This empirical double-blind multi-centre empirical study assessed the sources of stress, stress-related symptoms, role of psychosocial moderating variables and the role of micronutrients (specifically the effect of intervention with micronutrient supplementation) on stress levels and symptoms in South Africans. The sample consisted of 300 volunteer, English-speaking South Africans from two centres (KwaZulu-Natal and Gauteng) who had predetermined stress levels. The participants were evenly divided between the two centres (N=150 each). The Experimental Group (Active group) who comprised 151 participants received a multivitamin and mineral combination, while the Control Group (Placebo) group received a placebo. The research dealt with perceived stressors, coping resources and outcomes in the general population (both at baseline and after intervention). Outcome was assessed using standardized self-report instruments which examined stress levels and symptoms, perception of stress levels, anxiety, psychological general well-being and neurocognitive functions (verbal and visual memory). Univariate and multivariate correlational analyses were performed to investigate correlations and the predictive value of risk and rescue factors for the outcome variables. The findings indicate that there were no significant differences in the number of stressors between the two groups at baseline, although they differed in respect of two particular stressors (A>P regarding concern over children's future; P>A regarding life decisions). An interaction of stressors and moderating variables (life orientation and perceived coping incapacity) have an important role in predicting stress and stress outcome, and outcomes themselves may function as stressors. The bidirectional, circular interactive effects of stressors, moderators and outcomes are important in the stress and coping process. The study failed to find any effect of stress on the neurocognitive functions assessed. No significant treatment effect for the micronutrient was found, but a number of trends in respect of efficacy were suggested by the findings. The findings also suggested particular patterns of interactions in this regard for predicting pre-post differences (delta). Strengths and limitations of the study are highlighted and implications for intervention in respect of a stress management programme are also discussed. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2005.

This is the first time that multidisciplinary research has been conducted in South African music venues. The study investigated biopsychosocial health-related variables affecting workers in music venues giving special attention to sick building syndrome. Monitoring methodologies developed for this investigation can be applied in studies of a wide range of workplace environments. This study also resulted in the design of a questionnaire which provided interpretable data within statistical significance limits. The literature review fully describes the multidisciplinary nature of this research. Long established non-smoking offices were selected as controls. An environmental monitoring system was designed to record conditions whilst questionnaires on staff perceptions were personally administered. Psychosocial variables included job satisfaction, self-esteem, personal confidence and social interaction.Environmental comfort assessments included lighting, carbon dioxide, movement, temperature, relative humidity levels and air movement. Pollution impact monitoring involved noise, respirable aerosols, benzene, toluene, xylene, benzo(a)pyrene, total volatile and semi-volatile organic compounds. Comfort criteria were exceeded in all music venues which caused stress. Only 21,1% of respondents did not experience tiredness. Respiratory infection was higher in music venue staff than in office staff. Average age of staff in music venues was 25 years and 67,37% were smokers. Certain smokers were experiencing discomfort from tobacco smoke pollution. Tobacco smoke impact was demonstrated: mean benzene level for music venues was 12,9 u/m3 (maximum 42,44 u/m3) and in offices it was 0,606 u/m3 (maximum 1,24 u/m3). Multivariate models for sick building syndrome and allergies included tobacco smoke odour concern and the tobacco smoke indicators, xylene and toluene. Aerosol levels were 1,75 mg/m3 (maximum 45,98 mg/m3 ) in music venues compared to an office mean of 0,02 mg/m3 (maximum 0,58 mg/m3 ). Contributors were tobacco smoke and theatrical smoke. Burning eyes was the symptom causing most concern for 57,89% of respondents. Symptoms that affected 20% and more of the workers were itchy skin, throat irritation, coughing and difficulty in breathing. Tobacco smoke was considered the main stressor. Noise level mean for music venues was Neq 99,67 dB (A). Only 34,7% of the staff considered music noise a stressor, with 16,9% concerned about people noise. The percentage that considered their environment to be polluted was 81,06%, however, only 48,42% felt stressed. Virtually all univariate and multivariate associations between psychosocial and psychophysical variables suggest that satisfaction with psychosocial factors may have a positive influence on staff in places of entertainment. / Thesis (M.Med.Sc.)-University of Natal, 1995.

