The Importance of Symptom Reduction for Functional Improvement after Cognitive Behavioral Therapy for Anxiety and Depression: A Causal Mediation Analysis.

INTRODUCTION: The temporal relationship between symptoms and functioning in the context of cognitive behavioral therapy (CBT) for anxiety and depression is not fully understood, and there are few high-quality studies that have examined to what extent late intervention effects of CBT on functioning are mediated by initial intervention effects on symptoms while accounting for the initial effects on functioning and vice versa. OBJECTIVE: The aim of the study was to investigate whether intervention effects on symptoms and functioning at 12-month follow-up were mediated by intervention effects on these outcomes at 6-month follow-up. METHODS: Participants with anxiety and/or mild-to-moderate depression were randomly assigned to a primary mental health care service (n = 463) or treatment-as-usual (n = 215). Main outcomes were depressive symptoms (Patient Health Questionnaire [PHQ-9]), anxiety (General Anxiety Disorder-7 [GAD-7]), and functioning (Work and Social Adjustment Scale [WSAS]). Direct/indirect effects were derived using the potential outcomes and counterfactual framework. RESULTS: The intervention effect on functioning at 12 months was largely explained by intervention effects at 6 months on depressive symptoms (51%) and functioning (39%). The intervention effect on depressive symptoms at 12 months was largely explained by the intervention effect at 6 months on depressive symptoms (70%) but not by functioning at 6 months. The intervention effect on anxiety at 12 months was only partly accounted for by intervention effects at 6 months on anxiety (29%) and functioning (10%). CONCLUSIONS: The findings suggest that late intervention effects of CBT on functioning were to a substantial degree explained by initial intervention effects on depressive symptoms even after accounting for initial effects on functioning. Our results support the importance of symptoms as an outcome in the context of CBT delivered in primary health care.

Sleep patterns and insomnia in young adults: A national survey of Norwegian university students.

The aim of this study was to describe sleep patterns and rate of insomnia according to diagnostic criteria in college and university students, as well as to examine potential changes in sleep problems from 2010 to 2018. Data stemmed from a national student health survey from 2018 for higher education in Norway (the SHoT study), which invited all 162,512 fulltime students in Norway. A total of 50,054 students (69.1% women) aged 18-35 years were included, yielding a response rate of 30.8%. Sleep parameters, reported separately for weekdays and weekends, included calculations of bedtime, rise time, sleep duration, sleep-onset latency, wake after sleep onset, sleep need and sleep deficit. Insomnia was defined according to the Diagnostic and Statistical Manual of Mental Disorders (5th edn) criteria. For the trend analysis, we used one item measuring difficulties initiating and/or maintaining sleep, over three time points (2010, 2014 and 2018). The results from 2018 showed large weekday-weekend differences across most sleep parameters. Both male and female students obtained a mean sleep duration in the lower end of the normal range on weekdays (7:24 hr), but met their own sleep need and sleep recommendations at weekends (8:25 hr). The overall prevalence of insomnia was 34.2% in women and 22.2% in men. There was a substantial increase in sleep problems from 2010 (22.6%) to 2018 (30.5%), which was especially pronounced in women. We conclude that sleep problems are both prevalent and increasing among students. This warrants attention as a public health problem in this population.

Measuring mental well-being in Norway: validation of the Warwick-Edinburgh Mental Well-being Scale (WEMWBS).

