Self-reported health and physical activity among community mental healthcare users.

The aim of the study was to survey the self-reported health and physical activity in a sample of community mental healthcare users in a city of Sweden. The study was conducted through a cross-sectional design with participants requested to fill out a self-report questionnaire. Participants (n = 103) were persons with psychiatric disabilities living in residential psychiatric settings and/or participating in daily activities provided by community mental healthcare services. The results showed that the group is affected with serious risk factors, such as high body mass index, low rated extent and frequency of physical activity and low self-estimated general state of health. Even though some difficulties associated with the answering process of this questionnaire emerged, these self-reported results clearly confirm the fact that persons with psychiatric disabilities constitute a vulnerable group in need for health-promoting caring activities and interventions.

Factors influencing GPs' decisions regarding screening for high alcohol consumption: a focus group study in Swedish primary care.

OBJECTIVE: The aim of this study was to explore factors that influence general practitioners' (GPs') decisions regarding screening for high alcohol consumption. METHODS: GPs working at three primary healthcare centres in Sweden participated in focus group interviews. The interviews were recorded and transcribed verbatim, and a deductive framework approach was used for the analysis. RESULTS: The majority of the participating GPs did not believe in asking all patients about their alcohol consumption. Reported factors that influenced how many and which patients were questioned about alcohol consumption were time, age of the patient, consultation setting, patient-physician relationship, what symptoms the patient presented with, and knowledge of measures if patients appear to have a high alcohol consumption. Thus, alcohol screening and intervention were not performed in all patient groups as was originally intended, but were performed in limited groups of patients such as those with alcohol-related symptoms. CONCLUSIONS: Although the number of participants in this study was small and the conclusions cannot be generalized, the results provide some valuable insights into why GPs are hesitant to engage in screening for high alcohol consumption. Since prevention of alcohol-related health problems is an important public health issue, many different screening and intervention strategies have to be formulated and evaluated in order to reach patients with both hazardous and harmful alcohol consumption within the healthcare system. Screening all consecutive patients for a limited period or screening patient groups known to include a fairly high frequency of high alcohol consumers are two ways of limiting the time requirements and increasing role legitimacy. Still, there is a need for a broader public health strategy involving many players in the community in alcohol preventive measures, especially in more primary preventive approaches.

Chest pain and ischaemic heart disease in primary care.

BACKGROUND: Chest pain is the main symptom of first presentation with ischaemic heart disease (IHD). Little is known about the incidence of IHD among patients consulting the general practitioner (GP) for chest pain. AIMS: To estimate the occurrence of IHD among patients consulting for chest pain, to study the results of the bicycle exercise test, and to estimate the incidence of IHD in the population. DESIGN OF STUDY: Prospective descriptive study. SETTING: Three primary health centres in south-eastern Sweden. METHOD: All patients without a current IHD diagnosis, aged 20 to 79 years, and consulting for a new episode of chest pain, were included consecutively. The outcome was classified as IHD, possible IHD or not IHD, according to the results of a postal questionnaire, an exercise test or hospital care. Data from the hospital registry on patients with a diagnosis of IHD were analysed retrospectively. RESULTS: Out of 38,075 GP consultations, 577 (1.5%) were for chest pain. IHD was diagnosed in 41 (8%) of the chest pain patients, in 441 (83%) the diagnosis was excluded, and in 50 (9%) the diagnosis was judged as being uncertain. Even though the diagnostic criteria were strict, the exercise tests led to a diagnostic conclusion in 77% of the cases, most frequently a normal test result. Combining data from primary and hospital care, the yearly incidence of IHD was 6.5 diagnosed per 1000 inhabitants (aged 20 to 79 years old). CONCLUSION: The incidence of a new episode of chest pain bringing the patients to the GP was low. Eight per cent of the patients received an IHD diagnosis, and in 9% further investigation or clinical assessment is needed.

Reliability of a multidimensional questionnaire for adults with treated complete cleft lip and palate.

