Investigating the use of support in secondary school: the role of self-reliance and stigma towards help-seeking.

Purpose: Adolescents are the least likely to seek help for their mental health problems. School may be an important route to improve early recognition of adolescents with mental health problems in need for support, but little is known about the barriers to school support.Materials and methods: Data were collected in a longitudinal cohort study of Dutch adolescents (age 12-16) in secondary school (n = 956). We assessed the relation between level of psychosocial problems at the beginning of the school year (T1) and the support used in school at the end of that school year (T2), whether the willingness to talk to others (measured at T1) mediates this relation, and whether stigma towards help-seeking (T1) moderates this mediation.Results: Adolescents with more psychosocial problems were more likely to use support in school and were less willing to talk to others about their problems, but the willingness to talk to others was not a mediator. Stigma moderated the relationship between psychosocial problems and willingness to talk to others.Conclusions: Most adolescents with psychosocial problems get support in Dutch secondary school regardless of their willingness to talk to others about their problems. However, perceiving stigma towards help-seeking makes it less likely for someone to talk about their problems.

The role of functional health literacy in long-term treatment outcomes in psychosocial care for adolescents.

Although among adolescents with psychosocial problems low health literacy may increase the risk of poor treatment outcomes, the contributing mechanisms within treatment remain unclear. A better understanding of these mechanisms could contribute to improved treatment processes and outcomes. This study aims to examine the relationship between functional health literacy, treatment processes (treatment adherence, learning processes), and treatment outcome (level of psychosocial problems) in adolescents in psychosocial care. We used data from a prospective cohort study among adolescents aged 12-18 (N = 390), collected in four successive measurements: at entry into care, and 3, 12, and 24 months thereafter. We used a mixed effect model to investigate the association between level of functional health literacy (adequate vs. inadequate) and treatment processes (treatment adherence, learning processes) and treatment outcome (level of psychosocial problems). Between adolescents with adequate and inadequate functional health literacy, we found no differences or change over time in adherence or learning processes. The level of psychosocial problems significantly declined over time (ß = - 1.70, 95% CI [- 2.72, - 0.69], p = .001) to a similar degree in both groups, though, in all measurements, the level was consistently higher for adolescents with inadequate health literacy. We conclude that health literacy levels did not affect change in treatment processes nor in outcomes of psychosocial treatment. However, the consistently higher level of psychosocial problems among adolescents with inadequate health literacy suggests an unaddressed need in psychosocial care.

[Improving health literacy among older adults: Findings based on the IROHLA project]. / Förderung der Gesundheitskompetenz älterer Menschen : Ansatzpunkte auf Basis des EU-Projektes IROHLA.

Health literacy has been defined as the degree to which people are able to access, understand, appraise, and communicate information to make informed decisions about their health. It is therefore essential to be able to engage with the demands of different health contexts and to stay healthy. The topic of health literacy is thus receiving growing political and scientific attention and is becoming increasingly important in Germany too. Results of a survey on health literacy in Germany that were published by the AOK's scientific research institute, WidO, in 2014, stress the need for health literacy improvement. These results are briefly summarized. At a European level, the IROHLA (Intervention Research on Health Literacy among Ageing population) project was started in December 2012. IROHLA is aimed at introducing evidence-based guidelines for policy and practice to improve health literacy among the ageing population in the member states of the European Union (EU). The project consortium is led by the University Medical Center Groningen (UMCG) and consists of 22 partners from nine EU member states. German partners in the project are the Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung-BZgA), the Federal Association of the AOK (AOK-Bundesverband), liveonline coaching, and Jacobs University Bremen. The purpose of this article is to present the major findings of the IROHLA project and to point out approaches to improving health literacy among older adults. A key aspect within IROHLA is the comprehensive approach, which targets multiple groups, i.e., individuals and their social environment, in addition to professionals and the health system.

Multimorbidity prevalence and patterns and their associations with health literacy among chronic kidney disease patients.

