Promoting rational antibiotic use in Turkey and among Turkish migrants in Europe - implications of a qualitative study in four countries

Background

Antimicrobial resistance is considered one of the major threats to global health. The emergence of resistant microorganisms is a consequence of irrational use of antibiotics. In Turkey, the consumption of antibiotics is relatively high and antibiotics are among the most commonly used drugs. However, Turkey has adopted new, more restrictive policies and regulations on antibiotics. In addition, Turkish migrants to EU countries, such as Germany, the Netherlands and Sweden, may encounter health systems that promote a more restrictive and rational antibiotic use.

The objective of this paper was to explore the variation in implemented policies related to rational antibiotic use that citizens in Turkey and Turkish migrants in Germany, the Netherlands and Sweden are subjected to and to discuss the implications for the promotion of rational antibiotic use.

Data were collected through focus groups and individual interviews with citizens, physicians and pharmacists in the four countries. In total, 130 respondents were interviewed. Content analysis was used.

Results

Three relevant themes were identified: Implementation of regulations and recommendations, Access to antibiotics and Need for health communication. Irrational use of antibiotics was reported mainly in Turkey. While it had become less likely to get antibiotics without a prescription, non-prescribed antibiotics remained a problem in Turkey. In the three EU countries, there were also alternative ways of getting antibiotics. Low levels of knowledge about the rational antibiotic use were reported in Turkey, while there were several sources of information on this in the EU countries. Communication with and trust in physicians were considered to be important. There were also system barriers, such as lacking opportunities for physicians to manage care in accordance with current evidence in Turkey and factors limiting access to care in EU countries.

Conclusions

Several fields of importance for promoting rational antibiotic use were identified. There is a need for harmonisation of health-related regulations and policy programmes. Antibiotics should only be available with a prescription. Programmes for rational antibiotic use should be implemented on a broad scale, in medical care, at pharmacies and in the population. Methods for health communication and patient-centred care should be further developed and implemented in this field.

Professional development of civic and health communicators: a national platform in Sweden MILSA 3.0

Background

Establishing oneself in a new country is especially challenging for forced migrants affecting both physical and mental health. The Swedish introduction system includes a mandatory civic orientation program conducted in the refugeés native language, covering different aspects of the Swedish society. MILSA has advocated for including health promotion as a key component in the introduction system, stating that culturally sensitive health communication is a human right for refugees. Through this work, health communication is now included in the program in many parts of Sweden. However, there are challenges due to a lack of professional recognition related to the absence of a recognized training. In order to create a national capacity for a quality based civic and health communication, MILSA has developed a national training program carried out in collaboration with five universities, actors on local, regional, and national levels as well as NGOs and experts in different areas.

Methods

A web-based program including six physical workshops is given nationally. The program consists of 22 modules targeting society and public health issues but also pedagogy, leadership and communication. Evaluation studies are included in the program targeting the education itself and as well as investigating effects on the refugees.

Results

The program has been running for three years ending in autumn 2020 including four admission periods. The early evaluation showed very encouraging results where participants reported a deeper knowledge of civics and public health, resulting in being more secure and comfortable in their daily work, including improvements regarding skills in pedagogy, leadership and conflict management.

Conclusions

The need for an educational platform is recognized by many stakeholders in Sweden. The program has received a very positive evaluation. Due to this, MILSA has initiated a process of establishing a national commissioned program on permanent basis.

Key messages

The program has been highly regarded by the communicators, due to the gained knowledge in their everyday work. The importance of health communication and professional development and its value for the recipients of civic orientation is recognized by many stakeholders within but also outside the country.

Management of chronic diseases and healthcare use among the elderly in Turkey and Turkish migrants

Background

Turkish migrants are one of the largest groups of migrants in Germany, the Netherlands and Sweden. Particularly older migrants face different barriers in the health system that may limit their access to and quality of health care. The aim of this study was to examine how elderly people in Turkey and Turkish migrants in Germany, the Netherlands and Sweden manage chronic conditions, including how they utilize the respective healthcare systems.