The purpose of this study was to evaluate the reliability of a multidimensional questionnaire for Swedish adults with treated complete unilateral or bilateral cleft lip and palate (CLP). The questionnaire was designed to be used in the evaluation of adults with treated CLP after treatment. Before any conclusions were drawn from the results of the study we assessed the test-retest reliability of the questionnaire. The questionnaire included 168 questions and assessed the following domains: aesthetics, functions associated with CLP, satisfaction with treatment and perceived need for treatment, quality of life, depression and non-specific physical symptoms, body image, and jaw function. The subjects answered the questionnaire twice at a 2-3-week interval. Sixty-one adults (38 men, 23 women) mean age 24 years (range 20-29) participated in the study. The response rate for the questionnaire was acceptable at 75%. The test-retest reliability varied among the different domains. The reliability of questions regarding aesthetics, functions associated with CLP, and treatment satisfaction was good to excellent (intraclass correlation coefficient (ICC) = 0.51 to 0.89). Good to excellent (ICC = 0.61 to 1.0) reliability was also found for the quality of life in various life domains and the wellbeing scales. The reliability of the body image scale was moderate (kappa = 0.43-0.60) for most items and lower than that of other scales used in this study. The reliability of the mean depression symptom score (ICC = 0.93) and the mean non-specific physical symptoms score (ICC = 0.85) were excellent. The reliability of the mandibular function impairment was good (ICC = 0.67). The conclusion of the study is that an overall reliability was good for the multidimensional questionnaire.

[Functional evaluation of heart failure patients in primary care. The NYHA system is unreliable since intercurrent illness can give rise to similar symptoms]. / Funktionsvärdering av hjärtsviktspatienter i primärvården. NYHA-systemet opålitlight då annan sjukdom ger liknande symtombild.

A group of 158 patients with congestive heart failure was studied in detail concerning other types of morbidity. The purpose was to evaluate how often classification according to the NYHA system was disturbed by intercurrent disease with a similar set of symptoms. At the same time, a visual analogue scale for the evaluation of physical capacity was tested. Seventy-eight per cent of the patients had intercurrent disease putting them at risk of inadequate NYHA classification. There was no correlation between the patients' NYHA class and grade or type of echocardiographic ventricular dysfunction. However there was a correlation between NYHA class and the presence of intercurrent disease.

Quality of life in adults with repaired complete cleft lip and palate.

OBJECTIVE: This study evaluated the quality of life in adult Swedish subjects with repaired complete cleft lip and palate (CLP). DESIGN/PATIENTS: Sixty-eight adults with repaired CLP were compared with a group of 66 adults without cleft matched by gender and age. OUTCOME MEASURES: The outcome measures included a self-report questionnaire concerning quality of life in general, well-being, and health-related quality of life. RESULTS: The CLP group rated their quality of life significantly lower than did the control group in the areas of life meaning (p <.05), family life (p <.0001), and private economy (p <.01). There were no significant differences between the groups concerning well-being. In the CLP group, the health-related quality of life was significantly lower concerning global life (p <.0001), disturbance to life (p <.01), well-being (p <.0001), social contacts (p <.0001), and family life (p <.05) but significantly higher concerning ability to make the most of leisure time (p <.001) and to be active (p <.001). CONCLUSIONS: The CLP group perceived a marked impact of the handicap on their lives concerning global aspects, well-being, and social life. More practical and tangible aspects of their daily living, however, were not affected, and only some minor aspects of their quality of life in general were poor in comparison with the control group, which indicates a fairly good life adjustment in spite of the handicap.

Opinions about district nurses prescribing.

Opinions about district nurses prescribing The aim of this study was to investigate the opinions of district nurses (DNs) and general practitioners (GPs) about nurse prescribing in Sweden in order to elucidate similarities and differences, and relate different opinions to background and psychosocial working factors. In a questionnaire about psychosocial working conditions, seven statements about DNs prescribing were included. The questionnaire was sent to 554 DNs and 566 GPs with a participant rate of 83%. On all items as well as on the total score DNs rated more positively compared with GPs. Amongst the DNs a positive opinion was related to a traditional primary care organization, age < 50, good social support at work, and high workload. A positive opinion amongst GPs was associated with working in a traditional primary care organization, being male GP, and a good social support at work. In a multiple regression analysis, occupation and organization were independently associated with the total score. The result shows a strong professional solidarity amongst GPs and seems to be based on concern about the profession rather than patient care.

