Predictive factors for long-term sick leave and disability pension among frequent and normal attenders in primary health care over 5 years

OBJECTIVES: To find predictive factors for long-term sick leave (SL) and disability pension (DP) among frequent attenders (FAs) and normal attenders (NAs) in primary health care. STUDY DESIGN: A cohort study with follow-up over 5 years. METHODS: Groups of FAs and NAs were followed over 5 years. Information about background, situation, sociodemography, life events, social support and sense of coherence were gathered at baseline. Multiple logistic regression analysis was used to determine the influence of each variable on long-term SL and receipt of a DP. RESULTS: During the study period, 18.9% of FAs received long-term SL/DP compared with 6% of NAs. Chronic disease was a predictive factor for long-term SL/DP among FAs [odds ratio (OR) 7.0] and NAs (OR 3.4). Among FAs, a life event was also a predictive factor (OR 2.1). Each additional life event increased the ratio of FAs with long-term SL/DP by 110%. Conflicts and losses had the greatest negative effects on FAs. CONCLUSIONS: FAs are a high-risk group for long-term SL/DP. Besides chronic disease, a life event was the only predictive factor for long-term SL/DP among FAs. These findings indicate that FAs are a vulnerable group for stressful events. Consequently, healthcare personnel should take more notice of life events among FAs.     

Frequent attenders in general practice care: a literature review with special reference to methodological considerations

OBJECTIVE: To describe the basis on which our knowledge of frequent attendance in general practice rests and to propose recommendations for further research on frequent attenders (FAs). DESIGN: The literature review (finished February 2004) encompassed peer-reviewed articles in English describing contacts with general practice in terms of frequency. Searches were performed in the Medline, CINAHL, EMBASE, PsycINFO, Social Sciences Expanded Index and ISI Citation databases with additional searches in reference lists and the 'related articles' function in the ISI Citation database and Medline. SETTING: General practice. SUBJECTS: Sixty-one articles (54 studies). MEASURES: The articles were assessed according to the following design variables: setting; definition of FAs; sampling; sample size; control groups; study aim; study design; data sources; effect measure; and main results. RESULTS: There was no generally accepted definition of frequent attendance. Research designs differed substantially. Eight articles gave sufficient information on all design variables. The top 10% of attenders accounted for 30-50% of all contacts, and up to 40% of FAs were still FAs the following year. More than 50% of FAs had a physical disease, more than 50% of FAs suffered from psychological distress, social factors (low social support, unemployment, divorce) were associated with frequent attendance in more than 50% of FAs, multiproblems (physical, psychological and social) were found in one-third of FAs, and frequent attendance was associated with increasing age and female gender. CONCLUSION: The diversity of designs, definitions and methods in the current literature on FAs in general practice hampers comparison of their precision, validity and generalizability, and calls for cautious interpretation and adoption of a common, generally acceptable definition in future studies.     

Frequent attenders in out-of-hours general practice care: attendance prognosis.

OBJECTIVE: We aimed to describe the use of out-of-hours service and analyse attendance prognosis for frequent attenders and other groups of attenders, and to present a concept describing frequent attendance over time. METHODS: All adult attenders in 1990 were included in a 4-year follow-up study. Frequent attenders (FAs) were defined as those 10% among the attenders who most frequently used the out-of-hours service during a calendar year (12 months). This gave an intersection point of four or more contacts for frequent attenders. Three more groups were defined according to whether they had one, two or three contacts per year. The setting was out-of-hours general practice in Aarhus County, Denmark. Data were collected from the database of the Public Health Insurance, Aarhus County. The county had approximately 600,000 inhabitants, of whom 465,000 were aged 18 years and over. The subjects were 101,321 individuals aged 18 years and over who contacted the out-of-hours service in 1990. Outcome measures were attendance per year, age and sex. RESULTS: FAs made 42% of the out-of-hours contacts in 1990, and 33% of those who were FAs in 1990 were also FAs in 1991. Among the 1990 FAs, 67% contacted the out-of-hours service at least once in 1991, 25% contacted the service at least once in each of the following 4 years and 7% remained FAs in the following 4 years. The probability of being an FA rose with the duration of previous frequent attendance. Age above 50 years significantly predicted future status as an FA. Females made up two-thirds of FAs, but sex did not predict future frequent attendance. CONCLUSION: Frequent attendance could be regarded as a short-lived phenomenon. On the other hand, FAs were the most stable attenders of all groups of attenders over the years. Older FAs had the highest probability of remaining FAs.     