Methods

A qualitative study design was used. A total of 20 in-depth interviews with individuals in Turkey and 10 semi-structured in-depth interviews each with Turkish migrants in Germany, the Netherlands and Sweden were conducted during 07/2018 and 05/2019. The interviews were based on a topic guide and were analyzed using qualitative content analysis.

Results

Participants from all groups experienced barriers in accessing health services and described difficulties in managing chronic conditions in their daily life. Pathways to care and patterns of utilization strongly depended on the structure of the respective health systems and differed between all groups. Circular migrants to Turkey relied on health professionals from their respective host countries to treat their chronic diseases, consulting professionals in Turkey mostly for emergencies or acute illness.

Conclusions

Turkish migrants and elderly adults in Turkey experience similar barriers and challenges in managing chronic diseases. How they access and utilize health services is dependent on the respective health system structures. Circular migrants use the Turkish health system differently than health systems in their host countries and elderly adults from Turkey. These results can contribute to the development of diversity-sensitive health care strategies.

Key messages

Turkish migrants and adults in Turkey experience similar challenges in managing chronic diseases. How Turkish migrants and adults in Turkey access healthcare depends on the respective systems.

Experiences and needs concerning health related information for newly arrived refugees in Sweden

BACKGROUND

Owing to communication challenges and a lack of knowledge about the health care system, refugees may be at risk of having limited health literacy, meaning that they will have problems in achieving, understanding, appraising and using health information or navigating in the health care system. The aim of this study was to explore experiences and needs concerning health related information for newly arrived refugees in Sweden.

METHODS

A qualitative design with a focus group methodology was used. The qualitative content analysis was based on seven focus group discussions, including 28 Arabic and Somali speaking refugees.

RESULTS

Four categories emerged. 'Concrete instructions and explanations' includes appreciation of knowledge about how to act when facing health problems. 'Contextual knowledge' comprises experienced needs of information about the health care system, about specific health risks and about rights in health issues. 'A variation of sources' describes suggestions as to where and how information should be given. 'Enabling communication' includes the wish for more awareness among professionals from a language and cultural point of view.

CONCLUSION

Concrete instructions and explanations are experienced as valuable and applicable. Additional information about health issues and the health care system is needed. Information concerning health should be spread by a variety of sources. Health literate health organizations are needed to meet the health challenges of refugees, including professionals that emphasize health literacy.

Limited impact of an intervention regarding emergency contraceptive pills in Sweden—repeated surveys among abortion applicants

OBJECTIVE

To evaluate a community-based intervention consisting of an information campaign and advance provision of emergency contraceptive pills (ECP) to abortion applicants.

METHODS

Submission of repeated waiting room questionnaires to abortion applicants in two cities in mid-Sweden; one intervention city (IC) and one comparison city (CC) in 2002 (IC = 92, CC = 95) and 2003 (IC = 244, CC = 204).

RESULTS

The overall response rate was 90%. The percentage of women who had undergone an abortion within the previous year had decreased in the intervention group but not in the comparison group. Almost two-thirds (63%) of the targeted women had noticed the information campaign and one out of three (33%) who had visited a family planning clinic recalled being given information about ECP. There was a small decline in the use of combined oral contraceptives and intrauterine devices over time. After the intervention, women in the intervention city had better knowledge of ECP and had used it more than women in the comparison city did.

CONCLUSIONS

More than half of the targeted women had noticed the information campaign and it may have had a limited impact. Further investigations are needed to determine whether advance supply of ECP to abortion applicants can reduce repeat abortions.

Comparing hospital discharge records with death certificates: can the differences be explained?

STUDY OBJECTIVE

The quality of mortality statistics is important for epidemiological research. Considerable discrepancies have been reported between death certificates and corresponding hospital discharge records. This study examines whether differences between the death certificate's underlying cause of death and the main condition from the final hospital discharge record can be explained by differences in ICD selection procedures. The authors also discuss the implications of unexplained differences for mortality data quality.

