Cumulative risk factors for injuries and poisoning requiring hospital care in youth with prenatal substance exposure: A longitudinal controlled cohort study.

Aim: To investigate whether the youth with prenatal substance exposure (PSE) (aged 15-24 years, n = 615) had been in hospital care more often due to injuries and poisoning in comparison with unexposed matched controls (n = 1787). Methods: Data from medical records (exposure) and national health and social welfare registers (outcome and confounders) were combined and youths were monitored from birth until either outpatient or inpatient hospital care for injury or poisoning, death or the end of the study period (December 2016). Cox regression models were used in the analyses accounting for associated child and maternal risk factors. Results: Half (50.4%) of the exposed group and 40.6% of controls had been in hospital care due to injury or poisoning during the follow-up (p < 0.001). The difference between groups was diminished after controlling for postnatal child and maternal risk factors (hazard ratio [HR] = 0.88, 95% confidence interval [CI] 0.72-1.07, p > 0.05). Cumulative adversity, especially out-of-home care in combination with a diagnosed attention or behavioural dysregulation problem, posed the highest risk in both groups (exposed: HR = 1.65, 95% CI 1.24-2.19, p < 0.001; controls: HR = 1.84, 95% CI 1.33-2.56, p < 0.001). Conclusion: Hospital care for injury and poisoning is more common in youth with PSE, but this is largely explained by the related postnatal child and maternal factors. Long-term support to families with maternal substance abuse problems could prevent injury and poisoning among youth with PSE.

Adverse childhood experiences and neurodevelopmental disorders among youth with and without prenatal substance exposure: A longitudinal matched register-based cohort study.

Background: Previous research has shown an association between adverse childhood experiences (ACEs) and secondary mental health problems in youth with prenatal substance exposure (PSE), but the association between ACEs and neurodevelopmental disorders is less clear. Methods: This longitudinal register-based cohort study investigated relationships between health at birth, ACEs (out-of-home care (OHC) and maternal adversities), and neurodevelopmental disorders among youth with PSE (alcohol/drugs, n = 615) and matched unexposed controls (n = 1787). Hospital medical records and register data were merged and analysed using Cox regression models. Results: Conduct and emotional disorders (International Statistical Classification of Diseases and Related Health Problems ICD-10, F90-F94) were more common among the exposed than the controls but only when the exposed and controls with no OHC were compared. The difference appeared in hyperkinetic disorders (ADHD, F90), mixed disorders of conduct and emotions (F92) and emotional disorders with onset specific to childhood (F93). Among the exposed and controls with OHC, over 40% had received an F90-F94 diagnosis. Regarding specific developmental disorders (F80-F83, e.g., impairments in speech and language and scholastic skills) the moderate difference between the exposed and controls attenuated after adjustment for OHC. Again, the rates were highest among the exposed with OHC and the controls with OHC. OHC and maternal risks were interrelated and, together with male sex and low birth weight, were associated with neurodevelopmental disorders both among the exposed and controls and decreased the difference between them. Conclusions: A strong association between ACEs and neurodevelopmental disorders was found. Brain research is needed to examine whether ACEs worsen neurodevelopmental outcomes caused by PSE.

Mood and neurotic disorders among youth with prenatal substance exposure: A longitudinal register-based cohort study.

BACKGROUND: Prenatal substance exposure is associated with mood and neurotic disorders but this association is complex and understudied. This study investigated the recorded use of specialised healthcare services for mood and neurotic disorders among youth with prenatal substance exposure in comparison with an unexposed matched cohort. Furthermore, the influence of adverse maternal characteristics and out-of-home care (OHC) is investigated. METHODS: This longitudinal register-based matched cohort study included 594 exposed and 1735 unexposed youth. Cox proportional hazard regression models were applied to study the first episode of mood and neurotic disorders in specialised healthcare from 13 years of age, and the influence of adverse maternal characteristics and OHC. Mediation analysis was applied to study the mediating effect of OHC on the association between prenatal substance exposure and the disorders. RESULTS: The exposed cohort had a two-fold higher likelihood of being treated at specialised healthcare for mood and neurotic disorders compared with the unexposed cohort (HR 2.34, 95% CI 1.86-2.95), but this difference was attenuated to non-significant levels (AHR 1.29, 95% CI 0.92-1.81) following adjustments with adverse maternal characteristics and OHC. OHC mediated 61% (95% CI 0.41-0.94) of the association between prenatal substance exposure and youth's mood and neurotic disorders. LIMITATIONS: Register data likely include more severe cases of disorders, and as an observational study, causality cannot be assessed. CONCLUSION: Mood and neurotic disorders are more common following prenatal exposure to substances and interlinked with significant adversities in the postnatal caregiving environment and OHC.

