Inna Feldman

Associations of self-reported sleep disturbance and duration with academic failure in community-dwelling Swedish adolescents: Sleep and academic performance at school

OBJECTIVE To examine associations of self-reported sleep disturbance and short sleep duration with the risk for academic failure. METHODS A cohort of ~40,000 adolescents (age range: 12-19 years) who were attending high school grades 7, 9, and 2nd year of upper secondary school in the Swedish Uppsala County were invited to participate in the Life and Health Young Survey (conducted between 2005 and 2011 in Uppsala County, Sweden). In addition to the question how many subjects they failed during the school year (outcome variable), subsamples of adolescents also answered questions related to subjective sleep disturbance (n = 20,026) and habitual sleep duration (n = 4736) (exposure variables). Binary logistic regression analysis was utilized to explore if self-reported sleep disturbances and habitual short sleep duration (defined as less than 7-8 h sleep per night) increase the relative risk to fail subjects during the school year (controlled for possible confounders, e.g. body-mass-index). RESULTS Adolescents with self-reported sleep disturbances had an increased risk for academic failure (i.e., they failed at least one subject during the school year; OR: boys, 1.68; girls, 2.05, both P < 0.001), compared to adolescents without self-reported sleep disturbances. In addition, adolescents who reported short sleep duration on both working and weekend days were more likely to fail at least one subject at school than those who slept at least 7-8 h per night (OR: boys, 4.1; girls, 5.0, both P < 0.001). CONCLUSION Our findings indicate that reports of sleep disturbance and short sleep duration are linked to academic failure in adolescents. Based on our data, causality cannot be established.

Social inequalities in self-reported refraining from health care due to financial reasons in Sweden: health care on equal terms?

BackgroundThe main goal of the health care system in Sweden is good health and health care on equal terms for the entire population. This study investigated the existence of social inequalities in refraining from health care due to financial reasons in Sweden.MethodsThe study is based on 38,536 persons who responded to a survey questionnaire sent to a random sample of men and women aged 18-84 years in 2008 (response rate 59%). The proportion of persons who during the past three months due to financial reasons limited or refrained from seeking health care, purchasing medicine or seeking dental care is reported. The groups were defined by gender, age, country of origin, educational level and employment status. The prevalence of longstanding illness was used to describe morbidity in these groups. Differences between groups were tested with chi-squared statistics and multivariate logistic regression models.ResultsIn total, 3% reported that they had limited or refrained from seeking health care, 4% from purchasing medicine and 10% from seeking dental care. To refrain from seeking health care was much more common among the unemployed (12%) and those on disability pension (10%) than among employees (2%). It was also more common among young adults and persons born outside the Nordic countries. Similar differences also apply to purchasing medicine and dental care. The odds for refraining from seeking health care, purchasing medicine or seeking dental care due to financial reasons were 2-3 times higher among persons with longstanding illness than among persons with no longstanding illness.ConclusionsThere are social inequalities in self-reported refraining from health care due to financial reasons in Sweden even though the absolute levels vary between different types of care. Often those in most need refrain from seeking health care which contradicts the national goal of the health care system. The results suggest that the fare systems of health care and dental care should be revised because they contribute to inequalities in health care.

The Children and Parents in Focus project: a population-based cluster-randomised controlled trial to prevent behavioural and emotional problems in children

BackgroundThere is large body of knowledge to support the importance of early interventions to improve child health and development. Nonetheless, it is important to identify cost-effective blends of preventive interventions with adequate coverage and feasible delivery modes. The aim of the Children and Parents in Focus trial is to compare two levels of parenting programme intensity and rate of exposure, with a control condition to address impact and cost-effectiveness of a universally offered evidence-based parenting programme in the Swedish context.Methods/DesignThe trial has a cluster randomised controlled design comprising three arms: Universal arm (with access to participation in Triple P - Positive Parenting Program, level 2); Universal Plus arm (with access to participation in Triple P - Positive Parenting Program, level 2 as well as level 3, and level 4 group); and Services as Usual arm. The sampling frame is Uppsala municipality in Sweden. Child health centres consecutively recruit parents of children aged 3 to 5 years before their yearly check-ups (during the years 2013–2017). Outcomes will be measured annually. The primary outcome will be children’s behavioural and emotional problems as rated by three informants: fathers, mothers and preschool teachers. The other outcomes will be parents’ behaviour and parents’ general health. Health economic evaluations will analyse cost-effectiveness of the interventions versus care as usual by comparing the costs and consequences in terms of impact on children’s mental health, parent’s mental health and health-related quality of life.DiscussionThis study addresses the need for comprehensive evaluation of the long-term effects, costs and benefits of early parenting interventions embedded within existing systems. In addition, the study will generate population-based data on the mental health and well-being of preschool aged children in Sweden.Trial registrationISRCTN: ISRCTN16513449.