BACKGROUND: Health literacy is the ability to deal with information related to one's health. Patients with low health literacy have poor disease-management skills for chronic diseases, such as chronic kidney disease (CKD). This could influence the number and combination of their diseases. METHODS: We included adult patients with CKD stages 1-5 from the Lifelines Study (n = 2,742). We assessed the association between low health literacy and the number and patterns of comorbidities, considering them globally and stratified by age and sex, using multinomial logistic regression and latent class analysis, respectively. RESULTS: Low health literacy was associated with a higher number of comorbidities in the crude models, and after adjustment for age, sex, eGFR, smoking, and BMI. In the crude model, the OR for low health literacy increased from 1.71 (1.25-2.33) for two comorbidities to 2.71 (2.00-3.68) for four comorbidities. In the fully-adjusted model, the associations remained significant with a maximum OR of 1.70 (1.16-2.49) for four comorbidities. The patterns of multimorbidity were similar for low and adequate health literacy, overall and by sex, bur tended to be different for patients older than 65. Older patients with low health literacy had higher comorbidity prevalence and a relatively greater share of cardiovascular, psychiatric, and central nervous system diseases. CONCLUSIONS: Among CKD patients, low health literacy is associated with more multimorbidity. Health literacy is not associated with patterns of multimorbidity in younger patients, but a difference was observed in older ones. Improving low health literacy could be an intervention efficient also in decreasing multimorbidity in CKD patients.

[Photo stories instead of leaflets: support for people with low health literacy]. / Fotostrips in plaats van folders.

In the Netherlands, almost 30 percent of adults have limited levels of health literacy. They have difficulties finding, understanding and using health information. Comprehensible health information is extra important for people with low health literacy. A systematic review revealed that narrative health communication is a promising strategy to increase comprehension. We have investigated which interventions may improve comprehensibility of health-related documents for older adults with different levels of health literacy. We are currently exploring if and how photo stories on care and health topics can support people with low health literacy.

Determinants of salivary cortisol levels in 10-12 year old children; a population-based study of individual differences.

The hypothalamic-pituitary-adrenal (HPA)-axis is a central component of the body's neuroendocrine response to stress. Its major end-product cortisol has profound effects on mood and behavior. Although it has often been suggested, it remains unknown whether differences in HPA-axis physiology are part of an individual's vulnerability to psychopathology, and constitute a causal factor in its development. In order to study the contribution of HPA-axis physiology to the development of psychopathology, we measured HPA-axis physiology in a community-cohort of 1768 10-12 year-old children. The aims of the here presented study were twofold: (1) to obtain data on HPA-axis function in a large cohort of pre- and early-adolescent children, both in terms of total hormonal output and in terms of the dynamics of cortisol secretion (by means of the cortisol awakening response); and (2) to study potential confounders of the cortisol-psychopathology relationship in this age group, such as season of sampling, age, gender, pubertal development, perinatal variables and BMI. We found a wide interindividual variability in HPA-axis function. An increase in cortisol in the first 30 min after awakening was present in 70.7% of children, but the increase appears lower in children than in adults. In addition, this study suggests that season of sampling and gender may act as potential confounders in the cortisol-psychopathology relationship. We will follow these children longitudinally for the development of psychopathology in the period from childhood into adulthood. This period covers adolescence, which is a critical time for the appearance and development of psychiatric disorders.

Flexion relaxation during lifting: implications for torque production by muscle activity and tissue strain at the lumbo-sacral joint.

