Equity under pressure: An intersectionality-based policy analysis of Sweden’s COVID-19 response

Equity under pressure: An intersectionality-based policy analysis of Sweden’s COVID-19 response | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Equity under pressure: An intersectionality-based policy analysis of Sweden’s COVID-19 response Linnea Stansert Katzen, Daniela Holmberg, Jesper Löve, Ann Liljas, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9117388/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The COVID-19 pandemic exposed and, in many contexts, intensified pre-existing inequalities, highlighting the importance of examining how vulnerability and equity were conceptualised within pandemic governance. Sweden’s response, characterised by voluntary recommendations, provides an instructive case for analysing how epidemiological rationalities, civil liberties, and social equity were negotiated. This study applies an Intersectionality-Based Policy Analysis (IBPA) framework to examine how vulnerability was framed and how equity considerations were rendered visible and operationalised in COVID-19 management. Methods IBPA was applied to three data sources across Sweden’s governance levels: national press conference transcripts (n = 198), regional interviews with public health officials (n = 8), and municipal focus groups and interviews with health and civil society representatives (n = 11). Data were analysed thematically, first inductively and then guided by IBPA. Results Three interrelated themes (six sub-themes) were identified. First, vulnerability was predominantly framed in biomedical terms, with hospital-based care serving as the implicit reference point for action, recognition, and responsibility. Second, national communication relied on broad population categories, generating tension between epidemiological clarity and the socially patterned feasibility of compliance, while shifting interpretative work to regional and municipal actors. Third, uneven mandate clarity and variable inter-agency coordination shaped implementation; where communication was unidirectional or ambiguous, downstream burdens intensified and operational dilemmas emerged. Local adaptation enabled responsiveness but also exposed fragilities in coordination and decision support. Conclusion The findings indicate a persistent tension between standardised rapid guidance and context-sensitive governance. Protection was shaped not only by epidemiological risk but also by working and housing conditions, linguistic access, trust, and the governance architecture distributing interpretive and coordination responsibilities across institutional levels. Equitable crisis management may be strengthened through clear mandates, effective coordination, and sustained reciprocal communication embedded across governance levels. Integrating experiential and intersectional perspectives into preparedness planning may strengthen institutional capacity and support more context-responsive and resilient public health responses in future crises. Background The COVID-19 pandemic has constituted not only a global health crisis but also a critical test of policy frameworks’ capacity to recognise and respond to population heterogeneity in the formulation of recommendations and interventions. By May 2023, when the pandemic was no longer classified as a public health emergency, 765,222,932 cases and nearly seven million deaths had been reported worldwide [ 1 ]. Both the burden of disease and its wider social consequences were unevenly distributed. Evidence from diverse contexts indicates that pandemic responses intersected with, and at times intensified, pre-existing social and economic inequalities [ 2 , 3 ]. Elevated risks were documented among older adults [ 4 , 5 ], minority populations [ 6 , 7 ], people with lower incomes [ 8 ], migrants [ 9 , 10 ], and residents of socio-economically disadvantaged areas [ 7 ]. These patterns underscore the importance of examining how the pandemic and its policy responses were conceptualised [ 11 ], and of attending to the intersecting factors shaping exposure, susceptibility, and the capacity to withstand both infection and its broader social effects [ 12 – 14 ]. Pandemic management strategies varied considerably across national contexts, reflecting distinct institutional traditions, political cultures, and understandings of state responsibility and citizens’ rights [ 15 , 16 ]. Sweden’s approach—centred on voluntary recommendations and appeals to individual responsibility rather than legally enforced lockdowns—offers an instructive case for examining how policy assumptions mediated tensions between epidemiological rationalities, civil liberties, and social equity [ 15 , 17 , 18 ]. Sweden experienced one of Europe’s highest COVID-19 mortality rates during spring 2020, particularly within long-term care settings, while later followed a more differentiated trajectory [ 5 ]. This temporal variation highlights the need to assess pandemic governance beyond immediate epidemiological outcomes, with sustained attention to distributive effects, ethical considerations, and structural conditions over time. Where patterned differences in impact between social groups are evident, such disparities warrant closer scrutiny of the assumptions informing public health decision-making. Retrospective critical policy analysis contributes to this task by examining not only policy outcomes but also the normative premises through which problems are framed and rendered actionable [ 11 ]. As Bacchi [ 19 ] observes, policies do not merely respond to social problems; they participate in constituting them. Public health policy operates through formal instruments such as legislation and regulation, but also through discursive practices that shape what is recognised as risk, responsibility, and legitimate intervention [ 17 ]. The authority to determine which perspectives are foregrounded and which remain peripheral plays a central role in structuring the policy landscape [ 11 ]. Analysing these processes enables scrutiny beyond discrete decisions to examine the assumptions, silences, and power relations that shape policy processes: whose needs and experiences are recognised, and whose remain unarticulated? Intersectionality provides a conceptual lens for engaging with these questions by foregrounding how social positions—such as gender, age, socio-economic position, and migration status—intersect with institutional governance, cultural norms, and structural hierarchies [ 20 ]. These intersections influence exposure, and susceptibility to health risks, as well as the capacity to mitigate them [ 12 ], thereby shaping resilience in times of crisis. The Intersectionality-Based Policy Analysis (IBPA) framework [ 21 ] addresses a limitation of conventional policy analysis: the tendency to treat socially patterned risks, biological factors, and structural determinants of health as analytically separate rather than mutually constitutive [ 22 , 23 ]. By centring lived experience, contextual specificity, and epistemic plurality, IBPA enables a more critical appraisal of how social difference is constructed and governed within policy processes [ 21 ]. Despite the relevance of intersectional perspectives to the COVID-19 pandemic, their systematic integration into policy analyses has remained limited [ 10 , 24 , 25 ]. The pandemic’s entanglement with everyday living conditions, work environments, and social relations underscored the interdependence of structural determinants of health. Insufficient attention to these interconnections within pandemic governance may have contributed to the emergence or deepening of health inequities [ 25 , 26 ]. Against this backdrop, the study examines how equity considerations were articulated—or rendered less visible—within Sweden’s COVID-19 policy response, with particular attention to the initial acute phase, and considers implications for strengthening institutional and societal capacity to reduce risk exposure and enhance resilience in future pandemics. Objectives Applying the IBPA framework, this study examines how policy discourse and decision-making in Sweden’s COVID-19 response engaged with the socially differentiated contexts of health and illness. It pursues the following specific objectives: To analyse how Sweden’s COVID-19 policy responses recognised—or overlooked—variations in living conditions, structural determinants, and differentiated vulnerabilities across population groups, using an intersectionality-informed analytical lens. To examine how vulnerability and pandemic policy were framed and problematised, with particular attention to the perspectives, rationalities, and practices of key policy actors involved in the formulation and implementation of the response. Methods and material Methodological framework This study forms part of the broader EMBRACE project, which employs an integrated mixed-methods design to examine patterns of inequity in vulnerability to COVID-19 and to analyse interactions between public health institutions and local communities in managing of pandemic-related risks. The present sub-study is qualitative. It integrates two complementary policy analysis approaches—intersectionality and policy discourse analysis—which informed the study’s conceptual design. The IBPA framework guided the analytical design by structuring attention to how vulnerability, resilience, and relative advantage were represented across institutional levels [ 21 ]. It oriented the study towards examining how policy framings engaged with intersecting social positions and structural conditions within pandemic governance. In accordance with this framework, the analysis attended to nine identity dimensions commonly referenced in intersectionality scholarship: age; educational and employment status; ethnicity and indigeneity; gender and sex; income and material conditions; mental and physical characteristics; migration background; sexual orientation; and religion (definitions provided in Supplementary file 1). These dimensions are understood as socially situated and context-dependent, shaping lived experience as well as how individuals and groups are positioned within institutional and cultural frameworks [ 27 ]. Their intersections may generate marginalisation or relative privilege, depending on context. The analysis therefore approached identity categories as relational rather than fixed, attending to how their significance was produced within specific policy and governance settings. The study also drew on Bacchi’s problematisation approach [ 19 , 28 ], particularly the question ‘What is the [public health] problem represented to be?’, to examine how pandemic-related risks and responsibilities were discursively constructed. This lens supported critical interrogation of dominant framings and consideration of how alternative representations might render different inequities. Together, these approaches shaped the research questions, guided data collection, and oriented analytical strategies, ensuring attentiveness to structural conditions, institutional practices, and lived experiences across multiple levels of the policy process. Researcher characteristics and reflexivity This study was conducted by an interdisciplinary team of eight researchers with diverse disciplinary backgrounds, academic career stages, ages, and gendered and lived experiences across four continents. Guided by the IBPA framework, reflexive attention was given to how positionalities may have shaped interpretations of Swedish policy responses. Differing intersectional positions in relation to Swedish authorities and majority society—reflecting variations in institutional proximity, social location, and experience of governance contexts—enabled both contextual sensitivity and analytical distance in examining the material. Throughout the research process, iterative team discussions and ongoing analytic reflexivity were used to surface assumptions, examine power relations embedded in policy strategies, and consider how epistemic standpoints shaped knowledge production, thereby strengthening the study’s credibility, transparency, and analytical rigour. Context Sweden’s crisis and public health governance is organised according to constitutionally grounded principles of administrative autonomy and decentralisation, as set out in the Instrument of Government and sectoral legislation [ 29 – 32 ]. Responsibilities are distributed across national authorities, 21 self-governing regions, and 290 municipalities, each operating within defined statutory mandates [ 31 ]. At the national level, the Public Health Agency of Sweden (Folkhälsomyndigheten, FHM) holds responsibility for public health and communicable disease control under the Communicable Diseases Act and its agency ordinance [ 29 ]. Its mandate includes epidemiological surveillance, risk assessment, the issuance of regulations and recommendations, and public communication. In a pandemic, this encompasses monitoring infection trends, issuing guidance on testing, isolation and vaccination, and providing recommendations to sectors such as healthcare, education and workplaces [ 29 ]. The Swedish Civil Contingencies Agency (Myndigheten för samhällsskydd och beredskap, MSB; since 1 January 2026, Myndigheten för civilt försvar) is responsible for civil protection and national crisis management [ 33 , 34 ]. Its remit includes risk and vulnerability assessments, preparedness planning, and cross-sectoral coordination. While it does not determine communicable disease control measures, it supports inter-agency coordination, crisis communication systems, and logistical and continuity planning across sectors during public health emergencies [ 33 ]. The National Board of Health and Welfare (Socialstyrelsen, SoS) provides regulatory oversight and knowledge-based support for health and social care under the Health and Medical Services Act [ 30 , 35 , 36 ]. In public health emergencies, its functions include issuing binding regulations and general guidance, coordinating national resources and medical supplies, monitoring healthcare capacity, and supporting regional and municipal service planning. Within this decentralised system, the regions are responsible for organising and delivering healthcare and for implementing communicable disease control measures through regional infectious disease control physicians [ 29 – 31 ]. In a pandemic context, they operationalise national regulations and recommendations by organising testing and vaccination, ensuring infection prevention and control, and managing hospital and intensive care capacity. Sweden’s 290 municipalities are responsible for welfare and community services, including social services, eldercare, disability services, certain healthcare in residential and home-based settings, and compulsory and upper secondary education [ 31 , 37 ]. In a pandemic context, they implement infection prevention measures within these services and adapt local operations in accordance with national regulations and regional guidance [ 36 ]. The governance model thus distinguishes between national-level regulation and coordination, regional healthcare delivery and medical communicable disease control, and municipal responsibility for locally delivered welfare services. While mandates are formally delineated, effective pandemic management requires ongoing coordination across levels of government [ 31 , 36 , 38 ]. Data sources and data collection The qualitative study drew on three complementary data sources to capture multiple sites at which pandemic policy was formulated, communicated, and interpreted: 1) national-level press conference materials (PCM); 2) regional-level key informant interviews (KII) with pandemic leadership; and 3) municipal-level focus group discussions (FGD) and individual municipal-level interviews (IMI) with representatives of public health services and civil society organisations [Table 1 ]. Together, these sources enabled analysis across institutional levels within Sweden’s decentralised governance structure. Table 1 Overview of the data sources, participants and periods of data collection across societal levels. Societal level Participants Data category Data collection period National Representatives of FHM, MSB, and SoS, The Swedish Medicines Agency, The Swedish Association of Municipal Authorities and Regions. Press conference materials, video recordings and transcripts March 2020 - March 2022 Regional Directors of health and health care, vaccine coordinators, and infectious disease control managers. Key informant interviews Aug 2023 - Feb 2024 Municipal Representatives of primary healthcare centres, care homes for older adults; civil society organisations (including community meeting spaces, health initiatives, religious organisations). Focus group discussions and individual municipal-level interviews April - June 2024 National-level press conferences The press conference material (n = 198) comprised video recordings and transcripts from national briefings conducted between March 2020 and March 2022. These briefings were primarily led by FHM, with regular contributions from MSB and SoS and occasional participation from other governmental bodies. Although formally intended to inform the public, the briefings also provide insight into official communication practices, representations of risk, and the construction of target audiences. All available recordings and transcripts were included to enable comprehensive analysis of national-level policy communication. Materials were obtained from FHM’s press department via email request (14 February 2023). Regional-level key informant interviews Eight KII were conducted between August 2023 and February 2024 with senior officials in the Stockholm and the Västra Götaland regions, encompassing Sweden’s largest metropolitan areas. Participants were purposively selected public health actors with responsibilities for regional healthcare coordination, immunisation, and infectious disease control, and with direct involvement in pandemic-related decision-making. These interviews provided insight into how national guidance was interpreted, negotiated, and operationalised at the regional level, as well as how it was coordinated with and translated into practice in collaboration with municipal authorities. Municipal level focus group discussions and individual interviews At the municipal level, stakeholders within the two study regions were invited to participate in FGDs (n = 5) or IMIs (n = 6). Recruitment focused on DeSo areas (Demographic Statistical Areas) with the highest reported COVID-19 mortality rates among individuals aged 70 years and older, to engage actors working in contexts heavily affected during the initial phase of the pandemic. Participants were invited through primary healthcare centres, care homes for older adults, and civil society organisations (CSOs), including community meeting spaces, health initiatives, and religious organisations. Of 56 individuals invited, 18 participated in five FGDs (three to six participants per group), and six participated in IMIs, either due to scheduling constraints or preference for an individual format. These data illuminate how pandemic measures were enacted and experienced within locally delivered welfare and community services. Data collection procedures All interviews (KIIs, FGDs and IMIs) lasted approximately 60–90 minutes and were conducted by one or two members of the research team (AL, GP, LSK or MAA) using a semi-structured interview guide informed by the IBPA framework and complementary policy discourse analysis [ 19 , 28 ]. The guide addressed organisational roles and mandates, experiences of pandemic management, perceived challenges, examples of effective practice, and lessons learned (Supplementary file 2). All KIIs and FGDs were audio-recorded and transcribed verbatim. IMIs were likewise audio-recorded and transcribed, with the exception of one interview in which detailed notes were taken at the participant’s request. The use of multiple interview formats allowed flexibility in accommodating participants’ availability and preferences, while supporting depth and diversity of the empirical material. Data analysis To operationalise analysis of intersecting structural, normative, and identity dimensions, the study drew on the twelve core questions of the IBPA framework, organised into descriptive and transformative components [ 21 ]. These components partly overlap with Bacchi’s critical policy analysis approach [ 19 , 28 ]. The present analysis focused on the first six questions, which constitute the descriptive dimension. These address researcher positionality (Q1), the framing of policy problems (Q2-3), and how such framings shape the representation and treatment of different social groups (Q4-5). The sixth question identifies inequities emerging from the analysis and functions as a conceptual bridge to the transformative dimension. The latter (Q7–12), which concerns interventions and processes of change, falls beyond the scope of this study but will inform subsequent phases of the EMBRACE project. Data were analysed using thematic analysis, selected for its flexibility and suitability for identifying and interpreting patterns across heterogeneous qualitative material [ 39 ]. This approach enabled attention both to situated accounts and to the broader structural and discursive contexts in which they were embedded. The first analytical phase was primarily inductive. Line-by-line coding of PCM’s and interview transcripts facilitated close engagement with communicative practices and participants’ accounts. ATLAS.ti supported systematic organisation of the material. To enhance credibility, coding was conducted independently by pairs of researchers (AL and LSK; DH and LSK; DH and GP; LSK and MAA). For each pair, a randomly selected 20% subset of the same material was independently coded by a researcher not involved in the initial coding. Codes were compared and refined through iterative discussion to strengthen consistency and transparency. In the second