in Sweden varies by origin, duration of residence and age at migration.

Methods: Pooled cross-sectional survey data from the Västra Götaland region of Sweden, collected in 2011 and 2015, were linked to register data containing demo-graphic, socioeconomic and migration-related factors (i.e., country of birth, duration of residence, age at migration), for 7754 migrants and 68,493 Swedish-born individuals aged 18–84 years. Logistic regression analyses were applied to estimate odds ratios (OR) and 95% confidence intervals (CI) for hazardous drinking, identified by the validated Alcohol Use Disorders Identification Test.

Results: Relative to Swedish-born individuals, migrants from other Nordic countries had higher odds of hazardous drinking (OR 1.45, 95% CI 1.18–1.77), while migrants from other European (OR 0.55, 95% CI 0.44–0.69) and non-European (OR 0.25, 95% CI 0.20–0.31) countries showed lower likelihoods. Among non-Nordic migrants in particular, hazardous drinking was more common among those with a longer duration of residence and those who migrated at pre-school ages.

Discussion and Conclusions: Hazardous drinking among non-Nordic migrants increasingly resembled that of the Swedish-born population over time, aligning with findings in less restrictive alcohol policy contexts. Understanding how drinking patterns vary among migrant groups over time and across policy contexts is essential for developing effective public health strategies to reduce hazardous consumption and associated health and social harms.

Importance: Generous parental leave benefits have been associated with better mental health outcomes for parents after childbirth. However, few studies account for preconception mental health and working conditions, the latter being a requirement for generous parental leave benefits. Objective: To evaluate the association between levels of parental leave benefits and maternal postpartum mental health when preconception mental health, income, and employment status were considered. Design, Setting, and Participants: This population-based nationwide cohort study included first-time mothers aged 18 to 52 years who gave birth to a live singleton offspring between January 1, 2007, and December 31, 2011. Data were analyzed from March 8 to February 18, 2025. Exposure: Paid parental leave benefits, including higher level (qualified for earnings-related benefits equal to approximately 80% of their salary) vs basic level (a flat-rate benefit for those not meeting the work requirements for earnings-related benefits). Main Outcomes and Measures: Nationwide registers were used to perform multivariable logistic regression to calculate the odds of mental health outcomes from different levels of severity (prescription of antidepressants or anxiolytics, specialist outpatient care, and hospitalization) between mothers receiving higher-level and basic benefits. Decomposition analyses using the Karlson-Holm-Breen method were conducted to examine the contribution of preconception mental health, income, and employment status. Results: The sample included 210 800 first-time mothers (mean [SD] age, 28.6 [5.0] years), of whom 35 255 (16.72%) received basic benefits and 175 545 (83.28%) qualified for higher-level benefits. Mothers receiving basic benefits had higher odds of being prescribed antidepressants or anxiolytics (odds ratio [OR], 1.44; 95% CI, 1.37-1.51), receiving specialist outpatient care (OR, 2.27; 95% CI, 2.13-2.44), and being hospitalized (OR, 2.47; 95% CI, 2.06-2.97) compared with mothers receiving higher-level benefits. Higher odds remained after adjusting for preconception mental health, accounting for a 46.1% decrease for prescribed antidepressants or anxiolytics, 15.1% for outpatient care, and 10.7% for hospitalization. After adjustment for income and employment status, the odds remained elevated for specialist outpatient care (OR, 1.13; 95% CI, 1.02-1.24) and hospitalization (OR, 1.34; 95% CI, 1.03-1.76). Conclusions and Relevance: In this cohort study of first-time mothers in Sweden, higher-level benefits were associated with better mental health, particularly moderate-to-severe mental disorders. However, since eligibility for higher-level parental leave benefits is contingent on labor market attachment, both improving women's labor market attachment and relaxing the work requirements for higher-level parental leave could promote women's postpartum mental health.

Background  Immigrants continue to face challenges after entering the labor market and remain overrepresented in ‘3-D jobs’ (dirty, difficult, degrading). This study aims to investigate the differences in occupational injury due to accidents (OIA) among immigrants compared to native-born workers in Sweden, and to examine the role of migrant-specific and work factors in these differences.

Methods  This repeated cross-sectional study used nationwide registers including all gainfully employed individuals in 2004–2020 (average annual sample 4.5 million individuals). OIA was treated as a binary outcome and migrant status was categorized based on region of birth and reason for immigration. OIA odds were estimated using pooled logistic regression analyses, where the crude model was adjusted for sociodemographic factors, time since immigration, and work factors.

