Defining the data gap: What do we know about environmental exposure, hazards and risks of pharmaceuticals in the European aquatic environment?

Active pharmaceutical ingredients (APIs) and their transformation products inevitably enter waterways where they might cause adverse effects to aquatic organisms. Identifying the potential risks of APIs in the environment is therefore a goal and current strategic direction of environmental management described in the EU Strategic Approach to Pharmaceuticals in the Environment and the Green Deal. This is challenged by a paucity of monitoring and ecotoxicity data to adequately describe risks. In this study we analyze measured environmental concentrations (MECs) of APIs from 5933 sites in 25 European countries as documented in the EMPODAT database or collected by the German Environment Agency for the time period between 1997 and 2020. These data were compared with empirical data on the ecotoxicity of APIs from the U.S. EPA ECOTOX database. Although 1763 uniquely identifiable APIs are registered with the European Medicines Agency (EMA) for sale in the European Economic Area (EEA), only 312 (17.7%) of these are included in publicly available monitoring data, 36 (1.8%) compounds have sufficient ecotoxicological data to derive a PNEC, and only 27 (1.5%) compounds meet both the hazard and exposure data requirements required to to perform an environmental risk assessment according to EMA guidelines. Four of these compounds (14.8%) had a median risk quotient (RQ) > 1. Endocrine disruptors had the highest median RQ, with 7.0 and 5.6 for 17α-ethinyl-estradiol and 17β-estradiol respectively. A comparison of in-silico and empirical exposure data for 72 APIs demonstrated the high protectiveness of the current EMA guidelines, with predicted environmental concentrations (PECs) exceeding median MECs in 98.6% of cases, with a 100-fold median increase. This study describes the data shortfalls hindering an accurate assessment of the risk posed to European waterways by APIs, and identifies 68 APIs for prioritized inclusion in monitoring programs, and 66 APIs requiring ecotoxicity testing to fill current data gaps.

Trajectories of sickness absence among young people with prior depression/anxiety symptoms

Background

Depression and anxiety are associated with elevated risks of sickness absence (SA), but less is known about the development of SA over time in young people experiencing these mental health conditions. This study aimed to identify latent trajectories of SA in young people with a history of depression and/or anxiety symptoms, while accounting for sociodemographic factors.

Methods

This was an observational cohort study of 1,445 twin individuals who had elevated depression/anxiety symptoms in late adolescence or young adulthood (age range: 19-30), as assessed in Swedish surveys completed in 2005. Through linkage to the national registries, the individuals were prospectively followed from 2006 to 2018. The outcome included consecutive annual net days of SA, which were analyzed using group-based trajectory modeling with zero-inflated Poisson regression. Multinomial logistic regression estimating odds ratios (OR) with 95% confidence intervals (CI) was used to examine the influence of age, sex, and educational level on the resulting trajectory groups.

Results

Four distinct trajectories of SA were identified: ‘high-increasing’ (6%), ‘low-increasing’ (12%), ‘high-decreasing’ (13%), and ‘constant-low’ (69%). The constant-low was used as the reference in all analyses. Increasing age was found to be associated with higher odds of belonging to the low-increasing trajectory (OR = 1.07, 95% CI = 1.02-1.12). Women had higher odds of belonging to the low-increasing trajectory (OR = 1.67, 95% CI = 1.10-2.53), compared to men. Higher education was associated with lower odds of belonging to the high-increasing (OR = 0.34, 95% CI = 0.22-0.54) and high-decreasing (OR = 0.59, 95% CI = 0.43-0.81) trajectories, compared to lower education.

Conclusions

Distinct group-based trajectories of SA were identified in young people with early depression/anxiety symptoms. Targeted and timely public health strategies aiming to improve adolescent and young adult mental health may help reduce SA in the long run.

Key messages

• We identified four trajectories of sickness absence in young people with common mental health problems.

• Public health efforts to improve mental health may reduce sickness absence in vulnerable groups.

Having mental health problems but not sickness absent: factors of importance among privately employed

Background

Knowledge is scarce on individuals who are experiencing mental health problems but who have low or no sickness absence (SA). The aim of this study was to identify individual-level characteristics, including sociodemographic factors, morbidity, and lifestyle, among privately employed individuals with previous depression/anxiety but no SA during follow-up.

Methods

This prospective cohort study included 750 twin individuals born in Sweden in 1959-1986, employed in the private sector and with a history of depression/anxiety. Depending on the birth year, the twins were invited to participate in two different health-screening surveys in 2005, when study participants were aged 19-20 or 20-30, respectively. Survey data were used to evaluate depression and anxiety, self-rated health, stressful life events, emotional neglect, level of physical activity, and alcohol use. Study participants were prospectively followed regarding SA occurrence between 2006 and 2018. Data on SA, sociodemographic factors, outpatient healthcare use, and use of prescribed antidepressants were obtained from the Swedish national registries. Descriptive statistics will be reported with further analyses for the presentation.

