Diss. (sammanfattning) Stockholm : Karolinska institutet, 2009. / Härtill 4 uppsatser.

Thesis--University of Oklahoma. / Bibliography: leaves 76-79.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2010. / Härtill 5 uppsatser.

This thesis proposes an estimation approach for count data models with endogenous covariates. The maximum approximate composite marginal likelihood inference approach is used to estimate model parameters. The modeling framework is applied to predict crash frequency at urban intersections in Irving, Texas. The sample is drawn from the Texas Department of Transportation crash incident files for the year 2008. The results highlight the importance of accommodating endogeneity effects in count models. In addition, the results reveal the increased propensity for crashes at intersections with flashing lights, intersections with crest approaches, and intersections that are on frontage roads. / text

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Aim To describe the epidemiology of tuberculosis in the city of Liepaja during the last 27 years and the management of patients with tuberculosis during the period 1993-2002; to identify problems in tuberculosis management relevant to increasing level of morbidity and the registered high levels of drug-resistance. Material and methods The cases were all persons reported with tuberculosis in 1975-2002. The data sources were the yearly Health Statistics books at the Latvian Office of Medical Statistics. The study used data from the available 655 individual patient records from Liepaja Tuberculosis Dispensery and TB Register of 1993 – 2002. Information was extracted selectively and extraction sheets containing the variables of interest were developed. The incidence differences according to sex and age, possible clustering of patients in high-risk living areas of the city, differences in occupation of the patients were studied. The differences of time from disease symptoms to diagnosis, as well as investigation data, treatment regimens, the proportions of treatment outcomes were analysed. Analysis was done using EPI-INFO programme for statistical analysis. Results In the 1980s tuberculosis was under control in Latvia and the incidence was at the European average level. After Latvia had regained independence in 1991, with economical and political disruption and changes in the health care system, TB incidence and mortality in the country increased rapidly as well as in Liepaja. Although not very high compared to global TB rates, there was great concern about TB control in Latvia. In addition, the emergence of drug resistance and multi-drug resistant bacteria made the TB epidemic more serious. The TB incidence increase in children suggested that there was quite a big number of undetected cases of TB. Tuberculosis control and early detection activities were not integrated into the PHC system. Treatment results of TB were quite poor and showed high proportions of interruptions, defaults, relapses. The tuberculosis control Programme in Latvia and Liepaja put much effort into the improvement of the epidemiological situation with TB, focusing on TB control activities and management during the period 1993-2002. The incidence of tuberculosis in Liepaja was higher than in Latvia, particularly in some living areas in the city, and above endemic level. Mortality rate in average was higher as in the whole country. The proportion of socially sensitive groups (children, unemployed, pensioners, disabled) comprised more than 50 % of the tuberculosis incidence. Incidence among medical staff was higher than in general population in the all professional groups. Medical delay of diagnosis decreased, but early detection of tuberculosis was not fully integrated in PHC system. There were quite big differences in numbers of MDR-TB in years 1993-2002. DOTS was introduced in Liepaja five years later than in Latvia –in year 2000 and strategy was not fully successful. The number of positive treatment outcomes increased, but the registered numbers of treatment relapses and defaults were higher than in Latvia . Conclusions The situation with regard to tuberculosis development and tuberculosis management in Liepaja during the period under study was unfavourable. Particularly : the incidence and mortality rates, much variation in the diagnostic process, results of treatment ,a high proportion of MDR-TB , unsatisfactory links between local government, family doctors and medical professionals and multi-sectoral collaboration in TB control activities , the objectives set up by WHO for DOTS treatment were not reached / <p>ISBN 91-7997-139-3</p>