Results  First-generation immigrants (odds ratios [OR] 1.41; 95% confidence interval [CI] 1.40, 1.42) and second-generation immigrants (OR 1.10; 95% CI 1.09, 1.11) had higher odds of OIA than native-born workers. Among the first-generation immigrants, the strength of the association varied depending on region of birth and reason for immigration. Immigrating to Sweden for work reasons was associated with lower odds of OIA among first-generation immigrants (OR 0.62; 95% CI 0.61, 0.64). The elevated odds of OIA among immigrants relative to native-born workers remained after adjusting for important covariates.

Conclusions  The differences in OIA underscore the disparities among native-born and immigrant workers in Sweden. The current findings highlight the importance of addressing these issues to ensure a safe work environment for all.

Background and Aims: Fathers' parental leave has been associated with decreased risks of alcohol-related hospitalizations and mortality. Whether this is attributable to the health protections of parental leave itself (through stress reduction or behavioral changes) or to selection into leave uptake remains unclear, given that fathers are more likely to use leave if they are in better health. Using the quasi-experimental variation of a reform incentivizing fathers' leave uptake (the 1995 Father's quota reform), this study aimed to assess whether fathers' parental leave influences alcohol-related morbidity and mortality.

Design: Quasi-experimental interrupted time series and instrumental variable analyses.

Setting: Sweden.

Participants: Fathers of singleton children born from January 1992 to December 1997 (n = 220 412).

Measurements: Exposure was indicated by the child's birthdate before or after the reform and used to instrument fathers' 2- and 8-year parental leave uptake. Outcomes included fathers' hospitalization rates for acute alcohol-related (intoxication; mental and behavioral disorders) and chronic alcohol-related diagnoses (cardiovascular, stomach and other diseases; liver diseases), as well as alcohol-related mortality, up to 2, 8 and 18 years after the first child's birthdate.

Findings: In interrupted time series analyses, fathers of children born after the reform exhibited immediate decreases in alcohol-related hospitalization rates up to 2 (incidence rate ratio [IRR] = 0.66, 95% confidence interval [CI] = 0.51–0.87), 8 (IRR = 0.74, 95% CI = 0.57–0.96) and 18 years after birth (IRR = 0.72, 95% CI = 0.54–0.96), particularly in acute alcohol-related hospitalization rates, compared with those with children born before. No changes were found for alcohol-related mortality. Instrumental variable results suggest that alcohol-related hospitalization decreases were driven by fathers' parental leave uptake (e.g. 2-year hospitalizations: IRR = 0.16, 95% CI = 0.03–0.84).

Conclusions: In Sweden, a father's parental leave eligibility and uptake may protect against alcohol-related morbidity.

Aims: Among international immigrants, health changes by duration of residence are commonly interpreted as an expression of acculturation to the receiving country context. This study compares changes in immigrants’ health risk behaviors by duration of residence to changes by acculturation levels, in order to assess whether duration of residence can be regarded as a proxy for acculturation.

Methods: Using data from a previous systematic review, we identified 17 quantitative studies examining changes in alcohol, tobacco and drug use, physical inactivity, and diet by both duration of residence and acculturation level in the same population. We compared the directionality and consistency of these associations through tabulation and vote counting.

Results: The majority of studies reported no or inconsistent changes in health risk behaviors by duration of residence versus by acculturation, including with opposite directionality. Four studies reported significant estimates with consistent directionality, while five reported consistent, non-significant estimates.

Conclusions: Our findings suggest that duration of residence should not be used as a proxy for acculturation when studying health risk behaviors among immigrants. Researchers should consider additional time-dependent factors to explain behavioral changes by duration of residence.

Importance  Flexible parental leave schemes can help families balance work, childcare, and postpartum treatment, including treatment for mental health. In Sweden, both parents are eligible to use parental leave simultaneously in the first year after birth; however, the consequences for postpartum mental health care uptake remain underinvestigated.

Objective  To examine the association between parents’ use of simultaneous parental leave and their use of postpartum mental health care in Sweden.

Design, Setting, and Participants  This cohort study obtained baseline data from national registries in Sweden, including live births of singleton offspring between January 1, 2014, to December 31, 2015, and simultaneous parental leave use (any vs none) in the 12 months after birth. The population-based sample was composed of parental dyads (mothers and fathers) who were eligible for simultaneous parental leave and were followed up from January 1, 2015, to December 31, 2016. Statistical analyses were conducted between December 15, 2023, and August 14, 2024.

Exposure  Simultaneous parental leave use up to 12 months post partum.

