Psychosocial stressors and depression at a Swedish primary health care centre. A gender perspective study

<p>Abstract</p> <p>Background</p> <p>Psychosocial stress may account for the higher prevalence of depression in women and in individuals with a low educational background. The aim of this study was to analyse the association between depression and socio-demographic data, psychosocial stressors and lifestyle circumstances from a gender perspective in a relatively affluent primary care setting.</p> <p>Methods</p> <p>Patients, aged 18- 75 years, visiting a drop-in clinic at a primary care health centre were screened with Beck's Depression Inventory (BDI). The physicians used also targeted screening with BDI. A questionnaire on socio-demographic data, psychosocial stressors and use of alcohol and tobacco was distributed. Among patients, who scored BDI ≥10, DSM-IV-criteria were used to diagnose depression. Of the 404 participants, 48 men and 76 women were diagnosed with depression. The reference group consisted of patients with BDI score <10, 187 men and 93 women. Age-adjusted odds ratios (ORs) with 95% confidence intervals (CI) as being depressed were calculated for the psychosocial stressors and lifestyle circumstances, separately for men and women. Multiple logistic regression analyses were used to determine the age-adjusted main effect models for men and women.</p> <p>Results</p> <p>The same three psychosocial stressors: feeling very stressed, perceived poor physical health and being dissatisfied with one's family situation were associated with depression equally in men and women. The negative predictive values of the main effect models in men and women were 90.7% and 76.5%, respectively. Being dissatisfied with one's work situation had high ORs in both men and women. Unemployment and smoking were associated with depression in men only.</p> <p>Conclusions</p> <p>Three questions, frequently asked by physicians, which involve patient's family and working situation as well as perceived stress and physical health, could be used as depression indicators in early detection of depression in men and women in primary health care.</p

Transkulturell Allmänmedicin

Fem teoretiska begrepp för transkulturell vård presenteras. Dessa grundpelare eller ramar torde ge förutsättningar för god vård på lika villkor. Grundpelarna är kulturbegreppet, migrationsprocessen, emotionella karaktäristika, familjestrukturer, uttryck för stress samt förklaringsmodeller till sjukdom. Förutom att ge struktur till konsultationer där olika kulturer möts, inte bara invandrare utan även minoriteter och marginaliserade grupper, underlättar det diagnos och behandling samt värdering av förlopp och behandlingsresultat. Patient-doctor encounters are rich in cultural context. Primary care consultations have special framings where language and culture might differ largely between patients and care-givers. In such situations, the health professionals need extra skills to elucidate overt or covert messages from the patients. One skill is how to use professional interpreters. Other useful tools are the ability to identify one-self as a cultural person and a know-how about the migration process but also to recognize idioms of distress, family structures and patients’ explanatory models of illness

Pain drawings, interpreter support and clinical findings among immigrant patients on sick leave in Swedish primary health care

Aim: To evaluate the spread of pain and its correlates among immigrant patients on sick leave. Background: Backache, outspread pain and sick-leave questions are problematic to handle primary health care, especially in multicultural settings. Methods: Two hundred and thirty-five patients 20-45 years on paid sick leave (59% women, 93% foreign-born, mostly non-Europeans). Many had little formal education. One-third had professional interpreter support. The patients pointed out on their bodies where they felt pain. This information was transferred on a pain drawing [pain drawing fields (PDFs) 0-18] by a doctor. Major depression and psychosocial stressors were assessed using Diagnostic and Statistical Manual of Mental Disorders. Nociceptive locations for pain were established (pain-sites 0-18). Dependent variable was the number of PDFs. Independent variables were social data, sick leave, interpreter, depression, stress levels and number of pain sites. Calculations were done using descriptive methods and multi-variable linear regression in full models, by gender. Findings: Many patients had depression (51% women versus 32% men). A majority were exposed to psychosocial stressors. Women had more PDFs, in median 5 [inter-quartile ranges (IQR) 4-8] versus men 3 (IQR 2-5), and also more pain sites, in median 3 (IQR 2-5) versus men in median 2 (IQR 1-3). For men, the regression calculations revealed that numbers of PDFs associated only with increasing numbers of pain sites (B 0.871 P &lt; 0.001). For women, this association was weaker (B 0.364, P &lt; 0.001), with significant values also for age (B 0.103) and sick leave &gt; one year (B 0.767, P = 0.010), and a negative predicting value for interpreter support (B -1.198, P &lt; 0.043). To conclude, PDFs associated often with somatic findings but varied much among the women. This implies potential problems regarding cause, function and sick leave questions. However, support by professional interpreters may facilitate a shared understanding with immigrant women having long-standing pain

Illness, disease, sickness : Clinical factors, concepts of pain and sick leave patterns among immigrants in primary health care. Effects of different therapeutic approaches