Physical, mental and social factors associated with frequent attendance in Danish general practice. A population-based cross-sectional study

Knowledge of which factors are prompting patients to seek primary care is important to the ongoing effort to improve management in general, and management of frequent attenders (FAs) in particular. We conducted a cross-sectional population-based study with the aim at examining associations between physical, mental and social factors and frequent attendance in general practice. We collected questionnaire and registry data in the County of Aarhus (630,000 inhabitants), Denmark. Half of the county general practices (132 practices, 220 GPs) were selected randomly. FAs were defined as the top 10% attenders over the past 12 months. A questionnaire including SF-36 and questions about physical and mental health and social conditions was sent to age and gender stratified samples of FAs and non-FAs from these practices. Impairments (SF-36) associated with frequent attendance were physical in 54-71% (prevalence difference (PD): 16-33%, adjusted prevalence ratio (adj. PR): 1.1-1.7), mental in 58-70% (PD: 17-25%, adj. PR:1.1-1.4) and social in 40-59% (PD: 13-28%, adj. PR:0.9-1.5). Among FAs, 46-88% had used three or more different drugs (PD: 26-39%, adj. PR:1.5-2.3) and 27-41% had been referred one or more times to outpatient specialists (PD: 4-19%, adj. PR:1.2-2.5). Although our data cannot determine the direction of causality, they clearly demonstrate that FAs carry a large burden of physical, mental and social impairments which underpins the complexity and heterogeneity of the problems which they present. The results make clear that biopsychosocial management is a core issue in FA management in general practice.     

Frequent attendance at religious services and mortality over 28 years.

OBJECTIVES: This study analyzed the long-term association between religious attendance and mortality to determine whether the association is explained by improvements in health practices and social connections for frequent attenders. METHODS: The association between frequent attendance and mortality over 28 years for 5286 Alameda Country Study respondents was examined. Logistic regression models analyzed associations between attendance and subsequent improvements in health practices and social connections. RESULTS: Frequent attenders had lower mortality rates than infrequent attenders (relative hazard [RH] = 0.64;95% confidence interval [CI] = 0.53,0.77). Results were stronger for females. Health adjustments had little impact, but adjustments for social connections and health practices reduced the relationship (RH = 0.77; 95% CI = 0.64, 0.93). During follow-up, frequent attenders were more likely to stop smoking, increase exercising, increase social contacts, and stay married. CONCLUSIONS: Lower mortality rates for frequent religious attenders are partly explained by improved health practices, increased social contacts, and more stable marriages occurring in conjunction with attendance. The mechanisms by which these changes occur have broad intervention implications.     

Consultations for injuries by frequent attenders are found to be medically appropriate from general practitioners' perspective

AIMS: A study was carried out to determine whether frequent attenders' (FAs') consultations for injuries are medically appropriate or not. METHODS: A retrospective review was undertaken of medical records in a primary healthcare centre. All injury consultations by frequent attenders and controls during a period of one year were evaluated by two general practitioners (GPs). Outcome variables were: number of injuries, chronic diseases, type of injuries, and their treatments. The GPs made a comprehensive picture of each case and evaluated whether it was medically appropriate to consult a doctor or not. RESULTS: Injuries were 7.2 times more common among frequent attenders compared with the controls. Frequent attenders had significantly more chronic diseases. Mean number of injury consultations was the same for frequent attenders with or without chronic disease. There was no difference concerning medically appropriate consultations between frequent attenders and controls. CONCLUSIONS: Consultations for injuries with frequent attenders were considered medically appropriate. Chronic diseases did not explain the higher injury incidence among frequent attenders. These findings are interesting and contradict the opinion that increased healthcare consumption by FAs is a waste of resources. Our findings may suggest that FAs are more vulnerable individuals.     