<p>This thesis deals with a behavioural medicine approach to the management of patients with persistent musculoskeletal pain in primary health care physical therapy. The main aims of the thesis were; to develop, and evaluate the psychometric properties of, a screening instrument for risk of disability and; to evaluate the implementation and effects of a targeted and tailored treatment. </p><p>The studies comprise four samples of patients with musculoskeletal pain exceeding one month. All subjects were recruited when consulting physical therapists in Swedish primary health care settings. For development and evaluation of the Pain Belief Screening Instrument (PBSI) four samples were used; two samples (n₁ = 215 and n₂ = 93) in Study I, one sample (n = 168) in Study II, and one sample (n = 45) in Study III. For evaluation of implementation and effects of targeted and tailored treatment the 32 patients who completed treatment in Study III were used. In Study IV treatment documents of 18 patient cases from Study III were studied to evaluate treatment integrity. </p><p>The concurrent and predictive validity of the PBSI was good, and the instrument was therefore used to define subgroups with either a high or low risk for disability. A low treatment dosage of a tailored treatment for low risk patients was tried and found equally efficient as a longer treatment focusing physical exercise. Subjects who received a treatment tailored to individual patient characteristics perceived a better global outcome of treatment compared to subjects in the control group. However, no between-group differences in the disability measures were found. The evaluation of treatment integrity displayed low therapist adherence to the treatment rationale for the tailored treatment. </p><p>The studies demonstrate ways to systematically integrate a behavioural medicine approach and physical therapy. The results indicate efficiency in managing patients with persistent musculoskeletal pain in primary health care.</p>

Aim: The overall aim of this thesis was to study prognostic factors for prolonged disability in back pain in the general population and physiotherapists’ screening for prolonged disability, applying a social cognitive learning perspective. Methods and results: Studies I and II were based on a survey in the general population in Sweden. Study I included 1024 individuals aged 20-50 years, reporting non-specific back pain. Four groups (n = 100, 215, 172 and 537) based on duration and recurrence of back pain were formed and compared. After controlling for pain intensity, catastrophising and expectations of future pain were positively correlated to pain duration. Perceived social support was negatively correlated to pain duration. Study II was longitudinal over 12 months and analysed one group reporting first-episode back pain (n = 77), and one group reporting long-term back pain (n = 302). Future pain intensity and disability were predicted by initial levels of pain and disability and pain-related cognitions in both groups. Study III examined the inter-rater reliability of a research protocol for assessment of physiotherapists’ telephone screening for prolonged disability. The results demonstrated sufficient inter-rater reliability. Study IV evaluated the effect of a tailored skills training intervention on physiotherapists’ screening for prolonged disability in back pain. Four physiotherapists in primary care participated in four quasi-experimental single-subject studies. Effects were seen in all participants, with increased screening of prognostic factors and less time spent on detailed discussions about back pain. Conclusions: The identification of mainly cognitive explanatory variables indicates the relevance of a social cognitive perspective of back pain-related disability (studies I and II). Physiotherapists’ telephone screening for prolonged disability in back can be reliably assessed (study III). It is suggested that interventions based on social cognitive theory are effective in producing change in specified clinical behaviours in physiotherapists (study IV).

This thesis deals with a behavioural medicine approach to the management of patients with persistent musculoskeletal pain in primary health care physical therapy. The main aims of the thesis were; to develop, and evaluate the psychometric properties of, a screening instrument for risk of disability and; to evaluate the implementation and effects of a targeted and tailored treatment. The studies comprise four samples of patients with musculoskeletal pain exceeding one month. All subjects were recruited when consulting physical therapists in Swedish primary health care settings. For development and evaluation of the Pain Belief Screening Instrument (PBSI) four samples were used; two samples (n1 = 215 and n2 = 93) in Study I, one sample (n = 168) in Study II, and one sample (n = 45) in Study III. For evaluation of implementation and effects of targeted and tailored treatment the 32 patients who completed treatment in Study III were used. In Study IV treatment documents of 18 patient cases from Study III were studied to evaluate treatment integrity. The concurrent and predictive validity of the PBSI was good, and the instrument was therefore used to define subgroups with either a high or low risk for disability. A low treatment dosage of a tailored treatment for low risk patients was tried and found equally efficient as a longer treatment focusing physical exercise. Subjects who received a treatment tailored to individual patient characteristics perceived a better global outcome of treatment compared to subjects in the control group. However, no between-group differences in the disability measures were found. The evaluation of treatment integrity displayed low therapist adherence to the treatment rationale for the tailored treatment. The studies demonstrate ways to systematically integrate a behavioural medicine approach and physical therapy. The results indicate efficiency in managing patients with persistent musculoskeletal pain in primary health care.

