Spousal bereavement and its effects on later life physical and cognitive capability: the Tromsø study

Spousal bereavement is associated with health declines and increased mortality risk, but its specific impact on physical and cognitive capabilities is less studied. A historical cohort study design was applied including married Tromsø study participants (N=5739) aged 50-70 years with baseline self-reported overall health and health-related factors and measured capability (grip strength, finger tapping, digit symbol coding, and short-term recall) at follow-up. Participants had data from Tromsø4 (1994-1995) and Tromsø5 (2001), or Tromsø6 (2007-2008) and Tromsø7 (2015-2016). Propensity score matching, adjusted for baseline confounders (and baseline capability in a subset), was used to investigate whether spousal bereavement was associated with poorer subsequent capability. Spousal bereavement occurred for 6.2% on average 3.7 years (SD 2.0) before the capability assessment. There were no significant bereavement effects on subsequent grip strength, immediate recall, or finger-tapping speed. Without adjustment for baseline digit symbol coding test performance, there was a negative significant effect on the digit symbol coding test (ATT -1.33; 95% confidence interval -2.57, -0.10), but when baseline digit symbol coding test performance was taken into account in a smaller subsample, using the same set of matching confounders, there was no longer any association (in the subsample ATT changed from -1.29 (95% CI -3.38, 0.80) to -0.04 (95% CI -1.83, 1.75). The results in our study suggest that spousal bereavement does not have long-term effects on the intrinsic capacity components physical or cognition capability to a notable degree.

Life-course income trajectories of men and women in Norway: implications for self-rated health in later life

BACKGROUND

Socioeconomic inequalities in health are well-established, but studies addressing lagged effects of income or of fluctuations in income over the life course are relatively rare. The current study aims to (i) identify and describe life-course income trajectories for men and women who are currently in later life; and (ii) assess the association of income trajectories with self-rated health in older adults.

METHODS

The study sample consisted of 1625 men and 1634 women born between 1937 and 1955 who participated in the third wave of the Norwegian Life course, Ageing and Generation Study. Latent class growth analyses were used to estimate dominant income trajectories from ages 30 through 62 in men and women. Stepwise logistic regression analyses were specified to analyze the association of income trajectories with self-rated health in later life.

RESULTS

Four trajectories in women and three trajectories in men were estimated as dominant patterns of income over the life course. Differences in the level of income were considerable at age 30 and accumulated over time. Continued exposure to low income showed statistically significant higher odds for poor self-rated health in older men and women. This association remained significant after taking differences in educational attainment, working life, family formation and accumulated wealth into account.

CONCLUSION

The findings suggested remarkable rigidity in income groups that had formed by age 30. A significant share of men and women remain mired in relatively low-income status across the life course with negative implications for health in later life.

Socioeconomic Inequalities in Mortality After Age 67: The Contribution of Psychological Factors

Diverging trends of longer lives and increased inequalities in age-at-death invite to updated research on late-life mortality. Earlier studies have identified health behavior, childhood, psychosocial, and material conditions as key determinants of life expectancy, but the role of psychological factors remains a topic of debate. The current study is framed in a life course developmental perspective and assesses the mediating role of secondary control strategies (subjective age) and primary control capacity (perceived control) to socioeconomic (wealth and education) inequality in mortality after age 67. Data are derived from the second wave of the Norwegian Life Course, Ageing and Generation study (N=1,432 and age 67–85). All in all, 366 deaths were observed over a mean follow-up of 9.6years. Perceived control was measured by the Pearlin and Schooler Mastery Scale. SA was measured with proportional discrepancy scores in felt age and ideal age. Stepwise Cox proportional hazards regression analyses were conducted to analyze the relative contribution of SES (education and accumulated wealth), felt age, and ideal age discrepancies and perceived control on 11-year mortality. Findings show that lower levels of wealth and perceived control independently predict increased elderly mortality over an 11-year period. Feeling younger and smaller ideal age discrepancies are positively associated with perceived control, but do not account for additional variability in longevity among older adults. Findings add to the interdisciplinary field of socioeconomic inequalities in elderly mortality and underline the specific importance of structural conditions (wealth) and the continued importance of (perceived) primary control capacity for longevity also after age 67. Future research may assess in more detail how wealth and perceived control complement each other in contributing to healthy aging and longevity, for example, by longitudinal research including the role of significant life events in the second half of life in different welfare state contexts.

Nurses' assessments of horizontal collaboration in municipal health and care services for older adults: A cross-sectional study

Interprofessional and interorganizational collaboration is considered key to achieving high-quality care and positive patient outcomes, but there is limited research into how nurses working in nursing homes and home care services perceive collaboration with other municipal health and care service providers and how their assessments of collaboration vary with individual characteristics and context. The objective of this study was to map variation in nurses' assessments of horizontal collaboration with core care services for older adults, specifically nursing homes, home care services, general practitioners, the allocation office and physio- and occupational therapy services. The study draws on findings from a nationwide cross-sectional survey on posthospital care for older adults, conducted among nurses working in nursing homes and home care services in Norway (N = 3717). Nurses were asked to assess collaboration with these five services. Independent variables were workplace, age, years at current workplace, part-time work, postgraduate education, and municipality size. Statistical analyses were conducted using descriptive statistics and analysis of variance (ANOVA). A majority of nurses evaluated horizontal collaboration as good. Collaboration with the home care services was evaluated as best, while collaboration with general practitioners was evaluated as least good. The study showed that workplace and municipality size were important for nurses' assessments of collaboration. Generally, nurses in smaller municipalities evaluated collaboration as better than nurses in larger municipalities. That workplace and municipality size impact on nurses' evaluations of collaboration in municipal care services for older adults is important knowledge for leaders and policy-makers aiming to improve patient care and teamwork.

Nurses' assessments of staffing adequacy in care services for older patients following hospital discharge

Aims

To explore community nurses' assessments of staffing adequacy in care provision for older patients following hospital discharge and analyse the extent to which their assessments are associated with characteristics of the system level of municipality and vertical coordination between hospital and community care services.

