The overall aim of this thesis was to describe experiences of emergency treatment among people injured in traffic accidents, and to test and evaluate the effects of follow-up telephone calls from a nurse during the subsequent phase. The thesis is based on four sub-studies of motorists, bicyclists, and pedestrians who had fallen in traffic during the years 2002-2005. The participants were aged 18 to 70 years old and had minor (MAIS 1) or nonminor (MAIS 2+) injuries. Sub-study I was a qualitative study in which individual narrative interviews were conducted with nine persons who had sustained traffic injuries. The aim of this study was to describe the injured individuals’ experiences of pre-hospital and hospital care and subsequent rehabilitation. The interviews were analysed using content analysis, and the experiences of the interviewees were formulated into four themes: facing commotion, experiencing trust and security, lacking security and support, and struggling to return to everyday life. The results showed that a sensitive caregiver who provides comprehensible information facilitates both the emergency treatment and the subsequent period of care and rehabilitation. Sub-study II was a cross-sectional study in which the participants (n=565) estimated their perceptions of the quality of care in the accident and emergency department (A&E) after an injury event. The Mini-KUPP (“Quality from the Patient’s Perspective”) questionnaire was used to estimate quality of care at the A&E. The questionnaire was posted to the subjects’ home addresses three weeks after the visit to the A&E. The results showed that the quality of care was scored on the top half of the scale by all three road user categories. In a multiple logistic regression analysis, significant connections emerged between good quality of care and a short waiting time, non-minor injuries (MAIS2+), higher age, and higher levels of education. The factor most closely associated with the perception of good quality of care was a short waiting time. Sub-study III was a stratified and randomised intervention study including 568 injured persons. In addition to modern trauma care, the intervention group received follow-up via telephone, three weeks after the injury, by a nurse who provided advice and support during the rehabilitation period. The control group received modern trauma care but no follow-up. Both groups estimated their health-related quality of life two weeks (baseline) and six months after the injury. After six months, estimates of health-related quality of life were generally higher in the intervention group than in the control group. A sub-group analysis found that the differences were most pronounced for the group who had received adequate advice in connection with the telephone follow-up. Of the three road user categories, the motorists gained the greatest benefit from the telephone intervention, with milder problems with regard to pains/difficulties and essential activities. Sub study IV was a health economic study. The calculations were built on the results from study III (n=568). A cost utility analysis was performed, including the costs for the intervention and the QALYs gained. The results showed that the telephone intervention was cost-effective. The total gain in the intervention group was 2.60 QALYs, while the car occupants gained 1.54 QALYs. The cost per QALY gained was 16 000 SEK overall and 8 500 SEK for car occupants. Conclusion: A sensitive caregiver who also provides good information can instil security and trust in the patient. For the purposes of generally improving the quality of care in an A&E, the aim above all should be a short waiting time, but the treatment of minor injuries should also be improved. Access to a supportive nurse who is able to provide advice during the subsequent phase has the potential to improve health-related quality of life in a cost-effective way.

Delirium is common among old patients admitted to hospital, but is often a neglected problem in patient care. The principal aim of this thesis was to evaluate aspects of delirium in relation to incidence, risk factors, behavioural changes, cognitive function and health-related quality of life (HRQOL). A further aim was to describe patients’ experiences of being delirious. The study was prospective, descriptive and comparative, with repeated measures (six-month follow up). The sample consisted of 225 consecutive patients, aged 65 years or older, who were to be operated on due to hip fracture or hip replacement. Exclusion criteria were serious cognitive disorder or delirium on admission. Data were collected via frequent daily observations, cognitive functioning tests (MMSE), HRQOL questionnaires (SF-36) and interviews. Delirium was assessed according to the DSM-IV criteria. A total of 45/225 became delirious, with an incidence of 24.3% among patients undergoing hip fracture surgery and 11.7% among those with hip replacement surgery. A predictive model for delirium included four factors: impaired hearing, passivity, low cognitive functioning, and waiting more than 18h for hip fracture surgery. Disorientation and urgent calls for attention were the most frequent behavioural changes in the prodromal phase prior to delirium. Delirium in connection with hip fracture revealed deteriorated HRQOL and cognitive functioning when measured at a six-month follow-up. The experience of being delirious was described by the patients as a sudden change of reality. Such an experience gave rise to strong emotional feelings, as did recovery from delirium. Nurses’ observations of behavioural changes in old patients with impaired cognitive function may be the first step in managing and reducing delirium. The predictive model of delirium ought to be tested further before use in clinical practice.

