Population-based enrolment of adolescents in a long-term follow-up trial of human papillomavirus vaccine efficacy.

We evaluated a study setting for assessment of the long-term vaccine efficacy (VE) of human papillomavirus (HPV) virus-like-particle (VLP) vaccine against cervical carcinoma. A total of 22,412 16- to 17-year old adolescent women from seven cities in Finland were invited by letter to participate in a phase III study of a quadrivalent HPV (types 6, 11, 16, 18) VLP vaccine, between September 2002 and March 2003. A total of 30,947 18-year old women were invited to participate as unvaccinated controls. These women were asked about their willingness to participate in an HPV vaccination trial and to fill a health questionnaire. These three population-based cohorts of adolescent women, including women vaccinated with HPV vaccine or placebo vaccine and unvaccinated control women, are systematically followed over time. The study cohort database will be linked with the Finnish Cancer Registry using cervical carcinoma in situ (CIS) and invasive cervical carcinoma (ICC) as endpoints. Assuming that the cumulative incidence of CIS and ICC over 15 years is 0.45%, and that there is no loss to follow-up, and power of 80%, the determination of 70% total VE will require 3357 HPV vaccine recipients, 3357 placebo vaccine recipients, and 6714 unvaccinated controls. At the baseline, 2632 (12%) of the invited adolescents volunteered to the phase III vaccination trial, and 6790 (22%) responded to the questionnaire study. During a recruitment period of 10 months, 874 HPV vaccine recipients, 875 placebo recipients and 1919 unvaccinated controls were enrolled. Population-based enrollment of large cohorts of vaccinated and unvaccinated adolescents for passive registry-based follow-up with cervical carcinoma as the end-point is feasible and currently going on in Finland.

Risk-taking sexual behaviour and self-reported depression in middle adolescence--a school-based survey.

BACKGROUND: Early sexual activity has been widely studied in the context of pregnancies, substance use and antisocial behaviour, but the aspects of psychosexual health have received less attention. AIM: To study the associations of early sexual activity and self-reported depression. SETTING: A school survey in Finland in 1999 and 2000 in the eighth and ninth grades. METHODS: Adolescents with experience of sexual intercourse were studied (11,793 girls and 10,443 boys, mean age 15.5 years). Scores of 8 or more in the Beck Depression Inventory were regarded as indicative of self-reported depression. Associations with sexual behaviour variables were analysed using logistic regression models. RESULTS: In both genders, self-reported depression increased in proportion to the number of sexual partners and with the non-use of contraception. A higher number of coital experiences correlated with depression only among boys. Adjusting for age and age at menarche/oigarche did not affect the associations detected. In stepwise logistic regression, an increasing number of partners increased the risk for self-reported depression [for boys with at least five partners odds ratio (OR) 2.5, 95% confidence intervals (CI) 2.2-3.0, and for girls OR 2.7, 95% CI 2.3-3.2]. Boys and girls who did not use contraception showed roughly twice as high a risk as contraceptive users. However, girls with five or more coital experiences had a significantly lower risk for depression compared to girls with only one sexual intercourse. CONCLUSIONS: Multiple sexual partners and non-use of contraception may reflect a depressive disorder in both genders. While adolescent health service providers should be aware of the risk for depression among sexually active adolescents, the sexual health of depressed adolescents also warrants special attention.

Sociodemographic differences in the occurrence of teenage pregnancies in Finland in 1987-1998: a follow up study.

STUDY OBJECTIVE: To analyse sociodemographic differences in the occurrence of pregnancies to 14 to 19 year olds and changes in these differences from 1987 to 1998. DESIGN: Follow up of adolescent survey respondents using registers. SETTING AND SUBJECTS: The dataset includes information on all registered pregnancies (abortions, births, and miscarriages, n=2743) of the female respondents (n=28 914) to the Adolescent Health and Lifestyle Survey (AHLS) from 1987 to 1998. In the AHLS, self administered questionnaires were mailed every second year to independent samples of 12, 14, 16, and 18 year olds representative for Finland. MAIN OUTCOME MEASURE: Relative risk (hazard) of becoming pregnant at teenage. MAIN RESULTS: Girls from lower socioeconomic background had a higher pregnancy risk. Girls who did not live with both parents at the baseline survey had higher pregnancy risk than those who did, and girls who lived in a stepfamily had a higher risk than those who lived in a one parent family. Swedish speaking girls had a lower pregnancy risk than the Finnish speaking girls. There was no systematic change from 1987 to 1998 in most sociodemographic differentials in the teenage pregnancy risk, however, there was some increase in the differences by family structure. Changes in the sociodemographic structure did not explain the levelling off of the downward trend in teenage pregnancy risk, nor did the regional socioeconomic differences explain regional differentials in teenage pregnancy risk. CONCLUSION: Although the reduction of socioeconomic and regional differences has been a general objective in Finnish social and health policies, the relative differences in teenage pregnancies have not decreased.

