Depression in the oldest old in urban and rural municipalities.

INTRODUCTION: The aim was to compare an urban and a rural old population regarding depression. METHOD: A population-based, cross-sectional study in five depopulated areas and one expanding urban city in northern Sweden. Participants aged 85 and above were evaluated for depression. Data were collected from structured interviews and assessments and from relatives, caregivers and medical charts. Depression was screened for using the Geriatric Depression Scale-15 (GDS-15) and evaluated by the Montgomery-Asberg Depression Rating Scale (MADRS). RESULTS: In total, 29% of the 363 participants were depressed (34% in the rural municipality and 27% in the urban municipality). Fifty-one percent versus 69% were receiving treatment with antidepressants. In the rural areas, those with depression were less frequently treated with selective serotonin reuptake inhibitor (SSRI) medications (36% versus 65%; p = 0.004), instead there were participants treated with Tri Cyclic Antidepressant's (TCA's) (10%, versus 0%; p = 0.0018). A larger proportion of the participants in the urban sample had responded to treatment (59% versus 27%; p = 0.175). CONCLUSION: Depression in old age appears to be a common cause of emotional suffering among the oldest old. In the rural areas, depression was more often inadequately treated and it was also treated with inappropriate medications.

Striking a balance--health experiences of male ambulance personnel with musculoskeletal symptoms: a grounded theory.

BACKGROUND: Musculoskeletal disorders (MSD) are a dominant cause to long-term sick leave and early retirement. Some occupational groups are more affected than others and ambulance personnel are among them. Despite a vast amount of research, only a small part focuses the experiences of the affected. OBJECTIVES: The aim of the study was to explore the experience of illness and wellness in ambulance personnel with musculoskeletal symptoms. DESIGN: An emerging design was used in accordance with Grounded Theory. PARTICIPANTS: Informants in the study were ten men with musculoskeletal symptoms, working as ambulance personnel at an ambulance station located in a mid-sized city in Sweden. METHODS: Narrative interviews were performed, parallel to a constant comparative analysis. RESULTS: The study resulted in a model, which describes the experience of illness and wellness as characterised by an effort to strike a balance. Wellness through nurturing appeared parallel to encountering illness as an experience and a threat. Accepting and handling illness was of importance to maintaining wellness, and wellness through nurturing was the motivation for accepting and handling illness. CONCLUSIONS: Enhancing the understanding of wellness and illness makes it possible to avoid undermining the meaningfulness that support accepting and handling illness, and by understanding different aspects of illness prevention can become facilitated. This is of importance as other aspects than solely physical have shown to be similarly important in the development of MSD.

Resilience, sense of coherence, purpose in life and self-transcendence in relation to perceived physical and mental health among the oldest old.

Different concepts have been presented which denote driving forces and strengths that contribute to a person's ability to meet and handle adversities, and keep or regain health. The aim of this study, which is a part of The Umeå 85+ study, was to describe resilience, sense of coherence, purpose in life and self-transcendence in relation to perceived physical and mental health in a sample of the oldest old. The study sample consisted of 125 participants 85 years of age or older, who ranked themselves on the Resilience Scale, Sense of Coherence Scale, Purpose in Life Scale and Self-Transcendence Scale and answered the SF-36 Health Survey questionnaire. The findings showed significant correlations between scores on the Resilience Scale, the Sense of Coherence Scale, the Purpose in Life Test, and the Self-Transcendence Scale. Significant correlations were also found between these scales and the SF-36 Mental Health Summary among women but not among men. There was no significant correlation between perceived physical and mental health. The mean values of the different scales showed that the oldest old have the same or higher scores than younger age groups. Regression analyses also revealed sex differences regarding mental health. The conclusions are that, the correlation between scores on the different scales suggests that the scales measure some dimension of inner strength and that the oldest old have this strength at least in the same extent as younger adults. Another conclusion is that the dimensions that constitute mental health differ between women and men.

Comparison of health care utilization of postnatal programs in Sweden.