Illness, disease, sickness. Clinical factors, concepts of pain and sick leave patterns amongimmigrants in primary health care. Effects of different therapeutic approaches Monica Löfvander The outer framework for this thesis is the high rate of disability pensions amongsome immigrant groups in Sweden. The general aim for the research has been to understandthe phenomena of illness, disease and sickness certification in immigrants from aprimary care perspective and to test the effects on well-being and sickness certificationof different therapeutic approaches. The research has been done step-wise and hasmainly been of an inductive character. The first project is a descriptive - intervention study of sickness, disease andpsychosocial patterns in 105 consecutive, first-time health service visitors of Greekand Swedish origin with a ten year follow-up. In the second project, concepts ofbackache were explored in 15 consecutive Greek patients on long-term sick leave and21 healthy members of a Greek cultural association. The third project, comprising92 persons aged 25-45 years, consists of explorative studies of clinical factors,psychosocial stressors, sick leave patterns with a three year follow-up and conceptsof pain in the framework of a rehabilitation programme with two randomised treatmentgroups. Psychiatric ratings were performed according to the CPRS (first project) and DSM-III-R(third project). Criteria from the DSM-III were used for assessing psychosocial stressorsand social functioning. Global ratings of work incapacity were made jointly by theresearchers. Self-rated work ability and ratings of pain behaviour were includedin the third project. Concepts of pain were explored in thematic interviews. In the first project, a majority had pain complaints. In contrast to the Swedes,the Greeks exhibited a passive pain behaviour. Half the Greeks, but only few Swedes,had a mostly mild depressive/dysphoric illness often associated with psychosocialstressors. Counselling sessions with a Greek psychotherapist were generally not acceptedby the Greeks. Regarding work incapacitating diseases, the Greeks had chronic painand depression and the Swedes had other psychiatric disorders or chronic pain. Inspite of small differences in work incapacity between the ethnic groups, the Greekswere more often on long-term sick leave, a difference that increased over a ten yearperiod. In the second project, the concepts about backache among the Greek interviewees werefound to centre around the idea of a deteriorating disorder as the cause of persistentpain; a disorder inevitably leading to invalidity if the sufferer should deliberatelyaggravate the pain. The pain was also linked to much worrying, often shared by thewhole family. Chronic, benign pain, depressive disorders, pain anxiety, psychosocial stressorsand subjective work incapacity were also common among the immigrants in the thirdproject. In addition to physiotherapy and doctors' reassurance about the benignityof the pain, interviews and dialogue sessions about pain were included in one ofthe randomised groups. The interviews revealed two patterns of pain concepts. Oneconsisted of notions about a deteriorating disease along with worries for futuredisability; the other of vague ideas, concentrating on the immediacy of pain. Afterthe programme, pain anxiety and depressive symptoms had decreased, and self-ratedwork ability had increased significantly more among the interviewees than in thecontrol group. Self-rated work ability was a good predictor for returning to workand for staying at work the following years. In summary, pain anxiety was at the core of the illness, disease and sickness patternsof the immigrants in the research projects. Pain interviews and dialogue sessionsabout pain may reduce pain anxiety and depressive mood, increase self-rated workability, and increase the prospects of successful rehabilitation back to work. Key words: Immigrants, general practice, psykosocial stress, chronic pain, concepts,cross-cultural psychiatry, cognitive, sick leave, language, depression, social adjustment,psychosomatic disorders, qualitative research. Monica Löfvander ISBN 91-628-2662-

Long-term adherence and effects on grip strength and upper leg performance of prescribed supplemental vitamin D in pregnant and recently pregnant women of Somali and Swedish birth with 25-hydroxyvitamin D deficiency : a before-and-after treatment study

Background: Muscular weakness and severe vitamin D deficiency is prevalent in Somali (veiled) pregnant women, Sweden. The study aims here were to explore adherence to prescribed supplemental vitamin D in new mothers with vitamin D deficiency and its effects on grip strength and upper leg performance in Somali (target group TG) and Swedish women (reference group RG) from spring through winter. Methods: A before-and after study was designed. A cross-sectional sample of women in antenatal care with serum 25-OHD &lt;= 50 nmol/L were prescribed one or two tablets daily (800 or 1600 IU vitamin D3 with calcium) for 10 months. Reminders were made by Somali nurses (TG) or Swedish doctors (RG). Baseline and 10 month measurements of plasma nmol/L 25-OHD, maximal grip strength held for 10 s (Newton, N) and ability to squat (yes; no) were done. Total tablet intake (n) was calculated. Outcome variables were changes from baseline in grip strength and ability to squat. Predicting variables for change in grip strength and ability to squat were calculated using linear and binary regression in final models. Undetectable 25-OHD values (&lt; 10 nmol/L) were replaced with '9' in statistic calculations. Results: Seventy-one women (46 TG, 1/3 with undetectable baseline 25-OHD; 25 RG) participated. At the 10-month follow up, 17% TG and 8% RG women reported having refrained from supplement. Mean 25-OHD increased 16 to 49 nmol/L (TG) and 39 nmol/L to 67 nmol/L (RG), (both p &lt; 0.001). Grip strength had improved from 153 to 188 N (TG) (p &lt; 0.001) and from 257 to 297 N (RG) (p = 0.003) and inability to squat had decreased in TG (35 to 9, p &lt; 0. 001). Intake of number of tablets predicted increased grip strength (B 0.067, 95% CI 0.008-0.127, p = 0.027). One tablet daily (&gt; 300 in total) predicted improved ability to squat (OR 16; 95% CI 1.8-144.6). Conclusions: Adherence to supplemental vitamin D and calcium should be encouraged as an even moderate intake was associated to improved grip strength and upper leg performance, which was particularly useful for the women with severe 25-OHD deficiency and poor physical performance at baseline