BACKGROUND: Mental well-being is an important, yet understudied, area of research, partly due to lack of appropriate population-based measures. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) was developed to meet the needs for such a measure. This article assesses the psychometric properties of the Norwegian version of the WEMWBS, and its short-version (SWEMWBS) among a sample of primary health care patients who participated in the evaluation of Prompt Mental Health Care (PMHC), a novel Norwegian mental health care program aimed to increase access to treatment for anxiety and depression. METHODS: Forward and back-translations were conducted, and 1168 patients filled out an electronic survey including the WEMWBS, and other mental health scales. The original dataset was randomly divided into a training sample (≈70%) and a validation sample (≈30%). Parallel analysis and confirmatory factor analysis were carried out to assess construct validity and precision. The final models were cross-validated in the validation sample by specifying a model with fixed parameters based on the estimates from the trainings set. Criterion validity and measurement invariance of the (S)WEMWBS were examined as well. RESULTS: Support was found for the single factor hypothesis in both scales, but similar to previous studies, only after a number of residuals were allowed to correlate (WEMWBS: CFI = 0.99; RMSEA = 0.06, SWEMWBS: CFI = .99; RMSEA = 0.06). Further analyses showed that the correlated residuals did not alter the meaning of the underlying construct and did not substantially affect the associations with other variables. Precision was high for both versions of the WEMWBS (>.80), and scalar measurement invariance was obtained for gender and age group. The final measurement models displayed adequate fit statistics in the validation sample as well. Correlations with other mental health scales were largely in line with expectations. No statistically significant differences were found in mean latent (S)WEMWBS scores for age and gender. CONCLUSION: Both WEMWBS scales appear to be valid and precise instruments to measure mental well-being in primary health care patients. The results encourage the use of mental well-being as an outcome in future epidemiological, clinical, and evaluation studies, and may as such be valuable for both research and public health practice.

The factor structure of the Hopkins Symptoms Checklist (HSCL-25) in a student population: A cautionary tale.

AIMS: The Hopkins Symptoms Checklist (HSCL-25) is a widely used self-report measurement for mental health problems, but its factor structure is still uncertain, with divergent results in different social or cultural settings. We aimed to investigate the previously suggested factor structures of the HSCL-25, as well as a model including an explicit somatic factor among students in Norway. METHODS: The study population is based on data from the Norwegian study of students' health and wellbeing, SHoT ('Studentenes Helse- og Trivselsundersøkelse'), and the present study comprises N = 13,525 participants. Using confirmatory factor analyses we investigated previously suggested factor structures, as well as a 3-factor structure, with specific subscales for anxiety, depression and somatic symptoms, suggested by the authors. After identification of the best-fitting model(s), measurement invariance across sexes, as well as associations with self-reported socioeconomic and social factors, use of medication and help-seeking behaviour were examined. RESULTS: Based on the fit indices alone, bi-factor models fitted the data the best. However, upon further scrutiny when exploring the viability of the bi-factor models, we deemed the reliability of the specific subscales as extremely low and not viable as subscales. We therefore suggest that a uni-dimensional model was the most appropriate in our study. CONCLUSIONS: Based on considerations of fit indices, viability of subscales and associations with social and socioeconomic factors we suggest that a uni-dimensional model is most appropriate for HSCL-25 in a student population. Future investigations should examine how the revisions could improve the psychometric properties of the scale.

Predicting Primary and Secondary Abstinence Among Adolescent Boys and Girls in the Western Cape, South Africa.

Two of the most effective health behaviours with regard to HIV prevention are condom use and sexual abstinence. While determinants of condom use among sub-Saharan African adolescents have been studied extensively, factors related to abstinence have received far less attention. This study identified socio-cognitive determinants of primary and secondary abstinence intentions and of early sexual activity. This study also assessed whether these factors had a direct or indirect association with intentions to abstain from sex. A longitudinal design was used in which 1670 students (age 12-16) of non-private South African high schools filled in a questionnaire, with a follow-up after 6 months, concerning sexual abstinence, attitudes, social norms, self-efficacy, risk perception and knowledge. Logistic and linear regression analysis with latent factors was used to assess determinants of intentions and abstinence, and structural equation modelling was used to assess indirect effects. Results showed that among sexually inactive students, social norms predicted the intention to abstain from sex in the next 6 months. Among sexually active students, reporting less disadvantages of abstinence predicted the intention to abstain. Sexual activity at follow-up was predicted by attitudes and intention among sexually inactive girls, and by knowledge among sexually inactive boys. No predictors were found for sexually active adolescents. Structural equation modelling further showed that risk perception was indirectly related to intentions to abstain from sexual intercourse. We conclude that addressing socio-cognitive factors in order to motivate adolescents to delay sex is more likely to be successful before they experience sexual debut. In addition, this study shows that the effect of increasing risk perceptions, a strategy often applied by parents and HIV prevention programmes, is to a large extent mediated by more proximal cognitive factors such as attitude. Research is needed to identify factors that influence the execution of intentions to abstain from sex.