DESIGN

Using ACME, a standard software for the selection of underlying cause of death, the compatibility between the underlying cause of death and the final main condition was examined. The study also investigates whether data available in the hospital discharge record, but not reported on the death certificate, influence the selection of the underlying cause of death.

SETTING

Swedish death certificates for 1995 were linked to the national hospital discharge register. The resulting database comprised 69 818 people who had been hospitalised during their final year of life.

MAIN RESULTS

The underlying cause of death and the main condition differed at Basic Tabulation List level in 54% of the deaths. One third of the differences could not be explained by ICD selection procedures. Adding hospital discharge data changed the underlying cause in 11% of deaths. For some causes of death, including medical misadventures and accidental falls, the effect was substantial.

CONCLUSION

Most differences between underlying cause of death and final main condition can be explained by differences in ICD selection procedures. Further research is needed to investigate whether unexplained differences indicate lower data quality.

Bicycle helmet use among schoolchldren--the influence of parental involvement and children's attitudes

OBJECTIVE

To study attitudes towards and use of bicycle helmets among schoolchildren; to determine whether these attitudes are associated with the involvement of parents and school in bike safety.

SETTINGS

Nine intermediate level schools and five upper level schools in two Swedish municipalities.

METHOD

A survey with 1,485 participants aimed at pupils aged 12-15 years conducted during late spring 1997. Associations between parent and school involvement and children's attitudes and helmet use were studied using LisRel analyses.

RESULT

At some point during their school years, a majority of the children stopped wearing bicycle helmets. Of 12-13 year olds, 80% said that they had used helmets when they were younger but at the time of the study, only 3% aged 14-15 years used helmets. Use decreased significantly during school years (p<0.001). The majority stated they quit using helmets because they were ugly, silly, uncomfortable, or inconvenient. There was a strong association between parental involvement, children's attitudes, and helmet use. However, parent involvement decreased as the children grew older.

CONCLUSION

To increase the voluntary use of bicycle helmets among schoolchildren their attitudes must be influenced. An intervention aimed at both parents and children may be required.

Measures of prevalence: which healthcare registers are applicable?

AIMS

This study analyses the applicability of some of the registers used within the healthcare system for estimations of disease prevalence. The study focuses on the diagnoses of asthma, diabetes mellitus, chronic bronchitis/emphysema, hypertensive disease, and cerebrovascular disease.

METHODS

The study population comprised all inhabitants (n=20,037) in the municipality of Tierp on 31 December 1996. Diagnostic information was collected from primary healthcare and occupational healthcare in the municipality of Tierp and from inpatient and outpatient units at the hospitals in Uppsala County. The proportion of registered patients in the different registers was calculated in relation to the total number of patients who had been registered during 1996 with the selected diagnoses.

RESULTS

In the primary healthcare register, between 67% (cerebrovascular disease) and 85% (asthma) of all patients with selected diagnoses could be identified. A search on the inpatient care register (Hospital Discharge Register) led to the identification of between 8% (hypertensive disease) and 53% (cerebrovascular disease) of the patients.

CONCLUSIONS

For all of the examined diagnoses, most patients could be identified in the primary healthcare register. Register data from both primary healthcare and inpatient and outpatient care at hospital are needed to make reasonable estimates of prevalence.

Comparing Swedish hospital discharge records with death certificates: implications for mortality statistics

BACKGROUND

The quality of mortality statistics is of crucial importance to epidemiological research. Traditional editing techniques used by statistical offices capture only obvious errors in death certification. In this study we match Swedish hospital discharge data to death certificates and discuss the implications for mortality statistics.

METHODS

Swedish death certificates for 1995 were linked to the national hospital discharge register. The resulting database comprised 69 818 individuals (75% of all deaths), 39 872 (43%) of whom died in hospital. The diagnostic statements were compared at Basic Tabulation List level.