OBJECTIVE: To describe the utilization of health care services, based on number of outpatient visits and readmissions, by mothers and newborns following discharge postnatally after having received various types of maternity care. DESIGN: The design was a cohort of Swedish women giving birth at full term. All together, 773 women and 782 newborns were followed using questionnaires, registry data, and medical chart notes. The information served as a basis for analyzing utilization of health care services during the first 28 days post-delivery. RESULTS: Of the women, 15% sought medical care and 1.7% were readmitted, whereas 17% of the newborns received medical care and 2.9% were readmitted. At 6 months, about half were exclusively being breastfed. There was no difference in need to seek health care or breastfeeding outcome owing to type of maternity care. CONCLUSION: Mothers with newborns sought care relatively frequently but rarely needed to be readmitted after discharge from the maternity care. The risk of readmission during the first month after childbirth was not greater for mothers and children who received care through the family suite or early discharge programs.

Personal understandings of illness among people with type 2 diabetes.

BACKGROUND: Professionals and patients understand the experience of illness from different worlds. Professionals' explanatory models focus on aetiology, diagnosis, pathophysiology and treatment, while patients' explanatory models are more focused on consequences and influences on daily life. The differences between patients and professionals in their understanding often result in conflicting expectations about treatment, priorities and outcomes of care. AIM: The aim of this study was to describe personal understandings of illness among people with type 2 diabetes in Sweden. METHOD: A sample of 44 patients, 47-80 years, diagnosed with type 2 diabetes within the last 2 years, was recruited from four health care centres. Narrative thematic interviews were used covering the areas of developing, coping with and living with diabetes. Qualitative content analysis was performed. FINDINGS: The findings were formulated into six categories: image of the disease, meaning of the diagnosis, integration of the illness, space for the illness, responsibility for care and future prospects. CONCLUSIONS: The findings demonstrate that patients' personal understanding of illness is an important complement to the traditional professional view of diabetes. They could serve as a foundation for development of health history interviewing, as well as development of systems of documentation. Patients' personal understandings of diabetes in their daily lives are considered to be an important shared source of information for planning meaningful care.

Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness.

Qualitative content analysis as described in published literature shows conflicting opinions and unsolved issues regarding meaning and use of concepts, procedures and interpretation. This paper provides an overview of important concepts (manifest and latent content, unit of analysis, meaning unit, condensation, abstraction, content area, code, category and theme) related to qualitative content analysis; illustrates the use of concepts related to the research procedure; and proposes measures to achieve trustworthiness (credibility, dependability and transferability) throughout the steps of the research procedure. Interpretation in qualitative content analysis is discussed in light of Watzlawick et al.'s [Pragmatics of Human Communication. A Study of Interactional Patterns, Pathologies and Paradoxes. W.W. Norton & Company, New York, London] theory of communication.

Patients' experience of involuntary psychiatric care: good opportunities and great losses.

Patients who are involuntary admitted to psychiatric care are extremely vulnerable as a consequence of the control from others, and of the personal limitations due to a psychiatric disease that can influence their own control of their lives. This group of patients are seldom asked about their experiences of being cared for. In this study five involuntary hospitalized psychiatric patients narrated their experience of being subjected to involuntary psychiatric care. The aim of the study was to obtain a deeper understanding of this experience. The interview text was analysed by means of a phenomenological hermeneutic method. The result of the analysis gave a complex picture of both support and violation. On the one hand experiences of not being seen or heard, of loss of liberty and of violation of integrity were found. On the other hand, there were experiences of respect and caring and opportunities to take responsibility for oneself were offered. Being treated involuntarily in psychiatric care was interpreted as a balancing act between good opportunities and great losses.

Well-being, sense of coherence, and burnout in stroke victims and spouses during the first few months after stroke.

