Anna-Lena Undén

Development of a social support instrument for use in population surveys

A wide variety of measures have been used to assess the effects of social support on physical and psychological well-being. Many instruments have incomplete information about reliability and validity. Other instruments appear to be reasonably valid, but involve a large number of questions and are therefore not suitable in population surveys. The main purpose of the study was to examine whether a psychometrically well documented, but time consuming instrument. The Interview Schedule for Social Interaction, could be abbreviated and simplified for the use in population surveys. By means of both item and content analyses the original instrument was shortened and both versions were tested in a study group of 83 middle-aged Swedish men. The distribution of scale scores were similar in the complete and in the abbreviated version and so was reliability, measured as internal consistency and split-half reliability. Validity was examined by comparing the two versions in relation to other measures of social integration, as well as personality and behaviour characteristics. Men with low social support were less socially and physically active, were more depressed and were less trustful than men with high support. Men who scored low on social support were also more often smokers, of lower social class, lower occupational level and lower education and had more complaints of ill health, mainly of cardiovascular nature. The discriminative capacity was as good for the complete as for the abbreviated version. Thus no obvious disadvantages in terms of reliability and validity could be demonstrated for the abbreviated version.

The measurement of social support in population surveys.

There is an increasing interest to include measures of social support in population surveys of chronic disease risk. The choice among a variety of measurement instruments, however, is difficult. We reviewed social support instruments, which were potentially applicable in population studies. Their conceptual framework, their reported predictive capacity and their psychometric properties were compiled and systematically compared. The convenience, clarity and applicability of the social support instruments were tested in a group of health care employees. Two distinct groups of instruments were identified, those describing quantitative aspects of social network and social interaction and those describing functions and adequacy of social support. The former instruments were more easily applicable, questions were more easily and quickly understood and answered. Furthermore, these instruments had been found to predict physical illness in prospective studies. Their psychometric properties, however, were unknown. Qualitative instruments, on the other hand, were found to include questions, not universally applicable to a general population. These instruments were mostly carefully tested for psychometric properties, but their illness predictive capacity was found to be less well examined. Thus, instruments which satisfied all the desirable requirements could not be identified.

Self-rated health is related to levels of circulating cytokines.

Objective: Self-rated health is a powerful and independent predictor of long-term health, but its biological basis is unknown. Because factors associated with poor self-rated health (eg, pain, daily discomforts, and low energy and fitness) resemble symptoms of a generalized cytokine-induced sickness response, we examined the relationship between circulating cytokines and self-rated health. Methods: In 265 consecutive primary health care patients (174 women and 91 men), we examined self-rated and physician-rated health, circulating levels of interleukin (IL)-1β, IL-1 receptor antagonist (IL-1ra), IL-6, and tumor necrosis factor (TNF)-&agr; as determined from plasma samples using high-sensitivity enzyme-linked immunoassay. Results: Self-rated health correlated with levels of IL-1β (r = 0.27; p < .001), IL-1ra (r = 0.19; p < .05) and TNF-&agr; (r = 0.46; p < .001) in women but not in men. Thus, poorer subjective health was associated with higher levels of inflammatory cytokines. Even when controlling for age, education, physical health, and diagnoses in multiple regression analyses, self-rated health was an independent and more robust predictor of cytokine levels than physician-rated health. Conclusions: The present findings suggest that an individuals health perception may be coupled to circulating cytokines. Because epidemiological research established that self-rated health predicts morbidity and mortality, the biological correlates and mechanisms of self-rated health need to be understood.

Cardiovascular effects of social support in the work place : twenty-four-hour ECG monitoring of men and women

&NA; Psychosocial work characteristics, such as work demand, work control, and social support at work, have been shown to be related to the development of coronary heart disease in epidemiological studies. However, the mechanisms which mediate the social and psychological effects on the cardiovascular system are not known. We have studied the direct cardiovascular effects of psychosocial work environment characteristics in 148 working men and women, representing seven different occupational groups (physicians, teachers, musicians, policemen, train engineers, prison personnel, and saw mill workers). Besides standardized measures of work demand, work control, and social support, ambulatory 24‐hour monitoring of electrocardiograms in the customary work and home environment was performed. Systolic and diastolic blood pressure were measured as well as other standard physiologic risk factors for coronary heart disease. Mean heart rates were found to be significantly higher in persons reporting low social support at work. This effect was maintained during working hours as well as during leisure time and rest. Of the other related physiologic risk factors, systolic, but not diastolic blood pressure was found to be higher in persons reporting low social support. Smoking, alcohol consumption and relative body mass index were not related to social support at work. Controlling for age, sex and physical strain at work, strengthened the association of low social support with elevated heart rates.