Effects of PREPARE, a Multi-component, School-Based HIV and Intimate Partner Violence (IPV) Prevention Programme on Adolescent Sexual Risk Behaviour and IPV: Cluster Randomised Controlled Trial.

Young South Africans, especially women, are at high risk of HIV. We evaluated the effects of PREPARE, a multi-component, school-based HIV prevention intervention to delay sexual debut, increase condom use and decrease intimate partner violence (IPV) among young adolescents. We conducted a cluster RCT among Grade eights in 42 high schools. The intervention comprised education sessions, a school health service and a school sexual violence prevention programme. Participants completed questionnaires at baseline, 6 and 12 months. Regression was undertaken to provide ORs or coefficients adjusted for clustering. Of 6244 sampled adolescents, 55.3 % participated. At 12 months there were no differences between intervention and control arms in sexual risk behaviours. Participants in the intervention arm were less likely to report IPV victimisation (35.1 vs. 40.9 %; OR 0.77, 95 % CI 0.61-0.99; t(40) = 2.14) suggesting the intervention shaped intimate partnerships into safer ones, potentially lowering the risk for HIV.

Sociocognitive Predictors of Condom Use and Intentions Among Adolescents in Three Sub-Saharan Sites.

Many HIV intervention programs in sub-Saharan Africa have applied social cognitive theories such as the theory of planned behavior. However, a recent sub-Saharan African review was unable to show increased effectiveness for theory-based interventions. This study assessed whether the predictive value of attitudes, subjective norms, self-efficacy, and intention was similar to studies in Europe and the U.S., and whether there were differences between three sub-Saharan sites. Longitudinal multigroup structural equation modeling was used to assess whether attitudes, subjective norms, and self-efficacy predicted condom use intentions and condom use (after 6 months) among adolescents in three sites, namely Cape Town (South Africa; N = 625), Dar es Salaam (Tanzania; N = 271), and Mankweng (South Africa; N = 404). Condom use intentions were predicted by subjective norms and self-efficacy in all three sites. Attitudes were not related to intentions in Dar es Salaam and were moderately related to intentions in Cape Town and Mankweng. The proportions of explained variance in intentions and behavior were decent (37-52 and 9-19%, respectively). Although significant differences in predictive value were found between sites and in comparison to European and U.S. studies, intentions could adequately be explained by attitudes, subjective norms, and self-efficacy. However, the limited proportions of variance in behavior explained by intentions could signify the importance of contextual and environmental factors. Future studies are recommended to use an integrative approach that takes into account both individual and contextual factors, as well as social and environmental differences.

Dynamics of parent-adolescent communication on sexual health and HIV/AIDS in Tanzania.

Communication between parents and their adolescent children has been identified as one of the potential protective factors for adolescent sexual health. Qualitative exploration of sexual health communication with adolescents aged 12-15 (N = 114) and a sub-group of the parents (N = 20) was carried out. Four major themes emerged: reasons for parent-adolescent communications, or lack thereof; the focus of parental messages; the moral of the message; and the barriers to communication between parents and adolescents. Findings revealed similarities and discrepancies in views and perceptions between parents and adolescents. Adolescents and parents suggested that some sexual health communication was happening. Parents were reportedly likely to use fear to ensure that their children do not engage in risky sexual activities, while adolescents reported that conversations with their parents were mostly ambiguous and filled with warnings about the dangers of HIV/AIDS. Several communication barriers were reported by parents and adolescents. Parents of adolescents would benefit from HIV/AIDS specific communication skills.

Predicting condom use in South Africa: a test of two integrative models.

This study tested two integrative socio-cognitive models, namely the information-motivation-behavioral skills model (IMB) and the I-Change model (ICM), to assess their hypothesized motivational pathways for the prediction of condom use during last sexual intercourse. Students (N = 1066) from Cape Town, South Africa, filled out questionnaires at three different time points. Structural equation modeling demonstrated that self-efficacy did not predict behavior directly but indirectly via intention. Knowledge of how to use a condom and how STIs are transmitted directly predicted behavior when modeled as hypothesized by the IMB model, but indirectly when the factors attitude, subjective norms and self-efficacy were included as mediators, as hypothesized by the ICM. It is concluded that the ICM and IMB are similar in terms of model fit and explained variance, but that the ICM had a higher proportion of significant pathways.