Decision making in terminal care: a survey of finnish doctors' treatment decisions in end-of-life scenarios involving a terminal cancer and a terminal dementia patient.

GOALS: The physicians' decision-making process in terminal care is complex: medical, ethical, legal and psychological aspects are all involved, particularly in critical situations. Here, a study was made of the association of personal background factors with end-of-life decisions. METHODS: A questionnaire was sent to 300 surgeons, 300 internists, 500 health centre practitioners (GPs) and all 82 Finnish oncologists. The response rate was 62%. Two scenarios were presented: one involving a terminal cancer patient, the other a dementia patient. Sociodemographic factors, general life values and attitudes related to end-of-life care were asked. MAIN RESULTS: In the cancer case (Scenario 1) 17%, and in the dementia case (Scenario 2) 43% of all the respondents chose active treatment. In a logistic regression analysis of treatment decisions in Scenario 1, physician's age, specialty, marital status and attitudes to assisted suicide and withdrawal of life-sustaining treatment (LST) entered the model. In Scenario 2, the variables were physician's age, physician's own experience of severe disease in the family, attitude to withdrawal of LST and opinion of advanced directives. CONCLUSIONS: Doctors' end-of-life decisions vary widely according to personal background factors. The findings underline the importance of advance communication, making these decisions in accordance with the patient's wishes.

Factors affecting physicians' decisions to forgo life-sustaining treatments in terminal care.

OBJECTIVES: Treatment decisions in ethically complex situations are known to depend on a physician's personal characteristics and medical experience. We sought to study variability in decisions to withdraw or withhold specific life-supporting treatments in terminal care and to evaluate the association between decisions and such background factors. DESIGN: Readiness to withdraw or withhold treatment options was studied using a terminal cancer patient scenario with alternatives. Physicians were asked about their attitudes, life values, experience, and training; sociodemographic data were also collected. SETTING: Finnish physicians, postal survey. SURVEY SAMPLE: Five hundred general practitioners, 300 surgeons, 300 internists, and 82 oncologists. RESULTS: Treatments most often forgone were blood transfusion (82%) and thrombosis prophylaxis (81%). Least willingly abandoned were intravenous (i.v.) hydration (29%) and supplementary oxygen (13%). Female doctors were less likely to discontinue thrombosis prophylaxis (p=0.022) and supplementary oxygen (p<0.001), but more readily x ray (p=0.039) and laboratory (p=0.057) examinations. Young doctors were more likely to continue antibiotics (p=0.025), thrombosis prophylaxis (p=0.006), supplementary oxygen (p=0.004) and laboratory tests (p=0.041). Oncologists comprised the specialty most ready to forgo all studied treatments except antibiotics and blood transfusion. The family's wishes (alternative 1) significantly increased treatment activity. Young and female practitioners and oncologists were most influenced by family appeal. Advance directives (alternative 2) made decisions significantly more reserved and uniform. Different factors in the physician's background were found to predict decisions to withdraw antibiotics or i.v. hydration. CONCLUSION: The considerable variation observed in doctors' decisions to forgo specific life-sustaining treatments (LST) was seen to depend on their personal background factors. Experience, supervision, and postgraduate education seemed to be associated with more reserved treatment decisions. To increase the objectivity of end of life decisions, training, and research are of prime significance in this ethically complex area of medicine.

To resuscitate or not: a dilemma in terminal cancer care.

One of the difficult dilemmas in terminal care is the decision on whether to start or withhold cardiopulmonary resuscitation (CPR). Is this decision made on purely medical grounds, or is it also influenced by the physician's personal characteristics or education? The aim of this study was to look at factors affecting this decision. A questionnaire was sent out to a stratified sample of 1180 Finnish doctors. The response rate was 62%. The physicians were asked whether they would (a) start CPR or (b) withhold CPR in a scenario describing the unexpected death of a young terminal cancer patient. Data were also collected on demographics, post-graduate training, experience of terminal care, general life values and attitudes, and experiences of severe illness in the family. The proportion of surgeons, internists, GPs and oncologists who said they would have started CPR was 16, 10, 19 and 14%, respectively. Among physicians aged under 35 years, from 35 to 49 years and over 49 years, the proportions of physicians choosing active CPR were 29, 14 and 13%, respectively (P<0.001). As for those with personal experience of terminal care, 13% indicated they would have started CPR compared with 23% of those who had no experience (P<0.01). Those who made a decision in favour of CPR showed a significantly (P<0.001) more negative attitude to withdrawing life-sustaining treatment and valued length of life to a much greater extent (P<0.01).