Gender Differences in Self-Rated Health, Quality of Life, Quality of Care, and Metabolic Control in Patients with Diabetes

BACKGROUND Because the projected increase in the number of diabetic patients is expected to strain the capabilities of health care providers worldwide, we are challenged to find ways of reducing the burden of diabetes. Maintaining and improving health-related quality of life (QoL) for diabetic patients may be viewed as public health goals. OBJECTIVE The aim of this cross-sectional study was to compare different aspects of health, QoL, and quality of care (QoC) between men and women with diabetes as a basis for planning and managing diabees care. METHODS All patients in 2 age groups (aged 20-30 years [younger age group] and aged 50-60 years [middle-aged group]) who were registered with the Department of Endocrinology, Metabolism, and Diabetes at Karolinska University Hospital, Stockholm, Sweden, in October 2004, were recruited for a survey. Questions were included about self-rated health (SRH), QoL, QoC, diabetes-related worries, occupational status, physical activity level, living arrangements, and educational background. Glycosylated hemoglobin (HbA1c) values were obtained from medical records. RESULTS Of the 223 eligible patients (109 men, 114 women) in the younger age group, 49 men and 74 women responded to the questionnaire; of the 300 eligible patients (170 men, 130 women) in the middle-aged group, 120 men and 93 women responded. Middle-aged women rated their mental well-being and QoL as worse compared with men (P < 0.001 and P < 0.05, respectively). In both age groups, women reported more diabetes-related worries and less ability to cope (P < 0.05 for the younger age group and P < 0.001 for the middle-aged group for both variables), thus the differences were more marked for middleaged women. Although there were no gender differences in metabolic control, middle-aged women reported less satisfaction with diabetes care (P < 0.001). Higher HbA1c was related to worse SRH in both men and women when analyzing the age groups together (P < 0.05). This association was most prominent in young women, in whom having more diabetes-related worries was also related to higher HbA1c (P < 0.01). CONCLUSION In this study, women with diabetes appeared to have worse QoL and mental well-being compared with men with diabetes. Therefore, identifying strategies to improve SRH and QoL among diabetic patients, especially among women, is of great importance.

Quality-of-Life in Patients Treated with Atrioventricular Synchronous Pacing Compared to Rate Modulated Ventricular Pacing: A Long-Term, Double-Blind, Crossover Study

To investigate whether the preservation of afrioventricular (AV) synchronization matters for quality‐of‐life during pacemaker treatment we assessed 17 consecutive patients with high degree AV block and preserved sinus node function in a double‐blind, long‐term crossover study. A questionnaire with regard to cardiovascular symptoms, sleep disturbances, cognitive functioning, physical ability, social interaction, emotional functioning, and self‐perceived health was completed after 2 months of atrial synchronous (DDD) and rate modulated ventricular pacing (VVI,R), respectively. A significant improvement in shortness of breath, dizziness and palpitations as well as an improvement of cognitive functioning was observed during DDD pacing. Nine patients preferred the DDD mode and three the VVI,R mode. The remaining five patients did not express any preference. The preference for the DDD mode was explained by a significant reduction of cardiovascular symptoms and an improved self‐perceived health, physical ability, and psychological well‐being during DDD pacing. All differences in quality‐of‐life parameters between the two modes of pacing favored the DDD mode and no adverse effects of this mode were found. Thus, the maintenance of AV synchrony adds further symptomatic relief compared to rate increase alone. The results indicate that DDD pacing is the preferred mode of pacing in patients with high degree AV block and preserved sinus node function.

Eating meals irregularly: a novel environmental risk factor for the metabolic syndrome.

Background: Skipping meals is a common practice in our current society; however, it is not clear whether eating meals regularly is associated with the metabolic syndrome.

Do different factors explain self-rated health in men and women?