Chronic obstructive pulmonary disease, COPD, places a substantial burden of disability on the growing number of patients and causes large costs for the society. Tobacco smoke is the most important risk factor. Progressive exertional dyspnea is the major symptom which leads to diminished physical and social activities, reduced physical capacity and decreased health related quality of life, HRQoL. The aim of this thesis was to evaluate different physical training modalities in patients with COPD with regard to physical capacity and HRQoL. Patients with moderate to severe COPD were included in the studies. In the first intervention, 20 patients trained on a treadmill with or without supplemental oxygen, three times per week, during eight weeks. In the second intervention, 30 patients were randomised to high-intensity group training either in water or on land, and 13 patients were included in a control group. The patients in the water and land groups trained three times per week during three months and once a week during the following six months. Oxygen supplementation during physical training did not enlarge the positive effects of the same training with air in patients with exercise-induced hypoxaemia. Both groups improved the distance walked after training. High-intensity group training in water and on land was found to be effective with regard to walking distance and HRQoL compared to the control group. Training in water seemed to be of greater benefit compared to training on land concerning walking distance and experienced physical health when the training was accomplished three times per week. The thigh muscle strength increased after training in both the water and the land group. The muscle endurance in knee extension was low in the majority of the patients and was not improved after the training intervention. An evaluation of the long-term effects of physical group training and the effects of decreased training frequency showed that training with low frequency (once a week) during six months did not seem to be sufficient to maintain the level achieved after a three months period of higher frequency training (three times per week). However, the two periods combined seemed to prevent decline in physical capacity and HRQoL compared to baseline. The conclusion is that physical training is of benefit for patients with COPD with regard to physical capacity and HRQoL. Training can be performed individually or in groups, with high intensity, in water and on land. It is also concluded that the training can, under controlled conditions, be performed without supplemental oxygen even in patients with exercise-induced hypoxaemia.

Objective: To analyze the change in health-related quality-of-life (HRQoL) in patients with Parkinson’s disease (PD) and to identify different classes of HRQoL decline. Methods: A longitudinal cohort study was performed to assess clinical parameters (unified PD rating scale, Beck Depression Inventory) and HRQoL data (EuroQol, Parkinson’s Disease Questionnaire [PDQ]-39) at baseline, 3, 6, 12, 24, and 36 months. A total of 145 patients with PD were consecutively recruited in the county of Northern Hessia, Germany, between January and June 2000. A latent growth mixture model was applied to analyse the heterogeneity in HRQoL trajectories. Results: We successfully applied latent mixture growth modeling in order to identify different classes of HRQoL trajectories in PD. Three growth models were developed and each resulted in a four-class model of distinct patterns using the generic EuroQol instruments’ outcomes (EuroQol-5 Dimensions and visual analogue scale) and the disease-specific PDQ- 39. The four classes were defined by individual trajectory characteristics. Classes one and two represented trajectories with moderate declines over 36 months, but with different initial intercepts. Class three consisted mainly of patients who passed away during the observation period and therefore had a large HRQoL decline. Class four was characterized by a low level of HRQoL at baseline and a significant subsequent decline. Conclusions: The findings provide a more elaborate understanding of the variability in HRQoL reduction in PD over time. The classification of different HRQoL subgroups may help to explain the response of PD patients to the natural history of the disease. Future research will enable the identification of HRQoL responder subgroups on different treatment regimens.