Assessment of pain control in cancer patients during the last week of life: comparison of health centre wards and a hospice.

The aim of this prospective study was to assess the quality of cancer pain control during the last week of life in two different types of units for terminal cancer patients in Finland: on health centre wards (N=20) and in a hospice (N=30). Pain scores (VAS), defined daily doses (DDD), routes of administration and costs of pain medication were analysed for each patient. On the 7th-last day before death and during the very last day of life (24 h), respectively, the following results were seen: proportions of patients using strong opioids 64% and 84%, mean equivalent parenteral morphine doses of strong opioids 42 mg and 57 mg, mean pain scores (VAS 0-10) 3.11 and 3.05, mean daily cost of pain medication 2.22 and 2.90 euros. Pain control was thus found to be good with low costs. On the 7th day before death strong opioids were used for a greater proportion of patients on the health centre wards. Differences were also seen in the routes of administration used for strong opioids. Weak opioids were used more in the hospice and NSAIDs, more on the health centre wards. However, no differences were found either in the mean doses of strong opioids or in the quality or the costs of pain control between the health centre wards and the hospice.

Palliative cancer care in two health centres and one hospice in Finland.

This study evaluates palliative treatment of inpatient cancer patients in two health centres and in one hospice in Finland. Apart from outpatient clinics, health centres in Finland also have inpatient wards where patients are treated by GPs. The hospice provides a home-like environment for terminal patients, who are cared for by a specialist in internal medicine. Our patient population comprised 36 health centre patients and 36 hospice patients enrolled in 1998. A structured questionnaire was used containing information on diagnosis, duration of the illness, current medication, daily activities, and socioeconomic background. The nurses assessed their patients' emotional needs. We found that the two groups of patients were similar in terms of gender, marital status and social situation. The hospice patients were significantly younger (P < 0.05) and better educated than the health centre patients (P = 0.001), and their disease had lasted longer (P < 0.05). Upon admission, 12 (33%) of the hospice patients were using opioids, as were 6 patients (17%) in the health centre group. During the treatment period in the hospice the nurses reported more anxiety and depression in their patients (P < 0.05); staff in the health centres were more often unable to report on their patients' feelings. Hospice patients (20/35) were significantly (P < 0.001) more concerned about the wellbeing of their relatives than patients in the health centres (2/35). In the hospice 18 patients (50%) showed significantly (P < 0.001) more spiritual needs than health centre patients (4/34). We conclude that more education is needed to improve the awareness of the multidimensional needs of terminally ill cancer patients in primary health care.

Questionnaire study of use of emergency contraception among teenagers.

PIP: This is a report of a survey on the use of emergency contraception among teenagers in Finland. The school health promotion study provided data on adolescent health behaviors. Each of the 52,700 respondents from comprehensive schools and upper secondary schools answered a structured questionnaire. Findings showed that adolescent girls were widely aware of emergency contraception. Only a small proportion of teenagers had actually used emergency contraception. The proportion of girls who had used emergency contraception increased in proportion with age, but among multiple users, there was no evidence that multiple use increased systematically with age. The survey results suggest that accessibility of contraception and intensive sex education has not increased the level of adolescent sexual activity.^ieng

Do young women have specific problems in contraceptive use and counselling?

OBJECTIVES: To find out if young women have specific problems with the use of contraception or contraceptive services. STUDY DESIGN: A national postal survey was conducted, RR 74%. Women aged 18-34 years (with experience of contraceptive use) were included in this report (n=1239). RESULTS: Weekly need for contraception was highest in the age group 18-24 years (61%), oral contraception being the most widely used method regardless of parity. Condoms were used by 35-37% in all age groups, either alone or combined with oral contraceptives (17% of young nulliparas). Women aged 18-24 years had mainly used public or subsidized services (79%). Of quality characteristics, only satisfaction with the kindness of the service provider varied significantly by age. The cost of contraception was highest in the youngest age group. CONCLUSIONS: The study did not point at any serious problems in family planning among young women, but it did produce several clues for the development of family planning services in general.

Contraceptive health risks--women's perceptions.