Design

Nation‐wide cross‐sectional survey.

Methods

Web‐based survey conducted in 2017 among 3,461 nurses working with older persons (65+) in homecare services, residential care and nursing homes in Norway. Responses from individual homecare nurses were linked with municipal‐level register data (age structure, economic flexibility, service profiles). Stratified multilevel analyses were used to analyse the association of staffing adequacy with municipal characteristics and perceived quality of vertical coordination.

Results

Almost half of the nurses experienced inadequate staffing in general, whereas a similar share indicated that staffing was adequate. Nursing home nurses showed the least positive ratings of staffing adequacy. Most nurses indicated that there were too many unqualified care workers at their workplace. More positive assessments of staffing adequacy were associated with better vertical coordination. Average ratings of staffing adequacy were lower in larger municipalities and municipalities with an older population.

Conclusion

Healthcare providers, nurse managers and policy makers may benefit from a stronger focus on rebalancing skill‐mix and on new models of vertical coordination in addressing current and future nurse staffing shortages in care services for older people following hospital discharge.

Impact statement

This study adds to the scarce national and international research literature on nurse staffing in community care services, addressing the pressing challenges of staffing and skill‐ mix in long‐term care provision. Findings support the development of nurse‐led models of care coordination for older patients following hospital discharge and stimulate future research on the effects of recruitment and retainment strategies in different municipalities and different models of vertical coordination.

A nation-wide cross-sectional study of variations in homecare nurses' assessments of informational continuity - the importance of horizontal collaboration and municipal context

Background

Numerous studies have revealed challenges associated with ensuring informational continuity in municipal care services for older adults with comprehensive, prolonged and complex care needs. Most research is qualitative and on the micro-level. The aim of the current study is to map variation in homecare nurses’ assessments of available information in the municipalities’ documentation system and investigate the extent to which these assessments are associated with perceived quality of collaborations and with municipal context.

Methods

We used data from a nationwide web-based survey among 1612 nurses working with older adults (65+) in homecare services in Norway. Responses from individual homecare nurses were linked with municipal-level data from the public registers. Data were analysed with descriptive statistics and multilevel regression analyses.

Results

Information on the recipients’ medications and medical condition was considered most often available (42.8 and 20.0% responding very often/always), whereas information related to psychosocial needs and future follow-up was perceived less available (4.5 and 6.7% responding very often/always). Homecare nurses’ perceptions of the quality of collaboration with the GP and the allotment office were independently and positively associated with assessments of informational continuity (ß =0.86 and ß =0.96). A modest share of the total variation (8%) in assessments of informational continuity was at the structural level of municipality. Small municipalities (< 5000 inhabitants) had, on average, better informational continuity compared to larger municipalities (ß = -0.47).

Conclusions

Documentation systems have a limited focus on long-term care needs of older care recipients beyond clinical and medical information. There is a potential for enhanced communication- and care-pathways between GPs, the allotment office and nurses in homecare services. This can support the coordinating role of homecare nurses in ensuring informational continuity for older adults with prolonged and complex care needs and help develop the facilitating role of (electronic) documentation systems.

Are there educational disparities in health and functioning among the oldest old? Evidence from the Nordic countries

With the ageing of the population and recent pressures on important welfare state arrangements, updated knowledge on the linkage between socioeconomic status and health in old age is pertinent for shedding light on emerging patterns of health inequalities in the Nordic countries. This study examined self-rated health (SRH), mobility and activities of daily living (ADL) according to level of education in the three oldest old age groups 75–84, 85–94, and 95+, in four Nordic countries. Altogether, 6132 individuals from Danish Longitudinal Study of Ageing, Norwegian Life Course, Ageing and Generation study, Swedish Panel Study of Living Conditions of the Oldest Old, the 5-Country Oldest Old (Sweden) and Vitality 90 + Study were analysed. First, associations of education level with SRH, mobility, and ADL were estimated for each individual study by means of age- and gender-adjusted logistic regression. Second, results from individual studies were synthesized in a meta-analysis. Older adults with higher education level were more likely to report good SRH, and they were more often independent in mobility and ADL than those with basic education when all age groups were combined. In mobility and ADL, differences between education groups remained stable across the age groups but for SRH, differences seemed to be weaker in older ages. With only a few exceptions, in all age groups, individuals with higher education had more favourable health and functioning than those with basic education. This study shows remarkable persistence of health and functioning inequalities in the Nordic countries throughout later life.

Eight-year follow-up of a randomized clinical trial comparing ultrasound-guided foam sclerotherapy with surgical stripping of the great saphenous vein

BACKGROUND

This was an 8-year follow-up of an RCT comparing ultrasound-guided foam sclerotherapy (UGFS) with high ligation and surgical stripping (HL/S) of the great saphenous vein (GSV).

METHODS

Patients were randomized to UGFS or HL/S of the GSV. The primary outcome was the recurrence of symptomatic GSV reflux. Secondary outcomes were patterns of reflux according to recurrent varices after surgery, Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification, Venous Clinical Severity Score (VCSS) and EuroQol Five Dimensions (EQ-5D™) quality-of-life scores.

RESULTS

Of 430 patients originally randomized (230 UGFS, 200 HL/S), 227 (52·8 per cent; 123 UGFS, 103 HL/S) were available for analysis after 8 years. The proportion of patients free from symptomatic GSV reflux at 8 years was lower after UGFS than HL/S (55·1 versus 72·1 per cent; P = 0·024). The rate of absence of GSV reflux, irrespective of venous symptoms, at 8 years was 33·1 and 49·7 per cent respectively (P = 0·009). More saphenofemoral junction (SFJ) failure (65·8 versus 41·7 per cent; P = 0·001) and recurrent reflux in the above-knee GSV (72·5 versus 20·4 per cent; P = 0·001) was evident in the UGFS group. The VCSS was worse than preoperative scores in both groups after 8 years; CEAP classification and EQ-5D® scores were similar in the two groups.

