In the past decades there has been an improvement in the medical treatment of children born preterm or with reduced foetal growth. This has resulted in a much higher survival rate of these children, but also in a higher number of surviving children with chronic conditions. These changes have, in turn, increased interest in investigating the connection between birth-characteristics and outcomes in later life. The overall aim of the present thesis was to study the relations between birth-characteristics, subsequent hospitalisations, and childbearing by means of data available in Swedish population-based registries. The study population in this thesis consisted of women (and men in Paper III) born in 1973-75 according to the Medical Birth Register and the Total Population Register. Information available in other registries, such as the Hospital Discharge Register, was obtained by individual record linkage. In Paper I, 148,281 women, alive and living in Sweden at 13 years of age, were included. Of the women, 4.1% were born preterm and 5.4% were born small for gestational age, and approximately 30% of all women had given birth between 13 and 27 years of age. We found that reduced foetal growth and possibly preterm birth were related to the likelihood of giving birth during the study period. The intergenerational effects of preterm birth and reduced foetal growth were investigated in Paper II and the study population consisted of 38,720 mother-offspring pairs. An intergenerational effect of reduced foetal growth was found, and reduced foetal growth in the mother also increased the risk for preterm birth in the child. Paper III was concerned with 304,275 men and women living in Sweden at 13 years of age. Of these men and women, 30% were hospitalised during adolescence and early adulthood (i.e. between 12 and 23 years of age). We found that men and women born small for gestational age or preterm were more likely to be hospitalised, and that those born small for gestational age seemed to be more at risk compared to those born preterm. Finally, in Paper IV, the relation between hospitalisations during adolescence and the likelihood of giving birth was studied in 142,998 women living in Sweden at 20 years of age. We found that a majority of the causes of hospitalisation during adolescence were positively connected to the likelihood of giving birth between 20 and 27 years of age. The relations presented in Papers I-IV were evident although socio-economic characteristics were adjusted for.

In Sweden approximately 25000 distal radius fractures occur annually, which is 37 % of all fractures related to osteoporosis. In this thesis, risk factors for osteoporosis, bone mineral density (BMD) and health-related quality of life (the SF-36) were compared in patients who suffered a distal radius fracture after low energy trauma with a control group matched on the basis of age, gender, and municipality of residence. The aim was also to analyse, among these patients, whether a risk factor questionnaire, tests on dynamic and static balance and a one-leg rise test could identify those, who have osteopenia or osteoporosis, and run a risk of new falls. Moreover, in a three-year follow-up, mortality, the need for in- and outpatient care, and health-related quality of life after radius fracture were investigated and compared between the patients and matched controls. Finally, the effect of a preventive intervention program including patient education and self-training was evaluated. Falls were reported in a risk factor questionnaire and in a fall diary. The patients aged 45-64 years showed lower, although not statistically significant, BMD, compared with the controls of the same age, but there was no difference concerning their history of falls. In contrast, the patients aged 64 years or older had a history of falling more often than the corresponding controls, but no difference in BMD was found. For all other risk factors, except falls, no differences were found between the patients and the controls. The results of the one-leg rise test were associated with those of dynamic and static balance, but none of the functional tests were associated with the number of falls. Decreased height and cigarette smoking were the only risk factors, which predicted osteopenia and osteoporosis. Five patients, although none of the controls, died during the study time. The patients needed statistically significantly more episodes as inpatients than the controls. The patients also had lower SF-36, Role Physical scores, than the controls at three months. This difference disappeared by the time of the follow-up. Both the patients, who participated in a four-week intervention program, “the osteoporosis school” followed by a one-year home-based exercise program, and the controls showed statistically significantly improved dynamic and static balance, ability to walk backwards and to stand on one leg with eyes open and closed at the end of the study. However, no significant differences were found between the patients and the controls in any of the tests, in BMD or in the number of the falls. The thesis shows that, except for the falls in patients aged over 64 years, there were no significant differences between patients and controls with respect to BMD and other risk factors related to osteoporosis. Consequently, in patients aged 45-64 years and older, the underlying cause of a distal radius fracture is more related to falls than to osteoporosis. Furthermore, the thesis shows that the functional tests and the risk factor questionnaire seem to be of limited value for identifying 8 people with a radius fracture, who are at risk of falling or have osteopenia or osteoporosis. If, in spite of this, functional tests on musculoskeletal function are considered for testing of functional ability in patients with a recent radius fracture, the one leg-rise test may be sufficient. There seems to be an increased mortality and morbidity necessitating inpatient care among patients with a recent radius fracture. The osteoporosis school had no significant effect on BMD, balance, muscle strength or falls in this thesis. Therefore, the lack of proven efficacy of the osteoporosis school for the secondary prevention of distal radius fractures highlights the need for more and long-term randomised controlled follow-up studies in this specific population.