During the full flexion phase of the back lift movement the lumbar part of the erector spinae muscle exhibits a reduced activity level (flexion relaxation). This study addresses the question how the required extension torque in the lumbo-sacral joint (L5/S1 joint) is balanced during the period in which apparently the lumbar erector spinae ceases to take its share. Six subjects participated in the experiment in which they performed seven lifting tasks. The load, the range of movement, and the phase in which the load was handled (lifting or lowering) were varied. A dynamic linked segment model was applied to determine the momentary torques acting at the L5/S1 joint, while the EMGs of the lumbar and thoracic part of the erector spinae muscle were measured. Furthermore, the lengths between markers on the lumbar and thoracic part of the trunk were determined to reveal changes in length during the movement. The dynamic EMGs were normalized to trunk angle-dependent maximal levels. The L5/S1 joint torques were analysed and combined with the normalized EMG data and the kinematics of the trunk, which are assumed to indicate the elongation of passive tissues. Although in the normalization procedure the change of the length-force relationship of the erector spinae was taken into account, the dynamic lumbar EMG activity decreased to a low-activity level (the phenomenon of flexion relaxation). This coincided with a 25% increase in lumbar length suggesting that passive tissue strain provided part of the required extension torque. In the tasks where a barbell was handled a significant increase in EMG level of the thoracic part of the erector spinae occurred just before the flexion relaxation at the lumbar level. Apparently, the extensor function of the lumbar part is then taken over by the thoracic part of the erector spinae muscle. This suggests that an intricate coordinating mechanism is operative that apportions the load to be balanced over active--(lumbar and thoracic part of the erector spinae) and passive structures (post vertebral ligaments).

Ultrasound therapy for acute ankle sprains.

BACKGROUND: Ultrasound is used in the treatment of a wide variety of musculoskeletal disorders. OBJECTIVES: To evaluate the effects of ultrasound therapy in the treatment of acute ankle sprains. SEARCH STRATEGY: MEDLINE and EMBASE up to December 1998 and databases of the Cochrane Rehabilitation and Related Therapies Field and Musculoskeletal Injuries Group were searched. This was supplemented with citation tracking, and contact with colleagues. Date of the most recent search: April 1999. SELECTION CRITERIA: Randomised or pseudo-randomised trials were included in the review if the following conditions were met: at least one study group was treated with active ultrasound; the study included patients with acute lateral ankle sprains; and outcome measures included general improvement, pain, swelling, functional disability, or range of motion. Final selection of papers was conducted by two independent reviewers. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality using a standardised checklist, and extracted data. Whenever possible, the results were analysed on an intention-to-treat basis. Fixed odds ratios together with 95% confidence intervals were calculated for dichotomous outcomes, and weighted or, where different scales were used, standardised mean differences together with 95% confidence intervals for continuous outcome measures. Pooling of data was undertaken where there was clinical homogeneity in terms of subjects, treatments, outcomes, and follow-up time points. MAIN RESULTS: The four included trials, involving 514 patients, were only of modest methodological quality. None of the three placebo-controlled trials (sham ultrasound) could demonstrate statistically significant differences between true and sham ultrasound therapy for any outcome measure at seven days of follow-up. The pooled odds ratio for general improvement was 1.19 (Peto fixed effects model, 95% confidence interval 0.73 to 1.93) for the comparison between ultrasound and sham ultrasound. The differences between intervention groups were generally small, between 0 and 6% for most dichotomous outcomes. However, one trial reported relatively large differences for pain free status (20%) and swelling (25%) in favour of ultrasound treatment. REVIEWER'S CONCLUSIONS: The extent and quality of the available evidence for the effects of ultrasound therapy for acute ankle sprains are limited. The results of three placebo-controlled trials do not support the use of ultrasound in the treatment of ankle sprains. The magnitude of most reported treatment effects appeared to be small, and may be of limited clinical importance. As yet, only few trials are available and no conclusions can be made regarding an optimal and adequate dosage schedule for ultrasound therapy, and whether such a schedule would improve on the reported effectiveness of ultrasound for ankle sprains.

Ultrasound therapy for acute ankle sprains.