CONCLUSION

Surgical stripping had a technically better outcome in terms of recurrence of GSV and SFJ reflux than UGFS in the long term. Long-term follow-up suggests significant clinical progression of venous disease measured by VCSS in both groups, but less after surgery. Registration number: NCT02304146 (http://www.clinicaltrials.gov).

Educational inequalities in late-life depression across Europe: results from the generations and gender survey

This study explores country- and gender-stratified educational differences in depression among older adults from 10 European countries. We examine inequalities in both absolute (prevalence differences) and relative (odds ratios) terms and in bivariate and multivariate models. We use cross-sectional, nationally representative data from the generations and gender survey. The analysis comprises 27,331 Europeans aged 60-80. Depression is measured with a seven-item version of the Center for Epidemiologic Studies Depression scale. Findings show considerable between-country heterogeneity in late-life depression. An East-West gradient is evident, with rates of depression up to three times higher in Eastern European than in Scandinavian countries. Rates are about twice as high among women than men in all countries. Findings reveal marked absolute educational gaps in depression in all countries, yet the gaps are larger in weaker welfare states. This pattern is less pronounced for the relative inequalities, especially for women. Some countries observe similar relative inequalities but vastly different absolute inequalities. We argue that the absolute differences are more important for social policy development and evaluation. Educational gradients in depression are strongly mediated by individual-level health and financial variables. Socioeconomic variation in late-life depression is greater in countries with poorer economic development and welfare programs.

Social pathways to health: On the mediating role of the social network in the relation between socio-economic position and health

Good health is one of the key qualities of life, but opportunities to be and remain healthy are unequally distributed across socio-economic groups. The beneficial health effects of the social network are well known. However, research on the social network as potential mediator in the pathway from socio-economic position (SEP) to health is scarce, while there are good reasons to expect a socio-economical patterning of networks. We aim to contribute to our understanding of socio-economic inequalities in health by examining the mediating role of structural and functional characteristics of the social network in the SEP-health relationship. Data were from the second wave of the Norwegian study on the life course, aging and generation study (NorLAG) and comprised 4534 men and 4690 women aged between 40 and 81. We applied multiple mediation models to evaluate the relative importance of each network characteristic, and multiple group analysis to examine differences between middle-aged and older men and women. Our results indicated a clear socio-economical patterning of the social network for men and women. People with higher SEP had social networks that better protect against loneliness, which in turn lead to better health outcomes. The explained variance in health in older people by the social network and SEP was only half of the explained variance observed in middle-aged people, suggesting that other factors than SEP were more important for health when people age. We conclude that it is the function of the network, rather than the structure, that counts for health.

Changes in Health and Health Behavior Associated With Retirement

Objectives: While poor health contributes to early work exits, it is less clear how early work exits affect health. This study therefore examines changes in health associated with retirement. Method: Survey data from gainfully employed individuals aged 57 to 66 in 2002 were used to assess changes in health status and behaviors associated with retirement (49%) 5 years later ( N = 546). Results: Compared with workers, retirees were more likely to report improvements in mental health (odds ratio [OR] = 1.67), and less likely to report mental health deteriorations (OR = 0.56). Retirees were more likely to both increase (OR = 2.03) and reduce (OR = 1.87) their alcohol intake, and to increase physical activity (OR = 2.01) and lose weight (OR = 1.75). Discussion: As welfare states aim to extend working life to counteract repercussions of population aging, findings on possible health benefits for retirees may warrant more focus on the pros and cons of a prolonged working life.

Acute abdomen as the first presentation of a malignant lymphoma of the small intestine

Malignant small intestinal lymphoma is a quite rare disease that often has an atypical presentation with symptoms of abdominal pain, nausea and weight loss. However, as illustrated in the following cases, acute abdomen due to an intestinal perforation can be the first sign of malignant lymphoma.

Real teams and their effect on the quality of care in nursing homes

BACKGROUND

Use of teams has shown to be an important factor for organizational performance. However, research has shown that a team has to meet certain criteria and operate in a certain way to realize the potential benefits of team organizing. There are few studies that have examined how teams operate in the nursing home sector and their effect on quality of care. This study investigates the relationship between teams that meet an academic definition of the team concept and quality of care in nursing homes.

METHODS

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilized to test our research question: (1) self-report questionnaires to 444 employees, (2) interviews with 40 ward managers, (3) self-report questionnaires to 40 ward managers, (4) telephone interviews with 378 relatives, and (5) 900 hours of field observations. Use of teams in nursing home wards was assessed by field observations and by interviews with ward mangers. Quality of care was assessed by data from surveys and interviews with relatives and staff and through field observations. All data were aggregated to the ward level and two-level analyses were used to assess the relationships.

RESULTS

The multi-level analyses showed that teams - as operationalized in the present study - were significantly positively related to two out of the three quality of care indices when controlled for ward size, days of sick leave and care level. One significant interaction effect was found between teams and days of sick leave, implying that the effect of teams decreased with higher numbers of days of sick leave.

CONCLUSIONS

The results suggest that teams are related to higher levels of quality of care in nursing homes. However, the study shows that there is a substantial difference between real, functional teams that meet an academic definition of the concept and quasi teams, the latter having a significantly lower effect on quality of care. Hence, nursing home leaders, directors and ward leaders should be aware of the substantial differences betweens dysfunctional - or quasi - teams and real teams, and encourage the development of real functional teams to take advantage of the potential benefits of team organizing.