Results

Preliminary results showed that despite previous depression or anxiety, 35% of women and 52% of men were not on SA during the follow-up period. Those who had no SA during follow-up were more likely to have higher education >12 years (49%), experienced fewer stressful life events (43%) and emotional neglect (56%), had better self-rated health (95%), along with a lower use of antidepressants (11%) and outpatient healthcare (88%), as compared with those on SA (33%, 65%, 66%, 90%, 17%, and 98%, respectively).

Conclusions

Higher education, being male, fewer life adversities, good self-rated health and low use of antidepressants and outpatient healthcare were individual-level factors of importance for those with previous depression or anxiety and no incident SA during follow-up.

Key messages

Individual differences in sustainable working life: genetic and environmental contributions

Background

Previous research of aetiology of interruptions in working life have shown that both genetic and environmental factors contribute to individual differences in sickness absence (SA) and disability pension (DP). However, we still lack knowledge about etiological factors contributing to sustainable working life. The aim was to study the importance of genetics, shared (mainly childhood) environmental factors, and individual (unique) environmental factors for remaining in the work force over the life-course, i.e., having a sustainable working life.

Methods

The study population include 108,275 twin individuals born 1930-1990 (53% women) with comprehensive national register data on social security, health, and demographic factors. We utilized two measures of sustainable working life: 1) employed at least two consecutive years (n = 21,348), without interruptions due to SA (>14 days), DP, or unemployment; 2) 22-years of sustainable working life, i.e., those who were employed all years from 1994 to 2016 (n = 12,931) without SA (>14 days), DP, or unemployment. Old-age pension, emigration, or death were censored. The final sample included same-sexed twin pairs of known zygosity; monozygotic pairs n = 11,403 and dizygotic pairs n = 13,354. Classical twin modelling was applied to estimate the relative contributions of genetic and environmental factors to individual differences in sustainable working life.

Results

Individual differences for two consecutive years of sustainable working life were explained by genetics 36%, shared environment 8%, and unique environmental factors 56%. For 22-years of sustainable working life genetics accounted for 18%, shared environment 46%, and unique environmental factors for 37% of individual differences.

Conclusions

Individual variation in sustainable working life is due to both genetic and environmental factors. Environmental experiences that twin siblings share while growing up is of importance, especially for long-term sustainable working life.

Key messages

• Childhood environmental circumstances as well as environmental exposures later in life seem to outweigh genetic influences on long-term sustainable working life.

• From a public health perspective, the importance of family and surrounding environment on sustainable working life implies a potential for workplace or societal interventions, or individual support.

Life events as predictors of unsustainable working life trajectories from a life course perspective

Background

The association between family-related life events (e.g., getting married or having children) and unsustainable working life in terms of unemployment, sickness absence and disability pension (SA/DP) are rarely studied from a life-course perspective although having public health importance. We investigated trajectories of unsustainable working life, and the associations between change in family-related life events and unsustainable working life trajectories by controlling for familial factors.

Methods

This is a prospective cohort study of 37,867 Swedish twins aged between 20-40 years on 31st December 1994. Data on trajectories of annual unemployment, SA/DP, and a combined measure of unsustainable working life months was collected from the Swedish national registers. The trajectories over a 23-year period were analysed by group-based trajectory modelling. Associations of change in family-related life events with trajectory groups in the whole sample were estimated by multinomial logistic regression and in discordant twin pairs (n = 4,647 pairs) with conditional models.

Results

Most participants had no or low levels of unemployment, SA/DP or combined unsustainable working life during 1994-2016. Individuals who were stably married or changed from being single living without children to married living with children had a decreased risk of unsustainable working life compared to individuals with stable family-related life events. The risk of unsustainable working life months over time was higher among individuals who changed from married to single status regardless of having children (range of HRs:1.31-4.44).

Conclusions

Family-related life events such as maintaining the relationship or getting married and having children decreases the risk of unsustainable working life while divorce is a risk factor for unsustainable working life. From a public health perspective, actions to support family formation or life would consequently promote a sustainable working life.

Key messages

• Unsustainable working life was less likely among married and among those who changed from single living without children to married with children compared to those with stable family life events.

• Individuals who changed from being married to divorced status had an increased risk of unsustainable working life over time and therefore being potentially an important group for public health.

Prevention of sick leave at the workplace: design of a cluster-randomized controlled trial of a problem-solving intervention among employees with common mental disorders

Background

Common mental disorders are highly prevalent in the working population, affecting about 1 in 5 persons in the Organisation for Economic Co-operation and Development countries. About 30% of those affected have a first period of sick leave. Despite several attempts to reduce the risk of sick leave among employees with common mental disorders, there is a lack of knowledge about effective, preventive interventions which aim to reduce such risks. This protocol describes the design of a study to evaluate the effectiveness of a problem-solving intervention delivered by first-line managers to employees with common mental disorders on the prevention of sick leave during the 12-month follow-up.

Methods/design

The study applies a two-armed cluster-randomized trial design of a problem-solving intervention conducted in private-sector companies. First-line managers are randomized into intervention- or control groups by computer-generated random numbers, allocation ratio 1:1. Employees are eligible if at risk for future sick leave due to common mental disorders. These are identified by self-reported psychological health measured by the General Health Questionnaire 12-item, cut-off ≥3, or a positive answer to risk of sick leave.

