Publications by authors named "Anna-Mari Aalto"

48 Publications

Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study.

J Med Internet Res 2020 07 7;22(7):e17616. Epub 2020 Jul 7.

Finnish Institution for Health and Welfare, Helsinki, Finland.

Background: The number of online services in health care is increasing rapidly in developed countries. Users are expected to take a more skilled and active role in taking care of their health and prevention of ill health. This induces risks that users (especially those who need the services the most) will drop out of digital services, resulting in a digital divide or exclusion. To ensure wide and equal use of online services, all users must experience them as beneficial.

Objective: This study aimed to examine associations of (1) demographics (age, gender, and degree of urbanization), (2) self-rated health, (3) socioeconomic position (education, experienced financial hardship, labor market position, and living alone), (4) social participation (voting, satisfaction with relationships, and keeping in touch with friends and family members), and (5) access, skills, and extent of use of information and communication technologies (ICT) with perceived benefits of online health care and social welfare services. Associations were examined separately for perceived health, economic, and collaboration benefits.

Methods: We used a large random sample representative of the Finnish population including 4495 (56.77% women) respondents aged between 20 and 97 years. Analyses of covariance were used to examine the associations of independent variables with perceived benefits.

Results: Access to online services, ICT skills, and extent of use were associated with all examined benefits of online services. ICT skills seemed to be the most important factor. Poor self-rated health was also consistently associated with lower levels of perceived benefits. Similarly, those who were keeping in touch with their friends and relatives at least once a week perceived online services more often beneficial in all the examined dimensions. Those who had experienced financial hardship perceived fewer health and economic benefits than others. Those who were satisfied with their relationships reported higher levels of health and collaboration benefits compared with their counterparts. Also age, education, and degree of urbanization had some statistically significant associations with benefits but they seemed to be at least partly explained by differences in access, skills, and extent of use of online services.

Conclusions: According to our results, providing health care services online has the potential to reinforce existing social and health inequalities. Our findings suggest that access to online services, skills to use them, and extent of use play crucial roles in perceiving them as beneficial. Moreover, there is a risk of digital exclusion among those who are socioeconomically disadvantaged, in poor health, or socially isolated. In times when health and social services are increasingly offered online, this digital divide may predispose people with high needs for services to exclusion from them.
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http://dx.doi.org/10.2196/17616DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381057PMC
July 2020

General Health Questionnaire (GHQ-12), Beck Depression Inventory (BDI-6), and Mental Health Index (MHI-5): psychometric and predictive properties in a Finnish population-based sample.

Psychiatry Res 2020 07 7;289:112973. Epub 2020 May 7.

National Institute for Health and Welfare, Finland.

The short versions of the General Health Questionnaire (GHQ-12), Beck's Depression Inventory (BDI-6), and Mental Health Index (MHI-5) are all valid and reliable measures of general psychological distress, depressive symptoms, and anxiety. We tested the psychometric properties of the scales, their overlap, and their ability to predict mental health service use using both regression and machine learning (ML, random forest) approaches. Data were from the population-based FinHealth-2017 Study of adults (N = 4270) with data on all of the evaluated instruments. Constructive validity, internal consistency, invariance, and optimal cut-off points in predicting mental health services were tested. Constructive validity was acceptable and all instruments measured their own distinct phenomenon. Some of the item scoring in BDI-6 was not optimal, and the sensitivity and specificity of all scales were relatively weak in predicting service use. Small gender differences emerged in optimal cut-off points. ML did not improve model predictions. GHQ-12, BDI-6, and MHI-5 may be interpreted to measure different constructs of psychological health symptoms, but are not particularly useful predictors of service use.
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http://dx.doi.org/10.1016/j.psychres.2020.112973DOI Listing
July 2020

The turnover intentions and intentions to leave the country of foreign-born physicians in Finland: a cross-sectional questionnaire study.

BMC Health Serv Res 2019 Sep 3;19(1):624. Epub 2019 Sep 3.

National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.