Effects of guided written disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders

BACKGROUND: Psychosocial variables such as major stressful life events/daily stressful events have been associated with health care utilization. OBJECTIVE: Our aim was to examine the effects of a guided disclosure protocol (GDP) of past traumas on symptoms and clinic visits among frequent clinic attenders. METHODS: Forty-one frequent clinic attenders (> or =2 visits/3 months) took part. Patients were randomly assigned individually to either a casual content writing control group (n = 19) or a trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting event chronologically (day 1), verbally described their thoughts and feelings and described the event's impact on life (day 2), and finally wrote about their current perspective on and future coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits again. RESULTS: Compared with controls, GDP patients reported lower symptom levels at 3 months (2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month (5.1 versus 9.7) follow-ups. The percentage of GDP patients making > or =10 visits during the 15 month follow-up was smaller (10%) than among controls (33%). CONCLUSIONS: The findings extend previous findings to frequent clinic users, using a new form of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be an inexpensive additional intervention in primary care for reducing symptoms and clinic visits among frequent clinic users.     

Evaluation of clinical diagnosis and stressful life events in patients at a rural family practice centre

The occurrence of stressful life events in patients might be used as a cue for the diagnosis of psychosocial illness at a consultation where a physical symptom has been presented. In this study 555 patients attending a rural family practice clinic were interviewed about their stressful life events using a questionnaire. Stressful life events had occurred in 44.7% of patients and the total number of events recorded was 624. More life events were found in patients who were female, older and of lower social class. Three types of clinical diagnoses were recognized: simple physical diseases (55.1%) and psychosocial illness with and without physical diseases (36.8% and 8.1% respectively). Patients who were female, older and of lower socioeconomic status and who had experienced more life events had more psychosocial problems than the rest of the group (P less than 0.001). The diagnosis of psychosocial illness could be predicted by the variables of stressful life event and age up to 66%.     

Maternal stress, social support, and risk of neural tube defects among Mexican Americans

BACKGROUND: Studies suggest that maternal psychologic stress can increase the risk of congenital malformations, including neural tube defects (NTDs). We examined whether maternal stress and lack of social support contribute to NTD risk in a population living along the Texas-Mexico border. METHODS: Case mothers (N = 184) were Mexican-American women with NTD-affected pregnancies who delivered during 1995 to 2000 in one of the 14 Texas counties bordering on Mexico. Control mothers (N = 225) were randomly selected from Mexican-American women residing in the same area and delivering normal live births. We measured maternal stress by tallying the number of job changes, residential moves, and major injuries occurring during the year before conception. Social support was measured using social integration and perceived emotional support scales. RESULTS: Mothers who experienced one or more stressful life events during the year before conception had increased risks for NTDs (odds ratio [OR] = 2.9; 95% confidence interval [CI] = 1.8-4.7) compared with mothers experiencing no events. Mothers who scored low on emotional support had an elevated risk compared with those who scored high (OR = 4.6; CI = 2.2-9.7). Social support measures, such as network size and satisfaction, group interactions, and church attendance, were unrelated to NTD risk. The estimated effects were not modified or confounded by age, education, country of birth, income, obesity, vitamin supplements, dietary folate, cigarette smoking, or alcohol consumption. CONCLUSION: In this Mexican-American population, the occurrence of stressful life events was associated with NTD risk. These findings suggest that stress may exacerbate risk in populations with poor nutritional status and meager economic resources.     

Special status consultation for frequent attenders. Who are the candidates?