[Diagnosis and treatment of heart failure in primary health care. Low correlation between Pro-ANF and heart failure]. / Diagnostik och behandling av hjärtsvikt i primärvården. Låg korrelation mellan Pro-ANF och hjärtsvikt.

Three eastern Swedish primary care clinics serving a predominantly rural clientele monitored for 13 months all patients under 80 years of age with a diagnosis based on clinical signs alone of heart failure (n = 56) or suspected incipient heart failure (n = 62). Echocardiography was performed on all patients. For 64% of the former group, the putative diagnosis matched echocardiography findings. Results showed a purely diastolic disorder in one-fifth of all 118 patients, and a hemodynamically significant, hitherto unknown heart defect in about as many. Pro-ANF assays correlated poorly with manifest heart failure. Pharmacological treatments were registered, and at 6-month follow-up, 82% of patients with systolic failure were receiving ACE-inhibition.

Changes in attitudes and practices in primary health care with regard to early intervention for problem drinkers.

During an intervention period of 1 to 2 months, a project team supported general practitioners (GPs) and nurses in four primary health care centres in Sweden in introducing new routines for detection and treatment of problem drinkers. After the implementation of the new methods, the GPs reported increased involvement in early detection and intervention significantly more often than the nurses did. A majority in both groups reported perceived improvement in skills. There was a significant positive change of the attitudes concerning working with alcohol-related problems in the nurses reaching the same level as the GPs. In the nurses, attitudes and self-perceived intervention skills were improved, but to a lesser extent than their practice. The results indicate that future efforts concerning improvement of primary health care staff involvement in alcohol interventions should focus on training, supervision, and giving positive examples, rather than on changing an already positive attitude towards alcohol intervention. The potential role of nurses is still uncertain and not utilized sufficiently.

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.

Assessment of psychosocial work environment in primary care--development of a questionnaire.

Recent studies have indicated deteriorated working conditions of health care personnel. To have an efficient health care organization requires good working conditions and the well-being of the personnel. Today there are no "gold-standard" assessment tools measuring psychosocial working conditions. The aim of this study was to develop two valid and reliable questionnaires, one generic and one specific, measuring psychosocial working conditions for general practitioners (GPs) and district nurses (DNs) in Sweden, with a special emphasis on organizational changes. The construction of the questionnaires were made after a stepwise developing phase including literature review, interviews, and a pilot study. The pilot study included GPs n = 42 and DNs n = 39. The questionnaires were later on used in a main study (GPs n = 465, DNs n = 465). A factor analysis was carried out and showed that there were fewer items in the main study that had factor loading > or = 0.40 in more than one factor, compared to the pilot study. The factors from the main study were easier to label and had good correspondence with other studies. After this stepwise development phase good construct validity and internal consistency were established for the questionnaire.

The personal doctor reform in Sweden: perceived changes in working conditions.

BACKGROUND: In primary care in Sweden, several organizational changes have been implemented during the last decades in order to facilitate a shift from a high proportion of hospital care to a more primary-health-based care. The personal doctor reform has been one of the most important during recent years, for both personnel and patients. OBJECTIVES: We aimed to compare perceived changes in psychosocial working conditions for GP and district nurses in regions with traditional primary care and regions that have implemented a personal doctor system. METHODS: A questionnaire was mailed to 566 GPs and 554 district nurses in four selected county councils, two with traditional primary care and two with a personal doctor system. The overall response rate was 83%. A factor analysis of data concerning the experience of the organizational change revealed the following factors: fellowship at work, demands on the individual, influence and control, competence development and stimulation at work. RESULTS AND CONCLUSIONS: In the group as a whole, there was a general experience of deterioration of working conditions in all aspects except stimulation at work. This tendency was mostly marked in the regions with a personal doctor system. In these regions, GPs and district nurses reported significantly more impairments concerning demands on the individual and competence development. In addition, the district nurses also found themselves less able to exercise influence and control. These changes are neither desirable nor necessary consequences of an organizational development. It is important to follow continuously the personnel's experience in a changing primary health care system.