Health behaviour changes and onset of chronic health problems in later life

<p><em><strong>Objectives</strong></em>: To assess five-year changes in health behaviours in later life and associations with onset of chronic health problems. The results may inform policy and interventions to promote healthy life years in ageing populations.</p><p><em><strong>Methods</strong></em>: Data are derived from the Norwegian study on Life-course, Ageing and Generation (NorLAG), a five-year (2002-2007) panel survey comprising a nation wide community sample. The present analyses include a sample of 1,019 respondents aged 60 years and older. Five-year changes in smoking, alcohol use, physical exercise and Body Mass Index (BMI) are assessed according to prevalent and incident chronic health problems. Multivariate logistic analyses of “healthy” behavioural changes are conducted.</p><p><em><strong>Results</strong></em>: A total of 453 respondents (45%) reported at least one chronic condition and 13% (N=133) reported onset of chronic conditions in the course of the past five years. Over a five-year period, there was an overall reduction in smoking rates and a decrease in regular physical activity. Alcohol consumption in older people slightly increased over time, but the incidence of chronic health problems tended to reduce alcohol intake. Older persons experiencing chronic health problems were less likely to initiate physical activity.</p><p><em><strong>Conclusions</strong></em>: The results provide limited support for the assumption that the onset of a chronic health condition triggers improved health behaviours. This suggests that the health care system could do more in targeting a potential “window of opportunity” for individuals to adopt new healthy behaviours in later life.</p>

Life-course, ageing and generations in Norway:the NorLAG study

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Cancer incidence, prevalence and survival in an aging Norwegian population

<p><em><strong>Background</strong></em>: Cancer is a disease closely associated with aging. Aging populations will thus lead to a pronounced increase in the absolute number of elderly persons with cancer, resulting in profound public health challenges in the coming decades. Older patients have distinct treatment and care needs, but are nevertheless largely overlooked in studies. We therefore examine cancer incidence, prevalence and survival among older cancer patients to help guide various stakeholders in the acute and more long-term handling of this patient group.</p><p><em><strong>Data and methods</strong></em>: &gt;400 000 cancers diagnosed in individuals age 65+ in 1975-2009 were extracted from the Cancer Registry of Norway. Descriptive analyses of incidence and prevalence were undertaken, and survival analysis was used to model survival.</p><p><em><strong>Results:</strong></em> The absolute number of elderly (65-79 years) and oldest old (80+ years) patients has more than doubled since 1975, and will continue to grow towards 2030. A more than threefold increase in patients 80+ years has taken place. The largest patients groups comprise colorectal, prostate, lung and breast cancer. For all patients 65 and older, the median survival has increased with 135%. The increase has been most pronounced for the elderly patients. Surgical resection rates decline with increasing patient age. The difference in relative survival is around 8 percentage points at three years (60% vs 52%). It has been constant over time.</p><p><em><strong>Conclusion</strong></em>: “Best practice” guidelines for the large and increasing group of older cancer patients remain to be established. The gain in length of lives must be balanced against patients’ quality of life, and considered in a cost-benefit perspective for society at large.</p>

Norwegian sandwiches: On the prevalence and consequences of family and work role squeezes over the life course

Population ageing changes profoundly the current balance between generations. Governments are responding with policies to promote later retirement and family care, but these ideals may come in conflict in mid-life when family obligations can be hard to reconcile with employment. Yet we know little about the prevalence of being "sandwiched", and even less about the consequences. This article maps out the prevalence of different forms of family and work sandwiching for the Norwegian population, and explores adaptive strategies and psycho-social outcomes. The analyses are based on data from the NorLAG and LOGG studies (n = 15 109, age 18-84). Preliminary findings indicate that 75-80% of the population are located in-between younger and older family generations in mid-life, the great majority are at the same time in paid work, but comparatively few (8-9% aged 35-45) have both children and parents in need at the same time, and fewer still (3%) are then also caregivers to older parents. Although few in proportion of their age group, they add up to a considerable number of persons. Women are more likely to reduce work in response to family needs than men. Implications of family and work sandwiching for health and well-being are analysed.

Stability of health-related quality of life in the Norwegian general population and impact of chronic morbidity in individuals with and without a cancer diagnosis

The stability of Health-Related Quality of Life (HRQoL) in the general population (GenPop) over years has rarely been evaluated. Neither has the impact of chronic morbidity on HRQoL in cancer survivors been extensively assessed, when identified in the Norwegian GenPop. We studied both aspects. HRQoL was evaluated in two GenPop surveys in 1996 and 2004 using the EORTC QLQ-C30. The 2004 survey included self-reports of a malignant diagnosis and use of medication for hypertension, diabetes mellitus and/or anxiety/depression. Comparison of the results from both surveys revealed similarity of the HRQoL profiles of the two surveys and confirmed the associations between HRQoL and age and gender. Cancer survivors and individuals from the GenPop without chronic co-morbidity had similar HRQoL, except for poorer physical and role function in cancer survivors (p <0.01). HRQoL worsened significantly if a cancer survivor suffered from chronic co-morbidity. Multivariate analyses confirmed the associations between HRQoL and chronic common co-morbidity in cancer survivors and non-cancer persons. As common chronic co-morbidity significantly impairs HRQoL in cancer survivors, prevention of adverse health conditions represents a major challenge in such survivors. Further, in the interpretation of HRQoL in cancer survivors' co-morbid conditions and socio-demographic variables must be considered. Over an 8 years period the HRQoL of the Norwegian GenPop appeared to be stable.

Health related quality of life in patients with neuroendocrine tumors compared with the general Norwegian population

PURPOSE

Health related quality of life (HRQoL) was characterized among patients with neuroendocrine tumor (NET) and compared with the general Norwegian population.

METHODS

A cross sectional, comparative design was chosen, and the samples comprised 196 NET patients and 5,258 individuals from the general Norwegian population. We used Chi-square cross tab calculations to evaluate sociodemographic characteristics, T-tests for independent samples and Analysis of Variance (ANOVA) in order to compare HRQoL (SF-36) scores across a range of background variables. Furthermore, T-tests were used to analyze differences in HRQoL scores between the samples.

RESULTS

NET patients demonstrated significantly lower on all HRQoL subscales when compared with the general population with the lowest values on general health, physical limitation and vitality. Individuals above 70 years reported lower scores on physical functioning and physical limitations compared with those who were younger. Individuals with higher levels of education reported increased physical functioning compared with those with less education and full-time or part-time workers described higher physical functioning and less physical limitations compared with those who were retired.

CONCLUSIONS

All SF-36 HRQoL scores were significantly lower among the NET patients when compared with the general population. Assistance from health personnel to NET patients should focus on those domains.