The overall aims of the studies were to investigate the effects of different training modalities on exercise capacity and health-related quality of life (HRQoL) in patients with moderate or severe COPD and, further, to explore two of the physical tests used in pulmonary rehabilitation. In study I, the 12-minute walking distance (12MWD) did not increase on retesting in patients with exercise-induced hypoxemia (EIH) whereas 12MWD increased significantly on retesting in the non-EIH patients. In study II, we found that the incremental shuttle walking test was as good a predictor of peak exercise capacity (W peak) as peak oxygen uptake (VO2 peak) is. In study III, we investigated the effects of two different combination training programmes when training twice a week for eight weeks. One programme was mainly based on endurance training (group A) and the other on resistance training and callisthenics (group B). W peak and 12MWD increased in group A but not in group B. HRQoL, anxiety and depression were unchanged in both groups. Ratings of perceived exertion at rest were significantly lower in group A than in group B after training and during 12 months of follow-up. Twelve months post-training, 12MWD was back to baseline in group A, but significantly shorter than at baseline in group B. Thus, a short endurance training intervention delayed decline in 12MWD for at least one year. Patients with moderate and severe COPD responded to training in the same way. In study IV, both interval and continuous endurance training increased W peak, VO2 peak, peak exhaled carbon dioxide (VCO2 peak) and 12MWD. Likewise, HRQoL, dyspnoea during activities of daily life, anxiety and depression improved similarly in both groups. At a fixed, submaximal workload (isotime), the interval training reduced oxygen cost and ventilatory demand significantly more than the continuous training did.

Background: Over the past decades the public health relevance of mental health conditions in children and adolescents has been of growing concern. However, so far no detailed epidemiological data has been available for a representative national sample in Germany. Objectives: The present paper reports prevalence rates of general and specific mental health problems among children and adolescents in Germany and describes the link between symptoms and impairment as well as the treatment situation. Methods: The mental health module (BELLA study) examines mental health problems in a representative sub-sample of 2,863 families with children aged 7–17 from the National Health Interview and Examination Survey among Children and Adolescents (KiGGS). Mental health problems were determined using the extended version of the strengths and difficulties questionnaire (SDQ). Further standardised screening measures were employed to screen for anxiety disorders (SCARED), conduct disorder (CBCL), attention deficit-/ hyperactivity disorder (FBBHKS, Conners’ Scale) and depressive disorders (CES-DC). Furthermore, substance abuse and suicidal tendencies were assessed. Health-related quality of life (HRQoL) and health care use were determined. Results Overall, 14.5% of the children and adolescents aged 7–17 fulfilled the criteria for at least one specific mental health problem associated with impairment, or had an overall mental health problem indicated by an abnormal SDQ score and present impairment. However, high comorbidity was found in the children concerned. Symptoms of overall mental health problems were present in 8.6% of the children and 6.6% of the adolescents. This number was reduced to prevalence rates of 6.3 and 4.9% when additional impairment was taken as a criterion. Irrespective of the type of disorder, fewer than half of the children affected were reported as receiving treatment. However, for those suffering from mental health problems, large impairments in HRQoL were observed. Conclusions: The observed prevalence of mental health problems as well as their large impact on well-being and functioning calls for early prevention. This is especially important with regard to the large decrease in HRQoL in the children and adolescents affected.

Fonament. El concepte Qualitat de Vida Relacionada amb la Salut (QVRS) dóna informació addicional a les mesures funcionals dels usuaris de programes d'exercici físic per a gent gran. Sovintegen els estudis poblacionals que incorporen aquesta mesura perquè les dades són estables i amb poca variació estadística en el temps, el que permet una correcta fonamentació metodològica i teòrica. Objectius. 1. Conèixer la QVRS dels usuaris dels Programes d'Exercici Físic Comunitaris de Gent Gran de Catalunya (PEFCGGC's), i la relació amb la gent gran de Catalunya. 2. Conèixer la QVRS dels usuaris dels PEFCGGC's, respecte els que practiquen a l'aire lliure. 