phase, analysis adopted a more deductive orientation. Inductively generated codes were revisited and organised in relation to the IBPA guiding questions [ 21 ] in dialogue with Bacchi’s problematisation approach [ 19 ]. The process involved developing theoretically informed subthemes and synthesising overarching themes. The first and last authors led this stage, with iterative refinement through critical dialogue within the full research team. Consistent with the IBPA’s reflexivity commitments, discussions explicitly addressed positionality, interpretative assumptions, and potential sources of bias [ 21 ]. In parallel, emerging themes were examined in relation to organisational documents from FHM, SoS, and MSB, relevant scientific publications, and contemporary media coverage. Pre-pandemic preparedness guidance and other institutional texts were used to contextualise press conference statements and clarify formal mandates and roles [ 32 , 35 , 37 , 46 , 48 ]. As part of analytic validation, preliminary findings were presented at two stakeholder workshops in Stockholm and Gothenburg. All organisational representatives previously invited to FGDs, KIIs or IMIs were re-invited; 14 participated. These sessions enabled contextualisation and critical reflection on emerging interpretations, contributing to a more dialogical and situated understanding of the material [ 40 ]. Taken together, these strategies supported analytical rigour by integrating multiple data sources, reflexive team-based interpretation, stakeholder engagement, and systematic contextualisation within broader institutional and public discourses. Results and discussion The analysis identified three interrelated themes illuminating how pandemic policies were interpreted, adapted, and enacted within contexts shaped by intersecting living conditions and structural constraints. The themes are situated primarily in the uncertainties that characterised the early phases of the pandemic, when scientific knowledge was evolving and policy responses were shaped by tensions between predominantly biomedical framings and broader social and public health perspectives. Across themes, vulnerability emerged less as a fixed attribute than as something produced through intersecting discourses, classificatory practices, and institutional arrangements, shaping how guidance could be interpreted and enacted, which groups were reached, and how protection was distributed. The findings also point to the practical difficulties of mobilising organisational structures to support reciprocal communication and locally responsive interventions in a rapidly changing situation. More broadly, the analysis highlights tensions between formal preparedness frameworks and the contingencies of everyday practice, suggesting a need to reflect on the epistemological assumptions, policy discourses, and organisational routines—particularly those shaping communication across administrative levels—that condition how diverse social circumstances and structural inequities are recognised in public health emergencies. [Table 2 ]. Table 2 Identified themes and sub-themes illustrating intersectional dynamics in pandemic governance. Theme Sub-themes Moving beyond one-dimensional vulnerability and towards balanced biomedical-social framing Cyclical shifts in emphasis between biomedical and social determinants Shifting boundaries between medical and social domains of practice Making sense of generalisations amid local complexity and diverse population realities From categorical classifications to emerging awareness of intersecting social factors Local translation of broad population categories in diverse community contexts Negotiating institutional relationality and adaptive practises in pandemic governance Translating national recommendations in the absence of contextualised guidance Institutional coherence and reciprocal communication dynamics across governance levels Moving beyond one-dimensional vulnerability and towards a more balanced biomedical-social framing This theme examines how vulnerability—and responsibility for those positioned as vulnerable—was constructed in Sweden’s COVID-19 response, and how these constructions shifted over time. The analysis examines how vulnerability and responsibility for protection were framed: which dimensions were foregrounded or backgrounded over time, how they intersected, and with what implications for policy reasoning and practice. Cyclical shifts between biomedical risk and social determinants Pre-pandemic preparedness guidance distinguished predictable from unpredictable threats and acknowledged uncertainty regarding which groups might be most affected [ 32 ]. Early public communication reflected this orientation. Approximately six weeks after the first confirmed case, it was emphasised that: “Protecting vulnerable groups /…/ is what the entire fight against the pandemic is all about” (PCM 200310). Initially, attention centred on “identifying sick people who had been in areas where they could have been infected” (KII1). As mortality increased, the focus shifted towards individual susceptibility and biomedical categorisation. Age—and to a lesser extent biological sex—became prominent reference points in press briefings (e.g. PCMs 200321-0420). Risk was communicated through categorical contrasts (“the younger you are, the lower your risk”) and through appeals to protect older adults in the interest of health-system sustainability, including concern that intensive care entailed “a lot of time and resources and suffering for them and those around them” (PCMs 200321-0402). Vulnerability thus became closely aligned with measurable clinical attributes. Age and underlying conditions (diabetes, cardiovascular disease, and respiratory disorders) were repeatedly foregrounded (PCM 200316): ”Age is the main risk factor, but there are also other illnesses” (PCM 200413); “older people, especially those with underlying health conditions” [ 41 ]. By contrast, intersecting social determinants shaping exposure, capacity to follow recommendations, or access to support were comparatively under-articulated in early communications. Several informants described how social dimensions of vulnerability were not initially integrated at what they termed “the healthcare sector’s strategic level” (KII8). A predominantly biomedical rationality was perceived to structure early policy attention (KII5), requiring equity-oriented actors to “start knocking on different doors to raise awareness of equity perspectives” (KII8). Participants suggested that preparedness frameworks would benefit from more systematic incorporation of socio-structural considerations, including attention to “socio-economic structures” and those not “fully integrated into the welfare system” (KII6). As one interviewee observed, substantial effort was required to render visible that the pandemic was “not solely a matter of biology but also shaped by the broader circumstances individuals were experiencing.” (KII4). The case of older adults illustrates the limits of narrowly biomedical framing. Although the “70+” category was occasionally acknowledged as socially constructed (KII4), its wider policy and lived implications were seldom explored beyond specific debates (e.g. physicians over 70 continuing practice, PCM 200512). When isolation recommendations were introduced, participants noted that, while protective in intent, their broader consequences were not always fully anticipated (PCM 210701). Psychosocial harms among young people were periodically discussed (e.g. PCM 200316; PCM 200423; PCM 200529; PCM 201105), whereas comparable effects among older adults were perceived by some as receiving less sustained attention (FGD3; IMI2; IMI3). Some interviewees reflected that the impact of isolation at times exceeded what could be considered ethically proportionate (KII2; IMI3; IMI5). Another described profound loneliness among those without family contact: “Those who didn’t have any family... they had no one. They were completely alone, completely isolated. So, many people suffered enormously from this, from the isolation. It was bearable if you had /…/ relatives that visited. Even if there was a plexiglass [in between], at least someone was visiting.” (FGD2) As the pandemic unfolded, broader socio-economic consequences gained visibility. One participant remarked that “it didn’t really sink in until after a while” (KII3), and later press briefings acknowledged that “people in poverty, mental illness and addictions, their situation has worsened” (PCM 200209). Several participants described a temporary broadening of vulnerability to include social and material conditions alongside biological risk (KII2; KII4; KII8; FGD3). Yet, some perceived this expansion as short-lived: “Today, vulnerability tends to again be framed more narrowly, with recommendations focusing predominantly on biological aspects.” (KII8) Taken together, this trajectory suggests a cyclical pattern in which social dimensions of health intermittently gain visibility before receding in favour of biomedical framing. Such shifts matter because they stabilise particular forms of knowledge within public discourse and influence whether social conditions are recognised as shaping exposure and the practical capacity to comply with recommendations [ 21 ]. Prioritising clinical risk is understandable in the context of an acute infectious threat. Participants did not question the relevance of biological risk; rather, they highlighted that its interaction with social conditions was insufficiently integrated, particularly in the early stages. Although preparedness guidance articulated an ambition to minimise mortality and morbidity while also considering “other negative consequences for individuals and society” [ 32 ], its operational direction on how biological vulnerability intersects with socio-economic conditions appears limited, also documented elsewhere [ 4 , 42 – 44 ]. This is notable given the extensive evidence demonstrating how social determinants shape exposure and health outcomes [ 12 – 14 ] and given their formal embedding within Swedish public health policy [ 32 , 45 ]. While Sweden has been characterised as pursuing a research-informed approach in which expert agencies played a central role and the pandemic was not primarily framed as a political issue—alongside a public health rather than solely infection-control orientation [ 18 , 45 ]—the present findings indicate that this did not translate into the predominance of a social determinants perspective. During the initial phase of the pandemic, biomedical and clinical framings retained greater influence in shaping the response, despite established public health commitments to address interactions between biological and social conditions [ 32 ]. Shifting boundaries between medical and social domains of practice This sub-theme shifts from the definition of vulnerability to the institutional and professional contexts in which those designated as “vulnerable” were to be protected and cared for. It focuses on how responsibility and failure were narrated, and how these narratives shaped which institutional sites were positioned as central to the response and which were rendered peripheral or deficient. A marked asymmetry emerged in representations of hospital staff and municipal eldercare personnel (PCM 200504). Preparedness and response efforts appeared more consistently oriented towards hospital and emergency care settings than towards the organisational realities of residential eldercare [ 32 ]. Several participants described early national recommendations (e.g. PCM 200415; PCM 200528; PCM 200929) as insufficiently attuned to the conditions of care homes. Guidance on personal protective equipment, isolation and infection control did not fully reflect differences in training, staffing ratios and material infrastructures between municipal eldercare and regional hospitals, the latter operating in environments more closely aligned with intensive care standards (FGD1; FGD3). One informant recounted initiating “hygiene education” for municipal staff (KII7), despite this falling outside their formal remit, to compensate for perceived gaps. When outbreaks occurred in care homes, official responses often foregrounded site-specific review—“take a closer look at certain nursing homes to get a better picture of how we can help stop the spread of infection” (PCM 200406)—rather than articulating broader preparedness strategies or mechanism for sustained inter-organisational collaboration. Indications of limited institutional familiarity with the everyday organisation of care homes (e.g. PCM 200506) are notable given the substantial proportion of older adults residing in such settings (KII5). In line with previous research [ 46 ], the findings suggest that the pandemic exposed structural limitations in preparedness for eldercare contexts, despite advancing age being consistently identified as a key risk factor in national guidance [ 32 ]. Media narratives rendered this asymmetry particularly visible. Hospital personnel—particularly those working in technologically intensive settings such as intensive care—were publicly celebrated as “heroes in all the newspapers” (FGD1). By contrast, eldercare staff were described as “constantly questioned … even though they were working triple shifts and doing their best. … There was no trust in the staff” (FGD1). As mortality increased, professionals in residential eldercare were at times positioned as responsible (FGD3), whereas the national and regional authorities with formal mandates for coordination and support to municipal healthcare during pandemics [ 32 , 47 ] were less visibly scrutinised. As one respondent reflected: “It’s sad that eldercare ended up taking a great deal of undeserved flak, actually. … Eldercare has been made the scapegoat. … People didn’t understand that this isn’t healthcare. At its core, it’s a social intervention.” (FGD3) Accounts of intense media scrutiny further illustrate how stigma was experienced and narrated: “They [nursing assistants in eldercare homes] were really smeared by society. SVT [Swedish Television] was outside the windows, filming through the doors. We were on the news; we were on the radio and in the newspapers. [They were] saying that things were badly run. Even though it wasn’t really about that, it was about resources and what was possible to do. So, I became the ‘death nurse’. That’s how society portrayed me. There was a professor who was very categorical in his television statements /…/ saying that we euthanise older adults and don’t provide them with care.” (FGD1) While such explicit allegations were not identified in official communications (see, for example, PCM 200616), a broader discursive imbalance remained evident. Narratives of accountability, heroism and failure appeared unevenly distributed across institutional sites, with recognition and blame attaching to different professional locations. These patterns resonate with research indicating that work oriented towards the medically defined body tends to command higher institutional status, whereas expertise concerned with the social and relational dimensions of older people’s wellbeing remains comparatively less visible within governance arrangements [ 4 ]. The material (e.g. in KII6) also echoes scholarship on stratified conditions within care work, where residential care staff frequently occupy lower-paid and less formally recognised positions than hospital-based professionals [ 46 ]. The divergent representations of professional groups—each tasked with safeguarding those identified as most vulnerable—suggest that professional identity and structural inequalities shaped both pandemic governance and its lived consequences. When outcomes deteriorated in residential eldercare, participants described pandemic discourse as largely focusing on frontline practice and individual facilities, while the systemic conditions shaping what was feasible—resources, staffing, training, and coordination—were less consistently foregrounded. This asymmetry was not only descriptive but constitutive: hospitals became implicit reference points for preparedness, while municipal eldercare remained less visible within the policy imagination despite being central to protecting those repeatedly designated as most vulnerable. From an intersectional perspective, these dynamics reflect epistemic hierarchies in which biomedical knowledge and hospital-based spaces were privileged over social care contexts. In this configuration, education, employment conditions, and organisational location operated not merely as background characteristics but as structuring forces shaping professional visibility, legitimacy, and exposure to blame [ 21 ]. Such hierarchies may help explain why the early response, while coherent in biomedical terms, was less attuned to the institutional, relational, and material conditions through which vulnerability and resilience were constituted in everyday eldercare settings [ 48 ]. In this sense, pandemic management not only defined risk but also established hospital-based norms as benchmarks against which eldercare settings were assessed, without fully recognising their distinct care mandates and resource conditions. Making sense of generalisations amid local complexity and diverse population realities This theme examines the discursive construction of the ‘population’ within pandemic recommendations: how authorities defined those to be guided, and how such framings were interpreted and negotiated by actors working in direct contacts with communities. Two interrelated patterns emerged. First, national communication relied on broad, generalised categories that did not consistently reflect the intersecting social realities through which vulnerability was lived. Second, these categories required substantial interpretative work at regional and municipal levels, where actors were tasked with rendering abstract classifications meaningful in concrete settings. From categorical classifications to emerging awareness of intersecting social factors As noted, early communication privileged biomedical risk, with less explicit engagement with social and material conditions. A related simplification involved reliance on broad categories or singular identity markers, rather than recognition of intersecting determinants of vulnerability. During the initial phase—when individuals sought urgently to interpret official advice in relation to their own circumstances—the term “population” was frequently invoked as if denoting a relatively homogenous whole (PMC 200310; PCM 200316; PCM 200528). Recommendations to avoid public transport, work from home, and self-isolate illustrate this simplifying dynamic (PCM 200316; PCM 200402; PCM 200611). As one key informant observed, such guidance presupposed employment and housing arrangements that were not universally available. Workers in close contact with travellers, including taxi and bus drivers, were largely absent from early communications despite concerns about travel-related transmission (PCM 200310; FGD3; FGD5). When occupational exposure in service sectors was later addressed, it was described as a “superficial review” (PCM 200625). Similarly, advice to “stay at home if you are sick” (KII2), while epidemiologically coherent, did not explicitly engage with multi-generational or space-constrained households (PCM 200407). In such contexts, remaining at home did not necessarily reduce risk for co-habiting relatives, particularly where effective isolation was impracticable. A comparable pattern emerged in labour market contexts. For workers in eldercare, transport, and other public-facing services—many employed on temporary or hourly contracts—the ability to comply with national guidance was also shaped by income insecurity and limited employment protection (FGD3). As one participant reflected: “You don’t just tell a mother with five children to ‘stay home.’ She has to pay rent at the end of the month. Even if she has symptoms, she doesn’t want to stay home—she wants to go to work, and that affects older adults. Most people in this area work as assistant nurses, in home care, as bus drivers, or taxi drivers, so they meet lots of different people and spread the infection.” (FGD4) Here, the constraint lay not in disregard for recommendations but in limited room for manoeuvre within particular structural conditions. Although temporary increases in sick pay were introduced (PCM 200504), participants continued to describe uncertainty about job continuity and the consequences of absence (IMI1; FGD3). In this respect, generalised recommendations risked becoming normatively compelling without being fully actionable across diverse employment contexts. Even highly visible categories, such as age, were frequently framed in homogenising terms. The ‘70+’ group was presented as internally uniform despite considerable variation in health status, social participation, and living arrangements. Although media reporting at times acknowledged such heterogeneity [ 49 ], participants observed that nuance was rarely reflected in official recommendations. Public communication thus stabilised age as a singular defining marker and older adults as uniformly vulnerable. Some participants described this as experienced by certain older individuals as paternalistic: “My impression is that some seniors felt they were losing their autonomy—that someone else was telling them what to do—and that it was a strange situation: ‘I am an adult, and now I am not allowed to make my own decisions about my life; instead, the state has stepped in and told me what I can and cannot do’. This caused frustration.” (FGD4) Another prominent categorisation concerned “people with an immigrant background” (KII2). The term—and at times “ethnicity”—was used without clear definition (PCM 210624; KII1; FGD1)[ 50 ]. Migration background was sometimes closely associated with socio-economically disadvantaged areas (PCM 200429; PCM 200618), potentially reinforcing a linkage between ethnicity, place, and risk. At times, it appeared foregrounded as a principal explanatory factor for morbidity patterns: “We saw early in the outbreak people who were born outside Sweden, who had a high morbidity, they ended up in intensive care, and the deaths were significantly more common than among people born in Sweden.” (PCM 200618). Although later communication acknowledged heterogeneity within “foreign-born people” (PCM 210610) and referred more explicitly to socio-economic vulnerability (“low-paid jobs … mental illness and addiction”, PCM 240509), these recognitions were not consistently translated into differentiated public guidance. Patterns of selective visibility thus shaped not only how vulnerability was represented but also who received contextually meaningful advice. Where structural mediators of risk—such as occupational exposure, housing density, employment precarity—remained backgrounded [ 51 , 52 ], differential outcomes risked being attributed to categorical identities rather than to the intersecting structural constraints through which risk was produced and experienced This sits uneasily with the stated ambition of the Swedish pandemic strategy to promote inclusion and recognise diversity (PCM 200306; PCM 200330) [ 53 ]. As previous research suggests, the articulation of policy problems shapes how institutional responsiveness and legitimacy are experienced across diverse social positions [ 51 , 54 ]. The pandemic thus foregrounded the need to further develop public health communication in ways experienced as legitimate and supportive, and more closely aligned with the complex, intersecting realities within which individuals seek to act on advice. Local translation of broad population categories in diverse community contexts This sub-theme examines policy translation: how nationally produced categories entered regional or municipal practice, and the interpretative work required to render abstract classifications meaningful in concrete settings. Participants regarded the identification of locally relevant groups as largely their responsibility, given demographic and social variation (FGD1–3; KII1; KII8), while emphasising the complexity of this task. They described working with groups largely absent from national discourse, including individuals experiencing homelessness, substance dependence, involvement in sex work, or precarious migration status (FGD2; FGD5). Although occasionally mentioned in press briefings, such references often arose in response to journalists’ questions rather than through sustained or proactive framing (PCM 201117). Even where structurally attentive research was available (e.g. [ 55 , 56 ]) participants perceived limited incorporation of these insights into national messaging. More broadly, participants described uncertainty about how epidemiologically derived categories could be rendered actionable for people whose exposure and risk were shaped by overlapping and shifting conditions (PCM 200818; PCM 201117). Statistical abstractions did not readily correspond to lived configurations of work, housing, language, and social networks (FGD3; FGD5). References to the “population” or “majority” (see e.g. PMC 200528; PCM 200316) did not readily correspond to the intersecting social positions encountered in everyday work. Several participants expressed frustration that national authorities did not fully acknowledge the interpretative labour required to translate abstract categories into context-sensitive target groups (FGD1; KII2; KII5; KII8). As one respondent reflected: “You need to think about this when you are responsible for so many people who have different needs and come from different backgrounds.” (FGD3) Public health messaging appeared calibrated to the majority as an implicit population category, leaving local actors operating in socially stratified settings to undertake the necessary interpretative and relational work (FGD3). The practical meaning of recommendations needed to be clarified in direct encounters, when individuals asked, “Does this apply to me?” (KII8). Such questions underscore that policy categories do not automatically correspond to the social positions through which risk is experienced; they require institutional work to render individuals and situations legible within guidance [ 21 ]. As one regional representative explained: “When certain new measures were announced [at the press conferences], we had to adapt quickly. We really needed to identify what worked regionally for our population. ... So, we had to have a lot of municipal meetings... where everyone wants to know, ‘But what does it mean for me? For my football club, my community?’ All these national recommendations needed to be implemented and explained by us locally.” (KII1) Regional and municipal actors expressed readiness to implement national directives; however, alignment with everyday social complexity required ongoing interpretative work. As knowledge of COVID-19 evolved, local actors repeatedly reassessed which groups required targeted communication, rendering translation an iterative process rather than a one-off adjustment (FGD1; KII5; KII7). Importantly, these demands did not immobilise local actors. Rather, participants described extensive—and at times improvised—efforts to maintain contact with diverse groups (FGD2; FGD5), often driven by professional commitment rather than targeted directives. While operational responsibility rested with regional and municipal authorities, limited formal guidance fostered reliance on personal initiative, rendering implementation uneven and at times fragile (FGD1; FGD4). Outreach depended on established networks and individual discretion rather than systematic identification of prioritised groups. As one participant recounted: “There were some older ladies who used to sit and chat together at [local grocery shop]. ‘Where did they go?’ I asked about them, and someone said, ‘They live over there,’ or, ‘Their phone number is…,’ so I could call and give them information. They were so isolated that they didn’t know what to do. Others helped us by giving our phone numbers to older adults, so they could reach us—for example, when we would be at a vaccination site … and we could help them with the language and with information.” (FGD4) Over time, some practitioners also reflected critically on terminology. Whereas national discourse sometimes referred to “hard-to-reach groups” (FGD5), certain regional actors reframed this as a question of institutional accessibility: “We stopped talking about hard-to-reach-groups, because it wasn’t about the groups being hard to reach; it was about us actually having to work from an equal-terms approach. Then our work became more focused on equitably providing information and vaccination.” (KII8) This reframing relocates the issue from presumed deficits within populations to limitations in institutional communication and access pathways, consistent with attention to how problem framings allocate responsibility [ 21 ]. Translation constituted a form of policy work, as actors were required to specify, adapt, and at times reframe national categories so that prioritisation could become understandable locally. Together, these patterns illustrate how centrally produced population categories required translation through local interpretative labour to address vulnerabilities shaped by intersecting social conditions. More broadly, the material suggests that reliance on downstream translation can produce uneven implementation and place substantial burdens on practitioners [ 25 , 47 , 55 ]. In this case, the central challenge was not resistance to national guidance, but the sustained labour required to render abstract categories meaningful within intersecting social realities through which risk was experienced. Negotiating institutional relationality and adaptive practices in pandemic governance Following categorisation, the principal challenge identified by respondents concerned organisational conditions. This theme foregrounds how governance structures shaped implementation, specifically how institutional arrangements facilitated or constrained adaptive capacity, cooperation, and communication across administrative levels. Two analytically distinct but interrelated dynamics emerged. First, how general recommendations were translated into locally meaningful practice. Second, how institutional coherence and reciprocal exchange operated across governance tiers. Translating national recommendations in the absence of contextualised guidance The preceding sub-theme demonstrated how broad population categorisations generated substantial interpretive demands for local actors. Here, the focus shifts from population categorisations to the operational translation of generalised recommendations into measures responsive to differentiated local contexts. Sub-national actors described a deliberate effort to maintain alignment with national messaging—particularly daily press conferences—to avoid confusion and sustain public trust (FGD3; FGD5; KII3). At the same time, regional and municipal respondents reported difficulties in designing and adapting measures amid evolving knowledge about the virus, particularly where national communication was perceived as insufficiently attuned to local conditions. These challenges were understood not merely as technical shortcomings, but as reflecting implicit assumptions about media access, information practices, and linguistic norms (IMI2; FGD3; FGD4; KII2; KII5; KII8). As one participant observed: “The Public Health Agency started with very traditional information for a traditional Swedish majority society /…/ They translated the information, but they didn’t adapt it to the target group, and they still used the traditional channels, which don’t really reach this group. Eventually they realised: ‘Maybe we need some other channels as well’. But by then a lot of time had passed.” (FGD5) Although multilingual materials were made available early (PCM 200406; PCM 200330), translated information was not always experienced as accessible or culturally responsive. Local actors described how guidance perceived as unrealistic or difficult to enact in everyday life could generate distrust, prompting some residents to disengage (FGD3; FGD4; KII3; IMI3). Trust-building thus became a form of relational labour [ 57 ], particularly in communities historically less aligned with mainstream institutional communication. One-way messaging was widely regarded as insufficient; sustained dialogue and repeated encounters were often necessary: “It took time … Some came to us almost every day and asked the same question, and we gave the same answer every day. In the end they did vaccinate, but it required being patient … listening, being present.” (FGD3) A considerable share of the work involved disseminating information within communities unevenly positioned in relation to socio-economic resources, access to mainstream media, and institutional trust. While national agencies formulated general messages, adaptation—selecting channels, tailoring content, and engaging in dialogue—was largely carried by regional, municipal, and civil society actors (PCM 201117). Regional authorities described some formalised preparedness structures, whereas municipal respondents relied heavily on grassroots innovation, often improvised in real time by committed staff and civil society actors (IMI4; KII6; KII8). As knowledge of the virus evolved, recommendations changed accordingly, further complicating local implementation. Municipal actors sought to respond constructively, rapidly reconfiguring activities to sustain social support, including outdoor exercise sessions, balcony concerts in residential care homes, outdoor worship service, walking groups, and assistance with grocery shopping (FGD1; FGD5; IMI1; IMI3). These initiatives frequently drew upon existing relational infrastructure—civil society organisations, faith communities and multilingual health communicators—enabling flexible and rapid responses. Examples included collaboration with a local imam to formulate guidance on gatherings during Ramadan (FGD5), joint vaccine information videos produced by a mosque and a primary care clinic, and tailored outreach at community events for older residents (FGD1; FGD3). Over time, the limits of a standardised risk communication model became more visible at higher administrative levels, particularly regarding groups not routinely engaged by public services (KII8). Regional strategies gradually expanded to include more systematic collaboration with religious and community organisations (FGD5). As one informant noted: “That’s an important lesson: to think about how you can communicate more than one message, how you can reach different places. Later on, we had churches, Muslim organisations, so we were able to reach out to certain groups.” (KII1) A turning point occurred when disparities in vaccine uptake became evident, often overlapping with areas disproportionally affected by severe disease. At a national press conference, these efforts were framed as follows: “The areas with the lowest levels of vaccination coverage were often the same areas as those that had suffered from more severe cases of disease. It was a question of getting information out in every way possible /…/ We had /.../ letters to priority groups /.../ face-to-face meetings /…/ multilingual informers /…/ We worked with community leaders, faith communities, we put up posters, had mobile units, and vaccination buses.” (PCM 210902) Targeted measures were subsequently intensified, including multilingual information, cooperation with faith and community leaders, and mobile vaccination units (FGD1; FGD3; FGD5). Analytically, this juncture may be understood as a partial re-problematisation of vulnerability; disparities in uptake unsettled a purely universal communication model, foregrounding the intersecting social conditions through which protection is accessed. Some respondents, however, questioned whether these outreach initiatives were driven primarily by instrumental objectives rather than a sustained equity orientation, particularly in relation to vaccination (FGD3; KII3; KII5). Overall, this sub-theme highlights the tension between universalised recommendations and the situated practices through which they acquire meaning and practical effect. Local adaptation was indispensable yet made more demanding by evolving knowledge and by the absence of clear guidance regarding how broadly formulated recommendations should be specified. Improvisation—understood as the real-time production of context-sensitive solutions—emerged as both a strength and a structural vulnerability. While it enabled responsiveness to differentiated and intersecting needs, it also meant that access to protection depended significantly on local capacity rather than uniformly embedded governance infrastructures. In such situations, communities with established relational ties may therefore be differently positioned from those without such infrastructures [ 58 ]. In this sense, governance arrangements shape the distribution of protection: where coordination mechanisms and integrative infrastructures are uneven, so too are the conditions under which populations access timely and adequate support [ 59 ]. Governance design is therefore implicated in patterned distribution of risk and protection across intersecting social contexts. Institutional coherence and reciprocal communication dynamics across governance levels This sub-theme examines how formal mandates, communication channels, and inter-agency coordination shaped the translation of national strategies into practice across governance levels. Participants generally described existing arrangements as only partially supportive of implementing nationally announced pandemic measures (FGD1; KII5; KII6). Relationships between national and sub-national authorities were characterised unevenly. Collaboration between regions and FHM was often depicted as constructive and reciprocal, facilitated by early establishment of structured dialogue that enabled feedback and clarification (KII3; KII7). By contrast, cooperation with MSB and SoS was described as more limited and, at times, operationally unclear (KII1; KII2; KII8). Several accounts described communication perceived as directive rather than dialogical. One interviewee characterised the SoS communication style as “disastrous”, involving “a lot of impositions … without dialogue”, adding: “I am still waiting for the question … ‘How can we help you?’” (KII1). Another described uncertainty when centrally issued instructions lacked contextual grounding: “I’m at work when we receive a message from SoS saying: ‘You are not allowed to use the ventilators we’ve sent you, effective immediately, because they are not CE-marked.’ And I think to myself, okay, that’s an order—’effective immediately’—so then I wonder: should I turn off the ventilator? Should I send it back to the warehouse—with the patient attached? /…/ Am I supposed to turn off the ventilator, tell the patient or their relatives that we’re turning it off because it’s not CE-marked—with no consideration of the consequences?” (KII2) Such accounts illustrate how centrally formed directives, when detached from local realities, may shift ethical and practical dilemmas onto frontline professionals. Regional participants also described national decision-making as at times slow to adapt when emerging evidence suggested disproportionate impacts on specific groups (KII5; KII7), advocating for more iterative and responsive approaches: “I learned that it was better to make a decision and gather facts concurrently, then revise quickly. We made many decisions within [region X] and sometimes had to reverse them later, but by then the knowledge had grown. The state, meanwhile, waited too long to determine who should act, why, and how the situation was evolving. I hope we move away from that.” (KII6) Communication between municipal actors and national authorities—MSB and SoS—formally mandated to support them (PCM 200422) [ 32 ], was described as weak. Municipal participants did not refer to these authorities and expressed uncertainty regarding roles, expectations, and communication pathways, which were often perceived as predominantly top-down (FGD1; FGD3; FGD5). The early phase of the pandemic also revealed the absence of established channels for sustained vertical collaboration between regional and municipal levels. Regional actors noted that communication with municipalities was initially tentative, that community-embedded knowledge was not consistently integrated into regional strategies, and that municipal perspectives were sought on an ad hoc rather than systematic basis (KI1; KI2). Similar experiences were reflected in one focus group: I didn’t feel anyone was particularly interested in hearing how things were going. It was more like: ‘Do this’. And when the statistics showed how many people died, it was: ‘Well, it’s a shame—you must be doing something wrong.’ That was the kind of communication we received. “They did not know what these places looked like. And then… ‘Well, just do like this and it will be fine’, or ‘Follow this instruction and it will get better’, but that didn’t happen because it wasn’t possible to follow the advice.” (FGD3) Governance from higher administrative levels—national to regional, and regional to municipal—was thus experienced not only as unclear in prioritisation but as insufficiently attuned to local capacities and infrastructures. In this context, one municipal participant expressed frustration at what was perceived as a recurring “rediscovery” of local engagement at higher administrative levels: “I have talked about this before [the need for engaging with local communities], and the reaction is always: ‘Yeah. Good idea.’ But really, should one even have to say that? It should be obvious that the target group should be part of the work.” (FGD5) Over time, inter-level communication was perceived to improve (FGD4; KII4), accompanied by greater recognition of local expertise. Several participants described the period following the initial phase as marked by more constructive collaboration between civil society and public authorities, including inclusive online meetings to identify concerns and incorporate diverse perspectives prior to implementing interventions (FGD5; KII7). Professionals reported being consulted in outreach strategies: “We see a reality that many office workers are unaware of. So, we gathered information and ensured it reached the right person. In the end, they [the regional leadership] were desperate—people were dying, hospitals overloaded, staff exhausted. … They had to listen to do better.” (FGD3) Participants also described occasions when regional actors intervened beyond their formal mandate to support municipal care settings and sustain local action: “We had to call them and say: now you must do this and that.” (FGD1) Although commitment across administrative levels was widely acknowledged, such examples illustrate how coordination frequently relied on ad hoc interventions and individual initiative amid ambiguities in communication channels and decision-making processes (IMI2; IMI4). Across administrative positions, participants emphasised that effective crisis governance depends on established coordination structures rather than improvised arrangements (KII4; FGD5). The importance of “building on existing groups: collaborate, collaborate, collaborate” and ensuring “there is an organisation that holds it all together” (KII3) was repeatedly stressed. Collaboration was seen as central to both consistency and adaptability (FGD1; FGD5; KII6; KII7), alongside clearer delineation of responsibilities across civil society, municipalities, regions, and national authorities: “We won’t be able to solve a pandemic alone. … We have different roles, but the point is to see how each function in society can contribute: the role of civil society, of the region, of the municipalities, of the county administrative board, of the national level… so that genuine collaboration can occur.” (KII8). “The main lesson … is that as much as possible should be thought through in the pre-pandemic preparedness guides .... It’s important to recognise that there were already groups capable of handling many of the issues we were not prepared for. Much of this would not have needed to be created on the spot if we had had a clear organisational structure—how to set things up, define mandates, and coordinate the different aspects involved.” (KII1) However, some participants observed that as the acute phase receded, governance practices gradually reverted to more fragmented patterns (FGD3). The material therefore underscores the importance of institutionalised learning and structured knowledge exchange across administrative levels. While some shortcomings may reflect the unprecedented nature of the pandemic, preparedness might have been strengthened through more formalised coordination mechanisms across governance levels [ 60 ]. Participatory practices developed at municipal level could have been more systematically integrated into regional and national arrangements, potentially mitigating coordination burdens borne locally. Taken together, these accounts point to a misalignment between policy formulation and the institutional conditions through which measures were implemented, reflecting limited reciprocal exchange of situated knowledge. The findings align with scholarship indicating that Sweden’s decentralised administrative model distributes operational authority without always ensuring clear vertical alignment, thereby shifting responsibility for coherence to local actors [ 59 , 61 , 62 ]. While reflecting longstanding commitments to municipal self-government, decentralisation during crisis conditions requires robust coordination infrastructure and oversight across administrative levels. Clearer emergency mandates, attentive to capacities and institutional conditions at each level, therefore, appear central to enabling effective collaboration under acute circumstances. Limitations One limitation concerns the positionality of the research team. All participating researchers belong to population groups that were relatively privileged during the pandemic, including with regard to job security and the possibility of remote work. This may have influenced the interpretation of the data, although reflexive discussion within the research team were used to mitigate risk. As described in the methods section, we approached 56 potential participants across different levels of the public health sector, of whom 18 agreed to participate in interviews. While this level of participation is not uncommon in studies involving senior professionals, it may nevertheless introduce a degree of participation bias. We interpret the limited participation partly as a reflection of the high personnel turnover that occurred during and after the pandemic, particularly within municipal health and care services, where several individuals who had been active during the pandemic had moved to other positions. However, it may also reflect limited availability or willingness to participate, meaning that some perspective may not be represented in data. Furthermore, this study was conducted in 2024, meaning that a considerable amount of time had passed since the onset of the pandemic. While the interviews generated detailed reflections on pandemic governance and practice, some degree of recall bias cannot be excluded. Conclusions Drawing on the IBPA framework [ 21 ], this study examined how Sweden’s COVID-19 response engaged with socially differentiated contexts of health and illness, and how policy discourse and governance arrangements shaped what became recognisable—and actionable—as vulnerability. Viewed through this analytical lens, vulnerability emerges not as a fixed attribute simply identified by policy, but as a contingent and evolving construct, repeatedly produced and reformulated during the pandemic. Competing rationalities—clinical risk, health system sustainability, and, more intermittently, equity concerns—structured how vulnerability was defined and prioritised at different moments, influencing which risks were foregrounded and which remained less visible. From an intersectionality perspective, such selective visibility may be understood as producing ‘recognition gaps’, whereby certain social groups, conditions, and institutional realities remain insufficiently acknowledged within dominant policy narratives [ 54 ]. The findings further suggest that the governance of vulnerability extended beyond population risk categories to the institutional and professional settings responsible for protection. Responsibility and legitimacy were negotiated through contrasting representations of care environments and professional groups, with hospital-based biomedical settings often functioning as the implicit normative reference point despite a substantial share of care being delivered within long-term eldercare. Differentiated vulnerabilities thus emerged not only through classificatory practices, but also through the uneven structural capacities, mandates, and recognition accorded to different care settings. These patterns indicate that preparedness frameworks may benefit from more explicit attention to the organisational, relational, and workforce conditions of sectors tasked with safeguarding populations identified as vulnerable. Variations in living and working conditions were only intermittently reflected in national advice, even when such conditions shaped the feasibility of compliance. Broad population categories and behavioural expectations often rested on implicit assumptions about normative social arrangements, generating substantial interpretive demands for individuals and local organisations. The practical scope of protection depended in part on how national categories and recommendations were translated into the intersecting realities of work, housing, language, migration-related conditions, and institutional trust. Regional and municipal actors described considerable relational, interpretive, and organisational labour—through dialogue, adaptation, and improvisation—to render general guidance workable under conditions of uncertainty. In IBPA terms, these translational processes matter because they shape whether socially differentiated vulnerabilities can be recognised and addressed in ways that are timely, context-sensitive, and practically meaningful [ 21 ]. Taken together, these translational dynamics highlight that coordination, clarity of mandate, and reciprocal communication are not merely administrative concerns, but structural conditions shaping whether differentiated vulnerabilities can be recognised and addressed across governance levels [ 18 ]. Where established channels were limited, implementation relied more heavily on local initiative, relational infrastructure, and improvised forms of coordination [ 62 ]. At the same time, recommendations sometimes appeared to assume organisational capacities that were unevenly distributed across administrative levels, thereby embedding disparities in implementation potential from the outset. Sustaining and routinely exercising reciprocal engagement between national, regional, and municipal actors—including collaboration with locally embedded and civil society organisations during non-crisis periods—may help ensure that such mechanisms remain functional and trusted when emergencies arise [ 48 , 57 , 63 , 64 ]. Participants’ reflections on the gradual re-fragmentation of coordination structures following the acute phase further raise questions about institutional learning and the extent to which experiential and intersectional insights are embedded in routine preparedness planning. Overall, the findings suggest that the reach and feasibility of pandemic recommendations were mediated not solely by epidemiological risk, but by socially differentiated conditions—including material resources, employment security, communicative access, organisational capacity, and institutional trust. From an intersectional standpoint, vulnerability can thus be understood as co-produced through discourse, categorisation, institutional hierarchies, and governance architecture, as well as through how individuals and organisations interpret, negotiate, and act within these conditions. Attending to this situated co-production may support preparedness approaches that respond not only to biological threats, but also to the socially patterned conditions through which exposure, recognition, and protection are distributed, thereby contributing to more contextually responsive and equitable public health governance [ 25 ]. Abbreviations CSO Civil Society Organisation FGD Focus Group Discussion FHM The Public Health Agency of Sweden (Folkhälsomyndigheten) IBPA Intersectionality-Based Policy Analysis IMI Individual Municipal-level Interviews KII Key Informant Interviews MSB The Swedish Civil Contingencies Agency (Myndigheten för samhällsskydd och beredskap, since 1 January 2026, Myndigheten för civilt försvar) PCM Press conference materials SoS The National Board of Health and Welfare (Socialstyrelsen) Declarations Ethics approvals and consent to participate The study was carried out in accordance with the ethical principles outlined in the Declaration of Helsinki [65]. The Swedish Ethics Review Authority (decision letter number 2023-02140-01, dated 2023-05-17) has determined that formal ethical testing is not required for this study, given that it does not entail any intervention or processing of personal data. Nevertheless, to ensure compliance with the established ethical standards, we adhered to the established ethical principles, including providing participants with information about the study and their rights to withdraw, giving participants the opportunity to ask questions about their participation prior to their commitment, and all participants to provide their consent to participate. Consent for publication Not applicable Availability of data and materials The qualitative data generated and analysed during the current study are not publicly available due to ethical and confidentiality considerations and the need to protect participant anonymity. De-identified data may be made available from the corresponding author upon reasonable request and subject to applicable ethical approvals. The national press conference transcripts analysed in this study are publicly accessible through the Swedish Public Health Agency (Folkhälsomyndigheten). Competing interests The authors declare that they have no competing interests. Funding BB, GP, JL and NN received grant no. 2021-00284 from the Swedish Research Council for Health, Working Life and Welfare. The funding agency did not influence the design, conduct or analysis of the study. Authors’ contributions GP served as principal investigator of this qualitative EMBRACE sub-study and formulated the study design in collaboration with BB, JL, and NN. LSK coordinated study implementation, including data collection and analysis, together with AL, DH, GP, JL, and MAA. The manuscript was drafted by GP and LSK and revised with critical input from all co-authors prior to submission. Acknowledgements We thank all study participants for their commitment and for their invaluable contributions to this research. References United Nations. WHO chief declares end to COVID-19 as a global health emergency. UN News. 2023 May 5. Gravlee CC. 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J Occup Sci. 2022;29(3):402–16. Johansson-Pajala RM, Alam M, Gusdal A, Heideken Wågert PV, Löwenmark A, Boström AM, et al. Anxiety and loneliness among older people living in residential care facilities or receiving home care services in Sweden during the COVID-19 pandemic: a national cross-sectional study. BMC Geriatr. 2022;22:927. Skoog I. COVID-19 and mental health among older people in Sweden. Int Psychogeriatr. 2020;32(10):1173–5. Rasmussen J, Ørsten I, Kjeldsen J, Strategic. COVID-19 management in communicational practice: at the crossroads to remain open or not in Denmark, Norway, and Sweden. In: Rasmussen J, editor. Communicating a pandemic: crisis management and COVID-19 in the Nordic countries. Gothenburg: Nordicom; 2023. Szebehely M. The impact of COVID-19 on long-term care in Sweden. Stockholm: Long-Term Care Policy Network; 2020. Public Health Agency of Sweden. Folkhälsoarbetet i Sverige: en nationell kartläggning av kommuners, regioners och länsstyrelsers folkhälsoarbete 2022–2023. Stockholm: Folkhälsomyndigheten; 2024. Christensen T, Lægreid P. Assessing the crisis management of the COVID-19 pandemic: a study of inquiry commission reports in Norway and Sweden. Policy Soc. 2023;42(4):548–63. Bäsén A. Äntligen har de äldre förstått farorna. Expressen. 2020. Swedish Civil Contingencies Agency. Allmänhetens syn på råd och rekommendationer med anledning av coronapandemin: kvantitativ del. Karlstad: MSB; 2021. Bredström A, Mulinari S. Conceptual unclarity about COVID-19 ethnic disparities in Sweden: implications for public health policy. Health (London). 2023;27(2):186–200. Roble S, Wangdahl J, Warner G. COVID-19 information in Sweden: opinions of immigrants with limited proficiency in Swedish. Health Commun. 2022;37(12):1510–9. Tehler H, Cedergren A, Hassel H, Johansson J. Corona-pandemins kaskadeffekter på lokal och regional nivå med avseende på samhällsviktiga funktioner – mot ökad motståndskraft. Lund: Lund University; 2021. Voyer A, Barker V. Recognition gaps and COVID inequality: the case of immigrants in Sweden. Cult Sociol. 2023;19(1):67–88. Patel JA, Nielsen FBH, Badiani AA, Assi S, Unadkat VA, Patel B, et al. Poverty, inequality and COVID-19: the forgotten vulnerable. Public Health. 2020;183:110–1. Platt L, Elmes J, Stevenson L, Holt V, Rolles S, Stuart R. Sex workers must not be forgotten in the COVID-19 response. Lancet. 2020;396(10243):9–11. Calanan RM, Bonds ME, Bedrosian SR, Laird SK, Satter D, Penman-Aguilar A. CDC’s guiding principles to promote an equity-centered approach to public health communication. Prev Chronic Dis. 2023;20:E57. Zetterberg L, Santosa A, Ng N, Karlsson M, Eriksson M. Impact of COVID-19 on neighborhood social support and social interactions in Umeå municipality, Sweden. Front Sustain Cities. 2021;3. Smith RW, Jarvis T, Sandhu HS, Pinto AD, O’Neill M, Di Ruggiero E, et al. Centralization and integration of public health systems: perspectives of public health leaders on factors facilitating and impeding COVID-19 responses in three Canadian provinces. Health Policy. 2023;127:19–28. Wimelius ME, Strandh V. Organised crisis volunteers, COVID-19, and the political steering of crisis management in Sweden. Disasters. 2024;48(2):e12604. Sparf J, Petridou E, Granberg M, Becker P, Onn B. Pandemic responses at the subnational level: exploring politics, administration, and politicization in Swedish municipalities. Eur Policy Anal. 2022;8(3):327–44. Norvell Gustavsson I, Jonsson F. The practice of public health coordination in Sweden: roles, responsibilities, and realities. Health Promot Int. 2025;40(5). Carroll BJ, Brummel L, Toshkov D, Yesilkagit K. Multilevel governance and responses to the COVID-19 pandemic: a systematic literature review. Reg Fed Stud. 2023;35(2):305–26. Swall A, Hammar LM, Boström AM. Listen to the voices of nurses: the role of community chief nurses and registered nurses in the provision of care for older people in Sweden during the COVID-19 pandemic. BMC Geriatr. 2024;24:127. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human participants. JAMA. 2025;333(1):71–4. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.IntersectionalitymatrixEmbrace.pdf Supplementaryfile2.InterviewguidesFGDKIIIMI.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Daniela","middleName":"","lastName":"Holmberg","suffix":""},{"id":626087239,"identity":"34669c93-353f-48d1-adbd-88f963b7fd12","order_by":2,"name":"Jesper Löve","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Jesper","middleName":"","lastName":"Löve","suffix":""},{"id":626087240,"identity":"b3e3f96c-0451-4b78-9993-95b0f5b8f20b","order_by":3,"name":"Ann Liljas","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Ann","middleName":"","lastName":"Liljas","suffix":""},{"id":626087241,"identity":"58f9d300-5483-495c-9a1f-50097aa428cb","order_by":4,"name":"Maissa Al-Adhami","email":"","orcid":"","institution":"Karolinska 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18:23:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9117388/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9117388/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109329462,"identity":"eb6b50b2-ad47-4b12-bd23-691c06dd37f3","added_by":"auto","created_at":"2026-05-15 15:40:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":313743,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9117388/v1/1a8cfde3-7f79-49e3-ab5a-7a2566dc810d.pdf"},{"id":107741063,"identity":"89570e0e-d496-4808-8bb4-2e1a1c42b216","added_by":"auto","created_at":"2026-04-24 14:56:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":133536,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.IntersectionalitymatrixEmbrace.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9117388/v1/4bb4be3e08fb5d6834e956ae.pdf"},{"id":107741102,"identity":"fb0bdb4c-7d70-4857-8f85-140dc72ff28a","added_by":"auto","created_at":"2026-04-24 14:56:51","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":138455,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.InterviewguidesFGDKIIIMI.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9117388/v1/b8669bbaf62565f8722de3fe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Equity under pressure: An intersectionality-based policy analysis of Sweden’s COVID-19 response","fulltext":[{"header":"Background","content":"\u003cp\u003eThe COVID-19 pandemic has constituted not only a global health crisis but also a critical test of policy frameworks’ capacity to recognise and respond to population heterogeneity in the formulation of recommendations and interventions. By May 2023, when the pandemic was no longer classified as a public health emergency, 765,222,932 cases and nearly seven million deaths had been reported worldwide [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. Both the burden of disease and its wider social consequences were unevenly distributed. Evidence from diverse contexts indicates that pandemic responses intersected with, and at times intensified, pre-existing social and economic inequalities [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. Elevated risks were documented among older adults [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e], minority populations [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e], people with lower incomes [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e], migrants [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], and residents of socio-economically disadvantaged areas [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. These patterns underscore the importance of examining how the pandemic and its policy responses were conceptualised [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e], and of attending to the intersecting factors shaping exposure, susceptibility, and the capacity to withstand both infection and its broader social effects [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePandemic management strategies varied considerably across national contexts, reflecting distinct institutional traditions, political cultures, and understandings of state responsibility and citizens’ rights [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Sweden’s approach—centred on voluntary recommendations and appeals to individual responsibility rather than legally enforced lockdowns—offers an instructive case for examining how policy assumptions mediated tensions between epidemiological rationalities, civil liberties, and social equity [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Sweden experienced one of Europe’s highest COVID-19 mortality rates during spring 2020, particularly within long-term care settings, while later followed a more differentiated trajectory [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. This temporal variation highlights the need to assess pandemic governance beyond immediate epidemiological outcomes, with sustained attention to distributive effects, ethical considerations, and structural conditions over time. Where patterned differences in impact between social groups are evident, such disparities warrant closer scrutiny of the assumptions informing public health decision-making.\u003c/p\u003e \u003cp\u003eRetrospective critical policy analysis contributes to this task by examining not only policy outcomes but also the normative premises through which problems are framed and rendered actionable [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. As Bacchi [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] observes, policies do not merely respond to social problems; they participate in constituting them. Public health policy operates through formal instruments such as legislation and regulation, but also through discursive practices that shape what is recognised as risk, responsibility, and legitimate intervention [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. The authority to determine which perspectives are foregrounded and which remain peripheral plays a central role in structuring the policy landscape [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. Analysing these processes enables scrutiny beyond discrete decisions to examine the assumptions, silences, and power relations that shape policy processes: whose needs and experiences are recognised, and whose remain unarticulated?