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Last Updated: Sunday, 11 December 2005, 01:10 GMT
Keeping healthy, the Swedish way
By Nick Triggle
BBC News health reporter

People in a nightclub
Bouncers are trained to give help to people high on drugs or booze
They may not look like health workers, but the bouncers outside some of Stockholm's trendiest nightspots are still part of a push to improve lifestyles.

Bar and nightclub staff across Sweden's capital have been trained in how to spot and intervene when people are high on drugs and booze.

It means instead of just being turned away, people are offered advice about what help is on offer and warned about the risk of over-indulging.

The scheme is part of an anti-drug and alcohol programme called the Stad Project which has been funded by the city and county councils in Stockholm.

The programme has also given local GPs and nurses training in how to counsel "risk drinkers".

Stad co-ordinator Dr Sven Andreasson said: "The idea is to get everyone involved and responsible, not just the government.

"We have seen a reduction in violence and are working to improve referrals for help."

But such community schemes are far from unique in Sweden.

'Good record'

Chris Ham, professor of health policy at Birmingham University, believes the devolved nature of health in the country creates the ideal environment for health prevention to flourish.

The country's 21 county councils and 290 municipalities run and mostly fund hospitals, GPs and social services.

Professor Ham said: "They have a good record. From public health campaigns to accessing care and leisure services, Sweden does a lot to prevent ill health.

"Local government is much more used to dealing with health than it is in England."

The Swedish parliament adopted a new public health policy two years ago to improve public health and reduce inequalities in much the same way as the government's Public Health White Paper in November 2004 did in England.

The public health challenges and what is being done

But unlike the UK, which is more used to the central command structure of the NHS, Swedish councils have been using their tax-raising powers - they can levy a duty on incomes - and wide-ranging policy powers to pioneer ways of keeping people healthy.

Swedish municipalities have been upgrading and introducing new cycle routes to encourage people to get out of their cars.

And several have also demanded schools increase the number of sport and health lessons, which cover healthy eating and lifestyles with football practice.

Meanwhile, county councils have been encouraging GPs to give "exercise on prescription" and fund more home visits by nurses to address lifestyle.

But local government has also attempted to take simple measures such as introducing better street lighting to make people feel comfortable going out for walks and jogs.


Roger Molin, deputy director of the Swedish Association of Local Authorities, said: "Councils have been pretty innovative in this area. Preventing ill-health is the best way of dealing with it, rather than treating the symptoms."

And it is this bottom-up approach which has provided the ideal environment to tackling the issue, according to the Swedish National Institute of Public Health, which oversees the drive on behalf of the government.

Institute director general Gunnar Agren said: "We have a long tradition of self rule. There are no targets, but councils address the problems themselves when comparisons are published."

But when it comes to comparisons - even taking into account the lower levels of deprivation compared to the UK - there is little to fault Sweden for.

Research has shown that the conditions in which you live - employment opportunities, social interaction - play a huge part in public health
Bernt Lundgren, of the Swedish National Institute of Public Health

The average Swede can expect to live two years longer than a Briton with significantly lower rates of smoking, boozing and obesity.

What is noticeable about the Swedish government's public health policy is that it is not target-driven.

Instead, it focuses on creating the right environment for people to improve their own health through influencing workplace and education policy.

Mr Agren said the idea was to focus on what the state could influence.

"You cannot just say exercise more, but what you can influence is providing the opportunity for people to exercise through cycle lanes and parks."

It has meant that the institute has encouraged local government to take a much more holistic view to tackling improving public health.

In a recent report, the institute urged councils to adopt polices to reduce domestic violence, increase women's working opportunities and tackle crime.

Living conditions

Bernt Lundgren, head of analysis at the institute, said: "Research has shown that the conditions in which you live - employment opportunities, social interaction - play a huge part in public health."

But for all the focus on addressing ill-health at a community level, Sweden has also attempted to use legislation to force improvement.

In June, a smoking ban was introduced across all public places. Exemptions are given for pubs and nightclubs to allow "smoking rooms" but in practice less than 5% have opted to have them.

Gunnar Agren, director general of Swedish Institute of Public Health
The institute has been encouraging councils to adopt a range of measures

Mr Lundgren is hopeful that the ban will help to drive down the smoking rates - among the lowest in Europe at 17.5%.

But what is interesting is that the institute does not have much faith in other enforced measures.

A junk food advertising ban was introduced for children's television years ago - one of the measures being considered in the UK.

Mr Agren said: "I am not sure it has been that effective. The problems is that with satellite TV many programmes are broadcast from other countries, such as the UK, where there is not such a strict code.

"This has allowed advertisers to get around the ban."

Instead, Mr Agren believes countries should focus on providing opportunities for people to adopt healthier lifestyles.

"If I had one piece of advice I would say concentrate on the determinants, but from what I have seen there is too much focus on outcomes in the UK."

However, one area where Sweden has admitted it needs help is with alcohol consumption.

Drinking rates have been increasing for the last 15 years, showing a marked increase from the point where Sweden entered the EU in the mid 1990s.

Mr Agren said potentially effective measures such as increasing the price of drinks through taxation and changing licensing laws - pubs apply to councils for longer licences in a system similar to the one which has just started in England - were rendered next to useless because people could just go abroad and buy cheap booze.

"This needs to be tackled at an EU level. We are in this together."

Is the UK a model welfare state?
04 Aug 05 |  Business
UK learns from Swedish childcare
02 Jun 04 |  Education
Country profile: Sweden
04 Sep 05 |  Country profiles

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