This thesis is about a behavioural medicine approach in periodontal treatment and oral hygiene self-care. The aim of this thesis was to develop, describe, and evaluate an individually tailored oral health educational program on oral hygiene behaviour and non-surgical periodontal treatment success, and to determine factors of importance for predicting oral hygiene behaviour. Two separate studies, both conducted at a specialist clinic for periodontics in a Swedish county council are described. In the first study, the program was developed and described in two experimental single-case studies with multiple baseline designs (Paper I). The second study was a randomised controlled single-blinded trial [n = 113, mean age 51.2, 53% female] in which, the effectiveness of the program was compared with standard treatment on oral hygiene habits, plaque control, and gingivitis (Paper II), periodontal status (Paper III), and attitudes, subjective norms, and self-efficacy (Paper IV). The tailored oral health educational program included a motivational interviewing method and cognitive behavioural techniques, and the individual tailoring for each participant was based on participants’ thoughts and cognitions, intermediate and long-term goals, and oral health status. Participants in the individually tailored program reported higher frequency of daily interdental cleaning and were more confident about maintaining the attained level of behaviour change, had better oral hygiene, and healthier gingival tissue, particularly interproximally. There was a great reduction in periodontal pocket depth and bleeding on probing scores (BoP) for participants in both programs with a greater reduction in BoP scores in the tailored-treatment group. A lower dental plaque score at treatment start increased the predicted probability of attaining treatment success, and self-efficacy towards interdental cleaning predicted oral hygiene behaviour. These studies demonstrate an individually tailored oral health education program is preferable to standard program as an oral hygiene behaviour change interventions in non-surgical periodontal treatment. / Behavioural medicine perspectives for change and prediction of oral hygiene behaviour

ABSTRACT Aim: The aim of this study was to evaluate and study the effects of a tailored behavioural skills intervention on the amount of FaR® prescribed, and to describe self-efficacy over time for prescribing FaR® in participants from primary health care units. Method: A quasi-experimental single-case design with multiple–baseline across time and settings was used. Each baseline had an ABC design, baseline (A), intervention (B) and post-intervention (C). The intervention was introduced across two different PHCUs at different times. It was seven participants included. Primary outcome measurements were repeatedly collected for participants in settings. The method was based on behavioural medicine principles. Key concepts from SCT theory was used in the intervention. Result: The result seemed to demonstrate an effect on the prescribing behaviour in terms of a slightly increased amount of prescribed FaR® during the intervention phase, even though not for all participants. It was no or short latency for the changed behaviour during intervention. Adopted behaviour was not maintained in the post-intervention phase. Self-efficacy for prescribing FaR® varied. The variation of overall self-efficacy between baseline and post-intervention was from -10% to 81%. Conclusion: This study indicated that a tailored skills training programme might have the potential to change the prescribing behaviour among professionals in primary health care. An intervention lasting for eleven weeks seemed not enough to maintain the achieved performance. No conclusion could be done on self-efficacy. Keywords: Quasi-experimental single-case design, physical activity on prescription FaR®, behavioural medicine, implementation, primary care.

This empirical study assessed the perceived stressors in medical school environment and psychological outcomes in undergraduate medical students in a non - western sample. The sample consisted of African and Indian students in the Clinical group (N = 149) and a matched Control group, the Pre-clinical group (N = 158) bringing the total number of participants to 307. The research dealt with perceived stressors, coping mechanisms and outcomes in a medical school environment. Outcome was assessed using self-report instruments which examined stress symptoms and psychological distress. Both bivariate and multivariate correlational analyses were performed to investigate correlations and the predictive value of risk factors for psychological distress. The findings indicate that there are no significant differences in the perception of stressors in the medical school environment between the Pre-clinical and Clinical groups. Maladaptive coping strategies, perceived stressors and female gender have important roles to play in predicting psychological distress. High self-esteem and good social support for both groups, as well as optimism in the Clinical group protects against psychological distress. Strengths and limitations of this study as well as implications for intervention strategies among undergraduate medical students are also discussed. / Thesis (Ph.D.)-University of KwaZulu-Natal, 2003.