Empowerment among adult patients with type 2 diabetes: age differentials in relation to person-centred primary care, community resources, social support and other life-contextual circumstances.

BACKGROUND: Rising prevalence of type 2 diabetes (T2D), also among younger adults, constitutes a growing public health challenge. According to the person-centred Chronic Care Model, proactive care and self-management support in combination with community resources enhance quality of healthcare and health outcomes for patients with T2D. However, research is scarce concerning the importance of person-centred care and community resources for such outcomes as empowerment, and the relative impact of various patient support sources for empowerment is not known. Moreover, little is known about the association of age with these variables in this patient-group. This study, carried out among patients with T2D, examined in three age-groups (27-54, 55-64 and 65-75 years) whether person-centred care and diabetes-related social support, including community support and possibilities to influence community health issues, are associated with patient empowerment, when considering possible confounding factors, such as other quality of care indicators and psychosocial wellbeing. We also explored age differentials in empowerment and in the proposed correlates of empowerment. METHOD: Individuals from a register-based sample with T2D participated in a cross-sectional survey (participation 56%, n = 2866). Data were analysed by descriptive statistics and multivariate logistic regression analyses. RESULTS: Respondents in the youngest age-group were more likely to have low empowerment scores, less continuity of care, and lower wellbeing than the other age-groups, and to perceive less social support, but a higher level of person-centred care than the oldest group. Community support, including possibilities to influence community health issues, was independently and consistently associated with high empowerment in all three age-groups, as was person-centred care in the two older age-groups. Community support was the social support variable with the strongest association with empowerment across age-groups. Moreover, vitality was positively and diabetes-related distress negatively associated with high empowerment in all age-groups, whereas continuity of care, i.e. having a family/regular nurse, was independently associated in the youngest age-group only. CONCLUSION: Person-centred care and community support, including possibilities to influence community health issues, supports empowerment among adults with T2D. Findings suggest that age is related to most correlates of empowerment, and that younger adults with T2D have specific healthcare needs.

Completed secondary education among youth with prenatal substance exposure: A longitudinal register-based matched cohort study.

INTRODUCTION: The dual impact of prenatal substance exposure (i.e. alcohol/drugs) and adverse postnatal caregiving environment on offspring secondary education completion is an understudied research area. The aim was to investigate the influence of childhood adversities, out-of-home care, and offspring's mental and/or behavioural disorders on secondary education completion among prenatally exposed offspring in comparison to matched unexposed offspring. METHODS: This is a longitudinal register-based matched cohort study in Finland including offspring with a history of prenatal substance exposure and a matched unexposed cohort. The study sample included 283 exposed and 820 unexposed offspring aged 18-23 years. RESULTS: The results showed a time lag in secondary education completion and lower educational attainment overall among exposed compared with unexposed (37.8% vs. 51.0%, respectively). The results from the multivariate logistic regression models showed that the differences in the secondary education completion between exposed and unexposed were diminished in the presence of covariates. A cumulative childhood adversity score and out-of-home care were not associated with secondary education completion in the multivariate models, whereas the different domains of offspring's mental and/or behavioural disorders including psychiatric disorders (AOR 0.65, 95% CI 0.45-0.96), neuropsychological disorders (AOR 0.35, 95% CI 0.23-0.54) and dual psychiatric and neuropsychological disorder (AOR 0.29, 95% CI 0.18-0.48) showed an independent negative effect on secondary education completion. CONCLUSIONS: Inferior educational outcomes may not be directly linked with prenatal substance exposure but may rather reflect the extent of evolving offspring's mental and/or behavioural disorders over time influenced by childhood adversities.

Cohort profile: ADEF Helsinki - a longitudinal register-based study on exposure to alcohol and drugs during foetal life.