\u003c/p\u003e \u003cp\u003eIntersectionality provides a conceptual lens for engaging with these questions by foregrounding how social positions—such as gender, age, socio-economic position, and migration status—intersect with institutional governance, cultural norms, and structural hierarchies [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. These intersections influence exposure, and susceptibility to health risks, as well as the capacity to mitigate them [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e], thereby shaping resilience in times of crisis. The Intersectionality-Based Policy Analysis (IBPA) framework [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] addresses a limitation of conventional policy analysis: the tendency to treat socially patterned risks, biological factors, and structural determinants of health as analytically separate rather than mutually constitutive [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. By centring lived experience, contextual specificity, and epistemic plurality, IBPA enables a more critical appraisal of how social difference is constructed and governed within policy processes [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the relevance of intersectional perspectives to the COVID-19 pandemic, their systematic integration into policy analyses has remained limited [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. The pandemic’s entanglement with everyday living conditions, work environments, and social relations underscored the interdependence of structural determinants of health. Insufficient attention to these interconnections within pandemic governance may have contributed to the emergence or deepening of health inequities [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAgainst this backdrop, the study examines how equity considerations were articulated—or rendered less visible—within Sweden’s COVID-19 policy response, with particular attention to the initial acute phase, and considers implications for strengthening institutional and societal capacity to reduce risk exposure and enhance resilience in future pandemics.\u003c/p\u003e\n\u003ch3\u003eObjectives\u003c/h3\u003e\n\u003cp\u003eApplying the IBPA framework, this study examines how policy discourse and decision-making in Sweden’s COVID-19 response engaged with the socially differentiated contexts of health and illness. It pursues the following specific objectives:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo analyse how Sweden’s COVID-19 policy responses recognised—or overlooked—variations in living conditions, structural determinants, and differentiated vulnerabilities across population groups, using an intersectionality-informed analytical lens.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo examine how vulnerability and pandemic policy were framed and problematised, with particular attention to the perspectives, rationalities, and practices of key policy actors involved in the formulation and implementation of the response.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e\n\n\n\n \n\n \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e \n\n\n\n "},{"header":"Methods and material","content":"\u003ch2\u003eMethodological framework\u003c/h2\u003e\u003cp\u003e This study forms part of the broader EMBRACE project, which employs an integrated mixed-methods design to examine patterns of inequity in vulnerability to COVID-19 and to analyse interactions between public health institutions and local communities in managing of pandemic-related risks.\u003c/p\u003e\u003cp\u003eThe present sub-study is qualitative. It integrates two complementary policy analysis approaches—intersectionality and policy discourse analysis—which informed the study’s conceptual design. The IBPA framework guided the analytical design by structuring attention to how vulnerability, resilience, and relative advantage were represented across institutional levels [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. It oriented the study towards examining how policy framings engaged with intersecting social positions and structural conditions within pandemic governance.\u003c/p\u003e\u003cp\u003eIn accordance with this framework, the analysis attended to nine identity dimensions commonly referenced in intersectionality scholarship: age; educational and employment status; ethnicity and indigeneity; gender and sex; income and material conditions; mental and physical characteristics; migration background; sexual orientation; and religion (definitions provided in Supplementary file 1). These dimensions are understood as socially situated and context-dependent, shaping lived experience as well as how individuals and groups are positioned within institutional and cultural frameworks [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. Their intersections may generate marginalisation or relative privilege, depending on context. The analysis therefore approached identity categories as relational rather than fixed, attending to how their significance was produced within specific policy and governance settings.\u003c/p\u003e\u003cp\u003eThe study also drew on Bacchi’s problematisation approach [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e], particularly the question ‘What is the [public health] problem represented to be?’, to examine how pandemic-related risks and responsibilities were discursively constructed. This lens supported critical interrogation of dominant framings and consideration of how alternative representations might render different inequities.\u003c/p\u003e\u003cp\u003eTogether, these approaches shaped the research questions, guided data collection, and oriented analytical strategies, ensuring attentiveness to structural conditions, institutional practices, and lived experiences across multiple levels of the policy process.\u003c/p\u003e\u003ch3\u003eResearcher characteristics and reflexivity\u003c/h3\u003e\u003cp\u003eThis study was conducted by an interdisciplinary team of eight researchers with diverse disciplinary backgrounds, academic career stages, ages, and gendered and lived experiences across four continents. Guided by the IBPA framework, reflexive attention was given to how positionalities may have shaped interpretations of Swedish policy responses. Differing intersectional positions in relation to Swedish authorities and majority society—reflecting variations in institutional proximity, social location, and experience of governance contexts—enabled both contextual sensitivity and analytical distance in examining the material. Throughout the research process, iterative team discussions and ongoing analytic reflexivity were used to surface assumptions, examine power relations embedded in policy strategies, and consider how epistemic standpoints shaped knowledge production, thereby strengthening the study’s credibility, transparency, and analytical rigour.\u003c/p\u003e\u003ch3\u003eContext\u003c/h3\u003e\u003cp\u003eSweden’s crisis and public health governance is organised according to constitutionally grounded principles of administrative autonomy and decentralisation, as set out in the Instrument of Government and sectoral legislation [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. Responsibilities are distributed across national authorities, 21 self-governing regions, and 290 municipalities, each operating within defined statutory mandates [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt the national level, the Public Health Agency of Sweden (Folkhälsomyndigheten, FHM) holds responsibility for public health and communicable disease control under the Communicable Diseases Act and its agency ordinance [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Its mandate includes epidemiological surveillance, risk assessment, the issuance of regulations and recommendations, and public communication. In a pandemic, this encompasses monitoring infection trends, issuing guidance on testing, isolation and vaccination, and providing recommendations to sectors such as healthcare, education and workplaces [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Swedish Civil Contingencies Agency (Myndigheten för samhällsskydd och beredskap, MSB; since 1 January 2026, Myndigheten för civilt försvar) is responsible for civil protection and national crisis management [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. Its remit includes risk and vulnerability assessments, preparedness planning, and cross-sectoral coordination. While it does not determine communicable disease control measures, it supports inter-agency coordination, crisis communication systems, and logistical and continuity planning across sectors during public health emergencies [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe National Board of Health and Welfare (Socialstyrelsen, SoS) provides regulatory oversight and knowledge-based support for health and social care under the Health and Medical Services Act [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. In public health emergencies, its functions include issuing binding regulations and general guidance, coordinating national resources and medical supplies, monitoring healthcare capacity, and supporting regional and municipal service planning.\u003c/p\u003e\u003cp\u003eWithin this decentralised system, the regions are responsible for organising and delivering healthcare and for implementing communicable disease control measures through regional infectious disease control physicians [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. In a pandemic context, they operationalise national regulations and recommendations by organising testing and vaccination, ensuring infection prevention and control, and managing hospital and intensive care capacity.\u003c/p\u003e\u003cp\u003eSweden’s 290 municipalities are responsible for welfare and community services, including social services, eldercare, disability services, certain healthcare in residential and home-based settings, and compulsory and upper secondary education [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. In a pandemic context, they implement infection prevention measures within these services and adapt local operations in accordance with national regulations and regional guidance [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe governance model thus distinguishes between national-level regulation and coordination, regional healthcare delivery and medical communicable disease control, and municipal responsibility for locally delivered welfare services. While mandates are formally delineated, effective pandemic management requires ongoing coordination across levels of government [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003ch3\u003eData sources and data collection\u003c/h3\u003e\u003cp\u003eThe qualitative study drew on three complementary data sources to capture multiple sites at which pandemic policy was formulated, communicated, and interpreted: 1) national-level press conference materials (PCM); 2) regional-level key informant interviews (KII) with pandemic leadership; and 3) municipal-level focus group discussions (FGD) and individual municipal-level interviews (IMI) with representatives of public health services and civil society organisations [Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e]. Together, these sources enabled analysis across institutional levels within Sweden’s decentralised governance structure.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of the data sources, participants and periods of data collection across societal levels.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSocietal level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eData category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eData collection period\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRepresentatives of FHM, MSB, and SoS, The Swedish Medicines Agency, The Swedish Association of Municipal Authorities and Regions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePress conference materials, video recordings and transcripts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMarch 2020 - March 2022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRegional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDirectors of health and health care, vaccine coordinators, and infectious disease control managers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eKey informant interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAug 2023 - Feb 2024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMunicipal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRepresentatives of primary healthcare centres, care homes for older adults; civil society organisations (including community meeting spaces, health initiatives, religious organisations).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFocus group discussions and individual municipal-level interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eApril - June 2024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003ch2\u003eNational-level press conferences\u003c/h2\u003e\u003cp\u003eThe press conference material (n = 198) comprised video recordings and transcripts from national briefings conducted between March 2020 and March 2022. These briefings were primarily led by FHM, with regular contributions from MSB and SoS and occasional participation from other governmental bodies. Although formally intended to inform the public, the briefings also provide insight into official communication practices, representations of risk, and the construction of target audiences. All available recordings and transcripts were included to enable comprehensive analysis of national-level policy communication. Materials were obtained from FHM’s press department via email request (14 February 2023).\u003c/p\u003e\u003ch3\u003eRegional-level key informant interviews\u003c/h3\u003e\u003cp\u003eEight KII were conducted between August 2023 and February 2024 with senior officials in the Stockholm and the Västra Götaland regions, encompassing Sweden’s largest metropolitan areas. Participants were purposively selected public health actors with responsibilities for regional healthcare coordination, immunisation, and infectious disease control, and with direct involvement in pandemic-related decision-making. These interviews provided insight into how national guidance was interpreted, negotiated, and operationalised at the regional level, as well as how it was coordinated with and translated into practice in collaboration with municipal authorities.\u003c/p\u003e\u003ch3\u003eMunicipal level focus group discussions and individual interviews\u003c/h3\u003e\u003cp\u003eAt the municipal level, stakeholders within the two study regions were invited to participate in FGDs (n = 5) or IMIs (n = 6). Recruitment focused on DeSo areas (Demographic Statistical Areas) with the highest reported COVID-19 mortality rates among individuals aged 70 years and older, to engage actors working in contexts heavily affected during the initial phase of the pandemic.\u003c/p\u003e\u003cp\u003eParticipants were invited through primary healthcare centres, care homes for older adults, and civil society organisations (CSOs), including community meeting spaces, health initiatives, and religious organisations. Of 56 individuals invited, 18 participated in five FGDs (three to six participants per group), and six participated in IMIs, either due to scheduling constraints or preference for an individual format. These data illuminate how pandemic measures were enacted and experienced within locally delivered welfare and community services.\u003c/p\u003e\u003ch2\u003eData collection procedures\u003c/h2\u003e\u003cp\u003eAll interviews (KIIs, FGDs and IMIs) lasted approximately 60–90 minutes and were conducted by one or two members of the research team (AL, GP, LSK or MAA) using a semi-structured interview guide informed by the IBPA framework and complementary policy discourse analysis [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. The guide addressed organisational roles and mandates, experiences of pandemic management, perceived challenges, examples of effective practice, and lessons learned (Supplementary file 2).\u003c/p\u003e\u003cp\u003eAll KIIs and FGDs were audio-recorded and transcribed verbatim. IMIs were likewise audio-recorded and transcribed, with the exception of one interview in which detailed notes were taken at the participant’s request. The use of multiple interview formats allowed flexibility in accommodating participants’ availability and preferences, while supporting depth and diversity of the empirical material.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eTo operationalise analysis of intersecting structural, normative, and identity dimensions, the study drew on the twelve core questions of the IBPA framework, organised into descriptive and transformative components [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. These components partly overlap with Bacchi’s critical policy analysis approach [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. The present analysis focused on the first six questions, which constitute the descriptive dimension. These address researcher positionality (Q1), the framing of policy problems (Q2-3), and how such framings shape the representation and treatment of different social groups (Q4-5). The sixth question identifies inequities emerging from the analysis and functions as a conceptual bridge to the transformative dimension. The latter (Q7–12), which concerns interventions and processes of change, falls beyond the scope of this study but will inform subsequent phases of the EMBRACE project.\u003c/p\u003e\u003cp\u003eData were analysed using thematic analysis, selected for its flexibility and suitability for identifying and interpreting patterns across heterogeneous qualitative material [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]. This approach enabled attention both to situated accounts and to the broader structural and discursive contexts in which they were embedded.\u003c/p\u003e\u003cp\u003eThe first analytical phase was primarily inductive. Line-by-line coding of PCM’s and interview transcripts facilitated close engagement with communicative practices and participants’ accounts. ATLAS.ti supported systematic organisation of the material. To enhance credibility, coding was conducted independently by pairs of researchers (AL and LSK; DH and LSK; DH and GP; LSK and MAA). For each pair, a randomly selected 20% subset of the same material was independently coded by a researcher not involved in the initial coding. Codes were compared and refined through iterative discussion to strengthen consistency and transparency.\u003c/p\u003e\u003cp\u003eIn the second phase, analysis adopted a more deductive orientation. Inductively generated codes were revisited and organised in relation to the IBPA guiding questions [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] in dialogue with Bacchi’s problematisation approach [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. The process involved developing theoretically informed subthemes and synthesising overarching themes. The first and last authors led this stage, with iterative refinement through critical dialogue within the full research team. Consistent with the IBPA’s reflexivity commitments, discussions explicitly addressed positionality, interpretative assumptions, and potential sources of bias [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn parallel, emerging themes were examined in relation to organisational documents from FHM, SoS, and MSB, relevant scientific publications, and contemporary media coverage. Pre-pandemic preparedness guidance and other institutional texts were used to contextualise press conference statements and clarify formal mandates and roles [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs part of analytic validation, preliminary findings were presented at two stakeholder workshops in Stockholm and Gothenburg. All organisational representatives previously invited to FGDs, KIIs or IMIs were re-invited; 14 participated. These sessions enabled contextualisation and critical reflection on emerging interpretations, contributing to a more dialogical and situated understanding of the material [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTaken together, these strategies supported analytical rigour by integrating multiple data sources, reflexive team-based interpretation, stakeholder engagement, and systematic contextualisation within broader institutional and public discourses.\u003c/p\u003e"},{"header":"Results and discussion","content":"\u003cp\u003eThe analysis identified three interrelated themes illuminating how pandemic policies were interpreted, adapted, and enacted within contexts shaped by intersecting living conditions and structural constraints. The themes are situated primarily in the uncertainties that characterised the early phases of the pandemic, when scientific knowledge was evolving and policy responses were shaped by tensions between predominantly biomedical framings and broader social and public health perspectives. Across themes, vulnerability emerged less as a fixed attribute than as something produced through intersecting discourses, classificatory practices, and institutional arrangements, shaping how guidance could be interpreted and enacted, which groups were reached, and how protection was distributed. The findings also point to the practical difficulties of mobilising organisational structures to support reciprocal communication and locally responsive interventions in a rapidly changing situation.\u003c/p\u003e \u003cp\u003eMore broadly, the analysis highlights tensions between formal preparedness frameworks and the contingencies of everyday practice, suggesting a need to reflect on the epistemological assumptions, policy discourses, and organisational routines\u0026mdash;particularly those shaping communication across administrative levels\u0026mdash;that condition how diverse social circumstances and structural inequities are recognised in public health emergencies. [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIdentified themes and sub-themes illustrating intersectional dynamics in pandemic governance.