Background: A physician shortage is a worldwide problem and foreign-born physicians fill in the shortage of physicians in many developed countries. One problem that is associated with the physician shortage is increased physician turnover. Also, regarding foreign-born physicians, migration can be costly. The present study aimed to examine the turnover intentions and intentions to leave the country of foreign-born physicians. We examined how demographics, discrimination, language problems, perceived employment barriers, satisfaction with living in Finland, team climate, job satisfaction and patient-related stress were associated with these factors.

Methods: The present study was a cross-sectional questionnaire study among 371 foreign-born physicians in Finland that were aged between 26 and 65 (65% women). Binary logistic regression analyses were conducted to examine the associations.

Results: Half of the respondents had turnover intentions and 14.5% had considered leaving the country. High satisfaction with living in Finland was associated with a lower likelihood of both turnover intentions and intentions to leave the country. High levels of discrimination and employment barriers were associated with a high likelihood of turnover intentions whereas good team climate was associated with a low likelihood of turnover intentions. High levels of language problems were associated with a high likelihood of intentions to leave the country.

Conclusions: The present study showed the importance of satisfaction with living in the host country, the prevention of discrimination and employment barriers, language skills and a good team climate for the retention of foreign-born physicians in their current job and in the host country. Thus, to keep their foreign-born physicians, health care organisations should implement measures to tackle these challenges. Organisations could arrange, for example, diversity training, self-assessment, team reflections, leadership coaching and culturally-specific networks. Moreover, internships associated with the qualification process could be utilised better in order to give a thorough introduction to the host country's health care environment and the possibilities for learning the language.
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http://dx.doi.org/10.1186/s12913-019-4487-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6724339PMC
September 2019

Experienced time pressure and stress: electronic health records usability and information technology competence play a role.

BMC Med Inform Decis Mak 2019 08 14;19(1):160. Epub 2019 Aug 14.

The Department of Information Services, National Institute for Health and Welfare (THL), P.O. Box 30, FI-00271, Helsinki, Finland.

Background: Electronic health records (EHRs) are an elementary part of the work of registered nurses (RNs) in healthcare. RNs are the largest group of healthcare workers, and their experiences with EHRs and their informatics competence play a crucial role in a fluent workflow. The present study examined EHR usability factors and nurses' informatics competence factors related to self-reported time pressure and psychological distress.

Methods: A nationwide survey was conducted for working-age registered nurses in 2017. The study sample included 3607 nurses (5% men) in Finland. The association of age, sex, employment sector, EHR usability factors, and nurses' informatics competence factors with time pressure and psychological distress were examined with analyses of covariance.

Results: The EHR usability factors that were associated with high time pressure were low EHR reliability and poor user-friendliness. Regarding the nurses' informatics competence factors, only low e-Care competence was associated with time pressure. Of the EHR usability factors, low EHR reliability and low support for cooperation were associated with high psychological distress. Of the nurses' informatics competence factors, low e-Care competence was associated with high psychological distress.

Conclusions: Unreliability and poor user-friendliness of EHRs seem to be prominent sources of time pressure and psychological distress among registered nurses. User-friendly EHR systems and digital tools in healthcare are needed. Nurses' competence to use eHealth tools to tailor patient care should be strengthened through organizational and regional actions. For example, house rules about how to use eHealth tools and instructions on common practices in cooperation with other organizations could be useful.
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http://dx.doi.org/10.1186/s12911-019-0891-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694657PMC
August 2019

Developing the National Usability-Focused Health Information System Scale for Physicians: Validation Study.

J Med Internet Res 2019 05 16;21(5):e12875. Epub 2019 May 16.

National Institute for Health and Welfare, Helsinki, Finland.

Background: Problems in the usability of health information systems (HISs) are well acknowledged, but research still lacks a validated questionnaire for measuring and monitoring different dimensions of usability of HISs. Such questionnaires are needed not only for research but also for developing usability of HISs from the viewpoint of end-user experiences.

Objective: This study aimed to develop and test the validity of the questionnaire measuring the National Usability-Focused HIS-Scale (NuHISS) among a nationally representative sample of Finnish physicians.

Methods: We utilized 2 cross-sectional data collected from a random sample of Finnish physicians in 2014 (N=3781; of which 2340 [61.9%] were women) and 2017 (N=4018; of which 2604 [64.8%] were women). Exploratory and confirmatory factor analyses (structural equation modeling [SEM]) were applied to test the structural validity of the NuHISS. As the concurrent validity measure, we used the self-reported overall quality of the electronic health record system (school grade) provided by the participants using marginal structural models.