PURPOSE: The need for longitudinal studies on prenatal substance exposure (PSE) extending into adulthood is widely recognised. In particular, studies on the dual effect of exposure to substances and adverse childhood experiences are needed. This register-based matched cohort study investigates the effect of this dual exposure on the health and development of youth with PSE. The follow-up is from birth to young adulthood. PARTICIPANTS: The exposed youth were born in 1992-2001 to mothers with a significant substance misuse problem during pregnancy. The mothers were identified in primary care maternity clinics in the Helsinki metropolitan area and referred for intensified pregnancy follow-up in a tertiary care setting (HAL-clinics). Data from hospital medical records were collected for the mothers during the pregnancy follow-up and linked with register data from multiple national health and social welfare registers obtained for each mother-child dyad from birth until the end of 2015-2018. Similar register data were gathered for three matched mother-child dyads without any evidence of the mother's substance misuse in national health and social welfare registers. The study consists of 615 exposed and 1787 unexposed youth aged 15-24 years. FINDINGS TO DATE: A majority of the exposed youth (64%) had been in out-of-home care at least once compared with 8% among the unexposed. Outpatient and inpatient hospital care due to mental or behavioural disorders were two to three times more common among the exposed than among the unexposed. The exposed had less often completed secondary school education and had more often needed social assistance. FUTURE PLANS: The data comprise a wide range of information on infant health, youth's mental and somatic health and development, out-of-home care history, and mother's life situation at the delivery and later health. Risk and protective factors for different long-term developmental outcomes in adolescence or in young adulthood will be studied.

Prenatal substance exposure, adverse childhood experiences and diagnosed mental and behavioral disorders - A longitudinal register-based matched cohort study in Finland.

Both prenatal substance exposure (PSE, alcohol/drugs) and experiences during the first years of life have powerful effects on brain development. However, only a few studies have investigated the combined effect of PSE and adverse childhood experiences (ACEs) on mental and behavioral disorders among exposed adolescents and adults. This longitudinal register-based cohort study 1) compared the nature and extent of diagnosed mental and behavioral disorders among youth with PSE and matched unexposed controls, and 2) investigated the influence of PSE, health in infancy and ACEs (maternal risk factors and out-of-home care, OHC) on diagnoses of mental and behavioral disorders. The data consisted of 615 exposed youth aged 15-24 years and 1787 matched unexposed controls. Data from hospital medical records and nine registers were merged for the analysis. Descriptive analysis methods and Cox regression were used. The results showed that the prevalence of mental and behavioral disorders was twice as high among exposed compared with controls. The highest levels of mental and behavioral disorders and ACEs were found among exposed with at least one OHC episode. The difference in the risk of mental and behavioral disorders between exposed and controls diminished after controlling for the effect of ACEs. Low birth weight, maternal risk factors, and OHC were the strongest predictors of mental and behavioral disorders. The results suggest that PSE alone does not explain poorer mental health among exposed youth. Risk factors accumulate, and low birth weight and ACEs are strongly associated with increased risk of mental and behavioral disorders.

Does chronic pain hinder physical activity among older adults with type 2 diabetes?

Background: Physical activity (PA) is a key component in management of type 2 diabetes (T2D). Pain might be a barrier to PA especially among older adults with T2D, but surprisingly few studies have investigated the association between chronic pain and PA. Our aim was to evaluate the prevalence of chronic pain among older adults with T2D and to examine the association between chronic pain and PA while taking important life-contextual factors into account. Methods: Data of this register-based, cross-sectional study were collected in a survey among adults with T2D (n=2866). In the current study, only respondents aged 65-75 years were included (response rate 63%, n=1386). Data were analysed by means of descriptive statistics and multivariate logistic regression analysis. Results: In total, 64% reported chronic pain. In specific groups, e.g. women and those who were obese, the prevalence was even higher. Among respondents experiencing chronic pain, frequent pain among women and severe pain among both genders were independently associated with decreased likelihood of being physically active. Moreover, the likelihood of being physically active decreased with higher age and BMI, whereas it increased with higher autonomous motivation and feelings of energy. Among physically active respondents suffering from chronic pain, neither intensity nor frequency of pain explained engagement in exercise (as compared with incidental PA). Instead, men were more likely to exercise regularly as were those with good perceived health and higher autonomous motivation. Conclusions: The prevalence of chronic pain is high among older adults with T2D. This study shows that among those suffering from chronic pain, severe pain is independently and inversely associated with being physically active, as is frequent pain, but only among women. Moreover, the findings show the importance of autonomous motivation and health variables for both incidental PA and exercise among older adults with T2D experiencing chronic pain.

How to promote fruits, vegetables, and berries intake among patients with type 2 diabetes in primary care? A self-determination theory perspective.

The results of this study showed the importance of autonomous motivation for healthy eating. Autonomous motivation and female gender were the determinants most strongly associated with fruits, vegetables, and berries intake among patients with type 2 diabetes. Other determinants of fruits, vegetables, and berries intake were high education, high social support, high age, and a strong sense of coherence. Autonomous motivation and self-care competence mediated the effect of perceived autonomy support from a physician on fruits, vegetables, and berries intake. Thus, physicians can promote patients' fruits, vegetables, and berries intake by supporting their autonomous motivation and self-care competence. The results are in line with self-determination theory.