The intervention is based on problem-solving principles. It involves the training of the first-line managers who then deliver the intervention to employees identified at risk of sick leave. First-line managers in the control group receives a lecture. Primary outcome is number of registered days of sick leave due to common mental disorders during the 12-month follow-up. Secondary outcomes are general health, psychological symptoms, work performance, work ability and psychosocial work environment. A process evaluation will examine the intervention’s reach, fidelity, dose delivered, dose received, satisfaction and context. Research assistants managing the screening procedure, outcome assessors and employees are blinded to randomization and allocation.

Discussion

The study includes analyses of the intervention’s effectiveness and an alongside process evaluation. Methodological strengths and limitations, for example the risk of selection bias, attrition and risk of contamination are discussed.

Trial registration

Clinicaltrials.gov NCT04975750 Date of registration: 08/16/2021.

Sickness absence in relation to first childbirth by occupational group: a Swedish cohort study

Background

Childbirth has been suggested to increase sickness absence (SA) and disability pension (DP). This may vary by occupation; however, knowledge in this field remains limited. We explored SA and DP in the years before and after childbirth among women in four occupational groups and among those without any occupation.

Methods

We conducted a register-based study of nulliparous women aged 18-39 years, living in Sweden on December 31, 2004 (n = 492,504). Women were categorized into five skill-level based occupational groups and three childbirth groups; no childbirths within three years (B0), first childbirth in 2005 with no childbirth within three years (B1), and first childbirth in 2005 with at least one more birth within three years (B1+). We compared crude and standardized annual mean SA (in spells>14 days) and DP net days in the three years before and three years after first childbirth date.

Results

Women in the highest skill level occupations and managers had generally lower mean SA/DP days e.g., B0: 11.3, B1: 11.6, B1+: 6.8 during the third year after first childbirth than the lowest skill level occupations group; B0: 28.1, B1: 22.8, B1+: 15.2 days. In B1 and B1+, absolute differences in mean SA/DP, particularly in SA, among occupational groups were highest during the year before childbirth. DP was most common in B0, regardless of group and year.

Conclusions

We found that women's mean SA/DP days before and after first childbirth were higher with decreasing skill-level of the occupational group, with these differences being most pronounced in the year before childbirth. DP was most common among women not giving birth, regardless of occupational group.

Key messages

Women’s mean SA/DP days before and after first childbirth increased with decreasing skill-level of the occupational group and these differences were most pronounced in the year before childbirth.

Sick leave due to mental disorders, morbidity and mortality: a prospective study of discordant twin pairs

PURPOSE

To investigate if sick leave due to mental disorders increases the risk of morbidity measured by inpatient and specialized outpatient care, and mortality among women and men, independent of familial factors.

METHODS

An open cohort study of 4979 twin pairs discordant for sick leave due to mental disorders was conducted in 2005-2013. Twins were followed up in the cause of death and national patient registries until the end of study, emigration, death, and inpatient and specialized outpatient care. Conditional Cox proportional hazard regression, adjusting for the familial factors shared by the twins, was used to calculate hazard ratios (HR) with 95% confidence intervals (CI). In case of non-proportional hazards, time-varying covariates were used.

RESULTS

Sick leave due to mental disorders increased the risk for inpatient care among men (HR: 1.90, CI 1.66-2.17) and women (HR: 1.39, CI 1.27-1.51). For men, the risk of outpatient care was higher the first 2 years (HR: 2.08, CI 1.87-2.31), after which it was attenuated (HR: 1.32, CI 1.02-1.70). For women, the HR was 1.57 (CI 1.47-1.68) for the whole study time. There was an increased risk of death among men (HR: 2.91, CI 1.70-4.99), but not among women (HR: 0.84, CI 0.53-1.35).

CONCLUSIONS

Sick leave due to mental disorders was a risk factor for mortality for men only, and increased the risk of inpatient and specialized outpatient care among both women and men, but the risks were higher for men when stratifying for sex.

Risk factors of disability pensions – what will twin studies from Finland and Sweden add?

Background

Finland and Sweden have been forerunners to investigate social insurance in twin cohorts. Using twin cohorts to research disability pension (DP) has provided a unique possibility to control for genetic and environmental factors (i.e. familial confounding). This is important, since genetics is known to play an important role in many chronic diseases for DP such as low back pain (30%), depression (40%) and a moderate (35-48 %) role in DP. Furthermore, familial confounding can be expected to affect many risk factors, i.e. health and behavior related factors and is therefore of interest in the associations between risk factors and DP.

Methods

In twin cohort studies for DP, first, the twins are treated as singletons, and the effect of risk factors on the incidence of DP is analyzed by applying regression models. Second, analyzing twin pairs discordant for both outcome (DP) and risk factors provides a possibility to control for familial confounding. This co-twin-control design is a unique tool, includes investigation whether twins who are exposed to a specific factor of interest more often are granted a DP than their non-exposed co-twins.