Results: The exploratory factor analyses with Varimax rotation suggested that the 7-factor solution did offer a good fit to the data in both samples (C=2136.14 in 2014 and C=2109.83 in 2017, both P<.001). Moreover, structural equation modelling analyses, using comparative fit index (CFI), Tucker-Lewis Index (TLI), Normed Fit Index (NFI), root mean squared error of approximation (RMSEA), and Standardized Root Mean square Residual (SRMR), showed that the 7-factor solution provided an acceptable fit in both samples (CFI=0.92/0.91, TLI=0.92/0.91, NFI=0.92/0.91, RMSEA=0.048/0.049, and SRMR=0.040/0.039). In addition, concurrent validity of this solution was shown to be acceptable. Ease of use, but also all other dimensions, was especially associated with overall quality reports independent of measured confounders. The 7-factor solution included dimensions of technical quality, information quality, feedback, ease of use, benefits, internal collaboration, and cross-organizational collaboration.

Conclusions: NuHISS provides a useful tool for measuring usability of HISs among physicians and offers a valid measure for monitoring the long-term development of HISs on a large scale. The relative importance of items needs to be assessed against national electronic health policy goals and complemented with items that have remained outside the NuHISS from the questionnaire when appropriate.
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http://dx.doi.org/10.2196/12875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542250PMC
May 2019

Testing the psychometric properties of the Finnish version of the cross-cultural competence instrument of healthcare professionals (CCCHP).

BMC Health Serv Res 2019 May 8;19(1):294. Epub 2019 May 8.

National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland.

Background: To test the validity of the Finnish version of the Bernhard et al.'s Cross-Cultural Competence instrument of Healthcare Professionals (CCCHP).

Methods: The study sample comprised registered nurses (N = 810) from the Finnish "Competent workforce for the future" -project (COPE). Exploratory factor analyses and structural equation modelling were applied to test structural validity of the CCCHP. Internal consistency of the sub-scales was evaluated using the Cronbach's alphas. Criterion validity was explored in terms of received education for multicultural work, perceived difficulty of patients, and job satisfaction variables.

Results: The revised version of the instrument including four (motivation/curiosity, attitudes, skills and emotions/empathy) of the five original dimensions provided satisfactory psychometric properties (internal consistency, a good model fit of the data). Of the four remaining competence sub-scales, motivation/curiosity, attitudes and emotions/empathy were associated with the amount of received education for multicultural work, and all with perceived difficulty of patients, and all but attitudes with job satisfaction.

Conclusion: This revised Finnish version of the CCCHP provides a useful tool for studies focusing on the healthcare personnel's cross-cultural competence in delivering effective and culturally sensitive healthcare services for patients from different cultures.
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http://dx.doi.org/10.1186/s12913-019-4105-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6505538PMC
May 2019

The association between cross-cultural competence and well-being among registered native and foreign-born nurses in Finland.

PLoS One 2018 7;13(12):e0208761. Epub 2018 Dec 7.

Department of Social and Health Systems Research, National Institute for Health and Welfare, Helsinki, Finland.

Background: A growing body of research indicates that cross-cultural competence in nurses can improve migrant patients' health-related outcomes, but little is known about the potential benefits of cross-cultural competence on the nurses' own well-being.

Objective: To examine whether cross-cultural competence (empathy, skills, positive attitudes, and motivation) is associated with perceived time pressure at work, psychological distress, and sleep problems among registered nurses in Finland, and whether there are differences in these potential associations between native and foreign-born nurses.

Methods: The present cross-sectional study was based on a sample of 212 foreign-born nurses licensed to practice in Finland and a random sample of 744 native Finnish nurses. Data were collected with a questionnaire and analyzed using multiple linear regression and structural equation modeling (SEM).