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMoving beyond one-dimensional vulnerability and towards balanced biomedical-social framing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCyclical shifts in emphasis between biomedical and social determinants\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShifting boundaries between medical and social domains of practice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMaking sense of generalisations amid local complexity and diverse population realities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrom categorical classifications to emerging awareness of intersecting social factors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocal translation of broad population categories in diverse community contexts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNegotiating institutional relationality and adaptive practises in pandemic governance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTranslating national recommendations in the absence of contextualised guidance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitutional coherence and reciprocal communication dynamics across governance levels\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMoving beyond one-dimensional vulnerability and towards a more balanced biomedical-social framing\u003c/h2\u003e \u003cp\u003eThis theme examines how vulnerability\u0026mdash;and responsibility for those positioned as vulnerable\u0026mdash;was constructed in Sweden\u0026rsquo;s COVID-19 response, and how these constructions shifted over time. The analysis examines how vulnerability and responsibility for protection were framed: which dimensions were foregrounded or backgrounded over time, how they intersected, and with what implications for policy reasoning and practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCyclical shifts between biomedical risk and social determinants\u003c/h2\u003e \u003cp\u003ePre-pandemic preparedness guidance distinguished predictable from unpredictable threats and acknowledged uncertainty regarding which groups might be most affected [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Early public communication reflected this orientation. Approximately six weeks after the first confirmed case, it was emphasised that: \u0026ldquo;Protecting vulnerable groups /\u0026hellip;/ is what the entire fight against the pandemic is all about\u0026rdquo; (PCM 200310).\u003c/p\u003e \u003cp\u003eInitially, attention centred on \u0026ldquo;identifying sick people who had been in areas where they could have been infected\u0026rdquo; (KII1). As mortality increased, the focus shifted towards individual susceptibility and biomedical categorisation. Age\u0026mdash;and to a lesser extent biological sex\u0026mdash;became prominent reference points in press briefings (e.g. PCMs 200321-0420). Risk was communicated through categorical contrasts (\u0026ldquo;the younger you are, the lower your risk\u0026rdquo;) and through appeals to protect older adults in the interest of health-system sustainability, including concern that intensive care entailed \u0026ldquo;a lot of time and resources and suffering for them and those around them\u0026rdquo; (PCMs 200321-0402).\u003c/p\u003e \u003cp\u003eVulnerability thus became closely aligned with measurable clinical attributes. Age and underlying conditions (diabetes, cardiovascular disease, and respiratory disorders) were repeatedly foregrounded (PCM 200316): \u0026rdquo;Age is the main risk factor, but there are also other illnesses\u0026rdquo; (PCM 200413); \u0026ldquo;older people, especially those with underlying health conditions\u0026rdquo; [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. By contrast, intersecting social determinants shaping exposure, capacity to follow recommendations, or access to support were comparatively under-articulated in early communications.\u003c/p\u003e \u003cp\u003eSeveral informants described how social dimensions of vulnerability were not initially integrated at what they termed \u0026ldquo;the healthcare sector\u0026rsquo;s strategic level\u0026rdquo; (KII8). A predominantly biomedical rationality was perceived to structure early policy attention (KII5), requiring equity-oriented actors to \u0026ldquo;start knocking on different doors to raise awareness of equity perspectives\u0026rdquo; (KII8). Participants suggested that preparedness frameworks would benefit from more systematic incorporation of socio-structural considerations, including attention to \u0026ldquo;socio-economic structures\u0026rdquo; and those not \u0026ldquo;fully integrated into the welfare system\u0026rdquo; (KII6). As one interviewee observed, substantial effort was required to render visible that the pandemic was \u0026ldquo;not solely a matter of biology but also shaped by the broader circumstances individuals were experiencing.\u0026rdquo; (KII4).\u003c/p\u003e \u003cp\u003eThe case of older adults illustrates the limits of narrowly biomedical framing. Although the \u0026ldquo;70+\u0026rdquo; category was occasionally acknowledged as socially constructed (KII4), its wider policy and lived implications were seldom explored beyond specific debates (e.g. physicians over 70 continuing practice, PCM 200512). When isolation recommendations were introduced, participants noted that, while protective in intent, their broader consequences were not always fully anticipated (PCM 210701). Psychosocial harms among young people were periodically discussed (e.g. PCM 200316; PCM 200423; PCM 200529; PCM 201105), whereas comparable effects among older adults were perceived by some as receiving less sustained attention (FGD3; IMI2; IMI3). Some interviewees reflected that the impact of isolation at times exceeded what could be considered ethically proportionate (KII2; IMI3; IMI5). Another described profound loneliness among those without family contact:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Those who didn\u0026rsquo;t have any family... they had no one. They were completely alone, completely isolated. So, many people suffered enormously from this, from the isolation. It was bearable if you had /\u0026hellip;/ relatives that visited. Even if there was a plexiglass [in between], at least someone was visiting.\u0026rdquo; (FGD2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs the pandemic unfolded, broader socio-economic consequences gained visibility. One participant remarked that \u0026ldquo;it didn\u0026rsquo;t really sink in until after a while\u0026rdquo; (KII3), and later press briefings acknowledged that \u0026ldquo;people in poverty, mental illness and addictions, their situation has worsened\u0026rdquo; (PCM 200209). Several participants described a temporary broadening of vulnerability to include social and material conditions alongside biological risk (KII2; KII4; KII8; FGD3). Yet, some perceived this expansion as short-lived: \u0026ldquo;Today, vulnerability tends to again be framed more narrowly, with recommendations focusing predominantly on biological aspects.\u0026rdquo; (KII8)\u003c/p\u003e \u003cp\u003eTaken together, this trajectory suggests a cyclical pattern in which social dimensions of health intermittently gain visibility before receding in favour of biomedical framing. Such shifts matter because they stabilise particular forms of knowledge within public discourse and influence whether social conditions are recognised as shaping exposure and the practical capacity to comply with recommendations [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrioritising clinical risk is understandable in the context of an acute infectious threat. Participants did not question the relevance of biological risk; rather, they highlighted that its interaction with social conditions was insufficiently integrated, particularly in the early stages. Although preparedness guidance articulated an ambition to minimise mortality and morbidity while also considering \u0026ldquo;other negative consequences for individuals and society\u0026rdquo; [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], its operational direction on how biological vulnerability intersects with socio-economic conditions appears limited, also documented elsewhere [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This is notable given the extensive evidence demonstrating how social determinants shape exposure and health outcomes [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and given their formal embedding within Swedish public health policy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile Sweden has been characterised as pursuing a research-informed approach in which expert agencies played a central role and the pandemic was not primarily framed as a political issue\u0026mdash;alongside a public health rather than solely infection-control orientation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u0026mdash;the present findings indicate that this did not translate into the predominance of a social determinants perspective. During the initial phase of the pandemic, biomedical and clinical framings retained greater influence in shaping the response, despite established public health commitments to address interactions between biological and social conditions [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eShifting boundaries between medical and social domains of practice\u003c/h2\u003e \u003cp\u003eThis sub-theme shifts from the definition of vulnerability to the institutional and professional contexts in which those designated as \u0026ldquo;vulnerable\u0026rdquo; were to be protected and cared for. It focuses on how responsibility and failure were narrated, and how these narratives shaped which institutional sites were positioned as central to the response and which were rendered peripheral or deficient.\u003c/p\u003e \u003cp\u003eA marked asymmetry emerged in representations of hospital staff and municipal eldercare personnel (PCM 200504). Preparedness and response efforts appeared more consistently oriented towards hospital and emergency care settings than towards the organisational realities of residential eldercare [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Several participants described early national recommendations (e.g. PCM 200415; PCM 200528; PCM 200929) as insufficiently attuned to the conditions of care homes. Guidance on personal protective equipment, isolation and infection control did not fully reflect differences in training, staffing ratios and material infrastructures between municipal eldercare and regional hospitals, the latter operating in environments more closely aligned with intensive care standards (FGD1; FGD3). One informant recounted initiating \u0026ldquo;hygiene education\u0026rdquo; for municipal staff (KII7), despite this falling outside their formal remit, to compensate for perceived gaps.\u003c/p\u003e \u003cp\u003eWhen outbreaks occurred in care homes, official responses often foregrounded site-specific review\u0026mdash;\u0026ldquo;take a closer look at certain nursing homes to get a better picture of how we can help stop the spread of infection\u0026rdquo; (PCM 200406)\u0026mdash;rather than articulating broader preparedness strategies or mechanism for sustained inter-organisational collaboration. Indications of limited institutional familiarity with the everyday organisation of care homes (e.g. PCM 200506) are notable given the substantial proportion of older adults residing in such settings (KII5). In line with previous research [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], the findings suggest that the pandemic exposed structural limitations in preparedness for eldercare contexts, despite advancing age being consistently identified as a key risk factor in national guidance [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMedia narratives rendered this asymmetry particularly visible. Hospital personnel\u0026mdash;particularly those working in technologically intensive settings such as intensive care\u0026mdash;were publicly celebrated as \u0026ldquo;heroes in all the newspapers\u0026rdquo; (FGD1). By contrast, eldercare staff were described as \u0026ldquo;constantly questioned \u0026hellip; even though they were working triple shifts and doing their best. \u0026hellip; There was no trust in the staff\u0026rdquo; (FGD1). As mortality increased, professionals in residential eldercare were at times positioned as responsible (FGD3), whereas the national and regional authorities with formal mandates for coordination and support to municipal healthcare during pandemics [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] were less visibly scrutinised.\u003c/p\u003e \u003cp\u003eAs one respondent reflected:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It\u0026rsquo;s sad that eldercare ended up taking a great deal of undeserved flak, actually. \u0026hellip; Eldercare has been made the scapegoat. \u0026hellip; People didn\u0026rsquo;t understand that this isn\u0026rsquo;t healthcare. At its core, it\u0026rsquo;s a social intervention.\u0026rdquo; (FGD3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAccounts of intense media scrutiny further illustrate how stigma was experienced and narrated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;They [nursing assistants in eldercare homes] were really smeared by society. SVT [Swedish Television] was outside the windows, filming through the doors. We were on the news; we were on the radio and in the newspapers. [They were] saying that things were badly run. Even though it wasn\u0026rsquo;t really about that, it was about resources and what was possible to do.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSo, I became the \u0026lsquo;death nurse\u0026rsquo;. That\u0026rsquo;s how society portrayed me.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere was a professor who was very categorical in his television statements /\u0026hellip;/ saying that we euthanise older adults and don\u0026rsquo;t provide them with care.\u0026rdquo; (FGD1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile such explicit allegations were not identified in official communications (see, for example, PCM 200616), a broader discursive imbalance remained evident. Narratives of accountability, heroism and failure appeared unevenly distributed across institutional sites, with recognition and blame attaching to different professional locations.\u003c/p\u003e \u003cp\u003eThese patterns resonate with research indicating that work oriented towards the medically defined body tends to command higher institutional status, whereas expertise concerned with the social and relational dimensions of older people\u0026rsquo;s wellbeing remains comparatively less visible within governance arrangements [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The material (e.g. in KII6) also echoes scholarship on stratified conditions within care work, where residential care staff frequently occupy lower-paid and less formally recognised positions than hospital-based professionals [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe divergent representations of professional groups\u0026mdash;each tasked with safeguarding those identified as most vulnerable\u0026mdash;suggest that professional identity and structural inequalities shaped both pandemic governance and its lived consequences. When outcomes deteriorated in residential eldercare, participants described pandemic discourse as largely focusing on frontline practice and individual facilities, while the systemic conditions shaping what was feasible\u0026mdash;resources, staffing, training, and coordination\u0026mdash;were less consistently foregrounded.\u003c/p\u003e \u003cp\u003eThis asymmetry was not only descriptive but constitutive: hospitals became implicit reference points for preparedness, while municipal eldercare remained less visible within the policy imagination despite being central to protecting those repeatedly designated as most vulnerable. From an intersectional perspective, these dynamics reflect epistemic hierarchies in which biomedical knowledge and hospital-based spaces were privileged over social care contexts. In this configuration, education, employment conditions, and organisational location operated not merely as background characteristics but as structuring forces shaping professional visibility, legitimacy, and exposure to blame [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Such hierarchies may help explain why the early response, while coherent in biomedical terms, was less attuned to the institutional, relational, and material conditions through which vulnerability and resilience were constituted in everyday eldercare settings [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. In this sense, pandemic management not only defined risk but also established hospital-based norms as benchmarks against which eldercare settings were assessed, without fully recognising their distinct care mandates and resource conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eMaking sense of generalisations amid local complexity and diverse population realities\u003c/h2\u003e \u003cp\u003eThis theme examines the discursive construction of the \u0026lsquo;population\u0026rsquo; within pandemic recommendations: how authorities defined those to be guided, and how such framings were interpreted and negotiated by actors working in direct contacts with communities. Two interrelated patterns emerged. First, national communication relied on broad, generalised categories that did not consistently reflect the intersecting social realities through which vulnerability was lived. Second, these categories required substantial interpretative work at regional and municipal levels, where actors were tasked with rendering abstract classifications meaningful in concrete settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFrom categorical classifications to emerging awareness of intersecting social factors\u003c/h2\u003e \u003cp\u003eAs noted, early communication privileged biomedical risk, with less explicit engagement with social and material conditions. A related simplification involved reliance on broad categories or singular identity markers, rather than recognition of intersecting determinants of vulnerability.\u003c/p\u003e \u003cp\u003eDuring the initial phase\u0026mdash;when individuals sought urgently to interpret official advice in relation to their own circumstances\u0026mdash;the term \u0026ldquo;population\u0026rdquo; was frequently invoked as if denoting a relatively homogenous whole (PMC 200310; PCM 200316; PCM 200528). Recommendations to avoid public transport, work from home, and self-isolate illustrate this simplifying dynamic (PCM 200316; PCM 200402; PCM 200611). As one key informant observed, such guidance presupposed employment and housing arrangements that were not universally available. Workers in close contact with travellers, including taxi and bus drivers, were largely absent from early communications despite concerns about travel-related transmission (PCM 200310; FGD3; FGD5). When occupational exposure in service sectors was later addressed, it was described as a \u0026ldquo;superficial review\u0026rdquo; (PCM 200625).\u003c/p\u003e \u003cp\u003eSimilarly, advice to \u0026ldquo;stay at home if you are sick\u0026rdquo; (KII2), while epidemiologically coherent, did not explicitly engage with multi-generational or space-constrained households (PCM 200407). In such contexts, remaining at home did not necessarily reduce risk for co-habiting relatives, particularly where effective isolation was impracticable.\u003c/p\u003e \u003cp\u003eA comparable pattern emerged in labour market contexts. For workers in eldercare, transport, and other public-facing services\u0026mdash;many employed on temporary or hourly contracts\u0026mdash;the ability to comply with national guidance was also shaped by income insecurity and limited employment protection (FGD3). As one participant reflected:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;You don\u0026rsquo;t just tell a mother with five children to \u0026lsquo;stay home.\u0026rsquo; She has to pay rent at the end of the month. Even if she has symptoms, she doesn\u0026rsquo;t want to stay home\u0026mdash;she wants to go to work, and that affects older adults. Most people in this area work as assistant nurses, in home care, as bus drivers, or taxi drivers, so they meet lots of different people and spread the infection.\u0026rdquo; (FGD4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHere, the constraint lay not in disregard for recommendations but in limited room for manoeuvre within particular structural conditions. Although temporary increases in sick pay were introduced (PCM 200504), participants continued to describe uncertainty about job continuity and the consequences of absence (IMI1; FGD3). In this respect, generalised recommendations risked becoming normatively compelling without being fully actionable across diverse employment contexts.\u003c/p\u003e \u003cp\u003eEven highly visible categories, such as age, were frequently framed in homogenising terms. The \u0026lsquo;70+\u0026rsquo; group was presented as internally uniform despite considerable variation in health status, social participation, and living arrangements. Although media reporting at times acknowledged such heterogeneity [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], participants observed that nuance was rarely reflected in official recommendations. Public communication thus stabilised age as a singular defining marker and older adults as uniformly vulnerable. Some participants described this as experienced by certain older individuals as paternalistic:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;My impression is that some seniors felt they were losing their autonomy\u0026mdash;that someone else was telling them what to do\u0026mdash;and that it was a strange situation: \u0026lsquo;I am an adult, and now I am not allowed to make my own decisions about my life; instead, the state has stepped in and told me what I can and cannot do\u0026rsquo;. This caused frustration.