Results

Co-twin control design allows adjustment for familial confounding. Therefore, the results based on discordant twin pairs add to the epidemiological findings of unrelated subjects. Based on population-based twin cohort studies with long follow-up, indications exist that the familial confounding may have different role in the association between risk factors and DP depending on risk factors of interest but also on diagnosis group for DP.

Conclusions

Evidently the underlying medical condition is important, and the risk factors vary between diagnosis groups of DP. However, also familial factors play a role in process of sickness absence, in the transition from sickness absence to DP, and for DP. Therefore, need for early identification of risk factors and tailored interventions of prevention is emerged for public health.

Education, lifestyle and life course differences in level of work incapacity – genes and environment

Background

As many countries face an aging workforce, it is becoming ever more relevant to understand the underlying causes of work incapacity across the entire working age. Previous twin studies have demonstrated that work incapacity is influenced by genetic as well as environmental factors. Furthermore, educational attainment and lifestyle behaviors are relatively stable from early adulthood and are associated with work incapacity. This association may be confounded by unobserved factors - both genetic and environmental. In two separate twin studies, we examine 1) the stability and change in genetic and environmental factors influencing work incapacity from age 18 until retirement, and sex differences in these effects, and 2) the associations and likelihood of causality between educational attainment, lifestyle and sickness absence.

Methods

study 1: A population-based sample of 28,759 twins were linked to high quality national registry data and followed for up to 23 years. We measured work incapacity as the total proportion of potential workdays lost due to sickness absence, rehabilitation, and disability benefits.

study 2: Data from a subsample of 8,806 twins who completed health questionnaires were linked to registry data on sickness absence and educational attainment. Self-reported lifestyle behaviors were smoking, physical activity and BMI (height and weight).

Results

study 1: Structural equation modeling indicated moderate genetic influences on work incapacity throughout life in both men and women, with a high degree of genetic stability from young to old adulthood.

study 2: Preliminary regression analyses indicated that genetic factors largely confound the associations between educational attainment, lifestyle and sickness absence.

Conclusions

Genetic factors seem to be a major issue in understanding causes of work incapacity. Largely the same genetic factors influence individual differences in work incapacity throughout working age.

Do poor health behaviors have an impact on the transition from sick leave to disability pension?

Background

High age, being a woman, and having low socioeconomic status are among the important risk factors for transitioning from sickness absence (SA) to disability pension (DP). But, little is known about the effect of poor health behaviors, although there are indications that poor health behaviors increase the risk of both SA and DP. The aims were to study the associations between three poor health behaviors (current smoking, high alcohol consumption and low physical activity levels) and DP among individuals who recently been sickness absent, and to explore whether having multiple poor health behaviors increased the risk of transitioning from SA to DP.

Methods

This prospective cohort study included 1991 twin individuals aged 20-46 who participated in a survey in 2005 and who had been on long-term SA in the two years preceding baseline (date of answering the survey) data collection of health behaviors (smoking, alcohol and physical activity) and relevant covariates. The participants were followed up for incident all-cause DP until the 31st of December 2012 (mean follow-up 5.2 years). National register data of SA and DP were used, and the association between each health behavior and DP was estimated using Cox proportional hazards regression analyses. The results are presented as Hazard Ratios (HR) with 95% Confidence Intervals (CI).

Results

Results showed that compared to never smoking, current smoking was associated with a higher risk of transitioning from SA to DP (HR 1.76, 95%CI 1.08-2.84). Alcohol use, lack of physical activity or having several poor health behaviors showed no significant associations.

Conclusions

Being a current smoker influences the risk of transitioning from SA to DP. Poor health behaviors are well established risk factors for poor physical and mental health. Hence, from a public health perspective it is important to emphasize the value of improving health behaviors in general but also among people with a history of SA.

Key messages

Many factors including health behaviors influence the risk of transitioning from sickness absence to permanent work incapacity in terms of disability pension. Supporting people on sickness absence to improve their health behaviors, e.g. smoking cessation, could be a promising approach to prevent exit from the labor market through disability pension.

Sickness absences among young employees in private and public sectors

Background

Mental health problems among young adults is a public health problem as well as increasing work incapacity in terms of sickness absence (SA) due to mental diagnoses in Sweden. SA levels among those working in the public sector tend to exceed those working in the private sector. Knowledge is however lacking on whether experiencing mental health problems in young years can contribute to the association. The aim was to examine the association between type of employment and sickness absence among women and men, also adjusting for previously experienced depression and anxiety as well as for familial factors.

Methods

The study included data on 25,496 twins born in Sweden 1959-1990. Information on depression and anxiety as well as on type of employment was obtained from a web-based survey conducted in 2005. Twins were followed prospectively until 2013 through national register data on SA. Logistic regression analyses were run with adjustment for familial factors, such as common genetics and environmental factors related to the family. Odds ratios (OR) with 95% Confidence Intervals (CI) are presented.

