The effect of OSAS on sick leave and work disability.

The objective of the present study was to examine the independent contribution of symptoms of obstructive sleep apnoea syndrome (OSAS) to long-term sick leave and permanent work disability. Using a historical cohort design with 4 yrs of follow-up, information on sick leave and disability benefit recipiency were merged with health information from the Hordaland Health Study, carried out in western Norway during 1997-1999. Persons aged 40-45 yrs (n = 7,028) were assessed for self-reported symptoms of OSAS (snoring, breathing cessations and daytime sleepiness), body mass index, somatic conditions and other potential confounders. The outcomes, cumulative sick leave of > or =8 weeks and permanent work disability, were identified in records from the National Insurance Administration. After excluding participants with work disability at baseline, symptoms of OSAS were found to be a significant predictor of both subsequent long-term sick leave and permanent work disability. These effects remained significant after adjustment for a range of possible confounding factors. Daytime sleepiness showed the greatest explanatory power, followed by breathing cessations and snoring. It is concluded that self-reported symptoms of obstructive sleep apnoea syndrome are an independent risk factor for subsequent long-term sick leave and permanent work disability. These findings need to be replicated using objective measures of obstructive sleep apnoea syndrome.

Health status before, during and after disability pension award: the Hordaland Health Study (HUSK).

OBJECTIVES: Up to one in eight of the working age population receives permanent disability benefits. As little is known about the consequences of this major event, analysis aimed to compare health status before and after disability pension award. METHODS: Data from the population based Hordaland Health Study (HUSK) in Norway 1997-99 (n = 18 581) were linked to official disability benefits registries. The study identified 1087 participants who were awarded a disability pension before, during and after the health survey. These were grouped into different strata defined by temporal proximity between disability pension award and health survey participation. The study then compared health status across these strata covering the 7 years before to the 7 years after the award. RESULTS: The study found an inverse U-shaped trend with an increase in reported symptoms (anxiety, depression, pain distribution, sleep problems and somatic symptoms) approaching the award, and a reversing of this trajectory afterwards (p<0.05 for the non-linear trend for all symptoms). We found no similar trend for the more objective health measures blood pressure, physical diagnoses and prescribed medication. For most measures, similar levels of health problems were found 3-7 years before compared to 3-7 years after the award. CONCLUSION: When comparing the strata defined by time to the event of disability pension award, there was an increase in symptoms around the time of the disability pension award, with a subsequent return towards pre-award levels. The design precludes any firm conclusions as to what causes the observed results, but possible explanations include temporary adverse health effects from the process itself, the beneficial effects of being removed from harmful work conditions, and recovery after increasing health problems leading up to disability pension award.

Changes in smoking behavior after a myocardial infarction.

Among 383 participants in a longitudinal study of myocardial infarction (MI) patients, 230 smoked at the time of the MI. Posthospital smoking status was based on self-report for the day of follow-up, whereas information about length of continuous cessation was not available. Six months after the heart attack, 40.6% of the smokers had resumed smoking, whereas 49.4% smoked at a 3- to 5-year (M = 43-month) follow-up. Resumption of smoking within 6 months after the heart attack was associated with an increase in anxiety and depression during the first weeks after discharge, less cardiac health knowledge, and a less severe MI. In patients who relapsed at a later point, resumption of smoking was associated with a subsequent decline in general cardiac health knowledge, as well as in correct understanding of smoking at a risk factor. Long-term changes in smoking status were also related to previous heart disease, premorbid work instability, age, and severity of the MI. The results indicate that antismoking counseling of MI patients should not be limited to the health risks associated with smoking and that training in coping with negative affects without smoking may be valuable in promoting smoking cessation.

Self-assessment of health before and after a myocardial infarction.

Self-evaluated health represents an important aspect of quality of life that may influence the rehabilitation process after a major illness. However, health is a multi-dimensional concept and relatively little is known about the determinants of, and the interrelationships between the separate aspects of health. In a prospective longitudinal study of myocaridal infarction (MI) patients, two indices of self-evaluated health, maximal physical ability (MPA) and perceived global health (PGH), were used. On the average, both ratings were clearly reduced compared with pre-MI levels even as long as 3-5 yr after the MI. Females and older patients indicated lower MPA before and after the MI, whereas PGH was not related to any sociodemographic variable. The severity of the MI appeared to be of relatively limited importance for self-evaluated health. Heart-related symptoms before and after the MI were more strongly related to lower MPA, whereas non-cardiac health problems and psychological distress more clearly influenced PGH. However, initial illness perceptions were of some importance for both health perceptions. The data suggest that to some extent self-evaluated health can be influenced by educational or psychological support in order to faccilitate readaption and recovery after a MI.