Rheumatoid arthritis (RA) is a chronic disabling disease that is associated with a shortened life span. Cardiovascular disease (CVD) contributes to this increased mortality, and also to a great extent to the co-morbidity observed in patients with RA. This thesis aimed to investigate these issues further. The incidence of, and prognosis after an acute myocardial infarction (AMI) /or stroke in a cohort of RA patients was compared with that in the general population within the northern Sweden MONICA register. The standard incidence ratio (SIR) for AMI was 2.9 and for stroke 2.7 in RA patients compared with the general population (p<0.05 for both). During the first 10 years following an event, RA patients had a higher overall case fatality (CF) compared with controls (HR for AMI=1.67, 95%CI [1.02, 2.71], HR for stroke=1.65, 95%CI [1.03, 2.66]). An elevated level of homocysteine is regarded to be a risk marker for CVD. The effects of treatment with B vitamins on the homocysteine level in patients with RA were studied in a consecutive cohort of patients with RA. Sixty-two patients with RA having a homocysteine level of 12 mol were randomized to receive either a placebo or a combination of the vitamins B6, B12 and folic acid. The patients were treated and evaluated in a double-blind manner over 12 months. The homocysteine level was found to be significantly decreased in the B-vitamin treated patients compared with the placebo group (p<0.0001). To evaluate the progression of sub-clinical atherosclerosis in patients with very early RA compared with controls, all patients from the three most northern counties of Sweden newly diagnosed with RA and aged ≤60 years were consecutively recruited. Age and sex matched controls from the general population were also included. Intima media thickness (IMT) of the common carotid artery and endothelium dependent flow mediated dilation (ED-FMD) of the brachial artery were measured using ultrasonography. After 18 months the same measurements were undertaken in a sub-group of the patients with early RA and the relevant controls. There were no differences between patients with early RA and controls in terms of IMT or ED-FMD at inclusion into the study. However, after 18 months there was a significant increase in the IMT among the patients with early RA (p<0.05); no such increase occurred in the control group. Biomarkers of endothelial activation that may reflect the early atherosclerosis that occurs in RA were also evaluated. At inclusion, both IMT and ED-FMD among the patients with early RA related significantly to several of the biomarkers of endothelial activation. Furthermore, markers of inflammation (e.g., DAS28) were significantly related to biomarkers of endothelial activation. In conclusion, RA patients had a higher incidence of CVD and a higher CF after a CV event. The increased homocysteine level among patients with RA was as easy to decrease as in the general population. At the time of diagnosis of RA there were no differences in atherosclerosis between patients and controls, however the patients with RA had a more rapid progression of atherosclerosis than the control subjects. Moreover, there were implications of endothelial activation already in patients with very early RA. Taken together, these results emphasize the necessity of optimizing the preventive, diagnostic and caring strategies for CVD in patients with RA.

Den sociala ångesten många känner i olika situationer kan leda till undvikande, isolering och ibland även kompliceras av depressiva symtom och/eller alkoholanvändning. Huruvida ett samband mellan dessa problem kan visa sig i 16-17 årsåldern undersöktes genom en enkät om nedstämdhet, alkoholanvändning och social ångest. Resultatet visade att nedstämdhet hade en inverkan på grad av social ångest hos båda könen. Dock var tjejer i högre grad än killar mer nedstämda. Tjejer som drack mindre uppvisade en högre grad av social ångest. Alkoholanvändning hängde inte ihop med killars hantering av social ångest. Resultatet tyder på att samband mellan variablerna kan visa sig tidigt. Därför borde resurser sättas in tidigt för att förhindra en negativ utveckling, så att personer kan fungera i samhället. / The social anxiety many people feel in different situations can lead to avoidance, isolation and be complicated with depressive symptoms and/or alcoholuse. Whether it’s possible to find relationships between these syndromes in age 16-17 was investigated through a survey about depression, alcoholuse and social anxiety. The result showed that depression had an impact on level of social anxiety for both sexes. Gals were more depressed than guys, though. Gals who drank less had a higher level of social anxiety. Alcoholuse had no impact in coping with social anxiety for guys. The result showes a connection between the variables that can be seen early. Therefore, resources should be available to prevent a negative development, so that people can function in society.