Positive impact on vitamin D related lifestyle of medical advice in pregnant Somali-born women and new mothers : a mixed method study in Swedish primary care

Background A previous study showed that pregnant women/new mothers especially Somali-born and some Swedish-born had extremely low vitamin D levels and poor physical performance. Our study aimed to examine vitamin D related lifestyle, attitudes and behaviour before and after brief information about vitamin D, with special long-term focus on Somali-born women. Methods A cohort of 91 pregnant women/new mothers having serum hydroxyvitamin D (S-25-OHD)&lt;= 50nmol/L (n=51 Somali-born with one third &lt;10nmol/L of S-25-OHD) in primary health care in Sweden was targeted for intervention. Brief individual oral and visual information on vitamin D was given by doctors at baseline and after four and ten months. Questionnaires with ordinal scales on vitamin D related lifestyle of food, clothing, and outdoor activities were distributed on all occasions. Focus-group interviews with 15 women from the target-group were performed after two years. A Somali interpreter was available. Results Veiled clothing, indoor living, and a low intake of milk, cheese, and fatty fish were common in the target group. Consumption pattern had increased significantly among the Somali-born women at the four-month follow-up but declined to non-significant levels at the ten-month follow-up. The focus-group interviews showed improved understanding of vitamin D deficiency, symptoms and attitudes, but varying applied behaviours related to sun exposure. Sun exposure for the children and increased fish consumption was the most evident positive results. Conclusions Vitamin D related lifestyle, attitudes and behaviour improved in a Somali-born group of pregnant women/new mothers with severe vitamin D deficiency. The preventive measures suggested in our study may have impact on public health in relation to bone and muscle strength and immunity especially in vitamin D deficiency risk groups.Title in thesis list of papers: Impact on Vitamin D related lifestyle in Somali women with severe deficiency following medical advice by doctor: A mixed method study of before and after treatment</p

Pain intensity and severe pain in young immigrant patients with long-standing back pain

The aim of this study was to explore if self-rated pain intensity and severe pain differed significantly between immigrants from different regions, and if other socio-economic, or clinical, characteristics could predict severe pain. A total of 129 men and 217 women at a primary health centre in Stockholm, Sweden, 27–45 years, on long-term sick leave, were recruited in consecutive order and grouped into a Turkish (n = 122), Southern European (n = 52), Middle East (n = 69) and one Mixed (n = 173) group of immigrants. All were employed in service jobs. Somatic status, depression and level of psychosocial stressors, including pain anxiety, were established by standardized procedures. All reported long-standing disabling back pain. Patients rated intensity of pain “right now” on a 0–100 mm visual analogue scale (VAS) as a last part of the consultation with two doctors. Severe pain was defined as VAS 75–100. Median values (md) with inter-quartile ranges (IQR) were calculated for interval and ordinal data. Non-parametric statistics were used to calculate significant differences between groups. Crude and age-standardized odds ratios (OR) with 95% confidence intervals (95% CI) as rating severe pain were calculated by binary and forward conditional logistic regression. Men and women were analyzed separately. Women had more tender points, (P < 0.001), and reported pain anxiety more often (P < 0.01). Frequency of depression did not differ between the immigrant groups. The VAS-values varied, but not significantly, between the immigrant groups of men and women. Men had lower VAS values than women (md 50, IQR 36–69 vs. md 72, IQR 51–85), (P < 0.001). Women had a three-fold risk to rate severe pain (OR 2.9, 95% CI 1.8–4.7). By sex, no immigrant group had significantly elevated OR to rate severe pain. Being 40–45 year old doubled the OR as rating severe pain. Men with depression, or little education, had high risks as rating severe pain (age-standardized ORs 4.1; 95% CI 1.7–10.0 and 2.7; 95% CI 1.1–6.8, respectively), and so had depressed women (age-standardized OR 1.9; 95% CI 1.1–3.4). Women with pain anxiety had a doubled, not statistically significant, elevated risk (age-standardized OR 2.0, 95% CI 0.95–4.3). The groups did not differ significantly in pain intensity or severe pain. Severe pain was predicted by depressed mood and probably linked to gender, age and sick roles