Doctor of Philosophy / Despite the demonstrated efficacy of cognitive-behavioural therapy for chronic pain, recent research has attempted to identify predictors of treatment outcome in order to improve the effectiveness of such treatments. This research has indicated that variables such as the nature of the onset of the pain and psychopathology are associated with poor adjustment to chronic pain. Accordingly, these variables might also be predictive of poor response to treatment. Individuals who experience a sudden onset of pain following an injury or accident, particularly when the instigating event is experienced as psychologically traumatic, may present for treatment with high levels of distress, including symptoms consistent with a posttraumatic stress response. The impact of this type of onset of pain and posttraumatic stress symptoms on adjustment to chronic pain and treatment outcome is the focus of this thesis. Three studies were conducted to clarify and extend earlier research findings in this area. Using 536 patients referred for treatment in a tertiary referral pain management centre, the first study examined the psychometric properties of a widely used self-report measure of posttraumatic stress symptoms (the PTSD Checklist, or PCL), modified for use in a chronic pain sample. This study provided preliminary support for the suitability of the PCL as a self-report measure of Posttraumatic Stress Disorder (PTSD) symptoms in chronic pain patients. However, the study also highlighted a number of issues with the use of self-report measures of posttraumatic stress symptoms in chronic pain patient samples. In particular, PCL items enquiring about symptoms which are a common aspect of the chronic pain experience (e.g. irritability, sleep problems) appeared to contribute to high mean scores on the PCL Avoidance and Arousal subscales. Furthermore, application of diagnostic cut-off scores and an algorithm recommended for the PCL in other trauma groups suggested that a much larger proportion of the sample was identified as potentially meeting diagnostic criteria for PTSD than would have been expected from previous research. The second study utilised the modified PCL to investigate the impact of different types of onset of pain (e.g. traumatic onset) and posttraumatic stress symptoms on adjustment to chronic pain in a sample of 196 chronic pain patients referred to the same centre. For patients who experienced the onset of pain related to a specific event, two independent experts in the field of PTSD determined whether these events satisfied the definition of a traumatic event according to DSM-IV diagnostic criteria. Adjustment was assessed through a number of validated measures of mood, disability, pain experience, and pain-related cognitions. Contrary to expectations, comparisons between patients who had experienced different types of onset of pain revealed few significant differences between them. That is, analyses comparing patients presenting with accident-related pain, or pain related to other specific events, to patients who had experienced spontaneous or insidious onset of pain revealed no significant differences between the groups on measures of pain severity, pain-related disability, and symptoms of affective distress after adjustment for age, pain duration, and compensation status. Similarly, comparisons between patients who had experienced a potentially traumatic onset of pain with those who had experienced a non-traumatic or spontaneous or insidious onset of pain also revealed no significant differences on the aforementioned variables. In contrast, compensation status, age, and a number of cognitive variables were significant predictors of pain severity, pain-related disability, and depression. The final study investigated the impact of type of pain onset and posttraumatic stress symptoms on response to a multidisciplinary cognitive-behavioural pain management program. Unlike the previous study, this treatment outcome study revealed a number of differences between onset groups. Most notably, patients who had experienced an insidious or spontaneous onset of pain reported greater improvements in pain severity and maintained these improvements more effectively over a one month period than patients who had experienced pain in the context of an accident or other specific incident. There was also limited evidence that improvements in depression favoured patients who had experienced an insidious or spontaneous and non-traumatic onset of pain. Consistent with this, posttraumatic stress symptoms were a significant predictor of treatment outcome, with higher levels of symptoms being associated with smaller improvements in pain-related disability and distress. Notably, this study also revealed that certain cognitive variables (i.e. catastrophising, self-efficacy, and fear-avoidance beliefs) were also significant predictors of treatment outcome, consistent with previous findings in the pain literature. This provided some perspective on the relative roles of both PTSD symptoms and cognitive variables in adjustment to persisting pain and treatment response. These findings were all consistent with expectations and with previous research. Implications for future research and for the assessment and treatment of chronic pain patients who present with posttraumatic stress symptoms are discussed.