\u0026rdquo; (FGD4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother prominent categorisation concerned \u0026ldquo;people with an immigrant background\u0026rdquo; (KII2). The term\u0026mdash;and at times \u0026ldquo;ethnicity\u0026rdquo;\u0026mdash;was used without clear definition (PCM 210624; KII1; FGD1)[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Migration background was sometimes closely associated with socio-economically disadvantaged areas (PCM 200429; PCM 200618), potentially reinforcing a linkage between ethnicity, place, and risk. At times, it appeared foregrounded as a principal explanatory factor for morbidity patterns:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We saw early in the outbreak people who were born outside Sweden, who had a high morbidity, they ended up in intensive care, and the deaths were significantly more common than among people born in Sweden.\u0026rdquo; (PCM 200618).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough later communication acknowledged heterogeneity within \u0026ldquo;foreign-born people\u0026rdquo; (PCM 210610) and referred more explicitly to socio-economic vulnerability (\u0026ldquo;low-paid jobs \u0026hellip; mental illness and addiction\u0026rdquo;, PCM 240509), these recognitions were not consistently translated into differentiated public guidance.\u003c/p\u003e \u003cp\u003ePatterns of selective visibility thus shaped not only how vulnerability was represented but also who received contextually meaningful advice. Where structural mediators of risk\u0026mdash;such as occupational exposure, housing density, employment precarity\u0026mdash;remained backgrounded [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], differential outcomes risked being attributed to categorical identities rather than to the intersecting structural constraints through which risk was produced and experienced This sits uneasily with the stated ambition of the Swedish pandemic strategy to promote inclusion and recognise diversity (PCM 200306; PCM 200330) [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. As previous research suggests, the articulation of policy problems shapes how institutional responsiveness and legitimacy are experienced across diverse social positions [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. The pandemic thus foregrounded the need to further develop public health communication in ways experienced as legitimate and supportive, and more closely aligned with the complex, intersecting realities within which individuals seek to act on advice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLocal translation of broad population categories in diverse community contexts\u003c/h2\u003e \u003cp\u003eThis sub-theme examines policy translation: how nationally produced categories entered regional or municipal practice, and the interpretative work required to render abstract classifications meaningful in concrete settings.\u003c/p\u003e \u003cp\u003e Participants regarded the identification of locally relevant groups as largely their responsibility, given demographic and social variation (FGD1\u0026ndash;3; KII1; KII8), while emphasising the complexity of this task. They described working with groups largely absent from national discourse, including individuals experiencing homelessness, substance dependence, involvement in sex work, or precarious migration status (FGD2; FGD5). Although occasionally mentioned in press briefings, such references often arose in response to journalists\u0026rsquo; questions rather than through sustained or proactive framing (PCM 201117). Even where structurally attentive research was available (e.g. [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]) participants perceived limited incorporation of these insights into national messaging.\u003c/p\u003e \u003cp\u003eMore broadly, participants described uncertainty about how epidemiologically derived categories could be rendered actionable for people whose exposure and risk were shaped by overlapping and shifting conditions (PCM 200818; PCM 201117). Statistical abstractions did not readily correspond to lived configurations of work, housing, language, and social networks (FGD3; FGD5). References to the \u0026ldquo;population\u0026rdquo; or \u0026ldquo;majority\u0026rdquo; (see e.g. PMC 200528; PCM 200316) did not readily correspond to the intersecting social positions encountered in everyday work. Several participants expressed frustration that national authorities did not fully acknowledge the interpretative labour required to translate abstract categories into context-sensitive target groups (FGD1; KII2; KII5; KII8). As one respondent reflected:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;You need to think about this when you are responsible for so many people who have different needs and come from different backgrounds.\u0026rdquo; (FGD3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePublic health messaging appeared calibrated to the majority as an implicit population category, leaving local actors operating in socially stratified settings to undertake the necessary interpretative and relational work (FGD3). The practical meaning of recommendations needed to be clarified in direct encounters, when individuals asked, \u0026ldquo;Does this apply to me?\u0026rdquo; (KII8). Such questions underscore that policy categories do not automatically correspond to the social positions through which risk is experienced; they require institutional work to render individuals and situations legible within guidance [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As one regional representative explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;When certain new measures were announced [at the press conferences], we had to adapt quickly. We really needed to identify what worked regionally for our population. ... So, we had to have a lot of municipal meetings... where everyone wants to know, \u0026lsquo;But what does it mean for me? For my football club, my community?\u0026rsquo; All these national recommendations needed to be implemented and explained by us locally.\u0026rdquo; (KII1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRegional and municipal actors expressed readiness to implement national directives; however, alignment with everyday social complexity required ongoing interpretative work. As knowledge of COVID-19 evolved, local actors repeatedly reassessed which groups required targeted communication, rendering translation an iterative process rather than a one-off adjustment (FGD1; KII5; KII7).\u003c/p\u003e \u003cp\u003eImportantly, these demands did not immobilise local actors. Rather, participants described extensive\u0026mdash;and at times improvised\u0026mdash;efforts to maintain contact with diverse groups (FGD2; FGD5), often driven by professional commitment rather than targeted directives. While operational responsibility rested with regional and municipal authorities, limited formal guidance fostered reliance on personal initiative, rendering implementation uneven and at times fragile (FGD1; FGD4). Outreach depended on established networks and individual discretion rather than systematic identification of prioritised groups. As one participant recounted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;There were some older ladies who used to sit and chat together at [local grocery shop]. \u0026lsquo;Where did they go?\u0026rsquo; I asked about them, and someone said, \u0026lsquo;They live over there,\u0026rsquo; or, \u0026lsquo;Their phone number is\u0026hellip;,\u0026rsquo; so I could call and give them information. They were so isolated that they didn\u0026rsquo;t know what to do. Others helped us by giving our phone numbers to older adults, so they could reach us\u0026mdash;for example, when we would be at a vaccination site \u0026hellip; and we could help them with the language and with information.\u0026rdquo; (FGD4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOver time, some practitioners also reflected critically on terminology. Whereas national discourse sometimes referred to \u0026ldquo;hard-to-reach groups\u0026rdquo; (FGD5), certain regional actors reframed this as a question of institutional accessibility:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We stopped talking about hard-to-reach-groups, because it wasn\u0026rsquo;t about the groups being hard to reach; it was about us actually having to work from an equal-terms approach. Then our work became more focused on equitably providing information and vaccination.\u0026rdquo; (KII8)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis reframing relocates the issue from presumed deficits within populations to limitations in institutional communication and access pathways, consistent with attention to how problem framings allocate responsibility [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTranslation constituted a form of policy work, as actors were required to specify, adapt, and at times reframe national categories so that prioritisation could become understandable locally. Together, these patterns illustrate how centrally produced population categories required translation through local interpretative labour to address vulnerabilities shaped by intersecting social conditions. More broadly, the material suggests that reliance on downstream translation can produce uneven implementation and place substantial burdens on practitioners [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. In this case, the central challenge was not resistance to national guidance, but the sustained labour required to render abstract categories meaningful within intersecting social realities through which risk was experienced.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eNegotiating institutional relationality and adaptive practices in pandemic governance\u003c/h2\u003e \u003cp\u003eFollowing categorisation, the principal challenge identified by respondents concerned organisational conditions. This theme foregrounds how governance structures shaped implementation, specifically how institutional arrangements facilitated or constrained adaptive capacity, cooperation, and communication across administrative levels. Two analytically distinct but interrelated dynamics emerged. First, how general recommendations were translated into locally meaningful practice. Second, how institutional coherence and reciprocal exchange operated across governance tiers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTranslating national recommendations in the absence of contextualised guidance\u003c/h2\u003e \u003cp\u003eThe preceding sub-theme demonstrated how broad population categorisations generated substantial interpretive demands for local actors. Here, the focus shifts from population categorisations to the operational translation of generalised recommendations into measures responsive to differentiated local contexts.\u003c/p\u003e \u003cp\u003eSub-national actors described a deliberate effort to maintain alignment with national messaging\u0026mdash;particularly daily press conferences\u0026mdash;to avoid confusion and sustain public trust (FGD3; FGD5; KII3). At the same time, regional and municipal respondents reported difficulties in designing and adapting measures amid evolving knowledge about the virus, particularly where national communication was perceived as insufficiently attuned to local conditions. These challenges were understood not merely as technical shortcomings, but as reflecting implicit assumptions about media access, information practices, and linguistic norms (IMI2; FGD3; FGD4; KII2; KII5; KII8). As one participant observed:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The Public Health Agency started with very traditional information for a traditional Swedish majority society /\u0026hellip;/ They translated the information, but they didn\u0026rsquo;t adapt it to the target group, and they still used the traditional channels, which don\u0026rsquo;t really reach this group. Eventually they realised: \u0026lsquo;Maybe we need some other channels as well\u0026rsquo;. But by then a lot of time had passed.\u0026rdquo; (FGD5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough multilingual materials were made available early (PCM 200406; PCM 200330), translated information was not always experienced as accessible or culturally responsive. Local actors described how guidance perceived as unrealistic or difficult to enact in everyday life could generate distrust, prompting some residents to disengage (FGD3; FGD4; KII3; IMI3). Trust-building thus became a form of relational labour [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], particularly in communities historically less aligned with mainstream institutional communication. One-way messaging was widely regarded as insufficient; sustained dialogue and repeated encounters were often necessary:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It took time \u0026hellip; Some came to us almost every day and asked the same question, and we gave the same answer every day. In the end they did vaccinate, but it required being patient \u0026hellip; listening, being present.\u0026rdquo; (FGD3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA considerable share of the work involved disseminating information within communities unevenly positioned in relation to socio-economic resources, access to mainstream media, and institutional trust. While national agencies formulated general messages, adaptation\u0026mdash;selecting channels, tailoring content, and engaging in dialogue\u0026mdash;was largely carried by regional, municipal, and civil society actors (PCM 201117). Regional authorities described some formalised preparedness structures, whereas municipal respondents relied heavily on grassroots innovation, often improvised in real time by committed staff and civil society actors (IMI4; KII6; KII8).\u003c/p\u003e \u003cp\u003eAs knowledge of the virus evolved, recommendations changed accordingly, further complicating local implementation. Municipal actors sought to respond constructively, rapidly reconfiguring activities to sustain social support, including outdoor exercise sessions, balcony concerts in residential care homes, outdoor worship service, walking groups, and assistance with grocery shopping (FGD1; FGD5; IMI1; IMI3).\u003c/p\u003e \u003cp\u003eThese initiatives frequently drew upon existing relational infrastructure\u0026mdash;civil society organisations, faith communities and multilingual health communicators\u0026mdash;enabling flexible and rapid responses. Examples included collaboration with a local imam to formulate guidance on gatherings during Ramadan (FGD5), joint vaccine information videos produced by a mosque and a primary care clinic, and tailored outreach at community events for older residents (FGD1; FGD3).\u003c/p\u003e \u003cp\u003eOver time, the limits of a standardised risk communication model became more visible at higher administrative levels, particularly regarding groups not routinely engaged by public services (KII8). Regional strategies gradually expanded to include more systematic collaboration with religious and community organisations (FGD5). As one informant noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;That\u0026rsquo;s an important lesson: to think about how you can communicate more than one message, how you can reach different places. Later on, we had churches, Muslim organisations, so we were able to reach out to certain groups.\u0026rdquo; (KII1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA turning point occurred when disparities in vaccine uptake became evident, often overlapping with areas disproportionally affected by severe disease. At a national press conference, these efforts were framed as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The areas with the lowest levels of vaccination coverage were often the same areas as those that had suffered from more severe cases of disease. It was a question of getting information out in every way possible /\u0026hellip;/ We had /.../ letters to priority groups /.../ face-to-face meetings /\u0026hellip;/ multilingual informers /\u0026hellip;/ We worked with community leaders, faith communities, we put up posters, had mobile units, and vaccination buses.\u0026rdquo; (PCM 210902)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTargeted measures were subsequently intensified, including multilingual information, cooperation with faith and community leaders, and mobile vaccination units (FGD1; FGD3; FGD5). Analytically, this juncture may be understood as a partial re-problematisation of vulnerability; disparities in uptake unsettled a purely universal communication model, foregrounding the intersecting social conditions through which protection is accessed. Some respondents, however, questioned whether these outreach initiatives were driven primarily by instrumental objectives rather than a sustained equity orientation, particularly in relation to vaccination (FGD3; KII3; KII5).\u003c/p\u003e \u003cp\u003eOverall, this sub-theme highlights the tension between universalised recommendations and the situated practices through which they acquire meaning and practical effect. Local adaptation was indispensable yet made more demanding by evolving knowledge and by the absence of clear guidance regarding how broadly formulated recommendations should be specified. Improvisation\u0026mdash;understood as the real-time production of context-sensitive solutions\u0026mdash;emerged as both a strength and a structural vulnerability. While it enabled responsiveness to differentiated and intersecting needs, it also meant that access to protection depended significantly on local capacity rather than uniformly embedded governance infrastructures. In such situations, communities with established relational ties may therefore be differently positioned from those without such infrastructures [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. In this sense, governance arrangements shape the distribution of protection: where coordination mechanisms and integrative infrastructures are uneven, so too are the conditions under which populations access timely and adequate support [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Governance design is therefore implicated in patterned distribution of risk and protection across intersecting social contexts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eInstitutional coherence and reciprocal communication dynamics across governance levels\u003c/h2\u003e \u003cp\u003eThis sub-theme examines how formal mandates, communication channels, and inter-agency coordination shaped the translation of national strategies into practice across governance levels. Participants generally described existing arrangements as only partially supportive of implementing nationally announced pandemic measures (FGD1; KII5; KII6).\u003c/p\u003e \u003cp\u003eRelationships between national and sub-national authorities were characterised unevenly. Collaboration between regions and FHM was often depicted as constructive and reciprocal, facilitated by early establishment of structured dialogue that enabled feedback and clarification (KII3; KII7). By contrast, cooperation with MSB and SoS was described as more limited and, at times, operationally unclear (KII1; KII2; KII8).\u003c/p\u003e \u003cp\u003eSeveral accounts described communication perceived as directive rather than dialogical. One interviewee characterised the SoS communication style as \u0026ldquo;disastrous\u0026rdquo;, involving \u0026ldquo;a lot of impositions \u0026hellip; without dialogue\u0026rdquo;, adding: \u0026ldquo;I am still waiting for the question \u0026hellip; \u0026lsquo;How can we help you?\u0026rsquo;\u0026rdquo; (KII1). Another described uncertainty when centrally issued instructions lacked contextual grounding:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I\u0026rsquo;m at work when we receive a message from SoS saying: \u0026lsquo;You are not allowed to use the ventilators we\u0026rsquo;ve sent you, effective immediately, because they are not CE-marked.\u0026rsquo; And I think to myself, okay, that\u0026rsquo;s an order\u0026mdash;\u0026rsquo;effective immediately\u0026rsquo;\u0026mdash;so then I wonder: should I turn off the ventilator? Should I send it back to the warehouse\u0026mdash;with the patient attached? /\u0026hellip;/ Am I supposed to turn off the ventilator, tell the patient or their relatives that we\u0026rsquo;re turning it off because it\u0026rsquo;s not CE-marked\u0026mdash;with no consideration of the consequences?\u0026rdquo; (KII2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSuch accounts illustrate how centrally formed directives, when detached from local realities, may shift ethical and practical dilemmas onto frontline professionals. Regional participants also described national decision-making as at times slow to adapt when emerging evidence suggested disproportionate impacts on specific groups (KII5; KII7), advocating for more iterative and responsive approaches:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I learned that it was better to make a decision and gather facts concurrently, then revise quickly. We made many decisions within [region X] and sometimes had to reverse them later, but by then the knowledge had grown. The state, meanwhile, waited too long to determine who should act, why, and how the situation was evolving. I hope we move away from that.\u0026rdquo; (KII6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCommunication between municipal actors and national authorities\u0026mdash;MSB and SoS\u0026mdash;formally mandated to support them (PCM 200422) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], was described as weak. Municipal participants did not refer to these authorities and expressed uncertainty regarding roles, expectations, and communication pathways, which were often perceived as predominantly top-down (FGD1; FGD3; FGD5).