Latent classes of DSM-5 acute stress disorder symptoms in children after single-incident trauma: findings from an international data archive

Background: After a potentially traumatic event (PTE), children often show symptoms of acute stress disorder (ASD), which may evolve into posttraumatic stress (PTS) disorder. A growing body of literature has employed latent class analysis (LCA) to disentangle the complex structure underlying PTS symptomatology, distinguishing between homogeneous subgroups based on PTS presentations. So far, little is known about subgroups or classes of ASD reactions in trauma-exposed children. Objective: Our study aimed to identify latent classes of ASD symptoms in children exposed to a single-incident PTE and to identify predictors of class membership (gender, age, cultural background, parental education, trauma type, and trauma history). Method: A sample of 2287 children and adolescents (5–18 years) was derived from the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive, an international archive including studies from the USA, UK, Australia, and Switzerland. LCA was used to determine distinct subgroups based on ASD symptoms. Predictors of class membership were examined using a three-step approach. Results: Our LCA yielded a three-class solution: low (42%), intermediate (43%) and high (15%) ASD symptom severity that differed in terms of impairment and number of endorsed ASD symptoms. Compared to the low symptoms class, children in the intermediate or high severity class were more likely to be of female gender, be younger of age, have parents who had not completed secondary education, and be exposed to a road traffic accident or interpersonal violence (vs. an unintentional injury). Conclusions: These findings provide new information on children at risk for ASD after single-incident trauma,

Private Health Insurance in Sweden : Implications for the legitimacy of the public health care system

The market for private health insurance (PHI) is growing in many countries with public, tax-funded health care systems. In Sweden, this development has generated an at times intense and polarised debate, exposing that the principles on which the public health care system rests in many aspects collide with the construction of PHI. Two dimensions have been suggested as being important for maintaining the legitimacy of public health care systems. The first is that citizens support the normative principles underpinning the system, including solidaristic funding through general taxation. With this comes the willingness of the population, and in particular the middle classes as net contributors, to pay tax to support the system. The second dimension is related to how the population perceives the performance of public services, as it has been suggested that public services need to be of sufficiently high quality for private alternative to be considered redundant. The growing market for PHI, where people can duplicate the public health care coverage with private health care services, raises concerns regarding the legitimacy of public health care. The aim of this thesis was, therefore, to investigate how PHI affects the legitimacy of the public health care system in Sweden. Three research questions were raised, addressing the prevalence and scope of PHI in Sweden, whether the experience of having PHI affects willingness to pay tax towards public health care, and satisfaction with public services. Four studies consisting of two quantitative cross-sectional studies and two qualitative interview-based studies were conducted to answer these questions. The results indicate that PHI in Sweden provides benefits foremost for the healthy and wealthy. The findings furthermore suggest that the first dimension of health care legitimacy (willingness to pay tax towards public health care) does not seem to be reduced by the experience of having PHI. Regarding the second dimension of legitimacy (satisfaction with the public services), the results are mixed. PHI-funded services were preferred over publicly funded services in terms of access and service quality within the primary care sector, while the medical quality of the public sector was considered high. In conclusion, the legitimacy of the public health care system in Sweden appears fairly resilient to the impact of PHI, although decreasing satisfaction might, in the long run, challenge the stability of the system

Private Health Insurance in Sweden : Implications for the legitimacy of the public health care system

The market for private health insurance (PHI) is growing in many countries with public, tax-funded health care systems. In Sweden, this development has generated an at times intense and polarised debate, exposing that the principles on which the public health care system rests in many aspects collide with the construction of PHI. Two dimensions have been suggested as being important for maintaining the legitimacy of public health care systems. The first is that citizens support the normative principles underpinning the system, including solidaristic funding through general taxation. With this comes the willingness of the population, and in particular the middle classes as net contributors, to pay tax to support the system. The second dimension is related to how the population perceives the performance of public services, as it has been suggested that public services need to be of sufficiently high quality for private alternative to be considered redundant. The growing market for PHI, where people can duplicate the public health care coverage with private health care services, raises concerns regarding the legitimacy of public health care. The aim of this thesis was, therefore, to investigate how PHI affects the legitimacy of the public health care system in Sweden. Three research questions were raised, addressing the prevalence and scope of PHI in Sweden, whether the experience of having PHI affects willingness to pay tax towards public health care, and satisfaction with public services. Four studies consisting of two quantitative cross-sectional studies and two qualitative interview-based studies were conducted to answer these questions. The results indicate that PHI in Sweden provides benefits foremost for the healthy and wealthy. The findings furthermore suggest that the first dimension of health care legitimacy (willingness to pay tax towards public health care) does not seem to be reduced by the experience of having PHI. Regarding the second dimension of legitimacy (satisfaction with the public services), the results are mixed. PHI-funded services were preferred over publicly funded services in terms of access and service quality within the primary care sector, while the medical quality of the public sector was considered high. In conclusion, the legitimacy of the public health care system in Sweden appears fairly resilient to the impact of PHI, although decreasing satisfaction might, in the long run, challenge the stability of the system

Does voluntary health insurance reduce the use of and the willingness to finance public health care in Sweden?

Voluntary private health insurance (VHI) has generally been of limited importance in national health service-type health care systems, especially in the Nordic countries. During the last decades however, an increase in VHI uptake has taken place in the region. Critics of this development argue that voluntary health insurance can undermine support for public health care, while proponents contend that increased private funding for health services could relieve strained public health care systems. Using data from Sweden, this study investigates empirically how voluntary health insurance affects the public health care system. The results of the study indicate that the public Swedish health care system is fairly resilient to the impact of voluntary health insurance with regards to support for the tax-based funding. No difference between insurance holders and non-holders was found in willingness to finance public health care through taxes. A slight unburdening effect on public health care use was observed as VHI holders appeared to use public health care to a lesser extent than those without an insurance. However, a majority of the insurance holders continued to use the public health care system, indicating only a modest substitution effect

Market-orienting reforms in rural health care in Sweden : how can equity in access be preserved?

Background: Health care provision in rural and urban areas faces different challenges. In Sweden, health care provision has been predominantly public and equitable access to care has been pursued mainly through public planning and coordination. This is to ensure that health needs are met in the same manner in all parts of the country, including rural or less affluent areas. However, a marketization of the health care system has taken place during recent decades and the publicly planned system has been partially replaced by a new market logic, where private providers guided by financial concerns can decide independently where to establish their practices. In this paper, we explore the effects of marketization policies on rural health care provision by asking how policy makers in rural counties have managed to combine two seemingly contradictory health policy goals: to create conditions for market competition among health care providers and to ensure equal access to health care for all patients, including those living in rural and remote areas. Methods: A qualitative case study within three counties in the northern part of Sweden, characterized by vast rural areas, was carried out. Legal documents, the "accreditation documents" regulating the health care quasi-markets in the three counties were analyzed. In addition, interviews with policy makers in the three county councils, representing the political majority, the opposition, and the political administration were conducted in April and May 2013. Results: The findings demonstrate the difficulties involved in introducing market dynamics in health care provision in rural areas, as these reforms not only undermined existing resource allocation systems based on health needs but also undercut attempts by local policy makers to arrange for care provision in remote locations through planning and coordination. Conclusion: Provision of health care in rural areas is not well suited for market reforms introducing competition, as this may undermine the goal of equity in access to health care, even in a publicly financed health care system