The efficacy of cognitive-behavioural therapy (CBT) in the treatment of child anxiety disorders has been well established in the literature, with on average, just over 50% of children becoming free of their primary anxiety diagnosis immediately following treatment (James et al., 2008). Despite the existence of these efficacious treatments, up to two thirds of children with anxiety do not receive assistance for their difficulties (Essau et al., 2002). The reasons for this are varied, and include lack of available therapists or services, long waiting lists, high therapy costs and stigma associated with therapy. Computer- and internet-based interventions represent a modern alternative for delivering CBT interventions that may be more appealing and accessible to a greater proportion of children with anxiety. Various forms of computer-assisted therapies have been investigated, including palmtop computers, desktop computers, virtual reality and online programs. Although computerised interventions have demonstrated promise in the treatment of adult anxiety, they have only recently received interest in the child literature. Specifically, there are very few controlled trials evaluating the efficacy of computer- and internet-based interventions for childhood psychological disorders, including anxiety disorders. The present research involved the initial development and subsequent testing of an entirely internet-based, CBT intervention for child anxiety disorders. BRAVE-ONLINE was developed as an internet adaptation of The BRAVE Program, a clinic-based program which has demonstrated efficacy in the treatment of childhood anxiety. The online intervention is a therapist-mediated program, in which children and parents receive email and telephone assistance from a therapist throughout treatment. BRAVE-ONLINE is an interactive program consisting of 10 child and 6 parent sessions to be completed by families in their own home. Following the development of BRAVE–ONLINE, the first study of this thesis included a randomised control trial to investigate the efficacy of the internet-based intervention (NET) compared to a waitlist control (WL). Seventy-three children aged between 7 and 12 years, diagnosed with separation anxiety disorder, social phobia, generalised anxiety disorder or specific phobia were randomly allocated to NET and WL conditions. Treatment effects were evaluated at 10-14 weeks post-assessment and 6-month follow-up, using multiple outcome measures including a diagnostic interview, clinician ratings of severity, parent and child questionnaires. Results indicated that at post-assessment, 30% of NET participants in the completer sample (22.5% in the Intent-to-Treat (ITT) sample) no longer met criteria for their primary anxiety diagnosis, compared to 10% of WL participants. Significant gains were also evident for clinician severity ratings, global assessments of functioning, and several questionnaire measures. However, results also indicated that children and parents were slow to progress through therapy, such that a large proportion of families had not completed all treatment sessions at the post-assessment point. For this reason, 6-month follow-up may present a better indication of treatment efficacy. Indeed, at 6-month follow-up, treatment gains were improved upon such that 75% of children in the completer sample (52.5% in the ITT sample) no longer met criteria for their primary anxiety disorder. Reductions in severity ratings, global assessments of functioning and child and parent self-report measures were also improved upon at 6-month follow-up. Further, the online intervention was found to be highly acceptable to families and was associated with only minimal rates of attrition. The second study of this thesis aimed to explore factors associated with treatment outcome for the online intervention. Factors of interest included demographic factors (age, gender, income and educational background), treatment expectancy, initial symptom severity, program compliance and pre-treatment diagnostic comorbidity. Specifically, this study investigated the extent to which each of these factors predicted the improvement made by children on global assessments of functioning (CGAS) at 6-month follow-up. Results indicated that only some of these factors were directly associated with treatment outcome. Although treatment expectancy predicted compliance with the program, it was not associated with treatment outcome. Baseline severity also did not predict treatment outcome. Contrary to expectation, levels of program compliance by children negatively predicted outcome, such that children who were more compliant with the program showed fewer improvements in overall functioning. Parent compliance did not predict treatment outcome. A significant relationship was evident between diagnostic comorbidity (number of pre-treatment anxiety diagnoses) and treatment outcome, such that higher baseline comorbidity predicted poorer functioning on the CGAS at 6-month follow-up. None of the demographic factors were associated with treatment outcome. Overall, the findings of this research suggest that a CBT intervention delivered entirely over the internet was associated with reductions in indicators of anxiety at post-assessment, compared to a WL control, particularly for the completer sample. Further, these reductions were improved upon at 6-month follow-up, with a substantial proportion of children becoming free of their primary anxiety diagnosis. The results also indicated that the online intervention might not be as effective for children suffering from multiple anxiety disorders. The effects of program compliance were somewhat surprising and possible explanations are offered. Although these results are promising, conclusions should be regarded as tentative until further trials are conducted and the online intervention is compared with clinic-based treatments. Limitations of this research and areas for future research are discussed.