BACKGROUND Self-rated health has elicited special interest, in the wake of a number of studies demonstrating that it is a powerful predictor of future mortality, mare so for men than for women. The association between self-rated health and biological correlates also appears to differ between men and women, for reasons unknown. OBJECTIVE The purpose of this study was to examine gender differences in the interpretation and/or valuation of health-related information by comparing men and womens association of abroad array of perceived health determinants with their statements about health. METHODS We conducted a cross-sectional study in a randomly selected population of 8200 men and women aged >17 years in Stockholm, Sweden. Subjects received a 120-item questionnaire that included measures of health care utilization, lifestyle, demographics, psychosocial factors, and mental, functional, and physical health. RESULTS Among the 5470 people who responded to the questionnaire, most of the 42 potential correlates (41 for men, 40 for women) were significantly correlated to self-rated health. The overall association pattern was surprisingly similar for men and women. However, some small differences appeared: educational level, physical activity, and cultural activities played a more crucial role when men judged their health, whereas satisfaction with sleep and doctor visits played a more crucial role when women judged their health. These results were also for the most part confirmed in regression analyses that included all variables. The correlates explained 50% of the variance in self-rated health for both men and women. CONCLUSIONS Our results highlight the necessity of taking a broad perspective on potential correlates when analyzing mechanisms of self-rated health. When judging their own health, men and women appear to consider approximately the same broad array of factors. The similarities in association patterns indicate that men and women interpret and/or value health-related factors similarly when making statements about health. These results may influence the medical professions acceptance or consideration of self-rated health. Understanding the gender-specific mechanisms involved in the assessment of self-rated health may contribute to the promotion of health-protective behavior and health intervention practices.

Inflammatory cytokines, behaviour and age as determinants of self-rated health in women

Self-rated health is a powerful and independent predictor of long-term health, but its biological basis is unknown. We have shown previously that self-rated health is associated with increased levels of circulating cytokines in women. The main aim of the present study was to increase the understanding of the association between markers of wellbeing, such as self-rated health, and cytokines and to investigate the impact of age on these associations. In 174 female consecutive primary health care patients divided into three age groups, we examined subjective ratings of health and aspects of wellbeing and circulating levels of IL (interleukin)-1beta, IL-1ra (IL-1 receptor antagonist), IL-6 and TNF-alpha (tumour necrosis factor-alpha). Poor self-rated health was significantly associated with higher levels of TNF-alpha in all of the age groups. For IL-1beta and IL-1ra, the correlations with self-rated health were significant only in the oldest age group. Lower ratings of other measurements of health and wellbeing were related to higher levels of cytokines, most pronounced for TNF-alpha and IL-1beta, and in the middle and olderst age groups. More symptoms resembling a sickness response induced by inflammation were implicated to be associated with lower self-rated health. The strength of the association between inflammatory cytokines and poor health perception increased with advanced age, indicating an increased vulnerability for inflammatory activity during aging. It is suggested that higher levels of TNF-alpha are connected to a sickness response that, in turn, is connected to self-rated health. The results provide a possible psychobiological basis to understand better diffuse subjective symptoms and poor subjective health in women.

Patient charges -- a hindrance to financially and psychosocially disadvantage groups seeking care

This study examines the extent to which people forego seeking primary health care due to the cost and to investigate the associated demographic, physical, psychological and social factors. In 1995, questionnaires were sent to a random sample of the population in two healthcare regions in the Stockholm area in Sweden covering a total of about 400,000 inhabitants. Among the sample of 8200 people over the age of 17 yr, 69% replied to the questionnaire. About 22% stated that on one or more occasions during the past year they had foregone seeking care due to the cost. About 30% stated that they had foregone or hesitated seeking medical help due to the cost during the past year. This applied to women to a greater extent than men. Not seeking medical care was strongly correlated to a self-assessment of personal finances. Among those who described their financial situation as poor, more than half stated that, on at least one occasion, they had foregone seeking medical care due to the cost. As a consequence, weaker groups in society such as the unemployed, students, foreign nationals and single mothers were overrepresented in this group. Those who had foregone care perceive their health as worse and they had a greater degree of general pains and a higher occurrence of chronic disease/disability compared to those who had not foregone care. Between 1970 and 1995, patient charges for consulting a general practitioner within Stockholm County have increased more than three times faster than the consumer price index. The results suggest that the rapidly increasing patient charges particularly affect the weaker social groups and thus pose a threat to the aim of Swedish healthcare legislation--that good care should be available to everyone on equal terms.