Hintergrund: Angststörungen gehören zu den häufigsten psychischen Störungen im Jugend- und Erwachsenenalter. Ein Großteil der Betroffenen bleibt meist unbehandelt. Informationen über die Behandlungswahrscheinlichkeit bei Jugendlichen und jungen Erwachsenen in Abhängigkeit von der Störungs- und Behandlungsart, Lebensalter, Geschlecht und Komorbidität liegen bisher nicht vor. Methode: In einer repräsentativen Stichprobe 14- bis 34-Jähriger aus dem Großraum München (Early Developmental Stages of Psychopathology Studie, N = 3021) werden die Prävalenz und Lebenszeitinzidenz von Angststörungen sowie ihre Behandlungsraten mittels M-CIDI erfasst und differenziert für Lebensalter, Komorbidität und Geschlecht präsentiert. Ergebnisse: 30% der Befragten berichteten mindestens eine Angststörung in ihrem Leben. Fast die Hälfte der Betroffenen (43%) suchte irgendeine Behandlung, ein Drittel (28%) suchte einen Psychotherapeuten auf. Für die meisten Angststörungen lagen hohe Quoten psychotherapeutischer Behandlungen vor (Range: 50–61%). Jugendliche berichteten seltener als Erwachsene irgendeine Behandlung, eine psychotherapeutische Behandlung, die Konsultation eines Psychiaters oder Hausarztes. Frauen nahmen häufiger eine Psychotherapie in Anspruch als Männer. Das Vorliegen einer komorbiden Angst- oder depressiven Störung erhöhte die Behandlungswahrscheinlichkeit. Diskussion: Verglichen mit europäischen Studien berichtete die Stichprobe relativ häufig eine Behandlung, auch eine psychotherapeutische. Dies kann eine Folge des großen Behandlungsangebotes in München sein. Dennoch bleibt der Großteil der jungen Betroffenen unbehandelt. Zur Prävention langfristiger Beeinträchtigungen sowie sekundärer psychischer Störungen sollte das Versorgungssystem verstärkt auf diese Bevölkerungsgruppe ausgerichtet werden. / Background: Anxiety disorders are among the most frequent mental disorders in adolescence and adulthood. Most of the affected individuals do not receive treatment. Information about treatment use among adolescents and young adults, differentiated for the kind of treatment and anxiety disorder, age, gender and co-morbidity, is still missing. Methods: In a representative sample of 14–34 year-old adolescents and young adults of the Munich area (Early Developmental Stages of Psychopathology study, N = 3,021) prevalence and lifetime incidence of anxiety disorders and treatment use are assessed using the M-CIDI and will be presented for age, co-morbidity and gender. Results: 30% of all participants reported at least one lifetime diagnosis of an anxiety disorder. Almost half of those affected (43%) received some kind of treatment; one third (28%) received psychotherapy. Psychotherapy use was frequent in most anxiety disorders (range: 50–61%). Older individuals more frequently reported any treatment, psychotherapy, consultations with psychiatrists or general practitioners. Women used psychotherapy more often than men. Co-morbid anxiety or depressive disorders increased the probability of treatment use. Discussion: As compared to European estimations, we found relatively high rates of treatment use. This may be due to the many treatment possibilities in the Munich area. Nevertheless, most young people affected do not receive treatment. Considering the long-term effects of anxiety disorders and in order to prevent secondary disorders, efforts should be increased to reach these young individuals.

Background: Little is known about the experience and psychological outcomes for women who experience emergency peripartum hysterectomy (EPH). The objective of this study was to explore women's experiences of EPH and to determine if women who experience EPH were more likely to experience mental health sequelae. Methods: This mixed method design involved a quantitative and a qualitative phase. The quantitative phase used a retrospective cohort design. Women were sampled through on-line communities, including an EPH support group, and a larger website for mothers. Women completed on-line surveys covering sociodemographic, obstetric/gynecological/ and psychiatric information, including screens for depression and Post-Traumatic Stress Disorder (PTSD). Logistic regression was used to calculate the independent risk that exposure to EPH has on screening positive for PTSD. Participants from the EPH support group who completed the on-line interview were then selected to participate in the second phase. In-depth telephone interviews were conducted and analyzed using Constant Comparative Analysis. Results: 74 exposed women and 355 non-exposed women completed the survey. In the adjusted logistic regression model, women who experienced EPH were over 6 times more likely to screen positive for current PTSD compared to women who did not experience EPH (adjusted Relative Risk (aRR): 6.76; 95% CI: 4.24, 8.88). When women recalled their psychological state at 6 months postpartum, exposed women were 11 times more likely to screen positive for current PTSD (aRR: 11.35; 95% CI: 8.43, 12.95). In the qualitative phase, 15 women participated and 7 major themes were identified: fear, pain, death and dying, numbness or delay in emotional reaction, bonding with baby, communication and the need for information. A major finding is the need for additional follow-up visits to address the emotional after-effects and to fill in gaps in women's understanding and memory of what had occurred. Conclusion: Understanding women's experiences and sequelae can help providers address not only women's initial complications but provide needed long-term support.