BACKGROUND: The need to optimize frequent attender (FA) care and to economize on scarce resources in primary care has given rise to calls for intervention. However, precise knowledge of the specifics of this need is scarce, as is knowledge of how best to orchestrate intervention vis-à-vis particular FA groups. The aim of the study was to analyse the need for a special FA status consultation and to analyse if such need springs from physical, mental or social factors among FAs. METHOD: Half of the 270 general practices in the County of Aarhus, Denmark, were randomly allocated to the study group (in total 132 practices; 220 general practitioners (GPs)). From these practices age- and gender-stratified samples of FAs were drawn. FAs were defined as the top 10 per cent attenders in 12 months. Questionnaires were used to elicit FA and GP attitudes to the introduction of a status consultation and to obtain GPs' evaluation of their FAs' physical, mental and social status. The special FA consultation was introduced as a reimbursed half-hour consultation where the FA and the GP could discuss the patient's current and future care status. RESULTS: Over three-quarters of the FAs would accept the offer to have the status consultation, and the GPs would recommend it for one-fourth of their FAs. The expressed need was highly associated with an expected positive effect on health (prevalence ratio (PR) for GPs: 11.7 (8.9-15.5), PR for FAs: 1.6 (1.5-1.8)) and a decrease in attendance (PR for FAs: 1.4 (1.3-1.5)). The GPs quoted physical, mental and social indications for the consultation. The FAs who had high levels of functional symptoms were most likely to accept the consultation. CONCLUSIONS: There was an expressed need for an FA status consultation, which may lead to a positive effect on health and attendance. The GPs pointed to physical, mental and social indicators for a special FA consultation.     

Association of time elapsed since the last coronary event with health services utilization

Background: Patients with chronic illness use health services more often but little is known about the use that coronary heart disease patients make of primary care. Objective: To determine whether the time elapsed and the perceived quality of life following a major acute coronary event are associated with utilization rate of primary care services. Design: Cross-sectional, multicentre study. Setting: Twenty-three primary care health centres in Catalonia (Spain). Participants: Patients aged 30–80 years who had suffered a major coronary event in the previous 6 years. Main outcome measures: The number of consultations with the general practitioner during the year before the beginning of the study was noted and patients who consulted nine or more times were considered frequent attenders. The time elapsed since the last major coronary event was categorized using the median (2 years) as a cut-off value. The SF-12 quality of life questionnaire was administered. Results: A total of 1022 patients with coronary heart disease were included. The median number of consultations with a general practitioner within the previous year was 5 (range 0–36). Patients with a shorter time elapsed since the last coronary event were seen more often by their general practitioner. The probability of being frequent attender was 24% lower among patients with less recent coronary events (adjusted odds ratio: 0.76, 95% confidence interval: 0.69–0.85, p < 0.001). Quality of life scores were similar in frequent and non-frequent attenders. No relationship between comorbidity and frequent attendance was found. Conclusions: The shorter time elapsed since the last coronary event was an important factor related with frequent attendance in coronary heart disease patients regardless of cardiovascular comorbidity, and perceived quality of life.     

Socio-economic characteristics of adult frequent attenders in general practice: secondary analysis of data

OBJECTIVE: This study was carried out to determine the effect of a range of socio-economic features on frequent attendance in general practice from a large database of general practice consultations using two definitions of frequent attendance. METHODS: Secondary analyses were carried out of data from the Fourth National Survey of Morbidity in General Practice covering 60 general practices in England and Wales. A total of 283 842 adult patients and their consultations between September 1991 and August 1992 were examined. The main outcome measure was the odds ratio of being a frequent attender (95% confidence intervals). RESULTS: Using a definition of 12+ consultations/year, men were less likely to be frequent attenders (OR 0.14, 95% CI 0.13-0.17); however, the difference between men and women lessens with age. Patients who were more likely to be frequent attenders included those who were divorced or widowed (1.41, 1.31-1.51); from social classes IIIM (1.23, 1.17-1.29) and IV/V (1.33, 1.26-1.41); South Asian people (1.38, 1.16-1.65); or unemployed (1.61, 1.46-1.77). Other factors signifying isolation or poverty were also linked to frequent attendance. Using the definition of '6+ consultations for minor problems' produced broadly similar results although the relative weight of the factors showed some differences. CONCLUSIONS: Socio-economic factors were important indicators of frequent attendance in general practice. Results were very similar using either definition, suggesting that both are valid for further work. Furthermore, frequent attendance is a complex process associated with many factors outside the control of the GP.     