Can financial insecurity and condescending treatment explain the higher prevalence of poor self-rated health in women than in men? A population-based cross-sectional study in Sweden

IntroductionWomen have in general poorer self-rated health than men. Both material and psychosocial conditions have been found to be associated with self-rated health. We investigated whether two such factors, financial insecurity and condescending treatment, could explain the difference in self-rated health between women and men.MethodsThe association between the two factors and self-rated health was investigated in a population-based sample of 35,018 respondents. The data were obtained using a postal survey questionnaire sent to a random sample of men and women aged 18-75 years in 2008. The area covers 55 municipalities in central Sweden and the overall response rate was 59%. Multinomial odds ratios for poor self-rated health were calculated adjusting for age, educational level and longstanding illness and in the final model also for financial insecurity and condescending treatment.ResultsThe prevalence of poor self-rated health was 7.4% among women and 6.0% among men. Women reported more often financial insecurity and condescending treatment than men did. The odds ratio for poor self-rated health in relation to good self-rated health was 1.29 (95% CI: 1.17-1.42) for women compared to men when adjusted for age, educational level and longstanding illness. The association became, however, statistically non-significant when adjusted for financial insecurity and condescending treatment.ConclusionThe present findings suggest that women would have as good self-rated health as men if they had similar financial security as men and were not treated in a condescending manner to a larger extent than men. Longitudinal studies are, however, required to confirm this conclusion.

Cost-utility analysis of individual psychosocial support interventions for breast cancer patients in a randomized controlled study

The aim was to explore the cost–utility in providing complementary individual psychosocial support to breast cancer patients compared with standard care (SC).

A novel approach used outcome distribution curves to estimate the population-level impact of a public health intervention☆

OBJECTIVES To provide an analytical framework within which public health interventions can be evaluated, present its mathematical proof, and demonstrate its use using real trial data. STUDY DESIGN AND SETTING This article describes a method to assess population-level effects by describing change using the distribution curve. The area between the two overlapping distribution curves at baseline and follow-up represents the impact of the intervention, that is, the proportion of the target population that benefited from the intervention. RESULTS Using trial data from a parenting program, empirical proof of the idea is demonstrated on a measure of behavioral problems in 355 preschoolers using the Gaussian distribution curve. The intervention group had a 12% [9%-17%] health gain, whereas the control group had 3% [1%-7%]. In addition, for the subgroup of parents with lower education, the intervention produced a 15% [6%-25%] improvement, whereas for the group of parents with higher education the net health gain was 6% [4%-16%]. CONCLUSION It is possible to calculate the impact of public health interventions by using the distribution curve of a variable, which requires knowing the distribution function. The method can be used to assess the differential impact of population interventions and their potential to improve health inequities.

Exploring trends in and determinants of educational inequalities in self-rated health

Aims: Educational inequalities in self-rated health (SRH) in European welfare countries are documented, but recent trends in these inequalities are less well understood. We examined educational inequalities in SRH in different age groups, and the contribution of selected material, behavioural and psychosocial determinants from 2000 to 2008. Methods: Data were derived from cross-sectional surveys conducted in 2000, 2004 and 2008 including 37,478, 34,876 and 32,982 respondents, respectively, aged 25–75 in mid-Sweden. Inequalities were analysed by age-standardized and age-stratified rate ratios of poor SRH and age-standardized prevalence of determinants, and contribution of determinants by age-adjusted logistic regression. Results: Relative educational inequalities in SRH increased among women from 2000 (rate ratio (RR) 1.70, 95% CI 1.55–1.85) to 2008 (RR 2.07, 95% CI 1.90–2.26), but were unchanged among men (RR 1.91–2.01). The increase among women was mainly due to growing inequalities in the age group 25–34 years. In 2008, significant age differences emerged with larger inequalities in the youngest compared with the oldest age group in both genders. All determinants were more prevalent in low educational groups; the most prominent were lack of a financial buffer, smoking and low optimism. Educational differences were unchanged over the years for most determinants. In all three surveys, examined determinants together explained a substantial part of the educational inequalities in SRH. Conclusions: Increased relative educational health inequalities among women, and persisting inequalities among men, were paralleled by unchanged, large differences in material/structural, behavioural and psychosocial factors. Interventions to reduce these inequalities need to focus on early mid-life.