Attitudes towards smoking restrictions and tobacco advertisement bans in Georgia.

OBJECTIVES: This study aims to provide data on a public level of support for restricting smoking in public places and banning tobacco advertisements. DESIGN: A nationally representative multistage sampling design, with sampling strata defined by region (sampling quotas proportional to size) and substrata defined by urban/rural and mountainous/lowland settlement, within which census enumeration districts were randomly sampled, within which households were randomly sampled, within which a randomly selected respondent was interviewed. SETTING: The country of Georgia, population 4.7 million, located in the Caucasus region of Eurasia. PARTICIPANTS: One household member aged between 13 and 70 was selected as interviewee. In households with more than one age-eligible person, selection was carried out at random. Of 1588 persons selected, 14 refused to participate and interviews were conducted with 915 women and 659 men. OUTCOME MEASURES: Respondents were interviewed about their level of agreement with eight possible smoking restrictions/bans, used to calculate a single dichotomous (agree/do not agree) opinion indicator. The level of agreement with restrictions was analysed in bivariate and multivariate analyses by age, gender, education, income and tobacco use status. RESULTS: Overall, 84.9% of respondents indicated support for smoking restrictions and tobacco advertisement bans. In all demographic segments, including tobacco users, the majority of respondents indicated agreement with restrictions, ranging from a low of 51% in the 13-25 age group to a high of 98% in the 56-70 age group. Logistic regression with all demographic variables entered showed that agreement with restrictions was higher with age, and was significantly higher among never smokers as compared to daily smokers. CONCLUSIONS: Georgian public opinion is normatively supportive of more stringent tobacco-control measures in the form of smoking restrictions and tobacco advertisement bans.

An HIV/AIDS knowledge scale for adolescents: item response theory analyses based on data from a study in South Africa and Tanzania.

A 14-item human immunodeficiency virus/acquired immunodeficiency syndrome knowledge scale was used among school students in 80 schools in 3 sites in Sub-Saharan Africa (Cape Town and Mankweng, South Africa, and Dar es Salaam, Tanzania). For each item, an incorrect or don't know response was coded as 0 and correct response as 1. Exploratory factor analyses based on polychoric correlations showed two separate factors for all sites. Two-parameter item response theory (IRT) analysis (bifactorial multiple indicators multiple causes confirmatory factor analysis models) consistently showed a general first factor and a second 'method' factor. One single global latent variable seemed to sufficiently well capture most of the systematic variation in knowledge. Some items did not discriminate well between levels of the underlying knowledge latent variable and information values were highest for low levels of knowledge. The scale might be improved by adding items, in particular items that are more difficult to answer. Some differential item functioning effects related to site and socioeconomic status were identified. Scores on the latent knowledge variable were particularly low among females in Dar es Salaam and Mankweng, and were negatively associated with socioeconomic status. This study illustrates advantages of using IRT analysis instead of more conventional approaches to examining psychometric properties of knowledge scales.

Outcome expectations and use of smokeless tobacco (snus): a cross-sectional study among young Norwegian snus users.

In this study, measures of outcome expectancies related to use of snus (wet snuff) were used to predict reported frequency of snus use. Data stem from a nation-wide survey in Norway among 16- to 20-year-olds. Only users of snus were included in the statistical analyses (n = 589). The main outcome measure, frequency of snus use, was measured as a categorical variable - occasional, weekly and daily use. Four dimensions of outcome expectancies (mood regulation, smoking control, weight control and negative health outcomes) were measured and confirmed in a confirmatory factor analysis. Informants tended to believe that snus use is harmful to health, but still they supported the idea of snus as a way to control own cigarette smoking. In a SEM model, two of the four dimensions of outcome expectancies turned out to be particularly significant predictors of frequency of snus use - mood regulation and smoking control. No significant interactions with gender were found. Males scored higher than females on "mood regulation", and "smoking control", while females scored higher than males on "negative health outcomes". If more smokers were convinced that snus use is a less harmful alternative, more of them might start using snus, not only because there is some association between health outcome expectancies and snus use, but also because snus use by many is perceived as a remedy to stop smoking and as a way to gain some of the mood regulation benefits which are usually associated with smoking.