<p>The study proposed to conduct a descriptive study related to the correlation of infant feeding (EFF or EBF) and occurrence of morbidity diarrhoea and/or respiratory infections, in infants by 14 weeks of age. The study adopted a quantitative epistemological approach in seeking to describe the correlation of infant feeding and the occurrence of diarrhoea or respiratory infections by 14 weeks of age. The researcher embarked on a descriptive survey design and employed the questionnaire method during the data collection process. The Amathole District of the Eastern Cape Province was selected due to the accessibility of the targeted population. The unique demographic profile and rural-urban setting allows for a potentially rich data source whilst simultaneously reducing the potential incidence of bias in the data collection. The study sample was drawn from routine immunization and growth monitoring clinics in the Amathole district.</p>

Women treated for a gynecological cancer report longstanding post-treatment difficulties for which they rarely seek or receive help. Few intervention studies have successfully improved global sexual health within this population. Research in this domain is challenging due to inconsistent measurements of sexuality, low response rates and high attrition rates. The overarching study objectives were: (a) To contribute to the advancement of research on supportive care needs (including sexual health needs), desire for help, and predictors of needs; and, (b) To inform the development of services for gynecological cancer survivors. In Study 1, a qualitative interview study explored the experiences of 15 gynecological cancer survivors. Interviews were conducted and analysed based on the Interpretive Description approach . In Study 2 (for which results were analyzed in two parts), a descriptive, cross-sectional needs assessment was conducted to measure supportive care needs, desire for help, sexual health and vaginal changes, and service format preferences in 113 patients. In Part 1 of Study 2, descriptive and regression analyses explored patient needs, desire for help and potential predictors of these variables. In Part 2, a descriptive analysis explored sexual health needs and vaginal changes, desire for help with sexual health needs, and their associations with sociodemographic and medical variables. Qualitative results from Study 1 suggested that psychological, emotional and relational aspects of sexuality were as important to the participants as physiological sexual response. In the needs assessment, the strongest predictors of greater unmet needs and increased readiness for help were younger age and shorter time since treatment. Moderate to high sexual and social needs were equally prevalent in women recently treated and those treated several years prior to the study, suggesting that sexual and social needs may remain unaddressed over time. Further, many women who reported a need did not desire help, demonstrating the subjectivity of needs and distress, as well as the potential presence of barriers to seeking help. Both studies revealed a common finding, where sexual health needs were a product of the discordance between participants’ current sexual experiences and their perceptions of ideal sexual health. Overall, the two studies indicate that a significant subgroup of patients experience unmet needs in cancer survivorship, most of which are non-physical; also, while some needs were higher following treatment, unmet social and sexual health needs show little relationship with time since treatment. Ambivalence about receiving help with unmet needs is related to beliefs about the role of the health care team in meeting non-physical needs, as well as other perceived barriers. Patient’s perceived sexual health needs and barriers to receiving help should be evaluated within a comprehensive framework of needs and discussed one-on-one. Future research should explore the added predictive value of other groups of medical and psychological variables.

This thesis comprises three essays on “The Economic impact of adult mortality and morbidity on smallholder farm households in Malawi.” The first essay estimates the levels of technical efficiency of AIDS-affected and non-affected smallholder farm households, and examines the technical efficiency differentials. The study uses time-varying and timeinvariant inefficiency models of production. The results show that among both female and male headed households, for both affected and non-affected households, fertilizer and seeds are the only variables that contribute significantly towards technical efficiency. The mean efficiency levels of affected and non-affected households are statistically not different. The second essay examines the maize production differentials between AIDS-affected and nonaffected farm households using the difference in difference estimation method. The results show that, for both affected and non-affected households, the mean maize production levels are higher during 2006/07 compared to 2004/05 However, the difference between the mean maize production levels of affected and non-affected households over the 2004/05 and 2006/07 period is not statistically significant. The third essay examines the coping strategies used by households facing food security problems. The results from the multinomial logistic model show that during 2004/05 and 2006/07, the most dominant coping strategy used by both AIDS-affected and non-affected households facing food security problems, is buying food from market. This is followed by casual labour, obtaining food from relatives and friends, eating unripe maize before harvest, and irrigation farming. The results from logistic discriminant analysis function indicate that, for all households, ordinary coping strategies are dominant among food-insecure households with a total score of close to 80 percent, much higher than survival strategies at around 20 percent during 2004/05. / Thesis (Ph.D.)-University of KwaZulu-Natal, Westville, 2011.

Diss. (sammanfattning) Uppsala : Sveriges lantbruksuniv., 2002. / Härtill 6 uppsatser.