Anger expression, negative life events and violent behaviour among male college students in Ethiopia

AIMS: To assess the prevalence of violent behaviour and to identify risk factors associated with violent behaviour among male college students in Ethiopia. METHODS: A cross-sectional study among 1294 male college students in Awassa, Ethiopia was conducted in June 2006. A self-administered questionnaire was used to collect information concerning violent acts, anger expression, and sociodemographic and lifestyle characteristics. Multivariable logistic regression procedures were used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: More than half of the students (54.3%) reported committing at least one act of physical violence during the current academic year. Academic year of studies, use of khat, a natural stimulant with amphetamine-like effects, anger proneness and stressful life events were statistically significant covariates associated with committing acts of violence. Seniors, as compared with freshmen, were less likely to admit violent behaviour (OR=0.46; 95% CI 0.30-0.71). Those who reported using khat were more likely to report committing violent acts (OR=1.46, 95% CI 1.02-2.08) than were non-users. Students with moderate levels of anger expression (scores of 11- 14) were 3.40 times more likely to report committing acts of violence (OR=3.40; 95% CI 2.42-4.79) than were those with low levels of anger expression (scores v11). For students with high levels of anger expression (> or = 15 scores), the corresponding OR was 7.62 (95% CI 5.15-11.29). Participants who had experienced > or = 4 negative life events during the current academic year were more likely (OR=2.41; 95% CI 1.58-3.69) to report violent behaviour than were those with fewer stressful life events. CONCLUSIONS: Screening for violent behaviour and violence prevention programmes, particularly those in educational settings, should include strategies that address students' stressful life events, anger management, and substance use.     

Is attendance at Alcoholics Anonymous meetings after inpatient treatment related to improved outcomes? A 6-month follow-up study

AIMS: This study investigates the relationship between attendance at Alcoholics Anonymous (AA) meetings prior to, during, and after leaving treatment, and changes in clinical outcome following inpatient alcohol treatment. METHODS: A longitudinal design was used in which participants were interviewed at admission (within 5 days of entry), and 6 months following departure. The sample comprised 150 patients in an inpatient alcohol treatment programme who met ICD-10 criteria for alcohol dependence. The full sample was interviewed at admission to treatment. Six months after departure from treatment, 120 (80%) were re-interviewed. RESULTS: Significant improvements in drinking behaviours (frequency, quantity and reported problems), psychological problems and quality of life were reported. Frequent AA attenders had superior drinking outcomes to non-AA attenders and infrequent attenders. Those who attended AA on a weekly or more frequent basis after treatment reported greater reductions in alcohol consumption and more abstinent days. This relationship was sustained after controlling for potential confounding variables. Frequent AA attendance related only to improved drinking outcomes. Despite the improved outcomes, many of the sample had alcohol and psychiatric problems at follow-up. CONCLUSIONS: The importance of aftercare has long been acknowledged. Despite this, adequate aftercare services are often lacking. The findings support the role of Alcoholics Anonymous as a useful aftercare resource.     

Psychiatric characteristics of frequent attenders at accident and emergency: a case register comparison with non frequent attenders

BACKGROUND AND AIMS: Patients attending Accident and Emergency (A&E) on a frequent basis consume a large amount of NHS resources and often frustrate health workers employed in the service. This audit aimed to identify the personal and psychiatric characteristics of these patients and highlight areas where intervention may be helpful. METHODS AND RESULTS: Patients presenting to A &E more than 20 times in four years were comparison to non-frequent attenders using case register information. The study demonstrates that frequent attenders are well known to psychiatric services, but are not engaged in ongoing contact. This is not due to a difference in attendance rate between frequent attenders and controls but may represent reluctance for follow up either on the part of the patient or the psychiatrist. CONCLUSIONS: These patients have a combination of physical, psychiatric and social pathologies and the services to address these needs does not seem to currently exist but should be considered.     