3. Conèixer les característiques socials i demogràfiques relacionades amb la QVRS dels usuaris dels PEFCGGC's. 4. Conèixer les característiques socials i demogràfiques dels subjectes analitzats.Mètode. S'ha tingut com referència la mostra de la població de l'Enquesta de Salut de Catalunya de 2002 (ESCA'02) major de 60 anys, els usuaris que practiquen en PEFCGGC's i els majors de 60 anys que ho fan a l'aire lliure. S'ha utilitzat una mostra de 2.428 enquestats, mitjançant mostreig intencional. La mesura de QVRS s'ha efectuat mitjançant l'EuroQol EQ-5D. S'han calculat Descriptius, t-Student, χ Quadrat, ANOVA i Coeficient de correlació.Resultats. 1. Els que practiquen exercici físic en els PEFCGGC's presenten unes valoracions superiors a la gent gran sedentària de l'ESCA'02. 2. La QVRS és diferent en els usuaris que practiquen activitat física a l'aire lliure i els institucionalitzts respecte els de la resta d'usuaris dels PEFCGGC's. 3. Els usuaris dels PEFCGGC's que mostren menor puntuació amb l'EQ-5D són les persones més grans, les dones, les que estan soles, les que tenen un nivell formatiu i econòmic menor i els que viuen en poblacions més grans. 4. Són els practicants a l'aire lliure els més joves. Els institucionalitzats, mostren una major edat. Les dones tendeixen a practicar en els PEFCGGC's, i els homes prefereixen la petanca. Els homes tenen un itinerari esportiu més dilatat. / Fundamento. El concepto Calidad de Vida Relacionado con la Salud (CVRS) da información adicional a las medidas funcionales de los usuarios de programas de ejercicio físico para personas mayores. Son frecuentes los estudios poblacionales que incorporan este tipo de medidas porque los datos son estables y con pocas variaciones estadísticas en el tiempo, lo que permite una correcta fundamentación metodológica y teórica.Objetivos. 1. Conocer la QVRS de los usuarios de los Programas de Ejercicio Físico Comunitarios dirigidos a las Personas Mayores de Cataluña (PEFCGGC's) y la relación con las personas mayores de Cataluña. 2. Conocer la QVRS de los usuarios de los PEFCGGC's, respecto los que practican al aire libre. 3. Conocer las características sociales y demográficas relacionadas con la QVRS de los usuarios de los PEFCGGC's. 4. Conocer las características sociales y demográficas de los sujetos analizados.Métodos. Se ha tenido como referencia la muestra de la Encuesta de Salud de Cataluña de 2002 (ESCA'02) mayor de 60 años, los usuarios que practican en PEFCGGC's y los mayores de 60 años que lo hacen al aire libre. Se ha utilizado una muestra de 2.428 encuestados, mediante muestreo intencional. La medida de QVRS se ha realizado mediante EuroQol EQ-5D. Se ha calculado Descriptivos, t-Student, χ Cuadrado y Coeficiente de Correlación.Resultados. 1. Los que practican ejercicio físico en los PEFCGGC's presentan unas valoraciones superiores a las personas mayores sedentarias de la ESCA'02. 2. La QVRS es diferente en los usuarios que practican actividad física al aire libre y los institucionalizados respecto los del resto de usuarios de los PEFCGGC's. 3. Los usuarios de los PEFCGGC's que muestran menor puntuación con el EQ-5D son las personas más mayores, las mujeres, las que están solas, las que tienen un nivel formativo i económico menor y las que viven en poblaciones mayores. 4. Son los practicantes al aire libre los más jóvenes. Los institucionalizados, muestran una mayor edad. Las mujeres tienden a practicar en los PEFCGGC's, y los hombres prefieren la petanca. Los hombres tienen un itinerario deportivo más dilatado. / Background. Health-Related Quality of Life (HRQoL) gives additional information to the functional measures about physical programs for elderly users. There are many studies that include measures on HRQoL because the information is stable and it has few statistical variations upon the time. It allows a correct methodological theoretical foundation.Aims. 1. To study HRQoL of Community Exercise Programs for Elderly Users of Catalonia (CEPEU's) and the relation with individuals over 60 years old in Catalonia. 2. To study HRQoL of the subjects belonging to CEPEU's, in relation to those outdoors practitioners. 3. To study the social and demographic characteristics related to HRQoL of CEPEU's users. 4. To study the social and demographic characteristics of analyzed subjects, related to the king of program.Methods. The sample of the Catalan Health Survey of 2002 (CHS'02) over 60 years, users of CEPEU's, and elderly over 60 age who exercise outdoors, have been studied. CHS'02 has been administrated to a sample of 2.428 individuals, after a cross-sectional selection. Data were obtained of the Spanish version of EuroQol EQ-5D. Descriptives, t-Student, χ Square, ANOVA, Correlation Coefficient were calculated for statistical analysis.Results. 1. CEPEU's data showed higher values than sedentary subjects of CHS'02. 2. HRQoL were significantly different to that subjects that exercised outdoors and institutionalized elderly related to the other subjects of CEPEU's. 3. The CEPEU's subjects who presented lower scores on the EQ-5D correlated positively with increasing age, being female, being in a lower academic and economic levels, those living alone and those living in higher villages. 4. Outdoors exercising subjects are the youngest. Institutionalized are the oldest. Women were more numerous at CEPEU's while men prefer petanque. The men have a more extensive sports itinerary.