Construct validity of the five-factor Strengths and Difficulties Questionnaire (SDQ) in pre-, early, and late adolescence

BACKGROUND

The Strengths and Difficulties Questionnaire (SDQ) is designed to measure psychological adjustment in children and adolescents. Psychometric evaluations of the instrument have shown satisfactory convergent and discriminant validity, while factor analysis studies have shown mixed results across countries. In the present study, the construct validity of the five-factor SDQ is evaluated in a large community sample of Norwegian pre-, early, and late adolescents.

METHODS

The sample consisted of 26,269 children and adolescents (10-19 years) with valid answers on all 25 items of the SDQ self-report. Complete parent/proxy data of respective pre-adolescent children was available for 6,645 cases. A Lisrel approach to Confirmatory Factor Analysis (CFA) was used to evaluate the five-factor model and the presence of a positive construal factor. In the sample of pre-adolescents and their parents/proxies, convergent and discriminant validity was evaluated by a CFA approach to multitrait-multimethods (MTMM).

RESULTS

Fit statistics for the hypothesized five-factor model were satisfactory, but introducing correlated error terms for some of the items led to significant model improvement in all age groups. All factor loadings were higher than .30, except for item 11 (good friend). The loadings differed across age groups and differed markedly between the parent/proxy and self-report measures. The MTMM showed that the source of ratings made a difference on the validity of all subscale ratings, with self-reports discriminating more on ratings of emotional and peer problems, and parents/proxies discriminating more on hyperactivity symptoms. A positive construal factor was identified but had a modest effect compared with the original five traits. Results suggested an unclear construct and meaning of the Prosocial behaviour subscale.

CONCLUSION

The results of the present study indicated support for the proposed five-factor structure of the SDQ (Goodman, 2001) across a wide age range (10-19years), including older adolescents and different informants. However, some improvements should be considered to improve internal reliability and conceptual clarity.

Does esophageal atresia influence the mother-infant interaction?

PURPOSE

Chronic illness in infancy may influence parent-infant interaction. We assessed quality of mother-infant interaction in children with esophageal atresia (EA) and searched for predictors for impaired interaction.

METHODS

The study group comprised 37 one-year-old infants with EA born in 1999 to 2002 and their mothers. A comparison group comprised 10 infants with urologic problems without feeding difficulties and their mothers. Parent Child Early Relational Assessment was used to assess mother-child interaction in feeding and play situation. General Health Questionnaire and State Trait Anxiety Inventory were used to assess maternal psychological distress and anxiety.

RESULTS

Many aspects of mother-EA infant interaction showed strength. However, mothers of EA children were compared to control-mothers significantly influenced in their ability to interact and the EA-mothers' "positive affective involvement, sensitivity, and responsiveness" during feeding was in range of concern. Small but significant effect of the mother's feeling of incompetence on their interaction was found.

CONCLUSION

Mothers' attitude during feeding was negatively influenced in interaction between mother and infant with EA. The results suggest possibility for improvement in mother infant interaction by enhancing mothers' welfare when caring for infants with EA in medical services.

Psychological distress in mothers and fathers of preschool children: a 5-year follow-up study after birth

OBJECTIVE

Maternal and paternal psychological distress influence children's development and health beyond the perinatal period. The aim of our study was to describe psychological health during a 5-year period in parents of preschool children. Secondarily, we wanted to explore differences between mothers and fathers and identify predictors for increased psychological distress in parents.

DESIGN

Prospective cohort study.

SETTING

A county in Southern Norway 1998-2004.

POPULATION

One hundred and twenty-three mothers and 112 fathers were candidates for the follow-up study.

METHODS

Parental psychological responses were assessed using the General Health Questionnaire (GHQ-28), State Anxiety Inventory-X1 and Impact of Event Scale at 0-4 days, 6 weeks, 6 months and 5 years after delivery of a healthy child.

MAIN OUTCOME MEASURE

Parental psychological distress defined by GHQ-28 Likert sum score at 5-year follow-up.

RESULTS

Clinically important psychological distress (GHQ case score > or = 6) was reported by more mothers (29%) than by fathers (11%) (P = 0.004). In multivariate analysis, psychological distress (GHQ-28 Likert sum score) after 5 years was predicted by initial psychological distress, being single and low educational level in mothers, and unemployment and low quality of relationship with partner in fathers.

CONCLUSIONS

Fathers reported significantly lower frequency of clinically important psychological distress and more stable scores than mothers throughout the period. The results indicate that selected psychometric screening may be warranted for parents with known psychosocial risk factors.

Weekly Docetaxel and Prednisolone versus Prednisolone Alone in Androgen-Independent Prostate Cancer: A Randomized Phase II Study

BACKGROUND

Due to its palliative effect and prostate-specific antigen (PSA) decrease, many clinicians have considered prednisolone monotherapy to be the standard systemic treatment in patients with androgen-independent prostate cancer (AIPC). This approach should be compared with docetaxel (Taxotere)+prednisolone.

METHODS

A total of 109 eligible patients were entered into a randomized phase II study (arm A: Taxotere+prednisolone [30 mg m(-2) weekly during 5 of 6 wk+prednisolone 5 mg x 2 per os daily]; arm B: prednisolone [5 mg x 2 per os daily]). Biochemical response (confirmed > or = 50% PSA reduction of the baseline level at 6 wk) was the primary endpoint with subjective progression, quality of life, and progression-free and overall survival as secondary outcomes.

RESULTS

Biochemical response at 6 wk was recorded in 29 of 54 evaluable patients in arm A (54%; 95% CI: 40-67%) and 13 of 50 patients in arm B (26%; 95% CI: 14-38%), with similar response rates at 12 wk and if based on all eligible patients. Median progression-free survival was 11 mo (95% CI: 5.8-16.2 mo) in arm A and 4 mo in arm B (95% CI: 2.4-5.6 mo). Median overall survival was 27 mo in arm A (95% CI: 19.8-34.1 mo) and 18 mo in arm B (95% CI: 15.2-20.8 mo). Pain relief and quality-of-life assessment indicated superiority of the arm A treatment, without unacceptable toxicity.