Results

Higher rates of SA in the public (59%) as compared to the private (50%) sector were observed among women. There were 29% and 30% of men in public and private sectors, respectively, that have had at least one SA spell during the follow-up. Preliminary results showed that working in the private sector was associated with a higher risk for future SA among women (OR 1.63, 95% CI 1.14-2.33) but not among men (OR 0.66, 95% CI 0.41-1.07). The results changed only slightly after adjusting for previous depression or anxiety as well as for familial factors.

Conclusions

Higher rates of SA among women working in the public as compared to the private sector were not explained by previously experienced depression or anxiety disorders.

Key messages

Higher rates of SA were observed among women working in public as compared to private sector. Previously experienced depression and anxiety were of similar importance for future SA in both public and private sectors.

Mental health in childhood and adolescence in association to sickness absence and disability pension

Background

A large amount of studies have previously reported associations between sociodemographic, socioeconomic, health- and work-related factors and future sickness absence (SA) or disability pension (DP). However, the knowledge is still scarce regarding the associations between mental health problems and disorders during childhood and adolescence in association to future work incapacity, and regarding the role of familial influences on the associations.

Methods

The studies were based on 2,690 twins born 1985-1986 in Sweden who participated in the Twin Study of CHild and Adolescent Development (TCHAD). The twins were followed repeatedly at ages of 8-9, 13-14, 16-17, and 19-20 years. The presence of depressive, anxiety, rule-breaking, and social phobia symptoms were assessed through self-reports. SA and DP data were obtained from national registries. Group-based trajectory, logistic regression and Cox proportional regression analyses were applied.

Results

More than half of the twins that were on SA or granted DP had stable moderate levels of the mental health symptoms during adolescence. Cox regression analyses showed that rule-breaking behavior was associated with a higher risk for SA with the highest HR of 1.12 (95% CI 1.05-1.19) at age of 8-9 years. High levels of anxious and depressive symptoms were associated with DP despite age at symptom assessment. The associations attenuated slightly when familial factors were taken into account. The association between social phobia and SA was to some extent explained by sex and parental education except for when social phobia was measured at ages 19-20 years (OR 1.22, 95% CI 1.10-1.34). The results changed slightly when further adjusting for familial factors.

Conclusions

Familial factors had no major importance for the studied associations. Hence, early life public health interventions to improve mental health might reduce the risk of future work incapacity in young adulthood.

Adverse outcomes of sick leave due to mental disorders: prospective studies of discordant twin pairs

Background

Sick leave due to mental disorders is common. We investigated if sick leave due to mental disorders increased the risk of reoccurring sick leave, disability pension, unemployment, in- and specialized outpatient care, and mortality, using a co-twin design, taking genetics and shared environment (familial factors) into account.

Methods

The register-based open cohort studies contained twin pairs 18-64 years old discordant for sick leave due to a mental disorder. First, 2202 pairs were followed up to 8 years from the end of the sick leave spell for reoccurring sick leave, disability pension and unemployment. Second, 4979 twin pairs were followed up to 9 years from the beginning of the sick leave spell for death, inpatient and specialized outpatient care. Conditional Cox proportional hazard regression, adjusting for familial factors, was used to calculate Hazard Ratios (HR) with 95% Confidence Intervals (CI).

Results

Those with sick leave due to mental disorders had 3.64 (CI: 3.24-4.08) times higher risk of reoccurring sick leave the first two years and the first year, they had 12.24 (CI: 8.11-18.46) times the risk for disability pension. The risk of unemployment was 1.99 (CI: 1.72-2.31). The HR for inpatient care was 1.90 (CI: 1.66-2.17) among men but lower among women. For men the risk of outpatient care was higher the first 2 years (HR: 2.08, CI: 1.87-2.31), and for women the HR was 1.57 (CI: 1.47-1.68) for the whole study time. There was an increased risk of death among men (HR: 2.91, CI: 1.70-4.99), but not among women.

Conclusions

By adjusting for familial factors we could investigate if the same factors that predispose to sick leave due to mental disorders also predispose to morbidity, mortality and unemployment and hence explain the associations. But, sick leave due to mental disorders was associated with a higher risk of work related and health outcomes, independent of familial factors. The risks varied over time and differed among women and men.

Sickness absence and disability pension in relation to first childbirth: three cohorts in Sweden

Background

Childbirth is suggested to be associated with elevated levels of sickness absence (SA) and disability pension (DP). However, knowledge about patterns of SA/DP before and after childbirth as compared to patterns among women who remain nulliparous is limited. We aimed to compare SA/DP across several periods among women with different childbirth status.

Methods

We analysed three population-based cohorts of all women aged 18-39 years who had not previously given birth and who lived in Sweden on 31 December 1994, 1999, or 2004, respectively. We compared crude and standardized annual mean SA and DP net days during three years preceding to three years after the date of first childbirth, among women having (1) their first and only birth during the subsequent three years, (2) their first birth and at least another delivery, and (3) no childbirths before, nor during the study period.