The aim was to study women's concerns about health risks associated with contraceptives, in particular oral contraceptives and intrauterine devices (IUDs), and to investigate what factors are related to these concerns. A questionnaire was sent to a random sample of 3000 women aged 18-44 years in Finland in 1994. After two reminders, the response rate was 74% (n = 2189). Logistical models were used to examine factors that were related to concerns over oral contraceptives and IUDs. Half (n = 1096) of the respondents had at some time been concerned about the risks of contraceptives. Most concerns (71%) were related to oral contraceptives. Cardiovascular effects, cancer, infertility, mood changes and weight gain were the most commonly specified risks related to oral contraceptives, and infections, effects on menstruation and ectopic pregnancy were most mentioned regarding IUDs. Concerns about oral contraceptives were related to higher education [odds ratio (OR) 1.75; 95% confidence interval (CI) 1.38-2.21], past experience with the method (OR 1.81; 95% CI 1.45-2.26) and to a good knowledge about contraception and fertility (OR 1.68; 95% CI 1.29-2.19). Concern over IUD risks were most strongly related to past use of the method (OR 3.11; 95% CI 2.24-4.32) and higher age (35-44 years old, OR 2.99; 95% CI 1.52-5.87). Unlike women concerned about the risks of oral contraceptives, women with concerns about IUDs had had abortions more often than other women (OR 1.79; 95% CI 1.28-2.48). Women with concerns about oral contraceptives or IUDs used condoms or sterilization as their current contraceptive method significantly more often than other women. Results showed that concern about the risks of contraceptives is strongly related to women's past contraceptive experiences and influences their current use of contraceptives. More attention should be paid to information provided by health care professionals, especially that regarding risk probabilities.

Task profiles of district doctors in Estonia and general practitioners in Finland.

OBJECTIVE: To compare the task profiles of primary care doctors in two societies: district doctors in Estonia and general practitioners in Finland. DESIGN: A uniform questionnaire was developed and used in 30 European countries in 1993 (The European Study of GP Task Profiles). The questionnaire was sent to a random sample of Estonian district doctors and Finnish health centre doctors. Data from 139 respondents in Estonia and 239 respondents in Finland were obtained. MAIN OUTCOME MEASURES: Personal and practice information, proportion of doctors performing certain medical procedures in their practices by themselves and being the first contact in relation to different problems. RESULTS: The Finnish general practitioners (GPs) had more consultations per day, the Estonian district doctors made remarkably more home visits. Participation in on-duty work was 82% among the Finnish and 22% among the Estonian doctors. Most of the Finnish GPs worked by appointment, while this was uncommon in Estonia. More than 80% of the Estonian district doctors reported that they seldom or never performed the listed procedures by themselves. In Finland, more than 80% of the respondents carried out the procedures almost always by themselves. Handling children's and women's health problems was more frequent in Finland than in Estonia. The profiles of managing acute problems and problems of the elderly people were quite similar in both countries. The tackling of psychosocial problems as the first contact showed lower performance in both countries compared with somatic health problems. CONCLUSIONS: The task profiles of the Estonian district doctors and the Finnish GPs differed considerably. The distribution of the Estonian doctors' answers gives evidence for the existence of specialization already within primary health care where certain problems almost never reach the district doctor. The results of the present study supported the curriculum design for the retraining of currently practising district doctors.

Quality of care in abortion services in Finland.

BACKGROUND: The aim of this study was to describe the quality of abortion services and women's experiences with the care they had received during their abortion. METHODS: A population-based postal survey of 3000 randomly selected 18-44-year old Finnish women in 1994. The response rate was 74% (n=2189). The following were used as indicators of quality of services: referral problems, loss of follow up, adequacy of counseling, and satisfaction with treatment. RESULTS: Fifteen percent (n=320) of the respondents had experienced at least one abortion. After adjusting for age, women who had an abortion were more likely to come from the lower social class, to be divorced, widowed, or in a nonmarital relationship, and to have had previous pregnancies. Fifty-two percent reported not using any contraceptive method when getting pregnant. Altogether 6% reported referral problems and 8% did not have post-abortion follow-up. Twenty-five percent would have preferred more discussion with a physician or a nurse before the abortion and 30% after it. Psychological effects of abortion was the most often mentioned subject upon which they needed discussion. The need for discussion was not influenced by the length of time lapsed since the abortion. The satisfaction with treatment increased from 69% (abortion >10 years ago) to 82% (abortion <5 years ago). Dissatisfaction was related to need for more discussion and the abortion having been performed in a central hospital. CONCLUSION: The overall quality of abortion care was good but there is still a need for improvement, especially in the communication and human part of the care.

[The importance of subsequent contraception in reducing unwanted pregnancies]. / Jälkiehkäisyllä tärkeä sija ei-toivottujen raskauksien vähentämisessä.

