Concerns and future challenges of health literacy in the Nordic countries - From the point of view of health promotion practitioners and researchers.

BACKGROUND: Health literacy is an essential social determinant for promoting and maintaining the health of a population. AIM: From a health promotion perspective, explore health literacy issues, concerns and future challenges among Nordic practitioners and researchers. METHODS: Data were collected in a workshop at the 8th Nordic Health Promotion Conference, and in a literature review, with articles from five databases. The search included title and abstract with the search terms health literacy* and health literacy as a MeSH term and all the Nordic countries. Qualitative and quantitative analysis were used. RESULTS: Twenty-five persons participated in the workshop. The discussions were summarized in six themes: concept of health literacy in national language; risk of victim blaming; measuring health literacy; content in school curricula on health literacy; new technologies for information and communication; communication and collaboration between different actors in support of health. Forty-three articles on health literacy were identified, mainly conducted within three fields: development, test and adaptation of instruments for measuring health literacy; measurement of health literacy among patients, or other defined target groups and on populations; and developing and evaluating methods/tools for the training of personnel groups or different target groups. CONCLUSIONS: There is a need for further studies providing a more in-depth understanding of the health literacy concept, knowledge on how to measure health literacy, ethical aspects, application in intersectoral collaboration as well as the adaptation to new technologies for information and communication in education supporting health literacy. As health literacy is an essential social health determinant, a concern and a future challenge must be, to make the health literacy concept familiar and visible in health promotion policies, research and practice such as health education.

'Disgust, disgust beyond description'- shame cues to detect shame in disguise, in interviews with women who were sexually abused during childhood.

Shame is a recurrent theme in the context of sexually abused women. Sexual abuse is taboo and shameful, and so is shame. Shame affects the development of a person and relationships, and is mentally painful. It is often covert. One aim of the present study was to explore whether and how women exposed to sexual abuse during childhood verbally express unacknowledged overt and covert shame, when interviewed about their physical and mental health, relations and circumstances relating to the sexual abuse. Another aim was, if shame was present, to describe the quality of the shame expressed by the women. A mainly qualitative approach with semi-structured interviews was used. Ten women attending self-help groups for women who were sexually abused during childhood were recruited as informants. The interviews were analysed for verbal expressions of shame by identifying code words and phrases, which were first sorted into six shame indicator groups and then categorized into various aspects of shame. The frequency of the code words and phrases was also counted. The findings clearly reveal that the affect of shame is present and negatively influences the lives of the informants in this study. It was possible to sort the code words and phrases most often mentioned into the indicator groups 'alienated', 'inadequate' and 'hurt', in the order of their frequency. It is obvious that shame affects the lives of this study's informants in negative ways. One important clinical implication for professionals in health care and psychiatric services is to acknowledge both sexual abuse and shame in order to make it possible for patients to work through it and thereby help them psychologically to improve their health.

Intimate partner violence: forms, consequences and preparedness to act as perceived by healthcare staff and district and community leaders in a rural district in northern Vietnam.

OBJECTIVES: A qualitative study was conducted among healthcare staff and district and community leaders in May and June 2002 to describe their perceptions of violence occurring between intimate partners. It focused on male violence towards females, and its forms, consequences and preparedness to act in a rural setting in Vietnam. METHODS: Twenty men and 20 women were strategically selected for focus group discussions and a phenomenographic approach was employed. FINDINGS: Violence was described not only as physical but also, primarily, as affecting women's mental health status. Mental violence was exemplified as verbally offending, ignoring or humiliating a woman. Sexual abuse was mentioned less frequently. IPV was considered to be a private matter, occurring in the home away from relatives, neighbours and the local community. Only very serious cases would seek health care. Divorce and deteriorating family finances were reported as serious consequences, not least for the children. Local reconciliation groups, comprised of trusted community members, played a role in mediating, while health professionals were found to be uninformed about prevalence rates and reluctant to intervene. CONCLUSIONS: Gender-based violence needs to receive attention from policy makers, and effective advocacy programmes are needed at all levels. In Vietnam, partner violence against women seems to be recognized at Government level. At community level, Women's Union staff and local reconciliation groups are prepared to act. However, the subject is surrounded by silence. We found that healthcare workers exhibited a lack of understanding of violence against women as a health problem in their own working environment.

Differences in trigger factors and symptoms between patients with asthma-like symptoms and patients with asthma: development of a basis for a questionnaire.

Patients with asthma-like symptoms but with negative asthmatests are often misdiagnosed as having asthma and treated as asthmatics. They describe their trigger factors and symptoms very similar to those of patients with asthma. The aim of the study was to analyze differences in symptoms and trigger factors between asthma-like patients and asthmatics in order to elaborate a basis for a questionnaire for epidemiological and clinical use. A questionnaire with 54 questions about trigger factors and 137 questions about symptoms was sent to 40 patients with asthma-like symptoms and 40 with asthma, all consecutively selected from patients referred to an out-patient clinic for asthma and allergy for investigation of suspected asthma. Data were analyzed statistically in two steps using multiple logistic regression analysis. Significant differences were seen in several trigger factors and symptoms after the first analysis. After the second analysis, seven out of the 54 trigger factors and 22 out of the 137 symptoms emerged as those that most significantly discriminated between the two patient groups. These trigger factors and symptoms can be the basis of a new questionnaire with high discriminating power. Before using it, it is important to evaluate the best combination of variables, add some demographic variables and totestthe reliability and validity ofthis new questionnaire.