Association of Obsessive-Compulsive Disorder With Objective Indicators of Educational Attainment: A Nationwide Register-Based Sibling Control Study

Importance To our knowledge, the association of obsessive-compulsive disorder (OCD) and academic performance has not been objectively quantified. Objective To investigate the association of OCD with objectively measured educational outcomes in a nationwide cohort, adjusting for covariates and unmeasured factors shared between siblings. Design, Setting, And Participants This population-based birth cohort study included 2 115 554 individuals who were born in Sweden between January 1, 1976, and December 31, 1998, and followed up through December 31, 2013. Using the Swedish National Patient Register and previously validated International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes, we identified persons with OCD; within the cohort, we identified 726 198 families with 2 or more full siblings, and identified 11 482 families with full siblings discordant for OCD. Data analyses were conducted from October 1, 2016, to September 25, 2017. Main Outcomes and Measures The study evaluates the following educational milestones: eligibility to access upper secondary school after compulsory education, finishing upper secondary school, starting a university degree, finishing a university degree, and finishing postgraduate education. Results Of the 2 115 554 individuals in the cohort, 15 120 were diagnosed with OCD (59% females). Compared with unexposed individuals, those with OCD were significantly less likely to pass all core and additional courses at the end of compulsory school (adjusted odds ratio [aOR] range, 0.35-0.60) and to access a vocational or academic program in upper secondary education (aOR, 0.47; 95% CI, 0.45-0.50 and aOR, 0.61; 95% CI, 0.58-0.63, for vocational and academic programs, respectively). People with OCD were also less likely to finish upper secondary education (aOR, 0.43; 95% CI, 0.41-0.44), start a university degree (aOR, 0.72; 95% CI, 0.69-0.75), finish a university degree (aOR, 0.59; 95% CI, 0.56-0.62), and finish postgraduate education (aOR, 0.52; 95% CI, 0.36-0.77). The results were similar in the sibling comparison models. Individuals diagnosed with OCD before age 18 years showed worse educational attainment across all educational levels compared with those diagnosed at or after age 18 years. Exclusion of patients with comorbid neuropsychiatric disorders, psychotic, anxiety, mood, substance use, and other psychiatric disorders resulted in attenuated estimates, but patients with OCD were still impaired across all educational outcomes. Conclusions and Relevance Obsessive-compulsive disorder, particularly when it has an early onset, is associated with a pervasive and profound decrease in educational attainment, spanning from compulsory school to postgraduate education.

Cost-effectiveness of therapist-guided internet-delivered cognitive behaviour therapy for paediatric obsessive–compulsive disorder: results from a randomised controlled trial

Objectives To evaluate the cost-effectiveness of a therapist-guided internet-delivered cognitive behaviour therapy (ICBT) intervention for adolescents with obsessive–compulsive disorder (OCD) compared with untreated patients on a waitlist. Design Single-blinded randomised controlled trial. Setting A research clinic within the regular child and adolescent mental health service in Stockholm, Sweden. Participants Sixty-seven adolescents (12–17 years) with a Diagnostic and Statistical Manual of Mental Disorders Fifth Edition diagnosis of OCD. Interventions Either a 12-week, therapist-guided ICBT intervention or a wait list condition of equal duration. Primary outcome measures Cost data were collected at baseline and after treatment, including healthcare use, supportive resources, prescription drugs, prescription-free drugs, school absence and productivity loss, as well as the cost of ICBT. Health outcomes were defined as treatment responder rate and quality-adjusted life years gain. Bootstrapped mixed model analyses were conducted comparing incremental costs and health outcomes between the groups from the societal and healthcare perspectives. Results Compared with waitlist control, ICBT generated substantial societal cost savings averaging US

Are group-based parenting programmes in Sweden a cost-effective way of reducing early child behaviour problems?

−144.98 (95% CI −159.79 to –130.16) per patient. The cost reductions were mainly driven by reduced healthcare use in the ICBT group. From the societal perspective, the probability of ICBT being cost saving compared with waitlist control was approximately 60%. From the healthcare perspective, the cost per additional responder to ICBT compared with waitlist control was approximately US