Results

Despite an increase in SA in the year preceding the first childbirth, women who gave birth, and especially women with multiple births, tended to have lower levels of SA/DP days throughout the years than women without childbirths. SA/DP days varied across age groups; young women (aged 18-24 years) without childbirths had fewer SA days, but more DP days than their same-aged counterparts who gave birth, regardless of year. These results did not differ across the three cohorts, suggesting that the results were not affected by period effects.

Conclusions

Women with more than one childbirth had fewer days of SA and DP, as compared to women with one childbirth and to women having no births. Thus, childbirth does not seem to be associated with higher levels of SA and DP. Some of these results can be due to a health selection into giving birth, especially having more births.

Key messages

Except for the year before delivery, i.e., when pregnant, women giving birth had fewer SA and DP days than women with no births. Thus, childbirth does not seem to be associated with higher SA and DP. Women who had more than one childbirth had less SA/DP days than those with one childbirth.

The validity of socioeconomic status measures among adolescents based on self-reported information about parents occupations, FAS and perceived SES; implication for health related quality of life studies

BACKGROUND

Research has shown inconsistencies in results and difficulties in conceptualization of assessment of socioeconomic status (SES) among adolescents. The aim of this study was thus to test the validity of self-reported information on SES in two age-groups (11-13 and 14-16 years old) in an adolescent population and to evaluate its relationship to self-reported health related quality of life (HRQOL). Different measures of SES commonly used in research in relation to HRQOL were tested in this study; parent's occupations status, family material affluence status (FAS) and perceived SES.

METHOD

A cross-sectional study, with a sample of 948 respondents (n = 467, 11-13 years old and n = 481, 14-16 years old) completed questionnaires about SES and HRQOL. The adolescents' completion rates were used, with chi2-test, to investigate differences between gender and age-group. Correlation was used for convergent validity and ANOVA for concurrent validity.

RESULTS

We found a low completion rate for both fathers' (41.7 %) and mothers' (37.5 %) occupation status, and a difference in completion rate between gender and age-groups. FAS had the highest completion rate (100 %) compared to parent's occupations status and perceived SES. The convergent validity between the SES-indicators was weak (Spearman correlation coefficient below 0.3), suggesting that the indicators measured different dimensions of SES. Both FAS and perceived SES showed a gradient in mean HRQOL between low and high SES in relation to HRQOL, this was significant only for perceived SES (p < 0.01, both age-groups).

CONCLUSION

This study indicates the need for considering different approaches to measures of SES among adolescences and when evaluating SES in relation to HRQOL. Further research is needed to investigate sustainable ways to measure SES, delineating the relevance of tangible measures of education, occupation and income in relation to the perceived socioeconomic status in comparison with others in immediate social networks and in society at large.

'Through my eyes': health-promoting factors described by photographs taken by children with experience of cancer treatment

BACKGROUND

Health promotion for children with cancer should be based on the children's own needs and desires. Because there is a lack of knowledge in this area, the aim of this study was to explore what promotes health from the perspective of children with experience of cancer treatment.

METHODS

Fifteen children between 8 and 12 years of age participated in focus groups with three children in each group. The children were given a camera and instructions to photograph subjects that promote their health. Focus group discussions were based on the photographs and the children's own description of those photographs. The analysis of focus group discussions and photographs was conducted using inductive content analysis.

RESULTS

According to the children, health-promoting factors are defined as meaningful relationships, recreational activities and a trustful environment. Meaningful relationships include togetherness within the family, affection for pets and friendship with peers. Recreational activities include engagement in play and leisure, withdrawal for relaxation and feeling enjoyment. Trustful environment includes confidence in significant others and feeling safe.

CONCLUSIONS

Knowledge from this study can contribute to health promotion interventions and quality improvements in the health care of children with experience of cancer treatment. Children's experiences with what promotes health in their everyday lives provide a better understanding of the type of support children prefer when promoting their own health.

Synergistic effect between back pain and common mental disorders and the risk of future disability pension: a nationwide study from Sweden

BACKGROUND

The aim of this study was to analyse a possible synergistic effect between back pain and common mental disorders (CMDs) in relation to future disability pension (DP).

METHOD

All 4,823,069 individuals aged 16-64 years, living in Sweden in December 2004, not pensioned in 2005 and without ongoing sickness absence at the turn of 2004/2005 formed the cohort of this register-based study. Hazard ratios (HRs) and 95% confidence intervals (CIs) for DP (2006-2010) were estimated. Exposure variables were back pain (M54) (sickness absence or inpatient or specialized outpatient care in 2005) and CMD (F40-F48) [sickness absence or inpatient or specialized outpatient care or antidepressants (N06a) in 2005].

RESULTS

HRs for DP were 4.03 (95% CI 3.87-4.21) and 3.86 (95% CI 3.68-4.04) in women and men with back pain. HRs for DP in women and men with CMD were 4.98 (95% CI 4.88-5.08) and 6.05 (95% CI 5.90-6.21). In women and men with both conditions, HRs for DP were 15.62 (95% CI 14.40-16.94) and 19.84 (95% CI 17.94-21.94). In women, synergy index, relative excess risk due to interaction, and attributable proportion were 1.24 (95% CI 1.13-1.36), 0.18 (95% CI 0.11-0.25), and 2.08 (95% CI 1.09-3.06). The corresponding figures for men were 1.45 (95% CI 1.29-1.62), 0.29 (95% CI 0.22-0.36), and 4.21 (95% CI 2.71-5.70).