Background: There is a lack of the generic data comparing the influence of different diseases on health-related quality of life (HrQoL) in a representative sample of primary care patients. Methods: Patient data were collected in the DETECT (Diabetes Cardiovascular Risk Evaluation: Targets and Essential Data for Commitment of Treatment) study including 55,000 patients. Results: 3,109 patients (33.3% female) with myocardial infarction (MI), stroke or both were compared to patients with a wide range of other diagnoses. Stroke and MI patients revealed a lower HrQoL as compared to patients with other diagnoses. Stroke was associated with strongest quality of life reduction. Multivariate analysis revealed several different determining factors. Conclusions: The reduction of HrQoL of patients with MI and stroke is primarily determined by the CNS insult. These data provide further evidence that early diagnosis and treatment of cardiovascular risk factors is essential to reduce subsequent stroke.

Bakgrund: Trots all forskning och kunskap om vikten av fysisk aktivitet ökar livsstilrelaterade sjukdomar. WHO (Världshälsoorganisationen) har klassificerat fysisk inaktivitet som en av fyra ohälsosamma levnadsvanor som vid minimering kan förebygga sjukdom och för tidig död. Fysisk aktivitet på recept (FaR) inkluderar hälsofrämjande hälso- och sjukvård och ökad fysisk aktivitet som är två av Sveriges elva folkhälsomål. Syftet med litteraturstudien var att undersöka hur fysisk aktivitet på recept påverkar den fysiska aktivitetsnivån. Metod: En litteraturstudie gjordes och sökning utfördes i LibHub och Academic Search Elite av artiklar publicerade mellan 2005 och 2012. Inklusionskriterier var artiklar som innefattade hälsofrämjande arbete och undersökte fysisk aktivitet på recept, ordinerad till vuxna. Av 60 lästa abstract och 19 lästa artiklar valdes tio ut vilka delades in efter studiedesign.  Inledningen av analysprocessen gjordes oberoende av forskarna därefter sammanställdes materialet och följande tema framkom: Motivation, Implementering, Hälsoekonomiska konsekvenser och Hälsovinster. Resultat: FaR kan leda till ökad fysisk aktivitet och ökad livskvalitet. Framgångsfaktorer var motivation, stöd, samarbete, kunskap samt delaktighet. Resultatet från de olika studiemetoderna visade ingen signifikant skillnad. Resultatet påvisade behov av ytterligare implementering och utveckling av metoden FaR. Slutsats: All typ av beteendeförändring kräver tid och tålamod. För att nå målet ”en mer fysisk aktiv befolkning”, krävs noggrann uppföljning av de som fått FaR utskrivet samt stöd genom motiverande samtal (MI). Utmaningen är att övertyga samhället att FaR är en kostnadseffektiv metod som främjar en god folkhälsa, vilket är en investering för framtiden. / Background: Despite all research and knowledge of the importance of being physically active sickness, related to lifestyle are increasing. WHO (World health organization) have ranged physic inactivity as one of the four unhealthy living habits which can with small effort prevent disease and early death. Physical activity on prescription (PaP) includes health promoted care and increased physical activity which is two of Sweden’s eleven great goals for the public health. Aim: The intention of the literature study was to review how physical activity was given as a prescription and the affects the physical level of activity. Methods: The systematic search was in LibHub and Academic Search Elite of articles published between 2005 and 2012. Inclusioncriteria were articles that included health promotion, physical activity on prescription and were ordained to adults. When 60 abstract and 19 articles were read, ten articles were selected and separated by the study design. The beginnings of the analysis process was done independently by the researchers then compiled the material and the following themes emerged: Motivation, Implantation, Health economic implications and Health benefits .Results: PaP may result to increased physical activity and improved quality of life. Success factors were motivation, collaboration, knowledge and participation. The results from the different study methods showed no significant difference. The results demonstrate a need for the implementation and development of the method PaP.  Conclusions: All sorts of behaviour change demands time and patience and support from the environment. To be able to reach the goal with “a more physical active population “, close monitoring is required thorough follow-up of those who have a prescription for PaP and support through Motivational Interviewing (MI). The challenge is to convince the public that the PaP  is a cost effective method to promote good public health, which is an investment in the future.