BACKGROUND: Ultrasound is used in the treatment of a wide variety of musculoskeletal disorders. OBJECTIVES: To evaluate the effects of ultrasound therapy in the treatment of acute ankle sprains. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 15th 2001), the Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2001), MEDLINE (1966 to October 2001), EMBASE (1983 to 2001 week 45), CINAHL (1982 to October week 4 2001), and PEDro - The Physiotherapy Evidence Database (http://ptwww.cchs.usyd.edu.au/pedro/ accessed 15.11.01). We also searched the Cochrane Rehabilitation and Related Therapies Field database, reference lists of articles, and contacted colleagues. SELECTION CRITERIA: Randomised or pseudo-randomised trials were included in the review if the following conditions were met: at least one study group was treated with active ultrasound; the study included patients with acute lateral ankle sprains; and outcome measures included general improvement, pain, swelling, functional disability, or range of motion. Final selection of papers was conducted by two independent reviewers. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality using a standardised checklist, and extracted data. Whenever possible, the results were analysed on an intention-to-treat basis. Relative risks together with 95 per cent confidence intervals were calculated for dichotomous outcomes, and weighted or, where different scales were used, standardised mean differences together with 95 per cent confidence intervals for continuous outcome measures. Pooling of data was undertaken where there was clinical homogeneity in terms of subjects, treatments, outcomes, and follow-up time points. MAIN RESULTS: Five trials were included, involving 572 patients. Four of these trials were only of modest methodological quality and one placebo-controlled trial was considered to be of good quality. None of the four placebo-controlled trials (sham ultrasound) could demonstrate statistically significant differences between true and sham ultrasound therapy for any outcome measure at seven to 14 days of follow-up. The pooled relative risk for general improvement was 1.04 (random effects model, 95% confidence interval 0.92 to 1.17) for the comparison between ultrasound and sham ultrasound. The differences between intervention groups were generally small, between zero and six per cent for most dichotomous outcomes. However, one trial reported relatively large differences for pain free status (20%) and swelling (25%) in favour of ultrasound treatment. REVIEWER'S CONCLUSIONS: The extent and quality of the available evidence for the effects of ultrasound therapy for acute ankle sprains is limited. The results of four placebo-controlled trials do not support the use of ultrasound in the treatment of ankle sprains. The magnitude of most reported treatment effects appeared to be small, and may be of limited clinical importance. As yet, only few trials are available and no conclusions can be made regarding an optimal and adequate dosage schedule for ultrasound therapy, and whether such a schedule would improve on the reported effectiveness of ultrasound for ankle sprains.

Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomised clinical trials.

OBJECTIVE: To assess the effectiveness of physiotherapy for patients with soft tissue shoulder disorders. DESIGN: A systematic computerised literature search of Medline and Embase, supplemented with citation tracking, for relevant trials with random allocation published before 1996. SUBJECTS: Patients treated with physiotherapy for disorders of soft tissue of the shoulder. MAIN OUTCOME MEASURES: Success rates, mobility, pain, functional status. RESULTS: Six of the 20 assessed trials satisfied at least five of eight validity criteria. Assessment of methods was often hampered by insufficient information on various validity criteria, and trials were often flawed by lack of blinding, high proportions of withdrawals from treatment, and high proportions of missing values. Trial sizes were small: only six trials included intervention groups of more than 25 patients. Ultrasound therapy, evaluated in six trials, was not shown to be effective. Four other trials favoured physiotherapy (laser therapy or manipulation), but the validity of their methods was unsatisfactory. CONCLUSIONS: There is evidence that ultrasound therapy is ineffective in the treatment of soft tissue shoulder disorders. Due to small trial sizes and unsatisfactory methods, evidence for the effectiveness of other methods of physiotherapy is inconclusive. For all methods of treatment, trials were too heterogeneous with respect to included patients, index and reference treatments, and follow up to merit valid statistical pooling. Future studies should show whether physiotherapy is superior to treatment with drugs, steroid injections, or a wait and see policy.

The influence of maternal vulnerability and parenting stress on chronic pain in adolescents in a general population sample: the TRAILS study.

Investigating possible psychosocial predictors of unexplained chronic pain in adolescents is crucial in understanding its development and prevention. A general population sample of adolescents (n = 2230) from the TRAILS cohort study was investigated longitudinally to assess the influence of maternal vulnerability, in terms of anxiety, depression and stress, and parenting stress at age 10-12 years, on the presence of chronic pain at age 12-15 years. Of these adolescents, 269 (12.9%) reported experiencing chronic pain, of which 77% reported severe chronic pain and 22% reported multiple chronic pain. Maternal anxiety, maternal stress and higher levels of parenting stress were related to chronic pain at a later age. Subgroup analyses showed similar results for adolescents with severe chronic pain. Mediation analyses indicated that parenting stress mediates the effect between maternal anxiety, or stress, and chronic pain. The findings suggest that interventions to diminish maternal feelings of anxiety and stress, while in turn adjusting maternal behaviour, may prevent the development of chronic pain in adolescence.