The most established hormonal method of subsequent contraception is the so-called Yuzpe-method; another important method is placement of a copper coil. Hormonal subsequent contraception has no health-hazardous side effects, so there is nothing to prevent its use but a known pregnancy. More information about subsequent contraception and easier distribution are seen as important means of decreasing unwanted pregnancies as well as abortions.

PIP: Postcoital contraceptives have been known for 3 decades. In recent years the combination estrogen/levonorgestrel has been popular. It is administered 72 hours after intercourse and repeated 12 hours later. The use of the IUD within 5 days of coitus is another option. In Finland, the 4-tablet method was introduced in the mid-1980s. In 1996, a total of 32,000 such packets were sold. Women under the age of 25 used them primarily. A 1994 study demonstrated that the 18-24 age group used it at least once, versus 1-3% for those over 30 years of age. A 1996 study revealed that secondary school students were quite familiar with this method. Since hormonal contraceptives are not 100% reliable, up to 2% of users still get pregnant. 3-4% get pregnant if the coitus occurred in the middle of the cycle. If someone still gets pregnant, the fetus is not exposed to any harm by using them. Nausea and headache occur in half of the women who use them and vomiting in 15-20%. It is recommended that a pregnancy test be performed 2-3 weeks after the use of postcoital methods. The approach of using both OCs and the condom is increasingly accepted among young people. Counseling is indispensable for adolescents in order to avoid resorting to abortion, which should never be a method of family planning. There are calls for dispensing postcoital methods over the counter and allowing nurse-midwives to dispense them. The number of abortions in Finland dropped significantly during the 1990s, a result that can be partly credited to postcoital methods.

The role of gynaecologists in women's health care--women's views.

OBJECTIVE: Reproductive matters are common reasons to use health services, and both primary care providers (general practitioners and public health nurses) and specialists (gynaecologists) can be consulted. The purpose of this study was to find out how Finnish women think about and use specialist care in reproductive matters; gynaecological health checks, contraception, and prenatal care served as examples. METHODS: The data come from a questionnaire survey sent in 1994 to a representative sample (74% response rate) of 18-44-year-old Finnish women (n=2189). RESULTS: Most (87%) women considered regular health checks by a gynaecologist important, and 55% had visited a gynaecologist regularly in the past 5 years. Healthier women and women having more education were more likely to visit gynaecologists regularly. Most women (86%) preferred a gynaecologist to a general practitioner for contraceptive matters, and 54% reported visiting one for their last contraceptive visit. Maternity centres with their public health nurses and general practitioners were the main source of prenatal care. CONCLUSIONS: The results suggest the need to study the benefits of regular gynaecological health checks, and to define the best provider in common reproductive matters. Evaluation should include organizational impacts, such as those of the division of work between primary and secondary health care and small area population responsibility.

Quality of contraceptive services in Finland.

OBJECTIVE: To investigate whether the quality of contraceptive services in Finland varies by the type of care provider. DESIGN: A cross sectional questionnaire survey. PARTICIPANTS: A random sample of 3000 Finnish women aged 18-44 years (response rate 74%) in 1994. RESULTS: Almost all women (94%) had used contraception at some time and 75% were current users. Although self care was common (29% had obtained their latest method outside the health services), 83% had sometimes used the health services for contraception. For their last visit, 55% of women had chosen a health centre (a publicly administered and funded health service), and 33% a private unit. In the health centre, the care provider was usually a general practitioner or a public health nurse, whereas in private care the providers were gynaecologists. Women who used private care were more likely to be from higher social classes and urban areas. After adjustment for a women's background, the two groups were similar for most indicators of the quality of care, but access to care and woman's experiences of treatment were better with private care. CONCLUSIONS: In terms of availability and choices the current system of contraceptive services in Finland is adequate. It is not always an integral part of municipal primary health care, and many women prefer private care for gynaecological services; this may case problems of comprehensiveness and equality of care.

Knowledge and use of hormonal emergency contraception in Finland.

We studied the knowledge and use of hormonal emergency contraception (EC) in Finland by mailing a questionnaire to a national sample of 3000 women aged 18-44 years (response rate 74%). Ten percent of the women aged under 25 and 4% of all respondents had sometimes used EC. Unmarried women were more likely to report having used hormonal EC than were married women, and nulliparous women reported more use than did parous women. However, no statistically significant difference in EC use among women with or without previous abortion history was observed. Older women were less aware of EC than of other methods; only one-third of the women aged over 35 knew about this method. Current contraceptive practices were otherwise similar among ever-users and never-users of EC, but EC users more commonly reported using condom together with oral contraceptives or IUD. Nobody reported using EC as her only contraceptive method. Our findings suggest that EC is appropriately used in Finland, but more information about use of the method is still needed.