CONCLUSION

Docetaxel+prednisolone should become the first-line systemic standard treatment for AIPC as a more effective treatment than prednisolone monotherapy. Weekly applications of docetaxel are well tolerated.

Health-related quality of life and intellectual functioning in children in remission from acute lymphoblastic leukaemia

AIM

To evaluate the health-related quality of life (HRQOL) and intellectual functioning of children in remission from acute lymphoblastic leukaemia (ALL).

METHODS

Children and adolescents treated for ALL (n = 40; mean age 11.8 years, range 8.5-15.4) and healthy controls (n = 42; mean age 11.8, range 8.11-15.0) were assessed through a cross-sectional approach using the Pediatric Quality of Life inventory (PedsQL) 4.0 and the Wechsler Intelligent Scale for children-III (WISC-III).

RESULTS

Children and adolescents treated for ALL reported on average significantly lower HRQOL compared to healthy controls: the mother's proxy-report showed significantly lower HRQOL for their children, as did the father's proxy-report, measured by the PedsQL 4.0 Total Scale and Psychosocial Health Scale. Intellectual functioning as measured by the WISC-III Full Scale IQ was below that of the control group, but still within the normal range.

CONCLUSIONS

Significant differences found between children treated for ALL and their control group for the PedsQL Psychosocial Health Scale may indicate that the complex illness-treatment experience can make children more vulnerable with regard to psychosocial sequels, in spite of otherwise satisfactory physical and intellectual functioning. Follow-up programs that target the psychosocial health of children in remission from ALL should be implemented.

Quality of life after randomization to laparoscopic versus open living donor nephrectomy: long-term follow-up

BACKGROUND

The aim of this randomized study was to compare patient-reported outcome after laparoscopic versus open donor nephrectomy during 1 year follow-up. The evidence base has so far not allowed for a decision as to which method is superior as seen from a long-term quality of life-perspective.

METHODS

The donors were randomized to laparoscopic (n=63) or open (n=59) nephrectomy, with follow-up at 1, 6, and 12 months. Primary outcomes were health status (SF-36) and overall quality of life (QOLS-N). Secondary outcomes were donor perception of the surgical scar, the donation's impact on personal finances, and whether the donor would make the same decision to donate again.

RESULTS

There was a significant difference in favor of laparoscopic surgery regarding the SF-36 subscale bodily pain at 1 month postoperatively (P<0.05). Analysis based on intention to treat revealed no long-term differences between groups in SF-36 scores. When subtracting the reoperated/converted donors of the laparoscopic group, significant differences in favor of laparoscopy were revealed in the subscales bodily pain at 6 months (P<0.05) and social functioning at 12 months (P<0.05). No significant differences were found in QOLS-N scores between groups.

CONCLUSIONS

Laparoscopic donor nephrectomy is an attractive alternative to open donor nephrectomy because of less postoperative pain. However, long-term comparison only revealed significant differences in favor of laparoscopy when adjusting for reoperations/conversions. Both groups reached baseline scores in most SF-36 subscales at 12 months and this may explain why possible minor benefits are hard to prove.

Quality of life can both influence and be an outcome of general health perceptions after heart surgery

BACKGROUND

Our aim was to investigate the existence of a reciprocal relationship between patients' assessment of quality of life and their appraisal of health. If present, this relationship will interfere with the interpretation of heart surgery's effect on overall quality of life.

METHODS

Path analysis was used to investigate reciprocal causal relationships between general health perceptions and overall quality of life before and after heart surgery. Longitudinal data from a study of coronary artery bypass surgery were used to model lagged, cross-lagged, and simultaneous paths over four time-points of assessment from before surgery to one year afterwards. The conceptual framework for the analysis was the Wilson and Cleary causal pathway model. General health perceptions were measured with the Short Form 36. Overall quality of life was measured with i) a single question regarding life satisfaction and ii) the multi-item Quality of Life Survey.

RESULTS

Acceptable model fit was obtained for reciprocal causation between general health perceptions and overall quality of life. Regression coefficients changed over different phases of rehabilitation. Serial correlation accounted for much of the variance within variables over time.

CONCLUSION

The present analysis demonstrates that unidirectional models of causality are inadequate to explain the effect of heart surgery on overall quality of life. Overall quality of life can causally influence as well as be an outcome of health status after coronary artery bypass surgery.

The Effect of Hospital Size and Teaching Status on Patient Experiences With Hospital Care

BACKGROUND

Hospitals rapidly change structure and organization. Little research has been conducted that documents whether hospital size and teaching status is associated with patient experiences.

OBJECTIVES

We sought to assess the effect of hospital size and teaching status on patient experiences with hospital care.

METHODS

We undertook a cross-sectional survey of patients discharged from somatic hospitals in Norway. Multilevel regression analysis was used to assess the effect of interest. A total of 21,445 patients from 50 hospitals, categorized as small (36-85 beds, n=17), medium-sized (88-218 beds, n=17), large, nonteaching hospitals (226-725 beds, n=10), and large, teaching hospitals (380-997 beds, n=6) were studied. We used the Patients' Experiences Questionnaire (PEQ), which contains 10 scales measuring different aspects of hospital care.

RESULTS

In general, the 10,626 respondents (50% response) rated their experiences as positive. Intraclass correlation ranged from 0.23% (Scale Information About Examinations) to 6.5% (Scale Hospital and Equipment), indicating that a small to modest proportion of the variance was at the hospital level. On 5 of the 10 PEQ scales, a statistically significant part of the variance between hospitals was attributed to hospital category. Small hospitals received the highest ratings and large, teaching hospitals the lowest. Patient characteristics and hospital category contributed together to a proportional reduction in variance ranging from 7.6% (Hospital and Equipment scale) to 53.1% (Hospital Organization scale).