Predicting transitions in low and high levels of risk behavior from early to middle adolescence: the TRAILS study.

The present study examined the joint development of substance use and externalizing problems in early and middle adolescence. First, it was tested whether the relevant groups found in previous studies i.e., those with an early onset, a late onset, and no onset or low levels of risk behavior could be identified, while using a developmental model of a single, underlying construct of risk behavior. Second, departing from Moffitt's taxonomy of antisocial behavior, it was tested if early, but not late, onset risk behavior is predicted by a problematic risk profile in childhood. Data were used from TRAILS, a population based cohort study, starting at age 11 with two follow-ups at mean ages of 13.6 and 16.3 years. Latent transition analyses demonstrated that, both in early and middle adolescence, a single underlying construct of risk behavior, consisting of two classes (labeled as low and high risk behavior), adequately represented the data. Respondents could be clearly classified into four possible transition patterns from early to middle adolescence, with a transition from high to low being almost non-existent (2.5 %), low to low (39.4 %) and low to high (41.8 %) being the most prevalent, and high to high (16.2 %) substantial. As hypothesized, only the high-high group was characterized by a clear adverse predictor profile in late childhood, while the low-high group was not. This study demonstrates that the development of substance use is correlated with externalizing problems and underscores the theory that etiologies of early and later onset risk behavior are different.

Internalizing and externalizing problems in adolescence: general and dimension-specific effects of familial loadings and preadolescent temperament traits.

BACKGROUND: We investigated the links between familial loading, preadolescent temperament, and internalizing and externalizing problems in adolescence, hereby distinguishing effects on maladjustment in general versus dimension-specific effects on either internalizing or externalizing problems. METHOD: In a population-based sample of 2230 preadolescents (10-11 years) familial loading (parental lifetime psychopathology) and offspring temperament were assessed at baseline by parent report, and offspring psychopathology at 2.5-years follow-up by self-report, teacher report and parent report. We used purified measures of temperament and psychopathology and partialled out shared variance between internalizing and externalizing problems. RESULTS: Familial loading of internalizing psychopathology predicted offspring internalizing but not externalizing problems, whereas familial loading of externalizing psychopathology predicted offspring externalizing but not internalizing problems. Both familial loadings were associated with Frustration, low Effortful Control, and Fear. Frustration acted as a general risk factor predicting severity of maladjustment; low Effortful Control and Fear acted as dimension-specific risk factors that predicted a particular type of psychopathology; whereas Shyness, High-Intensity Pleasure, and Affiliation acted as direction markers that steered the conditional probability of internalizing versus externalizing problems, in the event of maladjustment. Temperament traits mediated one-third of the association between familial loading and psychopathology. Findings were robust across different composite measures of psychopathology, and applied to girls as well as boys. CONCLUSIONS: With regard to familial loading and temperament, it is important to distinguish general risk factors (Frustration) from dimension-specific risk factors (familial loadings, Effortful Control, Fear), and direction markers that act as pathoplastic factors (Shyness, High-Intensity Pleasure, Affiliation) from both types of risk factors. About one-third of familial loading effects on psychopathology in early adolescence are mediated by temperament.

Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement.