Smoking cessation among Norwegian adolescents and young adults: preferred cessation methods.

Despite generally declining smoking rates, particularly among young people, a large number of people remain smokers and many young people still pick up smoking. Helping smokers quit therefore remains a high priority for the public health sector. In the present study we examined adolescents and young adults' preferences regarding cessation methods and if these differed between genders and depended on smoking frequency. The data came from a nationally representative survey in Norway among 16-20 year olds. Only regular (weekly and daily) smokers were included in the statistical analyses (n = 509, 51% females). The findings suggest that the majority of both male (83.6%) and female (78.4%) smokers would prefer to quit smoking without help. More males than females reported that they would consider using snus as a cessation aid, while females more often reported willingness to attend cessation classes or use brochures and diaries as cessation aids. Both males and females had similar preferences albeit low, regarding the use of health services, nicotine gum or patches and internet and sms-services to quit smoking. Daily smokers would more often than weekly smokers prefer to attend cessation classes, seek help from health services, use nicotine gum or patches or use brochures and diaries. In contrast, weekly smokers preferred to use snus as a cessation aid more often than daily smokers. Identifying and making appropriate cessation methods attractive may lead to successful quitting and consequently public health gains.

Dating violence among school students in Tanzania and South Africa: prevalence and socio-demographic variations.

AIMS: Widespread adolescent dating violence (DV) in Sub-Saharan Africa calls for immediate action, particularly since it is linked to the spread of HIV/AIDS. This article presents prevalence and demographic correlates of DV among school students in Cape Town and Mankweng (South Africa) and Dar es Salaam (Tanzania). METHODS: Data were derived from the baseline data collection of a multi-site randomized controlled trial of an HIV prevention intervention among young adolescents. The results were confined to students who reported previously or currently being in a relationship (n = 6,979). Multiple logistic regression analysis with demographic predictors was employed, controlled for cluster effect. RESULTS: Within our sample 10.2%-37.8% had been victims, 3.1%-21.8% had been perpetrators, and 8.6%-42.8% had been both (percentages dependent on site and gender). Before controlling for other factors, religion was a protective factor against violence in Cape Town. After controlling for other factors, a higher age and lower socioeconomic status were associated with belonging to any of the three groups of violence. Being male in all sites was associated with perpetration; being female with victimization (except in Cape Town where the converse finding was obtained). Higher parental education in Cape Town was protective against all types of violence. Ethnicity and living with biological parents were not associated with violence. CONCLUSIONS: DV is prevalent and widespread in the study sites. Violence control policies and interventions should target young adolescents. Since there was not one clearly defined subgroup identified as being at high risk, such programmes should not be limited to high risk groups only.

Employees' job satisfaction after the introduction of a total smoke-ban in bars and restaurants in Norway.

The aim of the study was to investigate possible effects of a total smoke-ban in Norwegian bars and restaurants (introduced on June 1st 2004) on employees' job satisfaction. A national representative sample was randomly selected from the public registry of all companies in the hospitality business. A baseline survey was conducted in May 2004, follow-up measurements were performed in September/October 2004 and May 2005. Altogether, 1525 employees agreed to participate in the baseline survey. Among respondents at baseline, 894 (59.4%) remained in the sample at the first follow-up and 758 (49.7%) at the second follow-up. Analysis of variance for repeated measures revealed a significant three-way interaction between personal smoking behaviour, attitudes towards the ban before it was enacted and time from baseline to the second follow-up. A small decline in job satisfaction was found between baseline and the first follow-up among employees who were daily smokers and had a negative attitude towards the ban. There was, however, an increase in job satisfaction between the first and second follow-up among the others (non-smokers and smokers with a positive attitude towards the ban). While job satisfaction was higher among smokers with negative attitudes towards the ban than among other employees before the ban entered into force, the opposite was the case one year later. The work environments in bars and restaurants seem to have changed towards being more satisfactory for non-smokers and smokers with positive attitudes towards the ban before it was enacted. In contrast, a small but persisting worsening of job satisfaction was found among employees that were daily smokers and had a negative attitude towards the ban.