Patients' assessment of chronic illness care: a validation study among patients with type 2 diabetes in Finland.

BACKGROUND: To meet the challenges of the rising prevalence of chronic diseases, such as type 2 diabetes, new approaches to healthcare delivery have been initiated; among these the influential Chronic Care Model (CCM). Valid instruments are needed to evaluate the public health impact of these frameworks in different countries. The Patient Assessment of Chronic Illness Care (PACIC) is a 20-item quality of care measure that, from the perspective of the patient, measures the extent to which care is congruent with the CCM. The aim of this study was to evaluate the psychometric properties of the Finnish translation of the PACIC questionnaire, in terms of validity and reliability, in a large register-based sample of patients with type 2 diabetes. METHOD: The PACIC items were translated into Finnish in a standardized forward-backward procedure, followed by a cross-sectional survey among patients with type 2 diabetes (response rate 56%; n = 2866). We assessed the Finnish version of the PACIC scale for the following psychometric properties: content validity, internal consistency reliability, convergent and construct validity. We also present descriptive data on total scale as well as predetermined subscale levels. RESULTS: The item-response on the PACIC scale was high with only small numbers of missing data (0.5-1.1%). Ceiling effects were low (0.3-5.3%) whereas floor effects were over 20% for two of the predetermined subscales (problem solving and follow-up/coordination). The total PACIC scale showed a reasonable distribution and excellent internal consistency (alpha 0.94) while the internal consistency of the subscales were at least acceptable (0.74-0.86). The principal component analysis identified a two- or three-factor solution instead of the proposed five-dimensional. In other respects, the PACIC scale showed the hypothesized relationships with quality of care and outcome measures, thus demonstrating convergent and construct validity. CONCLUSION: A Finnish version of the PACIC scale is now validated in the primary care setting among patients with type 2 diabetes. The findings suggest comparable psychometric properties of the Finnish scale as of the original English instrument and earlier translations, and reasonable levels of validity and reliability.

Success in increasing physical activity (PA) among patients with type 2 diabetes: a self-determination theory perspective.

BACKGROUND: Increased physical activity (PA) is crucial for achieving and maintaining glycemic control and is beneficial for overall well-being of patients with type 2 diabetes as well. Despite that, many patients fail to make changes in their exercise behavior. Self-determination theory (SDT) addresses this problem and suggests that perceived autonomy support, autonomous motivation and self-care competence play a key role in the process of health behavior change. This study investigated the impact of these three factors on success in increasing PA among patients with type 2 diabetes but considered also the role of other important life-context factors, such as mental health, stress and social support. The effect of these other factors may outweigh the effect of SDT constructs; however, previous studies based on SDT have largely overlooked them. METHODS: This cross-sectional mail survey was carried out in 2011. Out of 2866 respondents, those who had been over 2 years in care in their present and principal primary care health center and had during the past two years tried to increase PA either with or without success (n = 1256, mean age 63 years, 52% men), were included in this study. Logistic regression and mediation analyses were the main methods used in the data analysis. RESULTS: Autonomous motivation predicted success in increasing PA even after controlling for the effect of other important life-context factors. Other predictors of success were felt energy, good perceived health, younger age and less social support. Autonomous motivation mediated the effect of perceived autonomy support from a doctor on success in increasing PA. CONCLUSION: The results were in line with SDT showing the importance of autonomous motivation for success in increasing PA. Doctor-patient relationships and lifestyle interventions should focus on promoting self-motivated reasons for health behavior change.

Success in Weight Management Among Patients with Type 2 Diabetes: Do Perceived Autonomy Support, Autonomous Motivation, and Self-Care Competence Play a Role?

Based on self-determination theory (SDT), this study investigated whether the three central SDT variables-perceived autonomy support (from a physician), autonomous motivation and self-care competence-were associated with success in weight management (SWM) among primary care patients with type 2 diabetes when the effect of other important life-context factors was controlled for. Patients participated in a mail survey in 2011. Those who had tried to change their health behavior during the past two years in order to lose weight, either with or without success (n = 1433, mean age 63 years, 50% men), were included in this study. The successors were more autonomously motivated and energetic than the non-successors. Moreover, male gender, younger age, taking oral medication only, and receiving less social support in diabetes care predicted better success. Autonomous motivation predicted SWM; self-care competence also played a role by partly mediating the effect of autonomous motivation on SWM. These results support the idea of SDT that internalizing the value of weight management and its health benefits is necessary for long-term maintenance of health behavior change. Perceived autonomy support was not directly associated with SWM. However, physicians can promote patients' weight management by supporting their autonomous motivation and self-care competence.