Results: Of all four dimensions of cross-cultural competence, only empathy was associated with perceived time pressure (β = -0.13, p = .018), distress (β = -0.23, p < .001), and sleep problems (β = -0.14, p = .004) after the adjustment for gender, age, employment sector, and frequency of interacting with patients and colleagues from different cultures. There were no differences between native and foreign-born nurses in these observed associations (all ps > .05).

Conclusions: Cross-cultural empathy may protect against perceived time pressure, distress, and sleep problems in both native and foreign-born nurses. Thus, the promotion of this component of cross-cultural competence among nursing personnel should be encouraged.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0208761PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6285347PMC
May 2019

How do health care workers manage a patient with multiple care needs from both health and social care services? - A vignette study.

Int J Care Coord 2018 Jun 21;21(1-2):5-14. Epub 2017 Nov 21.

National Institute for Health and Welfare, Finland.

Introduction: To assess how health care professionals outline the management of care and explore which health or social care professionals were involved in the patient's treatment.

Methods: A survey with a patient vignette for general practitioners (n = 31) and registered nurses (n = 31) working daily in Finnish health centres located in four cities. Respondents answered structural questions and explained in detail the care process that they tailored for the patient. The care process was examined using content analysis.

Results: A physician-nurse working pair was declared to be in charge of the care process by 27% of respondents, a registered nurse by 9% and a general practitioner by 11%. However, 53% reported that no single person or working pair was in charge of the care process (response rate 72%). The concluding result of the analyses of the presented process was that both treatment practices and the professionals participating in the patient's treatment varied. Collaboration with social services was occasional, and few care processes included referrals to social services.

Conclusion: For the patient who needs both health and social care services, the management of care is a challenge. To improve the chances of patients being actively involved in making treatment plans at least three factors need to be addressed. Firstly, a written treatment plan should explicate the care process. Second, collaboration and interaction between health and social care services should be strengthened, and third, a contact person should be named to avoid care gaps in primary health care. Next-step data from patients need to be collected to get their views on care management and compare these with those from general practitioners and registered nurses.
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http://dx.doi.org/10.1177/2053434517744070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5971361PMC
June 2018

Foreign-born physicians' perceptions of discrimination and stress in Finland: a cross-sectional questionnaire study.

BMC Health Serv Res 2018 06 7;18(1):418. Epub 2018 Jun 7.

National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.

Background: Foreign-born physicians fill in the shortage of physicians in many developed countries. Labour market theory and previous studies suggest that foreign-born physicians may be a disadvantaged group with a higher likelihood of discrimination and less prestigious jobs. The present study examines foreign-born physicians' experiences of discrimination (coming from management, colleagues and patients separately) and patient-related stress and integration-related stress, and it examines how gender, age, employment sector, country of birth, years from getting a practicing license in Finland, language problems, cross-cultural training, cross-cultural empathy, team climate and skill discretion were associated with these factors.

Methods: The present study was a cross-sectional questionnaire study among 371 foreign-born physicians in Finland, aged between 26 and 65 (65% women). Analyses of covariance and logistic regression analyses were conducted to examine the associations.

Results: A good team climate and high cross-cultural empathy were associated with lower likelihoods of discrimination from all sources, patient-related stress and integration-related stress. Skill discretion was associated with lower levels of integration-related stress and discrimination from management and colleagues. Language problems were associated with higher levels of integration-related stress. The biggest sources of discrimination were patients and their relatives.

Conclusions: The present study showed the importance of a good team climate, cross-cultural empathy and patience, skill discretion and language skills in regard to the proper integration of foreign-born health care employees into the workplace. Good job resources, such as a good team climate and the possibility to use one's skills, may help foreign-born employees, for instance by giving them support when needed and offering flexibility. Health care organizations should invest in continuous language training for foreign-born employees and also offer support when there are language problems. Moreover, it seems that training increasing cross-cultural empathy and patience might be beneficial.
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http://dx.doi.org/10.1186/s12913-018-3256-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5992868PMC
June 2018

Predictors of physicians' stress related to information systems: a nine-year follow-up survey study.

BMC Health Serv Res 2018 04 13;18(1):284. Epub 2018 Apr 13.

National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.