\u003c/p\u003e \u003cp\u003eThe early phase of the pandemic also revealed the absence of established channels for sustained vertical collaboration between regional and municipal levels. Regional actors noted that communication with municipalities was initially tentative, that community-embedded knowledge was not consistently integrated into regional strategies, and that municipal perspectives were sought on an ad hoc rather than systematic basis (KI1; KI2). Similar experiences were reflected in one focus group:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI didn\u0026rsquo;t feel anyone was particularly interested in hearing how things were going. It was more like: \u0026lsquo;Do this\u0026rsquo;. And when the statistics showed how many people died, it was: \u0026lsquo;Well, it\u0026rsquo;s a shame\u0026mdash;you must be doing something wrong.\u0026rsquo; That was the kind of communication we received.\u003c/p\u003e\u003cp\u003e\u0026ldquo;They did not know what these places looked like. And then\u0026hellip; \u0026lsquo;Well, just do like this and it will be fine\u0026rsquo;, or \u0026lsquo;Follow this instruction and it will get better\u0026rsquo;, but that didn\u0026rsquo;t happen because it wasn\u0026rsquo;t possible to follow the advice.\u0026rdquo; (FGD3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eGovernance from higher administrative levels\u0026mdash;national to regional, and regional to municipal\u0026mdash;was thus experienced not only as unclear in prioritisation but as insufficiently attuned to local capacities and infrastructures. In this context, one municipal participant expressed frustration at what was perceived as a recurring \u0026ldquo;rediscovery\u0026rdquo; of local engagement at higher administrative levels:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I have talked about this before [the need for engaging with local communities], and the reaction is always: \u0026lsquo;Yeah. Good idea.\u0026rsquo; But really, should one even have to say that? It should be obvious that the target group should be part of the work.\u0026rdquo; (FGD5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Over time, inter-level communication was perceived to improve (FGD4; KII4), accompanied by greater recognition of local expertise. Several participants described the period following the initial phase as marked by more constructive collaboration between civil society and public authorities, including inclusive online meetings to identify concerns and incorporate diverse perspectives prior to implementing interventions (FGD5; KII7). Professionals reported being consulted in outreach strategies:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We see a reality that many office workers are unaware of. So, we gathered information and ensured it reached the right person. In the end, they [the regional leadership] were desperate\u0026mdash;people were dying, hospitals overloaded, staff exhausted. \u0026hellip; They had to listen to do better.\u0026rdquo; (FGD3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants also described occasions when regional actors intervened beyond their formal mandate to support municipal care settings and sustain local action: \u0026ldquo;We had to call them and say: now you must do this and that.\u0026rdquo; (FGD1) Although commitment across administrative levels was widely acknowledged, such examples illustrate how coordination frequently relied on ad hoc interventions and individual initiative amid ambiguities in communication channels and decision-making processes (IMI2; IMI4).\u003c/p\u003e \u003cp\u003eAcross administrative positions, participants emphasised that effective crisis governance depends on established coordination structures rather than improvised arrangements (KII4; FGD5). The importance of \u0026ldquo;building on existing groups: collaborate, collaborate, collaborate\u0026rdquo; and ensuring \u0026ldquo;there is an organisation that holds it all together\u0026rdquo; (KII3) was repeatedly stressed. Collaboration was seen as central to both consistency and adaptability (FGD1; FGD5; KII6; KII7), alongside clearer delineation of responsibilities across civil society, municipalities, regions, and national authorities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We won\u0026rsquo;t be able to solve a pandemic alone. \u0026hellip; We have different roles, but the point is to see how each function in society can contribute: the role of civil society, of the region, of the municipalities, of the county administrative board, of the national level\u0026hellip; so that genuine collaboration can occur.\u0026rdquo; (KII8).\u003c/p\u003e\u003cp\u003e\u0026ldquo;The main lesson \u0026hellip; is that as much as possible should be thought through in the pre-pandemic preparedness guides .... It\u0026rsquo;s important to recognise that there were already groups capable of handling many of the issues \u003cem\u003ewe\u003c/em\u003e were not prepared for. Much of this would not have needed to be created on the spot if we had had a clear organisational structure\u0026mdash;how to set things up, define mandates, and coordinate the different aspects involved.\u0026rdquo; (KII1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some participants observed that as the acute phase receded, governance practices gradually reverted to more fragmented patterns (FGD3). The material therefore underscores the importance of institutionalised learning and structured knowledge exchange across administrative levels. While some shortcomings may reflect the unprecedented nature of the pandemic, preparedness might have been strengthened through more formalised coordination mechanisms across governance levels [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Participatory practices developed at municipal level could have been more systematically integrated into regional and national arrangements, potentially mitigating coordination burdens borne locally.\u003c/p\u003e \u003cp\u003eTaken together, these accounts point to a misalignment between policy formulation and the institutional conditions through which measures were implemented, reflecting limited reciprocal exchange of situated knowledge. The findings align with scholarship indicating that Sweden\u0026rsquo;s decentralised administrative model distributes operational authority without always ensuring clear vertical alignment, thereby shifting responsibility for coherence to local actors [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. While reflecting longstanding commitments to municipal self-government, decentralisation during crisis conditions requires robust coordination infrastructure and oversight across administrative levels. Clearer emergency mandates, attentive to capacities and institutional conditions at each level, therefore, appear central to enabling effective collaboration under acute circumstances.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOne limitation concerns the positionality of the research team. All participating researchers belong to population groups that were relatively privileged during the pandemic, including with regard to job security and the possibility of remote work. This may have influenced the interpretation of the data, although reflexive discussion within the research team were used to mitigate risk.\u003c/p\u003e \u003cp\u003eAs described in the methods section, we approached 56 potential participants across different levels of the public health sector, of whom 18 agreed to participate in interviews. While this level of participation is not uncommon in studies involving senior professionals, it may nevertheless introduce a degree of participation bias. We interpret the limited participation partly as a reflection of the high personnel turnover that occurred during and after the pandemic, particularly within municipal health and care services, where several individuals who had been active during the pandemic had moved to other positions. However, it may also reflect limited availability or willingness to participate, meaning that some perspective may not be represented in data.\u003c/p\u003e \u003cp\u003eFurthermore, this study was conducted in 2024, meaning that a considerable amount of time had passed since the onset of the pandemic. While the interviews generated detailed reflections on pandemic governance and practice, some degree of recall bias cannot be excluded.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDrawing on the IBPA framework [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], this study examined how Sweden\u0026rsquo;s COVID-19 response engaged with socially differentiated contexts of health and illness, and how policy discourse and governance arrangements shaped what became recognisable\u0026mdash;and actionable\u0026mdash;as vulnerability. Viewed through this analytical lens, vulnerability emerges not as a fixed attribute simply identified by policy, but as a contingent and evolving construct, repeatedly produced and reformulated during the pandemic. Competing rationalities\u0026mdash;clinical risk, health system sustainability, and, more intermittently, equity concerns\u0026mdash;structured how vulnerability was defined and prioritised at different moments, influencing which risks were foregrounded and which remained less visible. From an intersectionality perspective, such selective visibility may be understood as producing \u0026lsquo;recognition gaps\u0026rsquo;, whereby certain social groups, conditions, and institutional realities remain insufficiently acknowledged within dominant policy narratives [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings further suggest that the governance of vulnerability extended beyond population risk categories to the institutional and professional settings responsible for protection. Responsibility and legitimacy were negotiated through contrasting representations of care environments and professional groups, with hospital-based biomedical settings often functioning as the implicit normative reference point despite a substantial share of care being delivered within long-term eldercare. Differentiated vulnerabilities thus emerged not only through classificatory practices, but also through the uneven structural capacities, mandates, and recognition accorded to different care settings. These patterns indicate that preparedness frameworks may benefit from more explicit attention to the organisational, relational, and workforce conditions of sectors tasked with safeguarding populations identified as vulnerable.\u003c/p\u003e \u003cp\u003eVariations in living and working conditions were only intermittently reflected in national advice, even when such conditions shaped the feasibility of compliance. Broad population categories and behavioural expectations often rested on implicit assumptions about normative social arrangements, generating substantial interpretive demands for individuals and local organisations. The practical scope of protection depended in part on how national categories and recommendations were translated into the intersecting realities of work, housing, language, migration-related conditions, and institutional trust. Regional and municipal actors described considerable relational, interpretive, and organisational labour\u0026mdash;through dialogue, adaptation, and improvisation\u0026mdash;to render general guidance workable under conditions of uncertainty. In IBPA terms, these translational processes matter because they shape whether socially differentiated vulnerabilities can be recognised and addressed in ways that are timely, context-sensitive, and practically meaningful [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTaken together, these translational dynamics highlight that coordination, clarity of mandate, and reciprocal communication are not merely administrative concerns, but structural conditions shaping whether differentiated vulnerabilities can be recognised and addressed across governance levels [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Where established channels were limited, implementation relied more heavily on local initiative, relational infrastructure, and improvised forms of coordination [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. At the same time, recommendations sometimes appeared to assume organisational capacities that were unevenly distributed across administrative levels, thereby embedding disparities in implementation potential from the outset. Sustaining and routinely exercising reciprocal engagement between national, regional, and municipal actors\u0026mdash;including collaboration with locally embedded and civil society organisations during non-crisis periods\u0026mdash;may help ensure that such mechanisms remain functional and trusted when emergencies arise [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Participants\u0026rsquo; reflections on the gradual re-fragmentation of coordination structures following the acute phase further raise questions about institutional learning and the extent to which experiential and intersectional insights are embedded in routine preparedness planning.\u003c/p\u003e \u003cp\u003eOverall, the findings suggest that the reach and feasibility of pandemic recommendations were mediated not solely by epidemiological risk, but by socially differentiated conditions\u0026mdash;including material resources, employment security, communicative access, organisational capacity, and institutional trust. From an intersectional standpoint, vulnerability can thus be understood as co-produced through discourse, categorisation, institutional hierarchies, and governance architecture, as well as through how individuals and organisations interpret, negotiate, and act within these conditions. Attending to this situated co-production may support preparedness approaches that respond not only to biological threats, but also to the socially patterned conditions through which exposure, recognition, and protection are distributed, thereby contributing to more contextually responsive and equitable public health governance [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCivil Society Organisation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Public Health Agency of Sweden (Folkh\u0026auml;lsomyndigheten)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIBPA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntersectionality-Based Policy Analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIndividual Municipal-level Interviews\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKII\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKey Informant Interviews\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMSB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Swedish Civil Contingencies Agency (Myndigheten f\u0026ouml;r samh\u0026auml;llsskydd och beredskap, since 1 January 2026, Myndigheten f\u0026ouml;r civilt f\u0026ouml;rsvar)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePress conference materials\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSoS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe National Board of Health and Welfare (Socialstyrelsen)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approvals and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study was carried out in accordance with the ethical principles outlined in the Declaration of Helsinki [65]. The Swedish Ethics Review Authority (decision letter number 2023-02140-01, dated 2023-05-17) has determined that formal ethical testing is not required for this study, given that it does not entail any intervention or processing of personal data. Nevertheless, to ensure compliance with the established ethical standards, we adhered to the established ethical principles, including providing participants with information about the study and their rights to withdraw, giving participants the opportunity to ask questions about their participation prior to their commitment, and all participants to provide their consent to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe qualitative data generated and analysed during the current study are not publicly available due to ethical and confidentiality considerations and the need to protect participant anonymity. De-identified data may be made available from the corresponding author upon reasonable request and subject to applicable ethical approvals. The national press conference transcripts analysed in this study are publicly accessible through the Swedish Public Health Agency (Folkh\u0026auml;lsomyndigheten).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eBB, GP, JL and NN received grant no. 2021-00284 from the Swedish Research Council for Health, Working Life and Welfare. The funding agency did not influence the design, conduct or analysis of the study.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eGP served as principal investigator of this qualitative EMBRACE sub-study and formulated the study design in collaboration with BB, JL, and NN. LSK coordinated study implementation, including data collection and analysis, together with AL, DH, GP, JL, and MAA. The manuscript was drafted by GP and LSK and revised with critical input from all co-authors prior to submission.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe thank all study participants for their commitment and for their invaluable contributions to this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUnited Nations. WHO chief declares end to COVID-19 as a global health emergency. UN News. 2023 May 5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGravlee CC. Systemic racism, chronic health inequities, and COVID-19: a syndemic in the making? Am J Hum Biol. 2020;32(5):e23482.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO coronavirus (COVID-19) dashboard [Internet]. Geneva: WHO; 2023 [cited 2026 Mar 13]. 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The practice of public health coordination in Sweden: roles, responsibilities, and realities. Health Promot Int. 2025;40(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarroll BJ, Brummel L, Toshkov D, Yesilkagit K. Multilevel governance and responses to the COVID-19 pandemic: a systematic literature review. Reg Fed Stud. 2023;35(2):305\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwall A, Hammar LM, Bostr\u0026ouml;m AM. Listen to the voices of nurses: the role of community chief nurses and registered nurses in the provision of care for older people in Sweden during the COVID-19 pandemic. BMC Geriatr. 2024;24:127.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human participants. JAMA. 2025;333(1):71\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9117388/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9117388/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic exposed and, in many contexts, intensified pre-existing inequalities, highlighting the importance of examining how vulnerability and equity were conceptualised within pandemic governance. Sweden\u0026rsquo;s response, characterised by voluntary recommendations, provides an instructive case for analysing how epidemiological rationalities, civil liberties, and social equity were negotiated. This study applies an Intersectionality-Based Policy Analysis (IBPA) framework to examine how vulnerability was framed and how equity considerations were rendered visible and operationalised in COVID-19 management.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e IBPA was applied to three data sources across Sweden\u0026rsquo;s governance levels: national press conference transcripts (n\u0026thinsp;=\u0026thinsp;198), regional interviews with public health officials (n\u0026thinsp;=\u0026thinsp;8), and municipal focus groups and interviews with health and civil society representatives (n\u0026thinsp;=\u0026thinsp;11). Data were analysed thematically, first inductively and then guided by IBPA.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree interrelated themes (six sub-themes) were identified. First, vulnerability was predominantly framed in biomedical terms, with hospital-based care serving as the implicit reference point for action, recognition, and responsibility. Second, national communication relied on broad population categories, generating tension between epidemiological clarity and the socially patterned feasibility of compliance, while shifting interpretative work to regional and municipal actors. Third, uneven mandate clarity and variable inter-agency coordination shaped implementation; where communication was unidirectional or ambiguous, downstream burdens intensified and operational dilemmas emerged. Local adaptation enabled responsiveness but also exposed fragilities in coordination and decision support.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings indicate a persistent tension between standardised rapid guidance and context-sensitive governance. Protection was shaped not only by epidemiological risk but also by working and housing conditions, linguistic access, trust, and the governance architecture distributing interpretive and coordination responsibilities across institutional levels. Equitable crisis management may be strengthened through clear mandates, effective coordination, and sustained reciprocal communication embedded across governance levels. Integrating experiential and intersectional perspectives into preparedness planning may strengthen institutional capacity and support more context-responsive and resilient public health responses in future crises.\u003c/p\u003e","manuscriptTitle":"Equity under pressure: An intersectionality-based policy analysis of Sweden’s COVID-19 response","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 14:55:23","doi":"10.21203/rs.3.rs-9117388/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6dc54d7e-f6e6-4df0-b089-20c5682e1561","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T15:40:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 14:55:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9117388","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9117388","identity":"rs-9117388","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}