RESULTS

The last main diagnosis and the underlying cause of death agreed in 46% of cases. Agreement decreased rapidly after discharge. For hospital deaths, the main diagnosis was reported on 83% of the certificates, but only on 46% of certificates for non-hospital deaths. Malignant neoplasms and other dramatic conditions showed the best agreement and were often reported as underlying causes. Conditions that might follow from some other disease were often reported as contributory causes, while symptomatic and some chronic conditions were often omitted. In 13% of cases, an ill-defined main condition was replaced by a more specific cause of death.

CONCLUSIONS

There is no apparent reason to question the death certificate if the main diagnosis and underlying cause agree, or if the main diagnosis is a probable complication of the stated underlying cause. However, cases in which the main diagnosis cannot be considered a complication of the reported underlying cause should be investigated, and assessments made of the feasibility and cost-effectiveness of routinely linking hospital records to death certificates.

Studies of avoidable factors influencing death: a call for explicit criteria

OBJECTIVE

To analyse studies evaluating cases of potentially "avoidable" death.

DESIGN

The definitions, sources of information, and methods were reviewed with a structured protocol. The different types of avoidable factors,--that is, deficiencies in medical care that may have contributed to death--were categorised. The presence of explicit classifications and standards was examined. basic criteria for quality of the studies were defined and the numbers of studies fulfilling these criteria were assessed.

SETTING AND PARTICIPANTS

65 studies, published during 1988-93 in peer reviewed medical journal for which the title, or abstract, or both indicated that they had analysed potentially avoidable factors influencing death. Studies analysing aggregated data only, were not included.

RESULTS

Only one third of the studies fulfilled basic quality criteria,--namely, that the avoidable factors examined should be defined and the sources of information and people responsible for the judgements presented. The definitions used comprised two levels, one stating that there had been errors in management (process) and the other that the errors may have contributed to the deaths (outcome). Only 15% of the studies explicitly defined what type of factors they had looked for and 8% referred to specified standards of care.

CONCLUSIONS

Studies of avoidable factors influencing death may have considerable potential as part of a system of improving medical care and reducing avoidable mortality. At present, however, the results from different studies are not comparable, due to differences in materials and methods. There is a need to improve the quality of the studies and to define standardised explicit definitions and classifications.

Can regional variation in "avoidable" mortality be explained by deaths outside hospital? A study from Sweden, 1987-90

STUDY OBJECTIVE

This study aimed to calculate the proportion of deaths outside hospital in Sweden for some conditions for which the acute medical management may be important to the outcome and to analyse whether the proportion of deaths outside hospital can explain regional variations in mortality from these causes of death.

DESIGN

The place of death was registered on all death certificates in Sweden during the period 1987-90. The proportion of deaths outside hospital was calculated at the national level for selected causes of death. Variation in cause-specific mortality among the 26 administrative health areas in Sweden was analysed. Death rate ratios were calculated with standardisation for age and sex using the national rate as standard. The correlation between the proportion of deaths outside hospital in each health area and the cause specific mortality irrespective of place of death was calculated. For areas with a significantly high death rate the ratios for mortality outside hospital as well as in hospital were analysed in order to decide which component of mortality represented a high mortality risk.

SETTING AND PARTICIPANTS

All death registration in Swedish citizens and other residents in Sweden aged under 70 years between 1987 and 1990 which gave diabetes, asthma, ischaemic heart disease, cerebrovascular diseases, or ulcer of the stomach or duodenum as the underlying cause of death.

MAIN RESULTS

For asthma (58%) and ischaemic heart disease (54%), most deaths occurred outside hospital. For most causes of death, however, no correlation was found among the health areas between the proportion of deaths outside hospital and the SMR for mortality irrespective of the place of death. A high death rate was associated with a high proportion of deaths outside hospital, for diabetes in one area in the north of Sweden (Norrbotten) and for ulcer of the stomach and duodenum in one large municipality (Göteborg).

CONCLUSIONS

The high proportion of deaths outside hospital at the national level for some of the conditions studied suggests that in-depth studies of the process preceding death and the functioning of medical care are needed. In most cases, however, no evidence was found that regional variation in mortality could be explained by death outside hospital. The results for diabetes in Norbotten and ulcer of stomach and duodenum in Göteborg indicate that in-depth studies on the quality of care are required.