CONCLUSION

The effect of hospital category on patient experiences with hospital care was small. Hospital category was not a major determinant of patient experiences during hospitalization.

Percutaneous endoscopic gastrostomy in children: a safe technique with major symptom relief and high parental satisfaction

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is widely used for establishing enteral feeding. The aim of this study was to assess immediate and long-term results after PEG insertion.

PATIENTS AND METHODS

A total of 121 children were retrospectively reviewed. Median age was 2.4 years (range, 4 months-13.2 years) at the time of PEG insertion. Patient morbidity, indications for PEG, preoperative findings and perioperative complications were registered retrospectively. Parents/caregivers of 85 children were interviewed for long-term results.

RESULTS

Perioperative complications were seen in 12%. Twenty-four percent died at a median of 15 months (range, 1.5 months-8 years) after PEG. Eighty-five families were interviewed with a median follow-up time of 5.6 years (range, 1-10 years). A substantial majority (94%) of parents/caregivers reported that the PEG had a positive influence on their child's situation, and 98% would have chosen PEG insertion again. Vomiting/retching improved in 61% of the children, and oral intake enhanced in 43%. Stoma-related complications were frequent (73%). The gastrostomy tube was permanently removed at a median of 3 years (range, 7 months-7.3 years) after PEG placement in 25%. Delayed closure of the gastrocutaneous fistula after gastrostomy removal occurred in 48% of them. Time from insertion to removal was not predictive of delayed closure.

CONCLUSION

PEG is a safe technique for establishing enteral feeding, even in very sick children. Major complications are rare, although most children experience minor stoma-related problems. Parents/caregivers report that the gastrostomy is of great help for themselves and their child.

Measuring health-related quality of life in young adolescents: reliability and validity in the Norwegian version of the Pediatric Quality of Life Inventory 4.0 (PedsQL) generic core scales

Background

Health-Related Quality of Life (HRQOL) studies concerning children and adolescents are a growing field of research. The Pediatric Quality of Life Inventory (PedsQL™) is considered as a promising HRQOL instrument with the availability of age appropriate versions and parallel forms for both child and parents. The purpose of the current study was to evaluate the psychometric properties of the Norwegian translation of the Pediatric Quality of Life Inventory (PedsQL™) 4.0 generic core scale in a sample of healthy young adolescents.

Methods

A cross-sectional study of 425 healthy young adolescents and 237 of their caregivers participating as a proxy. Reliability was assessed by Cronbach's alpha. Construct validity was assessed using exploratory factor analysis and by exploring the intercorrelations between and among the four PedsQL subscales for adolescents and their parents.

Results

All the self-report scales and proxy-report scales showed satisfactory reliability with Cronbach's alpha varying between 0.77 and 0.88. Factor analysis showed results comparable with the original version, except for the Physical Health scale. On average, monotrait-multimethod correlations were higher than multitrait-multimethod correlations. Sex differences were noted on the emotional functioning subscale, girls reported lower HRQOL than boys.

Conclusion

The Norwegian PedsQL is a valid and reliable generic pediatric health-related Quality of Life measurement that can be recommended for self-reports and proxy-reports for children in the age groups ranging from 13–15 years.

Patient experiences with information in a hospital setting: Associations with coping and self-rated health in chronic illness

The structural relations between patient experiences with information provided by hospital staff, coping behaviour and changes in self-rated health were studied in a cohort of people with chronic illness (n=556) over a period of 2 years. A structural equation approach was applied to model cross-sectional and longitudinal effects. Positive experiences with information were cross-sectionally but not longitudinally associated with improved self-rated health. Patient experiences with information are not related to avoidance coping, but positive experiences contribute to more frequent use of supportant coping. The findings in the present study indicate that measures of patient experiences with information are not merely a reflection of patients' health or coping behaviour. More theoretical work is required to describe the relationships between different patient reported outcomes. The insight into mechanisms underlying changes in physical and mental health in chronic illness could be further improved by evaluating the effects of specific educational and psychosocial interventions in a longitudinal design.

Relationships between health domains and sense of coherence: a two-year cross-lagged study in patients with chronic illness

The latent structure of Sense of Coherence (SOC) and its relationship with three domains of health (body function, activity and participation) were studied in a cohort of people with chronic illness (n = 771) over a period of 2 years. A structural equation approach with cross-lagged and synchronous models was applied to each combination of SOC and domain of health. Over the 2-year period SOC had enhanced body function and participation. Conversely, levels of activities as well as body function had contributed to SOC 2 years later. Significant synchronous effects were found that indicated the presence of reciprocal causation between SOC and all three domains of health. These findings challenge existing SOC theory and suggest that SOC can be considered a relevant outcome variable in chronic illness care.

Hospital quality improvement in context: a multilevel analysis of staff job evaluations

OBJECTIVE

To investigate how much of the variance in data on nurse evaluation of different aspects of hospital work can be attributed to individual, ward, department and hospital levels, and to discuss the implication of the findings on quality improvement strategies.

DESIGN AND METHOD

National survey data of work experiences were collected from hospital nurses working at 124 hospital wards in 36 departments in 15 hospitals across Norway during the autumn of 1998. The multilevel structure of the variation of nine indices of job satisfaction was explored by fitting four-level random intercept models (nurse, ward, department and hospital).

RESULTS

A total of 2606 nurses (66%) responded. The indices showed varying clustering to organizational units. Intraclass correlations (ICCs) varied from 0.05 to 0.38, representing considerable higher level variation. The ward level was the dominating level for the clustering of nurses' job aspect evaluations.

CONCLUSION

Multilevel modelling of staff work experiences may identify which improvement goals can be addressed at which organizational level. Improvement efforts should be directed specifically towards each aspect of work and at its most relevant organizational level. Strategies aimed at the micro-organizational level (ward management) rather than the individual level or the macro level (hospital top management) might prove worthwhile.

Predictors of job satisfaction among doctors, nurses and auxiliaries in Norwegian hospitals: relevance for micro unit culture

OBJECTIVE

To explore what domains of work are important for job satisfaction among doctors, nurses and auxiliaries and to discuss differences between professional groups in the perspective of micro team culture.