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.

Sex differences in sickness absence in relation to parental status.

The aim of this study was to analyse sex differences in medically certified sickness absence with special regard to parental status and age. All new sick-leave spells exceeding seven days and certified by a physician in a county of Sweden were registered in 1985-1987. The data-base was related to the population at risk by using data from the Swedish Official Population and Housing Census 1985. The analysis concerned the employed population in the age group from 16 to 54 with and without custody of children younger than ten years. In all ages, women with children had more sickness absence than men with children. Corresponding sex differences did not appear for persons without children, except for the oldest age-groups. Men with children had the lowest sickness absence of all groups. Young women with children had the highest. These findings remained the same when pregnancy-related sickness absence was excluded. The common finding of sex differences in sickness absence is here highly interrelated to custody of small children. The results suggest that the often reported positive health effects of multiple roles in women may be counteracted by inequality between the sexes in the responsibility as parents.

Pharmacological intervention in older patients with rheumatoid arthritis. Quality of life aspects.

Despite the rather pessimistic outlook regarding the long term effects of pharmacological treatment of patients with rheumatoid arthritis (RA), there is no doubt that drug interventions can affect quality of life (QOL). The disease has a significant impact upon physical, psychological and social function, and QOL optimisation should cover all these dimensions. Swelling of joints and pain are important manifestations in assessing RA since these may result in sleep disturbances as well as depressed mood. This might be particularly significant for older persons with RA. Outcome parameters of RA can be divided into short, intermediate and long term. The long term results are quite disappointing with regard to disability and premature death. However, more intermediate outcome measures related to QOL might improve after pharmacological interventions. Patient preferences and expectations with regard to the outcome of pharmacological interventions are important parameters to assess. When assessing older patients with RA with QOL instruments, it is recommended that questionnaires are fairly short and easy to complete. Adverse effects of pharmacological interventions are important factors to monitor in QOL assessment in older patients with reduced remaining life span.

Sick-leave due to minor psychiatric morbidity: role of sex integration.

During the years 1985-1987 all sick-leave spells exceeding 7 days, together with a number of demographic variables, were registered in a Swedish county. Using this register, the 3,100 employed persons with at least one sick-leave per year due to minor psychiatric morbidity were analysed with regard to age, occupation and sex. The annual cumulative incidence was 1.7% of the employed population. In 1985 the female incidence was 2.1% and the male incidence was 1.3%. Incidence was highest in the middle-aged. The mean number of absence days per sick-listed person was 73 in 1985. For women, the corresponding figure was 63 and for men, 82. Industrial occupations had the highest incidence and with few exceptions, women had a higher incidence than men in each occupation. Occupations were categorized into five groups according to the number of women and men employed. Women in extremely male-dominated occupations had the highest incidence of all groups, 4.6%. Men in extremely female-dominated occupations had the highest incidence of all men, 2.9%. Occupations with an equal sex distribution had the lowest sick-leave incidence, 1.2%. Further studies on the influence of sex integration on sickness absence need to be done.

Type II diabetes and quality of life: a review of the literature.

In this review, an attempt was made to describe how non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) affects the life of the ill person. Patients are affected by and cope with this complex disease in different ways, depending on its severity and complications. Influences on well-being therefore also vary--from none to major deterioration. A substantial proportion of patients are primarily affected with fatigue, anxiety, and depression. Deteriorations in cognitive function have also been documented, although diverging evidence exists. Some negative social circumstances have also been noted. Social support, particularly specific support, appears to be helpful, although self-efficacy and health practices seem to be as important. Resistance to compliance with diabetes regimens together with reactions to the demands for increased levels of physical activity are often seen. Systematic focused studies examining how patients and significant others perceive the impact of the disease in retrospect are still awaited. There is a great need for more research on type II diabetes; broad prospective longitudinal follow-up studies monitoring natural disease progression, as well as examining the predictive significance of quality of life, would be welcome.