Socioeconomic differences in 'avoidable' mortality in Sweden 1986-1990

BACKGROUND

'Avoidable' mortality is commonly studied as an indicator of the outcome of health care. In this study socioeconomic differences in avoidable mortality in Sweden from 1986 to 1990 are analysed and related methodological issues discussed.

METHODS

The 1985 Swedish Population and Housing Census was linked to the National Cause of Death Register 1986-1990. Mortality from potentially 'avoidable' causes of death was analysed for the age group 21-64 years. Analyses were performed for different socioeconomic groups, blue-collar workers, white-collar workers and the self-employed as well as for individuals outside the labour market. Standardized Mortality Ratios were calculated using standardization by age and sex.

RESULTS

For all indicators studied, the death rates for those not in work were higher than for people at work. The largest differences were found for chronic bronchitis, diabetes, bacterial meningitis, ulcer of the stomach and duodenum, chronic rheumatic heart disease, asthma and hypertensive and cerebrovascular disease. For these causes of death the risk of dying was between 3.1 and 7.5 times greater in the non-working population than in the work-force. The differences in avoidable mortality between blue-collar workers and white-collar workers and the self-employed were, however, much smaller. For most of the indicators no significant differences were found. For ulcers of the stomach and duodenum, however the death rate for blue-collar workers was 2.8 times higher than those for other categories in work.

CONCLUSIONS

The small difference in mortality outcome for different socioeconomic groups within the work-force indicates an equal quality of care for these groups. The greatly increased risk among the non-working population, however, is a warning sign. These results may be due to a 'healthy worker' effect. The measurement of socioeconomic differences in mortality may be dependent on the time-period chosen between occupational exposure and mortality outcome.

A comparison of avoidable mortality in Lithuania and Sweden 1971-1990

BACKGROUND

In reforming the Lithuanian health care system it is important to evaluate the health status of the population and the outcome of health care by comparison to Western European countries. The aim of this study is to examine the possibility of comparing data on avoidable mortality in Lithuania with Sweden and, when realistic, to compare avoidable mortality rates between Lithuania and Sweden.

METHODS

Comparisons were made for the time period 1971-1990. During this period a basic tabulation list including 200 groups of causes of death modified from WHO's International Classification of Diseases was obligatory for all Soviet Republics. This limited the opportunity for comparisons with Western European countries. However, for most of the selected avoidable death indicators comparisons with Sweden were made possible by slightly modifying the indicators.

RESULTS

In the age group 5-64 years in 1971-1975 the total mortality in Lithuania was 60% higher than that in Sweden. In 1986-1990 this gap had increased to 90%. For most avoidable death indicators the difference was even greater, i.e. the death rate in Lithuania was several times higher than that in Sweden. For instance, death rates for tuberculosis were 36 times higher and for appendicitis, cholelithiasis and cholecystitis six times higher in Lithuania. For several avoidable causes of death, such as tuberculosis, appendicitis and hypertensive and cerebrovascular disease the gap widened during the study period.

CONCLUSIONS

The results indicate potential fields for improvement of the health care system in Lithuania. The importance of implementing international classification systems for epidemiological surveillance of the outcome of health care is stressed.

Systematic small-area variation in mortality for malignant neoplasms in Sweden 1975-1990

BACKGROUND

Cancer mortality has been stated to be the best single measure of progress in combatting cancer. The variation in total and cause-specific cancer mortality among health administrative areas in Sweden was analysed in order to find out if the mortality outcome has been equally distributed.

METHODS

Data on underlying causes of death for ages 0-74 years were analyzed for the 26 health administrative areas in Sweden, 1975-1990. Analyses of systematic (non-random) variance were performed and measures chosen in order to make comparisons possible between different malignant neoplasms and different periods of time.