A population-based cohort study of the effect of common mental disorders on disability pension awards.

OBJECTIVE: Mental illness is consistently underrecognized in general health care, which may lead to underestimation of its effects on awards for social security payments. The authors investigated empirically the contribution of psychiatric morbidity to the award of disability pensions, in particular those awarded for physical diagnoses. METHOD: Using a historical cohort design, the authors utilized a unique link between a large epidemiological cohort study and a comprehensive national database. Baseline information on mental and physical health was gathered from a 1995-1997 population-based health study of those of working age (20-66 years) in Nord-Trøndelag County, Norway, who were not recipients of disability pension (N=45,782). The outcome assessed was the awarding of disability pensions ascribed to specific ICD-10 diagnoses within 6 to 30 months as registered in the National Insurance Administration. RESULTS: Anxiety and depression were robust predictors of disability pension awards in general, even when disability pensions awarded for any mental disorder were excluded. These effects were only partly explained by baseline somatic symptoms and diagnoses and were stronger in individuals aged 20-44 than in those aged 45-66. Somatic symptoms accounted for far more disability pension awards than did somatic diagnoses. CONCLUSIONS: The cost of common mental disorders in terms of disability pensions and lost productivity may have been considerably underestimated by official statistics, particularly for younger claimants. The results suggest this might be due both to overuse of physical diagnoses and underrecognition of common mental disorders in primary care.

Unsafe sexual behaviour in South African youth.

A growing body of evidence points to the complexity of sexual behaviour. HIV risk behaviour is influenced by factors at three levels: within the person, within the proximal context (interpersonal relationships and physical and organisational environment) and within the distal context (culture and structural factors). This paper presents the findings of a review of research on the factors promoting and perpetuating unsafe sexual behaviour in South African youth. Papers included in the review were dated between 1990 and 2000 and addressed sexual behaviour of youth between the ages of 14 and 35 years. Both published works and unpublished reports and dissertations/theses were included. The review concluded that at least 50% of young people are sexually active by the age of 16 years; the majority of school students who had ever experienced sexual intercourse reported at the most one partner in the previous year, with a persistent minority of between 1% and 5% of females and 10-25% of males having more than four partners per year; and between 50% and 60% of sexually active youth report never using condoms. In terms of explanations for unsafe sexual behaviour among South African youth, the findings illustrate the powerful impact of the proximal and distal contexts, and in particular, the pervasive effect of poverty and social norms that perpetuate women's subordination within sexual relationships. Personal factors and the proximal and distal contexts interact to encourage HIV risk behaviour in ways that are not fully captured by social-cognitive models. The findings will be of interest to researchers and practitioners in the fields of adolescent sexual behaviour and HIV prevention in developing countries.

Subjective health complaints in adolescence: dimensional structure and variation across gender and age.

AIMS: The aim of this study is to investigate dimensional structures in subjective health complaints in adolescents and to examine the variation in levels and dimensionality across gender and age groups. METHODS: Data from two studies were used: (1) a study based on a convenience sample, consisting of 1427 Norwegian students (11- to 15-year-olds) from schools participating in the European Network of Health Promoting Schools; (2) a nationwide survey amongst 7,059 Norwegian students (aged 11, 13, 15, and 16) from the Health Behaviour in School-aged Children (HBSC) study. Subjective health complaints were measured by revised versions of the HBSC symptoms checklist (HBSC-SCL). RESULTS: In study 1 confirmatory factor analysis revealed that a model of two highly correlated factors, which can be labelled somatic and psychological, fitted the data reasonably well (CFI = 0.91). This two-factor model was applied in study 2 and latent means were tested across sub-samples defined by gender and age. The results indicate that girls show higher mean levels compared with boys on both factors. There is also an indication of an increase in these factors with age amongst girls, while amongst boys there is less, if any, difference across age groups. The correlation between the somatic and psychological factors was virtually constant across age groups and gender. CONCLUSIONS: The identification of a somatic and a psychological factor indicates the existence of two different dimensions that may have different aetiologies. The gender difference in latent means across age groups may suggest a different developmental pattern amongst girls and boys.