OBJECTIVES: To assess the interobserver agreement on the diagnostic classification of shoulder disorders, based on history taking and physical examination, and to identify the determinants of diagnostic disagreement. METHODS: Consecutive eligible patients with shoulder pain were recruited in various health care settings in the Netherlands. After history taking, two physiotherapists independently performed a physical examination and subsequently the shoulder complaints were classified into one of six diagnostic categories: capsular syndrome (for example, capsulitis, arthritis), acute bursitis, acromioclavicular syndrome, subacromial syndrome (for example, tendinitis, chronic bursitis), rest group (for example, unclear clinical picture, extrinsic causes) and mixed clinical picture. To quantify the interobserver agreement Cohen's kappa was calculated. Multivariate logistic regression analysis was applied to determine which clinical characteristics were determinants of diagnostic disagreement. RESULTS: The study population consisted of 201 patients with varying severity and duration of complaints. The kappa for the classification of shoulder disorders was 0.45 (95% confidence intervals (CI) 0.37, 0.54). Diagnostic disagreement was associated with bilateral involvement (odds ratio (OR) 1.9; 95% CI 1.0, 3.7), chronic complaints (OR 2.0; 95% CI 1.1, 3.7), and severe pain (OR 2.7; 95% CI 1.3, 5.3). CONCLUSIONS: Only moderate agreement was found on the classification of shoulder disorders, which implies that differentiation between the various categories of shoulder disorders is complicated. Especially patients with high pain severity, chronic complaints and bilateral involvement represent a diagnostic challenge for clinicians. As diagnostic classification is a guide for treatment decisions, unsatisfactory reproducibility might affect treatment outcome. To improve the reproducibility, more insight into the reproducibility of clinical findings and the value of additional diagnostic procedures is needed.

Occupational risk factors for shoulder pain: a systematic review.

OBJECTIVES: To systematically evaluate the available evidence on occupational risk factors of shoulder pain. METHODS: Relevant reports were identified by a systematic search of Medline, Embase, Psychlit, Cinahl, and Current Contents. The quality of the methods of all selected publications was assessed by two independent reviewers using a standardised checklist. Details were extracted on the study population, exposures (physical load and psychosocial work environment), and results for the association between exposure variables and shoulder pain. RESULTS: 29 Studies were included in the review; three case-control studies and 26 cross sectional designs. The median method score was 60% of the maximum attainable score. Potential risk factors related to physical load and included heavy work load, awkward postures, repetitive movements, vibration, and duration of employment. Consistent findings were found for repetitive movements, vibration, and duration of employment (odds ratio (OR) 1.4-46 in studies with method scores >/= 60%). Nearly all studies that assessed psychosocial risk factors reported at least one positive association with shoulder pain, but the results were not consistent across studies for either high psychological demands, poor control at work, poor social support, or job dissatisfaction. Studies with a method score >/=60% reported ORs between 1.3 and 4.0. Substantial heterogeneity across studies for methods used for exposure assessment and data analysis impeded statistical pooling of results. CONCLUSIONS: It seems likely that shoulder pain is the result of many factors, including physical load and the psychosocial work environment. The available evidence was not consistent across studies, however, and the associations were generally not strong. Future longitudinal research should evaluate the relative importance of each individual risk factor and the role of potential confounding variables-such as exposure during leisure time-to set priorities for the prevention of shoulder pain in occupational settings.

The responsiveness of the Shoulder Disability Questionnaire.

OBJECTIVE: To evaluate the responsiveness of the Shoulder Disability Questionnaire (SDQ). METHODS: The study was conducted within the framework of an observational study on shoulder disorders in primary care. After first presentation of their complaints to the general practitioner and after one and six months, participants completed the SDQ, a single question on functional status (FSQ), and an ordinal 11 point scale for the severity of pain (PSS). Responsiveness of the SDQ was evaluated compared with that of the FSQ and PSS, by calculating responsiveness ratios and by plotting receiver operating characteristic (ROC) curves. Recovery according to the patient was used as an external criterion for clinically relevant improvement (complete recovery or much improved on a six point Likert scale was denoted as clinically relevant improvement). RESULTS: A total of 349 consecutive patients with shoulder disorders were enrolled in the observational study. Response rates ranged between 96% and 89%. Responsiveness ratios were slightly higher for the PSS compared with the SDQ (2.53 versus 2.22 at one month, 2.24 versus 1.89 at six months). The area under the ROC curve was 0.84 for both the SDQ and the PSS, and 0.72 for the FSQ. CONCLUSION: The results of this study confirm the responsiveness of the SDQ, making it a useful instrument to assess functional disability in longitudinal studies.