Background: Among the important stress factors for physicians nowadays are poorly functioning, time consuming and inadequate information systems. The present study examined the predictors of physicians' stress related to information systems (SRIS) among Finnish physicians. The examined predictors were cognitive workload, staffing problems, time pressure, problems in teamwork and job satisfaction, adjusted for baseline levels of SRIS, age, gender and employment sector.

Methods: The study has a follow-up design with two survey data collection waves, one in 2006 and one in 2015, based on a random sample of Finnish physicians was used. The present study used a sample that included 1109 physicians (61.9% women; mean age in 2015 was 54.5; range 34-72) who provided data on the SRIS in both waves. The effects of a) predictor variable levels in 2006 on SRIS in 2015 and b) the change in the predictor variables from 2006 to 2015 on SRIS in 2015 were analysed with linear regression analyses.

Results: Regression analyses showed that the higher level of cognitive workload in 2006 significantly predicted higher level of SRIS in 2015 (β = 0.08). The reciprocity of this association was tested with cross-lagged structural equation model analyses which showed that the direction of the association was from cognitive workload to SRIS, not from SRIS to cognitive workload. Moreover, increases in time pressure (β = 0.16) and problems in teamwork (β = 0.10) were associated with higher levels of SRIS in 2015, whereas job satisfaction increase was associated with lower SRIS (β = - 0.06).

Conclusions: According to our results, physicians' cognitive workload may have long-lasting negative ramifications in regard to how stressful physicians experience their health information systems to be. Thus, organisations should pay attention to physicians workload if they wish physicians to master all the systems they need to use. It is also important to provide physicians with enough time and collegial support in their system-related problems, and in learning new systems and system updates.
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http://dx.doi.org/10.1186/s12913-018-3094-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5899365PMC
April 2018

Social relationships in physicians' work moderate relationship between workload and wellbeing-9-year follow-up study.

Eur J Public Health 2018 10;28(5):798-804

National Institute for Health and Welfare, Department of Health and Social Care Systems, Helsinki, Finland.

Background: Increasing wellbeing problems among physicians may lead to serious consequences in health care and means to prevent such development are called for. This study examined longitudinal associations between workload and changes in distress, sleep quality and workability in physicians and whether positive social relations at work would protect from such problems.

Methods: A baseline survey was conducted in 2006 for a random sample of 5000 physicians (n = 2841, response rate 57%). In 2015, the follow-up survey was sent to those 2 206 physicians who gave their consent (n = 1462, response rate 68.3%). The survey included scales for distress, sleeping problems, workability, workload, team climate, collegial support and questions for background information.

Results: Increased workload was associated with increased psychological distress, sleeping problems and decreased workability during the 9-year follow-up. Good team climate and collegial support were related to decreased distress and sleep quality and enhanced workability. Good collegial support buffered the associations of workload changes on distress and sleep quality changes. Team climate was more strongly associated with changes in sleep quality and workability among younger and middle aged physicians than older physicians. Also collegial support had a stronger association with sleep quality change among younger or middle aged physicians than older physicians. These associations were robust to adjustments for age, gender, specialization, leadership position, marital status and baseline wellbeing.

Conclusions: Health care organizations should take measures to decrease workload and to increase availability of social support for physicians in order to protect physicians from declining wellbeing.
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http://dx.doi.org/10.1093/eurpub/ckx232DOI Listing
October 2018

Better Usability and Technical Stability Could Lead to Better Work-Related Well-Being among Physicians.

Appl Clin Inform 2017 10 14;8(4):1057-1067. Epub 2017 Dec 14.

Unit of Social and Health Systems Research, Department of Health and Social Care Systems, National Institute for Health and Welfare, Helsinki, Finland.