The efficacy of cognitive-behavioural therapy (CBT) in the treatment of child anxiety disorders has been well established in the literature, with on average, just over 50% of children becoming free of their primary anxiety diagnosis immediately following treatment (James et al., 2008). Despite the existence of these efficacious treatments, up to two thirds of children with anxiety do not receive assistance for their difficulties (Essau et al., 2002). The reasons for this are varied, and include lack of available therapists or services, long waiting lists, high therapy costs and stigma associated with therapy. Computer- and internet-based interventions represent a modern alternative for delivering CBT interventions that may be more appealing and accessible to a greater proportion of children with anxiety. Various forms of computer-assisted therapies have been investigated, including palmtop computers, desktop computers, virtual reality and online programs. Although computerised interventions have demonstrated promise in the treatment of adult anxiety, they have only recently received interest in the child literature. Specifically, there are very few controlled trials evaluating the efficacy of computer- and internet-based interventions for childhood psychological disorders, including anxiety disorders. The present research involved the initial development and subsequent testing of an entirely internet-based, CBT intervention for child anxiety disorders. BRAVE-ONLINE was developed as an internet adaptation of The BRAVE Program, a clinic-based program which has demonstrated efficacy in the treatment of childhood anxiety. The online intervention is a therapist-mediated program, in which children and parents receive email and telephone assistance from a therapist throughout treatment. BRAVE-ONLINE is an interactive program consisting of 10 child and 6 parent sessions to be completed by families in their own home. Following the development of BRAVE–ONLINE, the first study of this thesis included a randomised control trial to investigate the efficacy of the internet-based intervention (NET) compared to a waitlist control (WL). Seventy-three children aged between 7 and 12 years, diagnosed with separation anxiety disorder, social phobia, generalised anxiety disorder or specific phobia were randomly allocated to NET and WL conditions. Treatment effects were evaluated at 10-14 weeks post-assessment and 6-month follow-up, using multiple outcome measures including a diagnostic interview, clinician ratings of severity, parent and child questionnaires. Results indicated that at post-assessment, 30% of NET participants in the completer sample (22.5% in the Intent-to-Treat (ITT) sample) no longer met criteria for their primary anxiety diagnosis, compared to 10% of WL participants. Significant gains were also evident for clinician severity ratings, global assessments of functioning, and several questionnaire measures. However, results also indicated that children and parents were slow to progress through therapy, such that a large proportion of families had not completed all treatment sessions at the post-assessment point. For this reason, 6-month follow-up may present a better indication of treatment efficacy. Indeed, at 6-month follow-up, treatment gains were improved upon such that 75% of children in the completer sample (52.5% in the ITT sample) no longer met criteria for their primary anxiety disorder. Reductions in severity ratings, global assessments of functioning and child and parent self-report measures were also improved upon at 6-month follow-up. Further, the online intervention was found to be highly acceptable to families and was associated with only minimal rates of attrition. The second study of this thesis aimed to explore factors associated with treatment outcome for the online intervention. Factors of interest included demographic factors (age, gender, income and educational background), treatment expectancy, initial symptom severity, program compliance and pre-treatment diagnostic comorbidity. Specifically, this study investigated the extent to which each of these factors predicted the improvement made by children on global assessments of functioning (CGAS) at 6-month follow-up. Results indicated that only some of these factors were directly associated with treatment outcome. Although treatment expectancy predicted compliance with the program, it was not associated with treatment outcome. Baseline severity also did not predict treatment outcome. Contrary to expectation, levels of program compliance by children negatively predicted outcome, such that children who were more compliant with the program showed fewer improvements in overall functioning. Parent compliance did not predict treatment outcome. A significant relationship was evident between diagnostic comorbidity (number of pre-treatment anxiety diagnoses) and treatment outcome, such that higher baseline comorbidity predicted poorer functioning on the CGAS at 6-month follow-up. None of the demographic factors were associated with treatment outcome. Overall, the findings of this research suggest that a CBT intervention delivered entirely over the internet was associated with reductions in indicators of anxiety at post-assessment, compared to a WL control, particularly for the completer sample. Further, these reductions were improved upon at 6-month follow-up, with a substantial proportion of children becoming free of their primary anxiety diagnosis. The results also indicated that the online intervention might not be as effective for children suffering from multiple anxiety disorders. The effects of program compliance were somewhat surprising and possible explanations are offered. Although these results are promising, conclusions should be regarded as tentative until further trials are conducted and the online intervention is compared with clinic-based treatments. Limitations of this research and areas for future research are discussed.

Motivational Interviewing (MI) is an evidence-based, directive, client-centered therapy designed to develop discrepancy and resolve ambivalence by eliciting and reinforcing client Change Talk. However, the exact link between the process engaged in during MI and outcome is only starting to be uncovered. The present thesis has replicated and expanded on the current knowledge of the relationship between Therapist and Client Behaviours during a MI-based intervention (Motivational Enhancement Therapy; MET) and outcome, and has provided support for the emergent theory of the inner workings of MI. This was achieved by coding 106 audiotaped MET sessions primarily by the methods outlined in the Motivational Interviewing Skill Code Version 2.0. Data was drawn from 28 participants who received 3-4 sessions of MET within the context of a randomised controlled trial for mild-moderate alcohol dependence at the Community Alcohol and Drug Service of Christchurch. Therapist and Client Behaviours were analysed within sessions (categorised into Early, Mid, or End Intervals) and across sessions, and compared with whether the client had drank within national drinking guidelines during the 6-months after MET (Controlled Drinkers). In terms of Client Behaviours during MET it was found that Uncontrolled Drinkers (compared with Controlled Drinkers) uttered a significantly higher frequency of Sustain Talk, lower Ability Language strength (over all MET and during End Intervals), and lower Commitment Language strength (during Session 2 and 4, and change over MET). Giving Information was the only Therapist Behaviour where significant differences were observed over all MET, with a higher frequency given to the Uncontrolled Drinkers. However, during End Intervals within MET Sessions, Controlled Drinkers received a significantly higher frequency of Advise without Permission and a lower frequency of Emphasise Control statements. In most instances MI-Consistent Therapist Behaviours were associated with higher strength of Ability and Commitment Language, and a lower frequency of Sustain Talk. MI-Inconsistent Therapist Behaviour, Direct, was associated with lower Client Language strength. Limitations to these results include small sample, limited ability to make inferences about causality, coder biases, and uneven reliability. However, this exploratory study was unique in investigating the relationship between Therapist Behaviours and the strength of Client Language, and in examining these factors within and across multiple sessions, and has produced a number of potentially valuable findings that warrant further investigation.