CONCLUSIONS

Co-morbidity of back pain and CMD is associated with a higher risk of DP than either individual condition, when added up, which has possible clinical implications to prevent further disability and exclusion from the labour market.

Service users' experiences of participation in decision making in mental health services

ACCESSIBLE SUMMARY

Despite the potential positive impact of shared decision making on service users knowledge and experience of decisional conflict, there is a lack of qualitative research on how participation in decision making is promoted from the perspective of psychiatric service users. This study highlights the desire of users to participate more actively in decision making and demonstrates that persons with SMI struggle to be seen as competent and equal partners in decision-making situations. Those interviewed did not feel that their strengths, abilities and needs were being recognized, which resulted in a feeling of being omitted from involvement in decision-making situations. The service users describe some essential conditions that could work to promote participation in decision making. These included having personal support, having access to knowledge, being involved in a dialogue and clarity about responsibilities. Mental health nurses can play an essential role for developing and implementing shared decision making as a tool to promote recovery-oriented mental health services.

ABSTRACT

Service user participation in decision making is considered an essential component of recovery-oriented mental health services. Despite the potential of shared decision making to impact service users knowledge and positively influence their experience of decisional conflict, there is a lack of qualitative research on how participation in decision making is promoted from the perspective of psychiatric service users. In order to develop concrete methods that facilitate shared decision making, there is a need for increased knowledge regarding the users' own perspective. The aim of this study was to explore users' experiences of participation in decisions in mental health services in Sweden, and the kinds of support that may promote participation. Constructivist Grounded Theory (CGT) was utilized to analyse group and individual interviews with 20 users with experience of serious mental illness. The core category that emerged in the analysis described a 'struggle to be perceived as a competent and equal person' while three related categories including being the underdog, being controlled and being omitted described the difficulties of participating in decisions. The data analysis resulted in a model that describes internal and external conditions that influence the promotion of participation in decision making. The findings offer new insights from a user perspective and these can be utilized to develop and investigate concrete methods in order to promote user's participation in decisions.

Sickness absence due to back pain or depressive episode and the risk of all-cause and diagnosis-specific disability pension: A Swedish cohort study of 4,823,069 individuals

BACKGROUND

The aim of this study was to investigate the associations between sickness absence due to back pain or depressive episode with future all-cause and diagnosis-specific disability pension, while adjusting for comorbidity and socio-demographics, for all and stratifying for sex.

METHOD

In total, 4,823,069 individuals aged 16-64 years, living in Sweden at the end of 2004, not on old-age or disability pension in 2005 and without ongoing sickness absence at the turn of 2004/2005 formed the study population. Crude and adjusted hazard ratios (HRs) for all-cause and diagnosis-specific disability pension (2006-2010) in relation to diagnosis-specific sickness absence with sickness benefits paid by the Social Insurance Agency were estimated using Cox regression.

RESULTS

The HR for all-cause disability pension was 7.52 (7.25-7.52) in individuals with an incident sick-leave spell due to back pain, compared to individuals without sickness absence in 2005 in the fully adjusted (socio-demographics and comorbidity) model. The fully adjusted (multivariate) HRs for diagnosis-specific disability pension were musculoskeletal diagnoses 23.87 (22.75-25.04), mental 2.49 (2.27-2.73) or all other diagnoses, 3.44 (3.17-3.75). In individuals with an incident sick-leave spell due to a depressive episode in 2005, the multivariate adjusted HR for all-cause disability pension was 12.87 (12.42-13.35), while the multivariate HRs for disability pension due to musculoskeletal diagnoses were 4.39 (3.89-4.96), for mental diagnoses 25.32 (24.29-26.38) and for all other somatic diagnoses 3.44 (3.09-3.82). Men who were sickness absent due to a depressive episode had a higher HR for disability pension compared to women.

CONCLUSION

Results indicate that sickness absence due to a depressive episode or back pain is a strong risk factor for a future disability pension due to mental, musculoskeletal or other somatic diagnoses.

The construct validity of a self-report questionnaire focusing on health promotion interventions in mental health services

Health promotion has become a widespread concept, although little empirical research as to its importance and outcome has been performed in the mental health field. The aim of the present study was to investigate the construct validity of a newly developed Health Promotion Intervention Questionnaire, intended to measure patients' subjectively experienced health-promoting interventions within mental health services. A total of 135 participants responded to the questionnaire and to validation measures assessing psychiatric symptoms, empowerment, helping alliance and satisfaction with care. Bivariate correlations showed that overall perceived health-promoting interventions were positively correlated to, helping alliance, client satisfaction with care and empowerment. Stepwise multiple regression analysis showed that the strongest relationship was found between perceived health promotion intervention and helping alliance. In conclusion, the construct validity of the scale was satisfactory, except for one of its subscales where further investigations are needed.