Ten stroke victims, who had recently suffered their first manifest stroke with lasting neurological symptoms, participated, together with their spouses, in a study aimed at elucidating the well-being, sense of coherence (SOC), and burnout during the first few months after discharge. The stroke victims had no substantial speech disturbances, and showed no evidence of significant cognitive impairment, signifying they were mildly to moderately impaired by their stroke. All subjects were investigated at 1 and 3 months after homecoming. The methods used in this study were open-ended interviews with all research participants, performed at two different appointments, and three self-reporting questionnaires: the well-being measure (WM), the SOC scale, and the burnout measure (BM). The instruments suit each other well, broaden the picture of living with stroke and give an attuned comprehensive understanding. The most striking finding was the substantial differences in the results, both regarding the stroke victims and their spouses, clearly indicating the limited value current generalizations have. The results also pointed to considerable distress both in stroke victims and spouses, although individuals with a weak SOC clearly displayed more difficulties in coping with the situation and risk of burnout, than did those with a strong SOC.

A model of consolation.

Consolation is needed when a human being suffers (i.e. feels alienated from him- or herself, from other people, from the world or from his or her ultimate source of meaning). The aim of this study was to illuminate the meaning of consolation. Tape-recorded narrative interviews were carried out with 18 professionals from various spheres. The transcribed interviews were interpreted hermeneutically. A model of consolation is outlined in a drawing. It states that the mediator and the receiver of consolation must become ready for consolation before it can take place. To be ready means to be present and available. Availability means expressing suffering and listening respectively, and thereby opening up for communion and consoling dialogue. Communion brings about contact with the sacred dimension that human beings share and thus with goodness, light, joy, beauty and life. Consolation involves a shift of perspective and an experience of meaning in spite of suffering.

Transitions experienced by women with fibromyalgia.

Fibromyalgia (FM) is a chronic pain syndrome the hallmarks of which are a chronic diffuse musculoskeletal pain, tender points, and fatigue. The majority of those who have FM are middle-aged women. The aim of this study was to illuminate the transitions experienced by women with FM. Twenty-five women with FM were interviewed about living with FM. The interviews were analyzed using thematic content analysis. The analysis revealed five categories; transitions in patterns of daily life, family life, social life, and working life, and learning to live with the changes brought about by FM. The categories were subsumed into one theme: FM as the choreographer of activity and relationships. The transitions experienced were illuminated in a core story. The experience of transitions is apparently something that is invisible to almost everyone except the women themselves. Paradoxically, the women described transitions in life due to the illness, but they felt that other people saw them as healthy. It is like living in two worlds simultaneously, the world of the sick and the world of the healthy.

Struggling for dignity: the meaning of women's experiences of living with fibromyalgia.

Fibromyalgia (FM) is a common chronic pain syndrome with an obscure etiology, which mostly afflicts middle-aged women. In this study, 14 women with FM were interviewed about the meaning of living with the illness. A phenomenological-hermeneutic method was used to analyze and interpret the interview texts. The findings show that being a woman with FM means living a life greatly influenced by the illness in various ways. The women's experiences of living with FM were presented in three major interlaced themes: loss of freedom, threat to integrity, and a struggle to achieve relief and understanding. This study highlights the importance of meeting people suffering in illness with respect for their human dignity. The care of women with FM must empower the women to bring to bear their own resources so that they can manage to live with the illness.

Women's perceptions of phenomena they label premenstrual tension: normal experiences reflecting ordinary behaviour.

Remarkably little empirical knowledge exists about premenstrual tension (PMT), a construct that has been studied intensively during the last 30 years. Practically nothing is known about the perceptions women have about PMT. The purpose of this study is to describe the perceptions healthy women have about PMT. Seventeen women, who had 4 years earlier participated in a concurrent diary study assessing the prevalence of PMT, were interviewed. The interviews were analysed by means of a qualitative content analysis. Four main categories describing the women's perceptions were formed: (1) individual experiences of phenomena referred to as PMT; (2) phenomena referred to as PMT reflect ordinary experiences in healthy women; (3) biopsychosocial explaining of phenomena referred to as PMT; (4) internal and external resources used to manage the variability of phenomena referred to as PMT. The content of these categories reflects the participants' perceptions of PMT as the common, normal and very variable experiences which women handle by the use of management strategies commonly used in contemporary society to deal with life in general. Experiences of women differ with respect to what they experience and the timing and persistence of those experiences. This the participants explain from a biopsychosocial perspective. It is suggested that women have adapted a medical term, PMT, to describe what they consider normal female phenomena.