DESIGN

Cross-sectional survey data from hospital staff working clinically at inpatient hospital wards in Norway in 2000.

MEASURES

Linear regression models predicting job satisfaction for the three professions were compared. First, five domains of hospital work were examined for general job satisfaction. Based on the result of the first regression, five items concerning local leadership were explored in a second regression.

RESULTS

A total of 1814 doctors, nurses and auxiliaries working at 11 Norwegian hospitals responded (overall response rate: 65%). The only domain of work that significantly predicted high job satisfaction important for all groups was positive evaluation of local leadership. Both steps of analyses suggested that professional development is most important for doctors. For registered nurses, experiencing support and feedback from the nearest superior was the main explanatory variable for job satisfaction. Job satisfaction of auxiliaries was equally predicted by professional development and local leadership. The results are discussed and interpreted as reflections of cultural values, loyalties and motivation.

CONCLUSION

The professional values of medicine, the organizational and holistic skills of nurses and the practical experience of auxiliaries should all be valued in the building of interdependent micro teams.

[Mutual evaluation as a method of quality assurance in hospital units]

BACKGROUND

Mutual visit schemes have been used in quality assurance of general practice. We have examined the effect of mutual evaluation in the quality assurance of patient care in hospital units.

MATERIAL AND METHODS

Four university hospital units for medical gastroenterology received and performed one visit each. The visits were performed by one doctor and two nurses and lasted two days. The visit resulted in written reports that were first discussed locally and subsequently jointly in connection with a seminar. The evaluation was based on reported experiences, proposed improvements and surveys of patient satisfaction before and after the mutual evaluation process. A method was developed for surveying patient satisfaction with outpatient endoscopy.

RESULTS AND INTERPRETATION

The mutual evaluation created enthusiasm, increased understanding and generated many proposals for improvement. Some improvement was observed in patients' satisfaction with the information given. The study suggests that mutual evaluation is a suitable method for quality assurance of patient care in hospital units.

The Patient Experiences Questionnaire: development, validity and reliability

OBJECTIVE

. To describe the development of the Patient Experiences Questionnaire (PEQ) and to evaluate reliability and validity of constructed summed rating scales.

DESIGN

Literature review, focus groups and pilot surveys. Two national cross-sectional studies performed in 1996 and 1998.

SETTING

Two postal surveys in a national sample of 14 hospitals stratified by geographical region and hospital size. Subjects. Patients consecutively discharged from surgical wards and wards of internal medicine. The surveys included 36 845 patients and 19 578 responded (53%).

RESULTS

We constructed 10 summed rating scales based on factor analysis and theoretical considerations: Information on future complaints, Nursing services, Communication, Information examinations, Contact with next-of-kin, Doctor services, Hospital and equipment, Information medication, Organization and General satisfaction. Eight scales had a Cronbach alpha coefficient of >0.70, the remaining two were >0.60. Repeatability was >0.70 for five scales and >0.60 for the remaining scales.

CONCLUSIONS

The PEQ is a self-report instrument covering the most important subjects of interest to hospital patients. Results are presented as 10 scales with good validity and reliability. It emphasizes practicability and comprehensibility while at the same time providing sufficient information about domains applicable to most patients admitted to medical and surgical wards.

Association of changes in health-related quality of life in coronary heart disease with coronary procedures and sociodemographic characteristics

Background

Few studies have focused on the association between the sociodemographic characteristics of a patient with the change in health-related quality of life (HRQOL) following invasive coronary procedures, and the results remain inconclusive. The objective of the present study was to measure the temporal changes in HRQOL of patients with coronary heart disease, and assess how these changes are associated with invasive coronary procedures and sociodemographic characteristics.

Methods

This was a prospective study of 254 patients with angina pectoris and 90 patients with acute coronary syndrome. HRQOL was assessed with the multi-item scales and summary components of the SF-36, both 6 weeks and 2 years after baseline hospitalization in 1998. Paired t-tests and multiple regression analyses were used to assess temporal changes in HRQOL and to identify the associated factors.

Results

Physical components of HRQOL had improved most during the 2 years following invasive coronary procedures. Our findings indicated that patients with angina pectoris who were younger, male, and more educated were most likely to increase their HRQOL following invasive coronary procedures. When adjusting for baseline HRQOL scores, invasive coronary procedures and sociodemographic characteristics did not explain temporal changes in patients with acute coronary syndrome, possibly due to higher comorbidity.

Conclusion

Sociodemographic characteristics should be taken into account when comparing and interpreting changes in HRQOL scores in patients with and without invasive coronary procedures.

Patient experiences with information in a hospital setting: a multilevel approach

BACKGROUND

Patients tend to be critical of poor communication and the provision of information from health professionals. One explanation may be related to organizational aspects characterizing the hospital unit. Studies have indicated quality of contact with nursing staff to be a major determinant of patients' experiences with information. Yet many studies do not simultaneously analyze the effects of patient and unit characteristics.

OBJECTIVE

To explore the extent to which variation in patients' experiences with the provision of information from hospital staff are associated with differences between patients, and the extent to which they are associated with differences between hospital wards.

RESEARCH DESIGN

Cross-sectional study of patients nested within hospital wards including hospital administrative data and survey data on patients' experiences with hospital care and nurses' assessments of working conditions and job satisfaction.

RESULTS

Multilevel regression analysis indicated low intraward correlation and high within ward variability. In explaining variability in experiences with information, patients' sense of coherence was the most important patient-level characteristic. The percentage of nurses satisfied with their work contributed to an additional proportional reduction in variance between hospital wards.

CONCLUSIONS

This study has illustrated the use of multilevel methods in analyzing patient perceptions of hospital care. Ward-level factors are at most modestly related to patients' experiences with information. The effect of hospital, department, and ward characteristics is likely to be mediated through the existence of microunits within hospital wards. Quality of contact with nursing staff may be a characteristic of the microunit rather than an organizational characteristic related to hospital wards.