Background and Objective Finnish physicians have been increasingly dissatisfied with poor usability of the electronic patient record (EPR) systems, which they have identified as an overload factor in their work. Our aim is to specify which factors in EPRs are associated with work-related well-being of physicians. Methods A web-based questionnaire was sent to Finnish physicians younger than 65 years; the responses (n = 3,781) represent one-fourth of these. This was a repetition of a survey in 2010, where this questionnaire was used for the first time. In addition to statements assessing usability, there were questions measuring time pressure and job control. The relation between usability and work well-being was investigated with hierarchical multivariate regression analyses: With time pressure and job control as dependent variables, EPR usability assessments and physicians' background information were used as independent variables. Results In the multivariate analyses, technical problems that are often experienced in the EPR were related to higher time pressure and lower job control. Active participation in the development of the EPR system was related to stronger time pressure and stronger job control. In addition, use of several systems daily and the experience of time-consuming documentation of patient information for statistical purposes (billing, national registries, and reporting) were related to higher time pressure, while those with longer experience with the EPR system and those experiencing easy-to-read nursing records reported higher job control. Conclusion To relieve time pressure and increase sense of job control experienced by physicians, usability, integrations, and stability of the EPR systems should be improved: fewer login procedures, easier readability of nursing records, and decreased need for separate documentation for statistical purposes. Physician participation in the EPR development would increase the feeling of job control, but would add the time pressure. Hence, time for developmental work should be arranged.
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http://dx.doi.org/10.4338/ACI-2017-06-RA-0094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802304PMC
October 2017

Finnish physicians' stress related to information systems keeps increasing: a longitudinal three-wave survey study.

BMC Med Inform Decis Mak 2017 Oct 17;17(1):147. Epub 2017 Oct 17.

National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.

Background: Poorly functioning, time-consuming, and inadequate information systems are among the most important work-related psychosocial factors causing stress in physicians. The present study examined the trend in the perceived stress that was related to information systems (SRIS) among Finnish physicians during a nine-year follow-up. In addition, we examined the associations of gender, age, employment sector, specialization status, leadership position, on-call burden, and time pressure with SRIS change and levels.

Methods: A longitudinal design with three survey data collection waves (2006, 2010 and 2015) based on a random sample of Finnish physicians in 2006 was used. The study sample included 1095 physicians (62.3% women, mean age 54.4 years) who provided data on SRIS in every wave. GLM repeated measures analyses were used to examine the associations between independent variables and the SRIS trend during the years 2006, 2010, and 2015.

Results: SRIS increased during the study period. The estimated marginal mean of SRIS in 2006 was 2.80 (95% CI = 2.68-2.92) and the mean increase was 0.46 (95% CI = 0.30-0.61) points from 2006 to 2010 and 0.25 (95% CI = 0.11-0.39) points from 2010 to 2015. Moreover, our results show that the increase was most pronounced in primary care, whereas in hospitals SRIS did not increase between 2010 and 2015. SRIS increased more among those in a leadership position. On-call duties and high time-pressures were associated with higher SRIS levels during all waves.

Conclusions: Changing, difficult, and poorly functioning information systems (IS) are a prominent source of stress among Finnish physicians and this perceived stress continues to increase. Organizations should implement arrangements to ease stress stemming from IS especially for those with a high workload and on-call or leadership duties. To decrease IS-related stress, it would be important to study in more detail the main IS factors that contribute to SRIS. Earlier studies indicate that the usability and stability of information systems as well as end-user involvement in system development and work-procedure planning may be significant factors.
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http://dx.doi.org/10.1186/s12911-017-0545-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5646125PMC
October 2017

What patients think about choice in healthcare? A study on primary care services in Finland.

Scand J Public Health 2018 Jun 19;46(4):463-470. Epub 2017 Sep 19.

1 National Institute for Health and Welfare, Finland.

Background: The ongoing Finnish health and social service reform will expand choice by opening the market for competition between public and private service providers. This study examined the attitudes of primary care patients towards choice and which patient-related factors are associated with these attitudes.

Methods: A sample of attenders during one week in health centres of 12 big cities and municipal consortiums (including seven outsourced local units) and in primary care units of one private company providing outsourced services for municipalities (aged 18-95, n=8128) was used. The questionnaire included questions on choice-related attitudes, sociodemographic factors, health status, use of health services and patient satisfaction.

Results: Of the responders, 77% regarded choice to be important, 49% perceived genuine opportunities to make choices and 35% were satisfied with the choice-relevant information. Higher age, low education, having a chronic illness, frequent use of services, having a personal physician and being satisfied with the physician and with waiting times were related to assigning more importance on choice. Younger patients, those with higher education as well as those with chronic illness regarded their opportunities of choosing the service provider and availability of choice-relevant information poorer.