Experiences by patients with asthma-like symptoms of a problem-based learning health education programme.

BACKGROUND: Eighteen patients with asthma-like symptoms but negative asthma tests, randomly selected, participated in a problem-based learning health education programme. The programme had a multidisciplinary approach and included exercises inspired by cognitive behavioural therapy. OBJECTIVE: The aim of this study was to describe how the patients experienced the programme. METHODS: After termination of the programme, semi-structured interviews with a phenomenographic approach were conducted with 15 of the participants. RESULTS: Two categories emerged, with three sub-categories each. In these, the informants described how they felt solidarity with the group, received confirmation from the other participants and had increased their self-confidence. They had started to look upon themselves and the disorder from a different perspective, they could describe the disorder in words and they had started to use new, conscious coping strategies. CONCLUSIONS: Patients with asthma-like symptoms benefit from taking part in a problem-based learning health education programme. It helps them to reflect upon themselves and the disorder and to use new strategies to cope with it.

Clinical health education for patients with asthma-like symptoms but negative asthma tests.

BACKGROUND: Patients with asthma-like symptoms but negative asthma tests often state that they lack strategies to cope with their symptoms. The aim of the study was to determine whether a problem-based health education program had a beneficial effect on the participants' experience of symptoms and subjective health. METHODS: Thirty-eight patients, consecutively drawn from an outpatient clinic for asthma and allergy, were randomly allocated to an intervention group (I group, n=18) and a control group (C group, n=20). The I group, divided into three subgroups, met on seven occasions over 5 months. The program had a multidisciplinary approach, used exercises inspired by cognitive behavioral therapy, and was performed according to the principles of problem-based learning. All patients answered the Nijmegen Symptom Questionnaire (NQ) and the SF-36 health survey before and 2 months after the training was terminated. RESULTS: Before the program, there were no significant differences between the groups in their earlier experience of symptoms. After it, the I group scored significantly lower on shortness of breath (P=0.001) and central tetany (P=0.05) than the C group. On both test occasions, the asthma-like patients scored lower on all variables of the SF-36 than the reference groups of asthmatics and healthy subjects. No significant differences were seen between the I group and the C group except for vitality, in which the C group scored lower before the intervention. CONCLUSIONS: Patients with asthma-like symptoms but negative asthma tests benefit from taking part in a problem-based health education program. It mainly reduces the frequency of symptoms.

The health-line--a method for collecting data on self-rated health over time: a pilot study.

BACKGROUND: There is a need for an instrument to record a life-course perspective of self-rated health. AIM: To test the "health-line", a simple, comprehensive method of collecting data on self-rated health over time. METHOD: In 1996, a questionnaire was mailed to people who in 1985 were aged between 25 and 34 years old and had a sick-leave spell >28 days with "back diagnoses". They were asked to rate their global health graphically with a "health-line" for the years 1985-95. Official data on sick leave and disability pension were obtained for the same period. In all, 37 out of 52 men and 60 out of 83 women answered; that is, they drew a health-line. RESULT: A statistically significant negative correlation between the mean number of absence days due to ill health and the health-line data was found for every year (r= -0.35 to -0.53; p<0.001) and for the whole period 1985-95 (r=-0.546; p<0.001) respectively. CONCLUSION: The method worked well and is well worth further development and testing.

Presence of hyperventilation in patients with asthma-like symptoms but negative asthma test responses: provocation with voluntary hyperventilation and mental stress.

BACKGROUND: A group of patients reporting asthma-like symptoms but with negative asthma tests has been identified. OBJECTIVE: The objective of this study was to determine whether hyperventilation might explain these symptoms and whether the tests could be used as diagnostic tools. METHODS: A hyperventilation provocation test (HVPT), a mental stress test, and the Word Color Conflict Test (WCCT) were performed on 10 patients with asthma-like symptoms, 10 patients with asthma, and 10 healthy subjects. End-tidal PCO 2 (PETCO2) was recorded 10 minutes after the HVPT and during the WCCT. Blood pressure, heart rate, and respiratory rate were also studied. The Nijmegen symptom questionnaire was used in the assessment of symptoms. RESULTS: After the HVPT, the PETCO2 values recovered most slowly in the study group, the difference being significant compared with the healthy group (P <.01). During the WCCT, the study group had the lowest PETCO2 values at the 10- and 15-minute measurements, the difference again being significant compared with the healthy group (P <.05). The study group more often experienced symptoms before the test than the group with asthma (P <.05) and the healthy group (P <.001). The study group recognized significantly more symptoms previously experienced during the HVPT than the group with asthma (P <.05) and the healthy group (P <.01) and during the WCCT than the healthy group (P <.05). The study group showed a negative correlation between the PETCO2 level and the number of symptoms after the HVPT at 8 (r = -0-72; P <.05) and 10 minutes (r = -0.76; P <.05) and after the WCCT (r = -0.59; P <.05). Blood pressure, heart rate, and respiratory rate showed small differences between the groups. CONCLUSION: Patients with asthma-like symptoms may experience hyperventilation when provoked. Mental stress might be 1 trigger factor. The HVPT and WCCT can be used as diagnostic instruments.