Normalt åldrande innebär förändringar hos individen som kan påverka tal, språk och sväljning. Ökad känslighet för inre och yttre påverkan hos den åldrande individen samt sjukdomsbild kan skapa problematik, vilken kan ge upphov till svårigheter med tal, språk och/eller sväljning, som i sin tur påverkar den upplevda livskvaliteten. Geriatriska patienter karaktäriseras av nedsatt funktionsnivå och kroniska sjukdomar, därför ställs krav på specialkompetens för vård och rehabilitering av dessa patienter. Syftet med föreliggande studie var att genom screening undersöka förekomst av tal-, språk- och sväljsvårigheter på geriatriska avdelningar i två städer i södra Sverige. Därtill undersöktes även orofacial påverkan och hälsorelaterad livskvalitet. Totalt 42 patienter från geriatriska avdelningar med inriktningarna allmängeriatrik, strokerehabilitering och ortopedi deltog. Screeninginstrument som användes var Nordiskt Orofacialt Test – Screening (NOT-S) för screening av orofaciala funktioner. Screening av tal baserades på delar ur NOT-S samt talade delar ur språklig screening. Delar ur Neurolingvistisk Afasi-undersökning (A-ning) valdes för screening av språk och Standardised Swallowing Assessment (SSA) användes för klinisk undersökning av sväljning. Hälsoenkäten the Short Form – 12 (SF-12) användes för skattning av hälsorelaterad livskvalitet. Identifierade svårigheter i patientgruppen var talsvårigheter hos 33 % (14 av 42), samt 40 % (16 av 40) och 37 % (15 av 41) språkliga svårigheter respektive sväljsvårigheter. Bland deltagarna hade 64 % svårigheter med en eller flera av de undersökta funktionerna. Förekomst av dessa svårigheter hade signifikant samband med nedsatt orofacial funktion. Lågt skattad hälsorelaterad livskvalitet hade signifikant samband med språkliga svårigheter och med orofacial dysfunktion. / Changes occur during the normal ageing process that can interfere with speech-, language- and swallowing functions. An increased occurrence of diseases increases the frailty in the ageing individual and may cause disordered speech, language and/or swallowing, in which case the health related quality of life may be negatively affected. The geriatric population is characterized by functional impairment and chronic diseases. This therefore poses special demands on specialist care and rehabilitation of these patients. The aim of this study was to examine the occurrence of speech, language and swallowing disorders in geriatric wards in two cities in the southern part ofSwedenusing screening. The orofacial influence on these functions and health related quality of life were also examined. In total 42 patients participated, from geriatric wards with general, stroke rehabilitation and orthopedic specialty. The instruments used for screening of orofacial functions was the Nordic Orofacial Test – Screening (NOT-S) and perceptual parameters for screening of speech based on speech parts from NOT-S and speech production from Neurolingvistisk Afasi-undersökning (A-ning). Parts of A-ning were also used for screening of language. Standardised Swallowing Assessment (SSA) was used for clinical examination of swallowing. The Short Form – 12 Health Survey (SF-12) was used to estimate the health related quality of life. Results showed that 33 % (14 of 42) had difficulties with speech, 40 % (16 of 40) and 37 % (15 of 41) showed difficulties with language and swallowing respectively. Of the participants, 64 % had difficulties with one or more of the examined functions. Occurrence of these difficulties associated significantly with impaired orofacial function. Language difficulties were associated with decreased mental health status and orofacial dysfunction with decreased physical health status, measured with the SF-12.