Quality of primary health care and autonomous motivation for effective diabetes self-management among patients with type 2 diabetes.

This study showed, in line with self-determination theory, that of the six central quality dimensions of primary health care (access to care, continuity of care, diabetes counseling, autonomy support from one's physician, trust, patient-centered care), autonomy support from one's physician was most strongly associated with autonomous motivation (self-regulation) for effective diabetes self-management among patients with type 2 diabetes (n = 2866). However, overall support for diabetes care received from friends, family members, other patients with diabetes, and health care professionals may even play a greater role.

Determinants of physical activity among patients with type 2 diabetes: the role of perceived autonomy support, autonomous motivation and self-care competence.

Based on self-determination theory (SDT), this study investigated, whether the three central SDT variables (perceived autonomy support, autonomous motivation and self-care competence), were associated with engagement in physical activity (PA) among patients with type 2 diabetes when the effect of a wide variety of other important life-context factors (perceived health, medication, duration of diabetes, mental health, stress and social support) was controlled for. Patients from five municipalities in Finland with registry-based entitlement to a special reimbursement for medicines used in the treatment of type 2 diabetes (n = 2866, mean age 63 years, 56% men) participated in this mail survey in 2011. Of all measured explanatory factors, autonomous motivation was most strongly associated with engagement in PA. Autonomous motivation mediated the effect of perceived autonomy support on patients' PA. Thus, perceived autonomy support (from one's physician) was associated with the patient's PA through autonomous motivation. This result is in line with SDT. Interventions for improved diabetes care should concentrate on supporting patients' autonomous motivation for PA. Internalizing the importance of good self-care seems to give sufficient energy to maintain a physically active lifestyle.

Health-care climate, perceived self-care competence, and glycemic control among patients with type 2 diabetes in primary care.

This study showed, in line with self-determination theory, that glycemic control among patients with type 2 diabetes (n = 2866) was strongly associated with perceived self-care competence, which in turn was associated with autonomous motivation and autonomy-supportive health-care climate. These associations remained after adjusting for the effect of important life-context factors. Autonomous motivation partially mediated the effect of health-care climate on perceived competence, which fully mediated the effect of autonomous motivation on glycemic control. The results of the study emphasize health-care personnel's important role in supporting patients' autonomous motivation and perceived self-care competence.

Job involvement of primary healthcare employees: does a service provision model play a role?

AIM: To investigate whether the development of job involvement of primary healthcare (PHC) employees in Southern Municipality (SM), where PHC services were outsourced to an independent non-profit organisation, differed from that in the three comparison municipalities (M1, M2, M3) with municipal service providers. Also, the associations of job involvement with factors describing the psychosocial work environment were investigated. METHODS: A panel mail survey 2000-02 in Finland (n=369, response rates 73% and 60%). The data were analysed by descriptive statistics and multivariate linear regression analysis. RESULTS: Despite the favourable development in the psychosocial work environment, job involvement decreased most in SM, which faced the biggest organisational changes. Job involvement decreased also in M3, where the psychosocial work environment deteriorated most. Job involvement in 2002 was best predicted by high baseline level of interactional justice and work control, positive change in interactional justice, and higher age. Also other factors, such as organisational stability, seemed to play a role; after controlling for the effect of the psychosocial work characteristics, job involvement was higher in M3 than in SM. CONCLUSION: Outsourcing of PHC services may decrease job involvement at least during the first years. A particular service provision model is better than the others only if it is superior in providing a favourable and stable psychosocial work environment.

Psychosocial work environment and emotional exhaustion--does a service provision model play a role?

OBJECTIVES: To investigate whether outsourcing of primary health care (PHC) services has affected the psychosocial work environment and emotional exhaustion. METHODS: Panel mail study 2000-2002 in Finland, 369 PHC employees. Comparison between Southern municipality (SM) after outsourcing PHC services to a not-for-profit organization and three municipalities with municipal service providers. RESULTS: Despite the positive development of the psychosocial work environment in SM, emotional exhaustion had increased there like in the comparison municipalities. However, in 2002 emotional exhaustion was at a lower level in SM than in one of the comparison municipalities. This difference could not be attributed to the production model itself but rather to baseline levels and changes in work demands and work resources. CONCLUSIONS: Outsourcing of PHC services may improve employee health and thus effectiveness of health care if a new service provider emphasizes employee health more than a previous one and is more flexible to improve the quality of the psychosocial work environment. However, change itself may be stressful, and frequent changes of service providers should be avoided.