Verbal denial and outcome in myocardial infarction patients.

In a prospective study of 367 myocardial infarction patients, in-hospital measures of three aspects of verbal denial were examined with regard to medical, social and psychological outcome during a 3-5 yr follow-up. A low level of Denial of Illness was associated with more problems related to work, sexual life, and physical activities; and with a higher mortality rate. Higher levels of Denial of Impact were related to better emotional outcome, but also weakly associated with increased mortality. In contrast, Suppression proved to be related only to self-reported emotional distress. The findings indicate that it is useful to distinguish among several forms of denial in medical patients according to what is being denied.

Psychological predictors for return to work after a myocardial infarction.

The relationships between a return to work (RTW) 6 months after a myocardial infarction and selected personality traits, emotional reactions, health knowledge and beliefs, expectations and global health perceptions have been examined in a prospective study of 249 patients below 67 yr of age. Patients' in-hospital expectations of their future work capacity proved to be a strong predictor for RTW. In addition, level of anxiety and depression during hospitalization and level of cardiac lifestyle knowledge were independently associated with RTW. These effects could not be explained by demographic, work-related, or medical factors. It is concluded that patients' early illness perceptions and affective reactions influence later work resumption. Outcome-specific expectancy measures may be the most effective methods for early identification of patients needing rehabilitation efforts after an acute somatic disease.

Patterns of emotional reactions after a myocardial infarction.

In a prospective study of 283 myocardial infarction (MI) patients, state-dependent feelings of anxiety, depression, and irritability were assessed twice during hospital stay, and four times during a 3-5 yr follow-up. A K-mean cluster analysis identified six subgroups of MI patients with different pattern of emotional reactions. Two groups, containing nearly half of the sample, had low average levels of emotional upset at all assessments. Two groups showed an intermediate long-term outcome: one of these had a high level of initial emotional upset that subsided during the first six months after discharge, whereas the other group showed increasing levels of emotional distress long-term follow-up. Finally, two groups failed to achieve long-term emotional readjustment. For one of these, a high level of emotional upset was evident from the first in-hospital assessment, whereas the other one had a sharp increase in emotional distress after discharge. In a series of psychological, social and medical variables, the former pattern was associated with more pre-MI medical and psychosocial problems, whereas the delayed emotional reaction was related to lower levels of cardiac health knowledge. Furthermore, high levels of emotional upset preceded both failure in resuming work and increased long-term rehospitalization. The findings indicate that emotional reactions after a MI should be monitored during convalescence to identify patients at risk for a failure in emotional readjustment. Furthermore, effective treatment of initial emotional reactions could promote resumption of work and reduce long-term morbidity.

Training for general practice: a look to Norway.

In the 1960s general practitioners were a dying race in Norway. Today general practice is a highly approved specialty among doctors as well as patients. Better education is one of the revitalizing factors. General practice is currently taught as a mandatory subject at all four universities in Norway. The practice apprenticeship is the essential element in our undergraduate curricula. In their fifth year, the students spend three to eight weeks in a structured training program supervised by general practice faculty. Approximately 500 general practitioners take part in this decentralized training network. In 1985 general practice was recognized as a specialty in Norway. The obligatory requirements in the five-year educational program are: -courses, 400 hours -hospital training, one year -general practice training, four years -group-based training program, two years The last element is based on a decentralized concept where a group of two to 10 trainees meet for three hours every two weeks during a two-year period. The group is headed by an appointed and qualified trainer. Besides being in accordance with the geography and demography of Norway, this model gives substance to the slogan "general practice can only be learnt in general practice."

Life after a myocardial infarction--the wives' point of view.

37 wives of patients with myocardial infarction (MI) were interviewed after the index MI to examine the consequences with regard to quality of marital relationship, symptoms of distress, worries and concerns and to evaluate the long-term outcome from the wives' personal point of view. The interviews were done at three times: during hospitalisation, three months after discharge, and 10 years post index MI. Our findings suggest relatively minor and time-limited adjustment problems concerning marital relationship and symptoms of distress. In a long-term perspective, only a few lasting changes were found. On the other hand, the wives' subjective assessment of the long-term effects of the infarct within different domains of life indicated that the illness episode had a comprehensive negative influence on their quality of life. In accordance with this, the majority reported that the myocardial infarction was still not a closed episode.

Multiple sclerosis and lifestyle factors: the Hordaland Health Study.