Sense of coherence as a moderator of the effects of stressful life events on health

STUDY OBJECTIVE: To test the hypothesis that Antonovsky's concept of sense of coherence (SOC) moderates (that is, buffers) the health impacts of stressful life events in a population based sample. DESIGN: Multiple linear and Poisson regression analyses of longitudinal data from a national survey of population health were used to examine the relations among SOC, the experience of recent stressful life events (for example, family breakdown, financial crisis, physical abuse), and two outcomes, self reported health status (SRH) and self reported number of physician visits during the previous year. SETTING: General population of Canada. PARTICIPANTS: Nationally representative sample of household residents aged 30 years of age or greater surveyed in 1998 and 2000 (n = 6505). MAIN RESULTS: After controlling for age, sex, and previous health status, a significant moderating effect (t = 2.24, p = 0.025) in the expected direction was found on respondents' SRH. The mean difference in SRH between those who did and did not experience a recent stressful life event was 0.24 (95% CI: 0.16, 0.32) in people with a below average SOC and 0.04 (95% CI: -0.04, 0.11) in people with a higher than average SOC score. The postulated moderating effect of SOC was not significant (t = 1.1, p > 0.05) in predicting the number of visits to a physician. CONCLUSIONS: SOC seems to buffer the impact of recent stressful life events on SRH.     

Usefulness of a dispensary-based case-control study for assessing morbidity impact of a treated net programme

BACKGROUND: Case-control studies have been proposed as an appropriate tool for health impact evaluation of insecticide-treated nets (ITN) programmes. METHODS: A dispensary-based case-control study was carried out in one village in Tanzania. Each case of fever and parasitaemia in a child under 5 years was paired with one community and one dispensary control without fever and parasitaemia. Cases and controls were compared with regard to ITN ownership and other factors assessed by a questionnaire. A cross-sectional survey of factors associated with parasitaemia, including ITN use, was carried out during the study. Dispensary attendance rates of the study children were calculated using passive case detection data. RESULTS: Cases and dispensary controls had higher dispensary attendance rates compared to community controls and children with nets attended more for most of the illness events. A comparison of cases and community controls showed a strong and statistically significant association between untreated net use and being a case (odds ratio [OR] = 2.1, 95% CI : 1.3-3.4). For those with ITN there was a smaller and weaker association between risk of being a case and ITN use (OR =1.4, 95% CI : 0.9-2.2). Comparison of cases and dispensary controls showed no association between untreated or treated nets and the risk of being a case (for treated nets OR = 0.9, 95% CI : 0.5-1.4 and for untreated nets OR = 1.2, 95% CI : 0.7-2.0). These results are contrary to those from the cross-sectional assessment, where children with ITN had a lower prevalence of parasitaemia than those with no nets (OR = 0.5, 95% CI : 0.3-0.9), and also contrary to other assessments of the health impact of ITN in this population. CONCLUSIONS:The positive association between mild malaria and net ownership is counter-intuitive and best explained by attendance bias, since children with nets attended more frequently for all curative and preventive services at the dispensary than those without nets. Dispensary-based case-control studies may not be appropriate for assessing impact of treated nets on clinical malaria, while cross-sectional surveys might represent an attractive alternative.     