The meaning of hospital care, as narrated by elderly patients with chronic heart failure.

Chronic heart failure is the most common reason for hospitalization among the elderly in western societies. To elucidate the meaning of the experience of care received in the hospital, as narrated by 12 elderly patients with severe chronic heart failure, interviews were analyzed by an approach inspired by Ricoeur's phenomenologic hermeneutics. The analysis revealed that the study respondents experienced the care as "unpredictable." This essential theme captured the divergent descriptions of 2 subthemes: care was either "confident but incomprehensible" or "nonconfident and incomprehensible." When the patients sought care, it was as though they were launching themselves into the unknown because they knew that many experiences would be unpredictable. Despite experiences of indifferent and unpredictable care, the narratives revealed a need to rely on the caregivers' expertise.

Could myocarditis, insulin-dependent diabetes mellitus, and Guillain-Barré syndrome be caused by one or more infectious agents carried by rodents?

The numbers of small rodents in northern Sweden fluctuate heavily, peaking every 3 or 4 years. We found that the incidence of Guillain-Barré syndrome and insulin-dependent diabetes mellitus, as well as the number of deaths caused by myocarditis, followed the fluctuations in numbers of bank voles, although with different time lags. An environmental factor, such as an infectious agent, has been suggested for all three diseases. We hypothesize that Guillain-Barré syndrome, myocarditis, and insulin-dependent diabetes mellitus in humans in Sweden are caused by one or more infectious agents carried by small rodents. Also, a group of novel picornaviruses recently isolated from these small rodents is being investigated as the possible etiologic agent(s).

Diabetes and it's complications in a Swedish county.

A cross-sectional survey with the aim to study the prevalence of diabetes and long-term complications was carried out in a health care district in Sweden with 125,500 inhabitants. Information was extracted from the medical records. 4127 people with diabetes were identified of whom 87% were classified as NIDDM (non-insulin-dependent diabetes mellitus), 12% as IDDM (insulin-dependent diabetes mellitus) and 0.7% as secondary or unclassified diabetes. The prevalence of diagnosed diabetes was 3.3%. A total of 83% received their regular routine care at primary health care centres, 31% were treated with diet only, 36% had oral hypoglycaemic agents, 31% had insulin and 2% had combination therapy. The mean HbA1c was 7.2% (ref. range 4.0-5.3%). Of the adults (> 18 years) 27% had retinopathy, 13% had nephropathy and 27% had loss of pallaesthesia. 50% had hypertension, 21% angina pectoris, 11% had had myocardial infarction, 11% stroke, 21% had signs of peripheral arterial disease, 2% had been amputated and 21% were smokers. The conclusion is that in a population of patients with diabetes with acceptable metabolic control, complications are still a great problem.

Living with fibromyalgia: sense of coherence, perception of well-being, and stress in daily life.

Fibromyalgia (FM) is a chronic pain syndrome that has a considerable impact on the ill person's daily life. The purpose of this study was to describe levels of sense of coherence (SOC), perceptions of well-being, and stress in daily life in women with FM in comparison with healthy women, and to determine whether SOC is related to perceived levels of stress and well-being. Thirty women with FM were compared with 30 healthy women matched for Type A behavior. The results revealed a complex picture of the women with FM. On the one hand, they reported many symptoms but, on the other, they rated themselves as feeling quite well and experiencing an SOC in life, despite severe problems. The FM women with a stronger SOC perceived greater well-being than those with a weaker SOC. They felt more hopeful, more free, more valuable, and more like others. Results suggest that women with a weaker SOC may need extra support. More research is needed to investigate the experience of living with FM in order to discover what it is that makes life worthwhile despite high symptom levels.

Metabolic control, food intake and mood during the menstrual cycle in patients with insulin-dependent diabetes.