RESULTS

The systematic variance for all malignant neoplasms was reduced by about 40% during the study period. The largest systematic variations in mortality were found for cancer of the oesophagus and lung, although the systematic variation for these neoplasms was lower in the 1980s than in the 1970s. Large systematic variation was also found for cancer of the cervix uteri and of the bladder. For these causes the variation remained constant throughout the period.

CONCLUSIONS

Generally speaking, the outcome of cancer has become more equally distributed across the country. Preventive measures should be possible for the malignant neoplasms with the largest regional variation.

Small-area variation in multiple causes of death in Sweden--a comparison with underlying causes of death

BACKGROUND

The effect of using multiple causes of death, i.e. all causes of death mentioned on the death certificates, compared to using the underlying cause of death only for analyses of regional variation among small areas in mortality for asthma, diabetes, hypertensive disease and cerebrovascular disease was studied.

METHODS

Standardized mortality ratios (SMR) were analysed for the different health administrative areas in Sweden using data from the Swedish cause of death register for the period 1987-1991. The SMR were calculated for each of the selected underlying causes of death as well as for multiple causes of death. The correlations between SMR for underlying and multiple causes were analysed.

RESULTS

The highest level of correlation of the SMR between multiple and underlying causes of death was found for cerebrovascular disease (0.96) and the lowest for hypertensive disease in the age group 0-64 years (0.51). For hypertensive disease, diabetes and asthma, when using multiple causes of death some further areas were found to have high SMR and the level of significance was higher. Significantly high SMR using underlying causes of death were, however, not shown to be false when multiple causes of death were used. In the case of cerebrovascular disease little additional information was gained.

CONCLUSION

By including multiple causes of death in small-area analysis more statistical outliers can be detected and the risk of false warning signals due to random effect can be limited. Analyses of underlying causes of death and multiple causes of death should preferably be combined.

Components of small area variation in death rates: a method applied to data from Sweden

STUDY OBJECTIVES

The study aimed to develop and evaluate a method for small area analysis of different non-random components of the variation in death rates. The method was applied to incidence and mortality data for selected malignant neoplasms in 26 administrative health areas in Sweden.

DESIGN

Variation in mortality and incidence rates for malignant neoplasms of the trachea, bronchus, and lung; colon; rectum; and cervix uteri in the 26 health areas were analysed after standardisation for age. In addition, the systematic and random components of variance were estimated. The systematic component of variance in mortality was divided into two additive components-one component was dependent on the variation in the corresponding incidence rates and the other remained after adjustment for incidence. SETTING AND PARTICIPANT: All cases diagnosed between 1972 and 1983 and all deaths between 1974 and 1985 for selected malignant neoplasms in Swedish citizens and other residents in Sweden, aged between 0 and 64 years, were analysed.

MAIN RESULTS

Much of the observed variation in mortality was explained by the estimated random variation. For malignant neoplasms of the trachea, bronchus, and lung the systematic variation in mortality was mainly explained by the variation in incidence. For cancer of the cervix uteri, alone, there was significant systematic variation of moderate magnitude that was not explained by the incidence rates.

CONCLUSIONS

These methods made it possible to divide the observed variance in mortality into different components. Random effects and variance in incidence rates were found to be of great importance when analysing the variance in death rates between health areas. By studying different systematic components of variation it is possible to identify fields for in depth studies on the quality of prevention and treatment.

Indicators of "avoidable" mortality in health administrative areas in Sweden 1974-1985

When comparing health administrative areas in Sweden the variation in death rates for 13 suggested indicators of avoidable mortality was analysed for the time periods 1974-79 and 1980-85. For most indicators the variation was significant. The level of systematic (nonrandom) variance differed between the sexes for certain conditions. According to the theory of mass-significance it would be appropriate to use a sharpened significance test of high SMRs. For certain health policy indicators it was possible to detect areas accounting for nearly all the deviation above the national standard using a sharpened test (p < 0.001). For most medical care indicators, however, the high death rates had a lower level of significance. When sensitivity is given priority an ordinary test (p < 0.05) should be preferred. This means, however, dealing with potential false positive warning signals. Epidemiological surveillance of indicators of avoidable mortality should be the starting point for in-depth studies.