Bakgrund: Antalet äldre i dagens befolkning ökar kraftigt. Flera biopsykosociala faktorer anses påverka äldres fysiska aktivitetsnivå. Fysioterapeuten arbetar hälsofrämjande med äldre främst genom att befrämja fysisk aktivitet. Syfte: Att ur ett biopsykosocialt perspektiv beskriva hemmaboende äldres upplevelse av vilka faktorer som har betydelse för deras fysiska aktivitetsnivå. Vidare är syftet att beskriva hur äldre upplever att en fysioterapeut kan understödja deras fysiska aktivitet. Metod: En kvalitativ, semistrukturerad intervjustudie med induktiv ansats användes. Ett ändamålsenligt bekvämlighetsurval gav fem deltagare ≥80 år. Materialet tolkades med en kvalitativ innehållsanalys och sorterades i kategorier och underkategorier. Resultat: Sju kategorier framkom gällande faktorer av betydelse för deltagarnas fysiska aktivitetsnivå: tankar och känslor, trötthet/orkeslöshet, kroppslig begränsning, åldrande, fysisk omgivning, vardagskrav och social omgivning. Fyra kategorier beskrev hur fysioterapeuten kan understödja deltagarnas fysiska aktivitet: Motivera till fysisk aktivitet, utföra fysisk aktivitet hos fysioterapeut, ge förslag på fysisk aktivitet samt hjälpa till att förbättra den fysiska funktionsförmågan. Slutsatser: Deltagarnas berättelser om faktorer som påverkar deras fysiska aktivitetsnivå kan kopplas till det biopsykosociala paradigmet. Deltagarna hade viss svårighet att beskriva hur de upplevde att en fysioterapeut kan understödja deras fysiska aktivitet, men flertalet förslag framkom. Framtida forskning bör främst fokusera på äldres upplevelser av hur fysioterapeuter kan understödja fysisk aktivitet. / Background: The older population is increasing in numbers. Several biopsychosocial factors are assumed to impact the older population’s physical activity level. The physiotherapist works with health promotion for older people primarily by promoting physical activity. Aim: From a biopsychosocial perspective describe factors that the older population living at home perceive as relevant to their physical activity level. Further to describe how the older population perceive that a physiotherapist can support their physical activity. Method: A qualitative, semi-structured interview study with an inductive approach was used. A purposive, convenience sampling resulted in five participants ≥80 years. The material was interpreted with qualitative content analysis and sorted into categories and subcategories. Result: Seven categories emerged for factors influencing the participant’s physical activity level: thoughts and feelings, tiredness/ weakness, bodily limitation, aging, physical environment, everyday demands and social environment. Four categories described how a physiotherapist can support the physical activity of the participants: motivate to physical activity, perform physical activity with a physiotherapist, give suggestions on physical activity and help to improve the physical functional capacity. Conclusion: The participant’s stories about factors influencing their physical activity level can be linked to the biopsychosocial paradigm. The participants had some difficulties describing how they perceived that a physiotherapist can support their physical activity, but several suggestions emerged. Future research should mainly focus on older people’s perception of how a physiotherapist can support physical activity.

The overall aim of this thesis was to study the daily process of coping, potential prognostic factors for recovery and evaluating an individually tailored behavioural medicine intervention in the acute stage of Whiplash Associated Disorders (WAD). The studies comprised three samples of patients with acute Whiplash Associated Disorders (WAD). All patients were included within the first month after the whiplash occurrence and were recruited from hospital emergency wards in six Swedish communities. Study I and II included 51 participants generating 260 daily coping diaries (WAD-DCA) during seven days in the acute stage of WAD. In Study I daily stressors and primary appraisal were analysed and in Study II patterns between stressors, appraisals, coping strategy profiles, daily activity level and well-being were described. The results showed a large variety of situations that the individuals perceive as stressful, not only pain itself. High self-efficacy was associated with high degree of physical/mental well-being. Threatening stressors and catastrophic thoughts were associated with low degree of physical and mental well-being. In Study III potential prognostic factors for good as well as poor recovery were studied more closely in a mildly affected sample (MIAS) (n=98) from within the first month after the accident up to one year later. Pain-related disability at baseline emerged as the only indicator of prognosis after 12 months in MIAS. Study IV (n=55) was a randomised control study, were current clinical recommendations of standard self-care instructions (SC) for the management of acute WAD was compared to an individually tailored behavioural medicine intervention delivered via Internet or face-to-face. The results showed that SC was not as effective as the behavioural medicine intervention. By early identification of situation-specific factors and potential behavioural (physical, cognitive and affective) determinants of activity performance, it seems possible to tailor a self-management intervention that decreases pain-related disability, fear of movement and catastrophising and increases self-efficacy. The use of innovative methods such as the Internet of distributing treatment interventions showed to be a good alternative to more traditional forms. The results of this thesis uncover new insights in understanding the individual’s specific perspective as applied in a behavioural medicine approach in acute WAD.