The impact of menstruation on metabolic control was studied among 20 insulin-dependent diabetics (IDDM) and 20 healthy controls during two menstrual cycles. No systematic fluctuation in glycated protein, blood glucose levels, food intake, intake of mono- and disaccharides, body weight, or mood could be seen during different weeks in the menstrual cycle. A tendency towards menstruation-related variations in the number of insulin reactions and amount of extra injected insulin was observed in the patient group. Levels of glycated protein were significantly (P < 0.05) higher during the premenstruational than during the postmenstruational week, although the difference was small in absolute terms. A poorer mood during the premenstruation weeks (indicating premenstruation syndrome) was associated with a high number of hypoglycemic events (P < 0.01) and frequent changes in insulin doses (P < 0.01). Thus, taken as a group diabetic women do not experience great changes in food intake or metabolic control during the menstrual cycle. This does not exclude the possibility that a small proportion of women have major menstruation related difficulties in controlling their diabetes.

The significance of a sense of coherence for subjective health in persons with insulin-dependent diabetes.

The strength of an insulin-dependent, diabetic (IDDM) person's sense of coherence (SOC), conceptualized according to Antonovsky's salutogenetic model, was related to patterns of problem-solving and to emotional coping strategies. These personal SOC scores were also related to reported positive experiences, problems in daily life, problems in relation to the environment, worries about long-term complications, tedium and well-being which had been measured 5 years earlier. In the entire IDDM group the mean score for the SOC was 143. There was a significant correlation between the SOC scores and coping patterns (Z--2.053, P < 0.04). The subgroup labelled 'experts' had the highest SOC scores. There were also significant correlations between the SOC scores and problems in relation to the environment (r--0.08, P 0.03), tedium (r--0.69 P 0.01) and well-being (r--0.64, P 0.02). There were no correlations between the SOC scores and metabolic control, reported experiences that the disease had positively influenced the diabetic person's life, problems in daily life, or worries about long-term complications. It was concluded that a sense of coherence seems an important factor which contributes to successful emotional coping with the demands of the disease. As subjective health is an important nursing goal the salutogenic model appears to have potential utility in the care for the person with IDDM.

Severe hypoglycaemia during treatment with glipizide.

In the years 1980-87, 19 cases of severe hypoglycaemia during treatment of Type 2 diabetes with glipizide were reported to the Swedish Adverse Drug Reactions Advisory Committee. Patient age was 75 +/- 9 years (mean +/- SD) (significantly higher than in all patients on glipizide in Sweden), and the duration of glipizide treatment ranged from 1 day to 4 years. Eleven patients presented with coma, three with reduced consciousness and five with other symptoms. An uneventful early recovery occurred in 14 patients. The remaining five patients had prolonged or recurrent hypoglycaemia for up to 60 h. Two of the patients, both with complicating disorders, died. In a case-control substudy, patients with glipizide-associated hypoglycaemia were found to have renal impairment more often than age- and sex-matched controls treated with glipizide (odds ratio 4.0). The median dose of glipizide (10 mg per day) was identical to that in controls. Other drugs, notably diuretics and benzodiazepines, were more commonly used by hypoglycaemic patients (median 5 vs 2 concomitant drugs, p less than 0.001). We conclude that the use of glipizide is associated with a risk of developing severe hypoglycaemia with a clinical course that is not always benign.

Living with diabetes: perceptions of well-being.

A group of 192 adult insulin-dependent diabetic patients free from manifest late complications were asked, through mailed questionnaires, about the influence of the disease on their daily life and about their feelings of well-being. Well-being was measured using 11 semantic differentials comprised of bi-polar adjectives. Only a minority of patients reported that the disease caused them considerable problems in daily life. The greatest problems occurred in connection with regularity in daily life (26% of subjects) and diet management (24%). Although a large proportion of the patients were very concerned about retinopathy (45%), other complications were of great concern for only 10 to 25%. Younger age was significantly associated with more problems in daily life and more worries about complications. There also were associations between younger age and feelings of anxiety, lack of freedom, insecurity, and reduced self-esteem. Most of the patients, both men and women, had a general feeling of well-being. Living with insulin-dependent diabetes appears to be quite consistent with experiencing well-being and feeling fit provided that no severe complications have developed.