Wartime determinants of arteriographically confirmed coronary artery disease in Beirut

This study investigates the association of wartime stress variables and coronary artery disease as determined by coronary angiography in Lebanon in 1986, a country with an ongoing civil war for over a decade. A total of 127 patients who underwent coronary angiography at the American University of Beirut Medical Center were individually matched on age and sex with visitor controls free from any evidence of clinical coronary artery disease. Arteriographic cases (greater than or equal to 70% maximal stenosis) were compared with two control groups: arteriographic controls (entirely normal coronaries) and visitor controls. Findings suggest that there is a relation between exposure to both acute and chronic war events and coronary artery disease in this patient population. The reporting of exposure to acute war events was significantly higher in cases compared with both visitor controls (odds ratio (OR) = 2.4, 95% confidence interval (Cl) 1.17-4.90) and arteriographic controls (OR = 2.8, 95% Cl 0.93-8.47). Crossing the "green-lines" that separate two belligerent sides, considered as an attribute of war-related chronic stress, was more frequent in cases compared with visitor controls (OR = 3.25, 95% Cl 1.54-6.89) and arteriographic controls (OR = 5.38, 95% Cl 1.65-17.6). The relation observed between wartime stress and coronary artery disease could not be explained by possible overreporting of stressful events in patients with suspected coronary artery disease or by an increase in clinical awareness for the disease for those under continuous stress. Adjusting for the effect of the well-established coronary artery disease risk factors did not alter the above findings.     

Stressful Life Events and Physical Abuse Among Pregnant Women in North Carolina

Objectives: This study estimates the prevalence of stressful life events and physical abuse among North Carolina women prior to infant delivery, and examines potential associations between abuse and the other stressors. Methods: Data were from the North Carolina Pregnancy Risk Assessment Monitoring System, a statewide representative survey of over 2,600 postpartum women. The survey assessed women's sociodemographic characteristics and their experiences of physical abuse and 13 other stressful life events before delivery. The prevalences of each life event and abuse were estimated. Logistic regression modeled the probability of women having high levels of stressful life events in relation to physical abuse and sociodemographics. Results: Most women were married, white, high school graduates, aged 20 or older. The most common stressful life events were residential moves, increased arguing with husbands/partners, family member hospitalizations, financial hardship, and deaths of loved ones. Fourteen percent of women had high levels of stressful events (5 or more), and almost 9% were physically abused. Abuse was positively associated with increased arguing with husbands/partners, physical fighting, having someone close with an alcohol/drug problem, becoming separated/divorced, and financial hardship. Logistic regression analysis showed that a high level of stressful life events was significantly more likely among women abused both before and during pregnancy (OR = 11.94) and among women abused before but not during pregnancy (OR = 14.19). Conclusions: The high frequency of multiple stressful events and abuse in women's lives suggests that women's care providers should ask their patients about these issues, and offer appropriate referral/interventions to those in need.     

Factors associated with perceived health among 12-year-old school children. Relevance of physical exercise and sense of coherence

BACKGROUND: Poor perceived health during childhood may affect an individual's well-being throughout life. In adult studies, sense of coherence (SOC) has been shown to be associated with perceived health. AIMS: The aim of this study was to determine which factors with an emphasis on SOC and physical exercise were associated with perceived health among 12-year-old children. METHODS: A total of 1,231 12-year-old school children (83%) completed a questionnaire. Most of the 37 questions had multiple-choice types of response. The questions were largely based on those used in the Health Behaviour in School-aged Children (HBSC) study coordinated by the WHO. SOC was determined using the 13-item scale developed by Antonovsky. Factors used in calculating performance at school were marks (given by the teachers, range 4-10, 10 being the best) in mathematics, native language, and first foreign language. Statistical analysis involved the use of logistic regression models and the so-called generalized estimation technique because of the multi-level study design. RESULTS: In a multivariate model adjusted for reported psychosomatic symptoms, insufficient physical exercise was clearly (OR 4.6) associated with poor perceived health. Other variables with significant associations (OR 1.4-1.7) were a mark below 9 in mathematics, belonging to the weakest SOC tertile, reporting of problems of perceived support from teachers, and reporting of various problems involving the class climate. CONCLUSIONS: Among the studied variables physical exercise was the most strongly associated with perceived health, even when several social and psychological risk factors were included in the analysis. SOC and variables of social support were also of importance.