This study compared multiple sclerosis (MS) patients (n=87) with the general population and with people reporting angina pectoris (n=109), asthma (n=1,353) and diabetes (n=219) regarding health-related quality of life (SF-12), working status and lifestyle factors including smoking, alcohol consumption, body mass index (BMI) and leisure physical activity. The study was cross-sectional and included the birth cohorts from 1950 to 1957 living in Hordaland County, Norway in 1997. A total of 22,312 people participated, yielding a response rate of 65%. The MS patients had a high rate of smoking and a low mean BMI, despite lower leisure physical activity compared with the rest of the study population. This suggests that it may be advisable to increase the focus on smoking, physical activity and the balance between energy intake and use.

[Health and the quality of life. Concepts and definitions]. / Helse og livskvalitet. Begreper og definisjoner.

The concepts "health" and "quality of life" have multiple meanings and are both unsatisfactorily defined. At least three different meanings of health can be identified: as the absence of illness; as a personal characteristic; and as a state of equilibrium and well-being. Broadly speaking, quality of life has been conceived in four different ways: as satisfaction with life; as satisfaction of defined needs; as happiness; and as self-realization and growth. It is argued that health and quality of life should be viewed as complementary concepts with a considerable overlap, but also with distinct features. Both concepts are needed. However, they should be more precisely defined in relation to each other.

[Health education in municipal health services--status 1991]. / Helseopplysning i kommunehelsetjenesten--status 1991.

The organization and level of activity of health education were examined in a national survey among the Norwegian municipal health services in 1991. The results were compared with a similar survey conducted in 1987. In 1991, 32% of the municipalities had local health education committees compared with 24% in 1987, and 59% had budgets for health education (1987: 52%). Compared with 1987, more of the municipalities took part in national health education campaigns, but locally initiated activities had become less common. Health promotion initiatives involving the public as active participants were clearly more common than in 1987. Local health education did not depend on the size of the population or other features of the municipality. However, the level of health promotion planning and budgeting were reflected in the health education activities. Cooperation with non-governmental organizations seemed to be the most crucial factor for municipal health education for primary health personnel.

[Changing patients' health behavior--consultation and physician-patient relationship]. / A påvirke pasienters helserelaterte atferd--konsultasjonen og lege-pasient-forholdet.

Studies indicate that doctors' advice concerning changes in patients' lifestyle meet with relatively little success. The article gives a summary of empirical studies on patient compliance in relation to the doctor's behaviour and attitudes; the quality of the patient-doctor relationship; and the content and form of the doctor's message. A patient-oriented style of communication; an ability to explore and discuss patients' expectations and behaviour; a warm and friendly approach; and an ability to gain the trust of the patient, are attributes that have been found to be effective in influencing patients' behaviour. The content of the information should be limited and specific, and the delivery should be structured. Perhaps the most important factor is a shift in power and control from the doctor to the patient when encouraging changes in health-related behaviour.

Predicting long-term mortality after a myocardial infarction from routine hospital data.

Among 528 patients under 67 years of age discharged alive after a myocardial infarction (MI), the cumulative survival rates after 3, 5, and 7 years were 84.1%, 75.9% and 68.6%, respectively. Compared with the "normal" population, the relative mortality risk was 4.8 for the first year, 3.1 for the second, and on average 2.1 for the next 5 years. Significant age differences were not observed for relative mortality. A multivariate Cox proportional hazards model showed long-term mortality to be independently related to higher age, a reduced working activity before the MI, previous cardiovascular disease, and a higher inhospital complication score, which was computed by summing eight defined clinical events weighted for severity. The results indicate that a reasonable prediction of long-term survival after a MI can be made from routine hospital data.

The effects of an in-hospital educational programme for myocardial infarction patients.

The effects of a standardized audiovisual educational programme for myocardial infarction (MI) patients have been evaluated in 4 hospital departments using a time-sequential quasi-experimental design. Compared with controls, patients offered the educational programme were more knowledgeable and had less fear-provoking beliefs about the MI, expressed more optimistic expectations about future physical ability, resumed physical activities more rapidly, reported less initial emotional disturbances, and consulted physicians less often during the first 6 weeks after discharge. Six months mortality-rate was significantly lower in the educational group, but long-term survival was identical in the two groups. The educational programme had no effect on smoking, return to work, resumption of sexual activity, or number of re-hospitalizations. The results indicate that standardized patient teaching during hospitalization is feasible and improves short-term coping behaviour after a MI.

[Locally based health promotion. Meetings of citizens as a tool for population mobilization]. / Naermiljøbasert helsefremmende arbeid. Folkemøter som redskap i befolkningsmobilisering.