Main Outcomes and Measures  Total population register data were used to identify maternal and paternal outpatient care visits for mental health (substance use disorder [SUD], mood or affective disorders, and stress-related disorders) and psychotropic prescription dispensations (antidepressants and anxiolytics) during the first postpartum year. Logistic regression was applied to estimate the odds of these outcomes by simultaneous parental leave use, controlling for parents’ age, sociodemographic characteristics, and prebirth mental health care use. Robustness analyses using propensity score matching were performed.

Results  The sample comprised 207 283 parental dyads, of whom 153 342 (74.0%) did not use simultaneous parental leave in the first postpartum year and 53 941 (26.0%) did. Among those who used simultaneous parental leave, the mean (SE) age at childbirth was 29.63 (0.02) years for mothers and 32.80 (0.03) years for fathers. Compared with mothers who did not use parental leave simultaneously with their partners, mothers who did were more likely to receive antidepressant prescriptions in the first postpartum year (odds ratio [OR], 1.07; 95% CI, 1.02-1.11). Fathers who used simultaneous parental leave vs those who did not had increased odds of SUD-related outpatient care visits (OR, 1.10; 95% CI, 1.02-1.20). Longer simultaneous parental leave was associated with greater odds of mental health care use for both parents, and earlier leave was associated with greater odds of health care use by mothers. Findings for mothers, but not fathers, remained significant in robustness analyses using propensity score matching.

Conclusions and Relevance  This cohort study found that simultaneous parental leave use was associated with greater health care uptake for postpartum mental health conditions in both mothers and fathers. This finding supports the need to consider the benefits of generous family policies as well as the risks of structural obstacles to postpartum mental health care access across the world.

Importance  The 1980 and 1986 Swedish so-called speed premium policies aimed at protecting parents’ income-based parental leave benefits for birth intervals shorter than 24 and 30 months, respectively, but indirectly encouraged shorter birth spacing and childbearing at older ages, both risk factors for several perinatal health outcomes. Whether those policy changes are associated with perinatal health remains unknown.

Objective  To evaluate the association between the 1980 and 1986 speed premium policies and perinatal health outcomes.

Design, Setting, and Participants  This cross-sectional study investigated data from 1 762 784 singleton births in the Swedish Medical Birth Register from January 1, 1974, through December 31, 1991. Data were analyzed from October 11, 2022, to December 12, 2023.

Interventions  Speed premium policy introduction (January 1, 1980) and extension (January 1, 1986).

Main Outcomes and Measures  Total population register data were used in an interrupted time series analysis with segmented logistic regression to calculate the odds of preterm birth, low birth weight, small for gestational age (SGA) at preterm, and stillbirth measured before and after the speed premium policy reforms. Subgroup analyses by maternal origin were conducted to evaluate changes by different policy responses.

Results  Among 1 762 784 births analyzed, 4.8% were preterm (of which 12.0% were SGA), 3.2% had low birth weight, and 0.3% were stillbirths. The 1980 speed premium policy was associated with a 0.3% monthly increase in the odds of preterm birth compared with the period before the reform (odds ratio [OR], 1.0029 [95% CI, 1.002-1.004]), equivalent to a 26.4% increase from January 1, 1980, to December 31, 1985. After the 1986 relaxation of the policy, preterm birth odds decreased 0.5% per month (OR, 0.9951 [95% CI, 0.994-0.996]), equivalent to an 11.1% decrease across the next 6 years. Low birth weight displayed a similar pattern for both reform periods, that is, increased 0.2% (OR, 1.0021; 95% CI, 1.001-1.003) per month in 1980 through 1985 compared with baseline, and decreased 0.3% (OR, 0.9975; 95% CI, 0.996-0.998) per month in the following period, but was attenuated when considering low birth weight at term. Odds of SGA at preterm were decreased after 1980 (OR, 0.9965; 95% CI, 0.994-0.999) but not in 1986 (OR, 1.0009; 95% CI, 0.998-1.003), whereas stillbirths did not change following either reform (1980: OR, 1.0020 [95% CI, 0.999-1.005]; 1986: OR, 1.0002 [95% CI, 0.997-1.003]). Subgroup analyses suggested that perinatal health changes were restricted to births to Swedish- and Nordic-born mothers, the primary groups to adjust their fertility behaviors to the reforms.

Conclusions and Relevance  Despite its economic advantages for couples, especially for mothers, the introduction of the speed premium policy was associated with adverse perinatal health consequences, particularly for preterm births. Family policies should be carefully designed with a “Health in All Policies” lens to avoid possible unintended repercussions for fertility behaviors and, in turn, perinatal health.