Nurses' conceptions of how health processes are promoted in mental health nursing

The health and well-being of the individual is a central goal in nursing, and health promotion seeks to enable people to increase control over and improve their health. In mental health care, health is often described in negative terms such as the absence of mental illness, which may create hopelessness and constitute a barrier to a policy of health promotion. The aim of this study was to describe nurses' conceptions of how health processes are promoted in mental health nursing. Twelve nurses working in mental health care were interviewed and the data were analysed using a phenomeographic approach. The nurses expressed 11 different conceptions of the phenomenon, which were summarized into three descriptive categories: presence, balance of power, and focus on health. The findings show that the nurses expressed ambiguous attitudes towards meeting the patient in mental health care. It is suggested that the goal of nursing care should be clarified for nurses in practice, otherwise they may adopt the perspectives of other mental health professionals.

Patients' conceptions of how health processes are promoted in mental health nursing. A qualitative study

The most important goal of nursing care is to promote the subjective experience of health. The health promoting efforts of mental health care nurses must be aimed at creating encounters where the patient will be confirmed both existentially and as an individual worthy of dignity. The patient in mental health care is often viewed by the nurse as nothing more than a passive recipient of care and the belief in the patient's potential is minimal. This can lead to a situation where the patient loses control in the caring situation and feels unable to improve his/her health, which conflicts with the goal of the nursing care. The aim of the study was to describe patients' conceptions of how health processes are promoted in mental health nursing. Twelve patients with experience of mental health nursing were interviewed, and the data material was analysed using a phenomenographic approach. The results show 13 different conceptions of the phenomenon, and these were summarized into four descriptive categories: interaction, attention, development and dignity. The conceptions described show that the patients need to be treated as equals and that the nurse must trust the patient's ability to make decisions and to promote his/her health process. It is suggested that mental health nursing should be built on humanistic science and its view that every individual has the ability to grow and develop. This view is one of the most important preconditions for the promotion of health processes in mental health nursing.

The Swedish Twin Registry: a unique resource for clinical, epidemiological and genetic studies

The Swedish Twin Registry (STR), which today has developed into a unique resource, was first established in the late 1950s to study the importance of smoking and alcohol consumption on cancer and cardiovascular diseases whilst controlling for genetic propensity to disease. Since that time, the Registry has been expanded and updated on several occasions, and the focus has similarly broadened to most common complex diseases. In the following, we will summarize the content of the database, describe for the first time recent data collection efforts and review some of the principal findings that have come from the Registry.

Extra-intestinal manifestations associated with irritable bowel syndrome: a twin study

BACKGROUND

Little is known about the role of genetic and environmental factors in irritable bowel syndrome. Various extra-intestinal manifestations are more prevalent in cases than in controls. Genetic effects may be important in the liability to develop functional bowel disorders.

AIMS

To evaluate the associations of irritable bowel syndrome with several disorders co-morbid with the condition, using both a case-control design and a co-twin control design.

METHODS

A sample of 850 Swedish twin pairs, aged 18-85 years, was contacted for a telephone interview. Through a diagnostic algorithm, 72 unrelated cases of irritable bowel syndrome and 216 age- and gender-matched controls were identified. Fifty-eight twin pairs discordant for irritable bowel syndrome were evaluated in co-twin analyses.

RESULTS

Renal problems (odds ratio (OR)=3.3; confidence interval (CI), 1.3-8.2), obesity (OR=2.6; CI, 1.0-6.4), underweight in the past (OR=2.4; CI, 1.1-6.4), gluten intolerance (OR=9.0; CI, 1.4-60.1), rheumatoid arthritis (OR=3.2; CI, 1.1-9.4) and poor self-rated health (OR=1.8; CI, 1.0-3.2) were significantly associated with irritable bowel syndrome. In the co-twin analyses, the only factors maintaining significance were renal and recurrent urinary tract problems.

CONCLUSIONS

The association between irritable bowel syndrome and renal and urinary tract problems does not reflect a genetic or familial mediation. Eating disorders in childhood represent a familial-environmental influence on irritable bowel syndrome, whereas the association with rheumatoid arthritis and perhaps gluten intolerance probably reflects genetic mediation.

Education and the risk of Alzheimer's disease: findings from the study of dementia in Swedish twins

The association between dementia and education was studied in 143 twin pairs discordant for dementia, using a matched-pair design, and in 221 dementia cases and 442 unrelated controls from the same twin registry, using a case-control design. Low education was defined as 6 years or less of schooling. Case-control analyses with prevalent cases showed low education to be a risk for Alzheimer's disease but not dementia in general. Low education did not significantly predict incident cases. In the matched-pairs analysis, which controls for genetic and other familial influences, differences in education between demented twins and twin partners were not statistically significant. However, for Alzheimer's disease, odds ratios resulting from matched pairs and case-control analyses were similar. Twins' comparative reports about intellectual involvement earlier in their lives suggest a long-standing difference on this dimension, with less involvement by the twin who became demented.