It is necessary to involve the local population to a greater extent in the work of health promotion and prevention of disease. In the municipality of Askvoll the results of a household survey were used as an educational tool at popular meetings in the different settlements. At these meetings, the local citizens themselves chose actual health promotion projects and elected committees to carry them out. The article describes our experiences from this way of mobilizing the community. The attendance rate varied from 3% to 29% of the local population aged over 15 years. More women than men participated. A total of 17 local projects were chosen. We conclude that popular meetings can be a useful tool in local health promotion work.

[The Kvernevik Study. II. Satisfaction with the care among the population 5 years after the opening of a new health center]. / Kvernevik-undersøkelsen II. Befolkningens tilfredshet med legetjenestene fem år etter åpningen av et nytt legesenter.

Information from a survey conducted in 1984 among the adult population in a suburban area in Stavanger was applied in the planning of a new health centre. Five years later a similar survey was conducted to evaluate the innovations in primary care. Greater satisfaction was noted in regard to accessibility of the doctors. Compared with the general population, regular users of the new health centre were more satisfied with such aspects of service as accessibility by telephone, waiting time and opening hours. There was, a decline, however, in doctor-patient continuity. In general, satisfaction with primary care increased with age. There was no difference in satisfaction between males and females.

[Environmental health promotion in municipalities--resources, organization and activities]. / Miljørettet helsevern i kommunene--ressurser, organisering, samarbeid og aktiviteter.

The Municipal Health Services Act with amendments from 1988 defines environmental health promotion activities directed at physical, chemical, biological and social factors as mandatory for the local Norwegian health authorities. In addition, the municipal health services are responsible for health surveillance and for initiating cross-sectorial preventive measures. In 1991, we undertook a national survey among the Norwegian municipal health services to monitor planning activities, manpower resources, cross-sectorial cooperation, and project-oriented activities within the field of environmental health promotion. Less than one-third of the municipalities employed technically trained hygienic personnel. However, three of four municipalities had carried out some environmental health promotion projects within the last two years. The following factors were all independently related to level of environmental health promotion activity: the availability of technical assistance, the level of cross-sectorial cooperation and the size of the population in the municipality. We conclude that this area of health promotion should be improved by better planning, a higher level of technical hygienic competence within the municipal health services, more inter-sectorial cooperation and greater emphasis on visible projects of limited duration.

Return to work after a myocardial infarction: the influence of background factors, work characteristics and illness severity.

The relationship between return to work (RTW) within 6 months after a myocardial infarction (MI) and selected demographic factors, characteristics of prior work situation, pre-MI health status, and clinical severity of the MI has been studied in 249 patients below 67 years of age living in urban and rural areas of Western Norway. At the follow-up 8 out of 10 urban patients and 6 out of 10 rural patients were back at work. The RTW rate for the total sample was 73%. Age below 51 years, high educational and income level, working in tertiary industries, and in a job characterized by low physical activity and little psychosocial stress were all factors associated with a favourable work resumption. Multivariate analyses showed that socioeconomic or work-related factors could not fully explain the urban-rural differences in RTW. Stepwise discriminant analysis identified the following factors as important and independent predictors for RTW: Place of residence, age, education, perceived job stress, and clinical complications during hospitalization. Failure to return to work after a MI can be explained by a number of individual and social factors and only to a limited degree by the medical status of the patient. More knowledge is needed concerning the socio-cultural differences among both patients and attending physicians in attitudes towards work resumption after a MI.

Use of health services after a myocardial infarction.

Short-term and long-term use of physician consultations and rehospitalizations were studied in 383 myocardial infarction (MI) patients in relation to demographic, medical, and psychological factors. Short-term (i.e. within 6 months post-MI) utilization of physicians was only related to patients' health locus of control. In comparison, a higher number of physician consultations 3-5 years after the MI was independently related to female sex, more non-cardiac limitations before the MI, more complications during hospitalization, less cardiac lifestyle knowledge, and higher levels of anxiety and depression short time after the MI. Every second patient was readmitted to the hospital before the 3-5 years follow-up but only 14% suffered a non-fatal reinfarction. More rehospitalizations were independently related to a higher number of previous hospitalizations for heart disease, more pre-MI cardiac limitations, less cardiac lifestyle knowledge, and higher initial level of emotional distress. Discriminant analysis identified female sex and patients' initial expectations of reduced emotional control as the best predictor variables for a rehospitalization caused by chest pain without a new infarction, whereas a reinfarction was best discriminated by the number of previous hospitalizations for heart disease. We conclude that psychological factors influence health services utilization to a comparable extent as medical factors. These findings may indicate a greater need for long-term professional support in patients with less initial cognitive and emotional control.