Physical capacity and dyspnea in patients with asthma-like symptoms but negative asthma tests.

Ten female patients with asthma-like symptoms but negative asthma tests (study group) were compared with 10 female asthmatics in an exercise test with and without pretreatment with beta 2-stimulants. The aim was to determine whether the asthma-like symptoms in the patients of the study group could be explained by bronchoconstriction, circulatory abnormalities, or physical unfitness when provoked physically, and whether the exercise test could be used to distinguish these patients from asthmatics. Without pretreatment, the asthma group reacted with bronchoconstriction, as indicated by postexercise systematic changes in PEFR, FEV1, FVC, and SaO2, which were not seen in the study group. The groups differed in the ratings of "difficulty in getting air", as only the asthma group had significantly lower ratings when pretreated. The study group's mean test performance was 94 W; the asthma group's was 106 W. The low performance was not explained by disturbances in heart rate, electrocardiogram, or blood pressure or physical unfitness. The exercise test was found to distinguish between the groups, especially for bronchoconstriction, oxygen saturation, and ratings of dyspnea. It could be used complementary to lung function tests to eliminate bronchoconstriction, circulatory abnormalities, and physical unfitness as a cause of the asthma-like symptoms.

Walking around in circles--the life situation of patients with asthma-like symptoms but negative asthma tests.

In-depth interviews were conducted with fourteen women with asthma-like symptoms but negative asthma tests. In collecting and analysing data the method of grounded theory was used. A core category emerged, Walking around in circles, and three main categories, Subjective Hyperreactivity, Social Limitations and Non Confirmation which elucidated the life situation and psychosocial processes involved in having the breathing disorder. The findings were characterised by numerous self-reinforcing vicious circles. The symptoms were especially associated with subjective hyperreactivity with strong sensitivity to odours, impaired ability to perform physical activities and mental stress, which in turn impose social limitations. These restrictions arouse feelings of social isolation and distress, which implies mental stress and thereby increased attention and sensitivity to adverse stimuli. The fact that the medical experts cannot offer diagnosis and treatment engenders feelings of confusion, non-confirmation and thereby anxiety which further aggravate the vicious circles described. Most informants considered that they had few coping strategies. Some stated that they had changed their strategies from being passive, taking no responsibility, to become more active, not caring about the reactions of others and taking the risk of being ill, favouring social contacts and thus minimising the impact of the disorder.

Psychological differences between asthmatics and patients suffering from an asthma-like condition, functional breathing disorder: a comparison between the two groups concerning personality, psychosocial and somatic parameters.

Fifteen patients with asthma were compared with thirteen patients with asthma-like symptoms but without physiological signs of asthma. This condition is termed Functional Breathing Disorder, FBD. All patients were examined with regard to relevant physiological variables, and to specific personality traits and psychosocial status by means of psychological tests and questionnaires. The results indicated that the patients suffering from FBD were more psychologically distressed and had lower quality of life than the asthma patients. Further, they suffered from a significantly greater variety of symptoms and more intense symptoms than the asthmatics. Such symptoms included sleeping disturbances and somatic symptoms such as chest pain, cold hands or feet, blurred vision. The FBD patients had significantly more problems in their social and family lives, at work and in their leisure time than the asthmatics. They were significantly more depressed, less hedonic and more hypochondriac than the asthmatics. Moreover, they trusted other people to a significantly lesser degree. The patients with FBD had been hospitalized less often than the asthmatics, but they had sought medical care more often. The present study indicates that it is important to identify patients suffering from FBD at as early a stage as possible in order to offer them proper treatment.

Education of adult patients at an "asthma school": effects on quality of life, knowledge and need for nursing.

The effect of education of adult asthma patients at a special "asthma school" was studied with regard to knowledge of the disease and its treatment and quality of life measured by leisure activities, social interaction and psychological well being. We also studied if there were any differences in number of days in hospital and emergency visits before and one year after the asthma-school. Patients were randomised to an intervention group (7 men and 13 women) and a control group (7 men and 11 women). The age-range was 22-66 yrs. Both groups answered the same standardized and quantified questionnaires on three occasions, before the start of the asthma school, after five months and after twelve months. Both groups increased their knowledge of the disease and how to treat it, with slightly better results in the intervention group. The self-assessments all showed that patients in the intervention group felt better than those in the control group. The number of days in hospital as well as acute visits to out patients clinics were reduced significantly after the asthma school. The intervention did not influence spirometric variables.