"Avoidable" causes of death in Sweden 1974-85

Mortality from potentially avoidable causes of death in Sweden 1974-85 for ages 0-64 years was analysed, based on a list published by Rutstein et al., [N Engl J Med 294: 582, 1976] of conditions that were suggested to serve as negative indicators of the quality of health care. In females 22% of deaths and in males 18% of deaths had underlying causes that were included in the list. Deaths from avoidable causes in the Rutstein list were concentrated to a limited number of causes of death and cause of death groups, such as neoplasms and diseases of the respiratory system. Both preventable and treatable conditions were found among the most common avoidable causes of death. There were differences in the causes of death that were most common between different age groups. A large number of the avoidable causes of death were relatively rare in Sweden. Areas for continued methodological development are suggested concerning the choice of avoidable causes of death and the definition of standards.

Trends in "avoidable" mortality in Sweden, 1974-1985

STUDY OBJECTIVE

The aim was to analyse trends in "avoidable" mortality in Sweden, and to contribute to the methodology of avoidable mortality as an index of the quality of care.

SETTING AND PARTICIPANTS

All deaths of Swedish citizens and other residents in Sweden during the period 1974-1985 were analysed as to causes of death between ages 0 and 64 years.

MEASUREMENTS AND MAIN RESULTS

Total mortality delined during the 12 year period studied. Avoidable causes of death were grouped into preventable and treatable causes according to Rutstein's classification. In men, treatable diseases declined more during the 12 year period studied than did total mortality. When lung cancer was excluded, preventable diseases declined for both sexes. Certain avoidable causes of death decreased compared to total mortality, while some others showed an increase. The death rate increased for some avoidable causes of death such as pneumonia other than viral. In women death rates increased for chronic bronchitis and emphysema as well as for malignant neoplasms of trachea, bronchus, and lung, while for boys aged 1-14 years bronchitis NOS and asthma showed an increasing death rate.

CONCLUSIONS

The study indicates that the avoidable mortality method is sensitive enough to describe important changes in the mortality pattern. The explicit definition of treatable and preventable causes of death constitutes a methodological development in epidemiological analysis of this type. Further studies on the quality of care should combine this method with other methods examining the structure and process of health care.

The European Community 'avoidable death indicators' in Sweden 1974-1985

Avoidable mortality in Sweden 1974-1985 was analysed using a European Community (EC) Working Group list of 'avoidable death indicators." The list includes causes of death that in certain age groups were defined as indicators of the outcome of medical care intervention or for some conditions, indicators of the national health policies. About 10 out of 14 medical health care indicators occurred in less than 50 cases per year. Death rates decreased over the 12-year period studied for most avoidable death indicators. For women, however, the death rate for malignant neoplasms of the trachea, bronchus and lung increased significantly. Swedish total mortality for ages 5-64 years was lower than the EC standards 1974-1978 and 1980-1984. Most of the avoidable causes of death had a relatively low standard mortality rate (SMR) when compared to both the EC standard and to the Swedish SMR for total mortality. For asthma, however, the Swedish SMR was higher. The development and implementation of the avoidable death concept and methodology is discussed.

Diagnoses associated with the prescription of psychotropic drugs at a Swedish health centre

Data on drug prescribing to residents of the municipality of Tierp in 1978 were linked to data on visits to the Tierp health centre in order to examine which diagnoses were associated with psychotropic drug prescribing. The diagnostic patterns were analyzed with respect to sex, age, and level of drug use of patients. Only one quarter of the patients for whom psychotropic drugs were prescribed in connection with a visit to the health centre were also given a psychiatric diagnosis. Even among those patients who were prescribed five or more psychotropic drugs, only four out of ten had a psychiatric diagnosis. Among those patients who were prescribed an antidepressant, only six out of ten had a psychiatric diagnosis. A relation between psychotropic drug use and certain non-psychiatric diagnoses such as hypertension, diabetes and ischaemic heart disease was observed.