Conclusions: The Finnish primary care patients value choice, but they are critical of the availability of choice-relevant information. Choices of patients with complex health care needs should be supported by developing integrated care alternatives and by increasing the availability of information on existing care alternatives to meet their needs.
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http://dx.doi.org/10.1177/1403494817731488DOI Listing
June 2018

Does Organizational Justice Modify the Association Between Job Involvement and Retirement Intentions of Nurses in Finland?

Res Nurs Health 2016 10 27;39(5):364-74. Epub 2016 Jun 27.

Head of Unit, National Institute for Health and Welfare (THL), Health and Social Care System Department, Social and Health System Research Unit, Helsinki, Finland.

Given the growing aging population in Finland, retaining health staff to care for them is important. In an exploration of predictors of quitting before the typical retirement age, which ranges from 63 to 68 years in Finland, we examined whether organizational justice moderated the association between job involvement and retirement intentions among nurses 50 years and over. The sample was 446 nurses (70% practical nurses) working in 134 assisted living facilities providing 24-hour care for older residents in Finland. Job involvement was measured with the Job Involvement Questionnaire, and organizational justice with a scale that tapped its three dimensions: distributive justice, procedural justice, and interactional justice. In covariance analyses, low organizational justice and low job involvement were associated with a higher likelihood of retirement intention. Both interactional justice and procedural justice moderated the association of job involvement with retirement intentions. Among nurses with low job involvement, those who experienced unjust treatment, that is, low interactional justice, and evaluated organizational procedures as unjust had significantly stronger retirement intentions than nurses with high levels of interactional and procedural justice. Distributive justice was associated with retirement intentions in both high and low job-involved respondents. Organizational justice may act as a buffer against retirement intention as one consequence of nurses' low job involvement. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/nur.21740DOI Listing
October 2016

Structural and functional aspects of social support as predictors of mental and physical health trajectories: Whitehall II cohort study.

J Epidemiol Community Health 2016 Jul 14;70(7):710-5. Epub 2016 Jan 14.

Institute of Behavioural Sciences, University of Helsinki, Helsinki, Finland National Institute for Health and Welfare, Helsinki, Finland.

Background: Social support is associated with better health. However, only a limited number of studies have examined the association of social support with health from the adult life course perspective and whether this association is bidirectional.

Methods: Participants (n=6797; 30% women; age range from 40 to 77 years) who were followed from 1989 (phase 2) to 2006 (phase 8) were selected from the ongoing Whitehall II Study. Structural and functional social support was measured at follow-up phases 2, 5 and 7. Mental and physical health was measured at five consecutive follow-up phases (3-8).

Results: Social support predicted better mental health, and certain functional aspects of social support, such as higher practical support and higher levels of negative aspects in social relationships, predicted poorer physical health. The association between negative aspects of close relationships and physical health was found to strengthen over the adult life course. In women, the association between marital status and mental health weakened until the age of approximately 60 years. Better mental and physical health was associated with higher future social support.

Conclusions: The strength of the association between social support and health may vary over the adult life course. The association with health seems to be bidirectional.
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http://dx.doi.org/10.1136/jech-2015-206165DOI Listing
July 2016

Stressful work environment and wellbeing: What comes first?

J Occup Health Psychol 2015 Jul 23;20(3):289-300. Epub 2015 Feb 23.

Department of Epidemiology and Public Health, University College London.

The association between the psychosocial work environment, including job demands, job control, and organizational justice, and employee wellbeing has been well established. However, the exposure to adverse work environments is typically measured only using self-reported measures that are vulnerable to reporting bias, and thus any associations found may be explained by reverse causality. Using linear regression models and cross-lagged structural equation modeling (SEM), we tested the direction of the association between established job stress models (job demand control and organizational justice models) and 3 wellbeing indicators (psychological distress, sleeping problems, and job satisfaction) among 1524 physicians in a 4-year follow-up. Results from the longitudinal cross-lagged analyses showed that the direction of the association was from low justice to decreasing wellbeing rather than the reverse. Although the pattern was similar in job demands and job control, a reciprocal association was found between job control and psychological distress.
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http://dx.doi.org/10.1037/a0038684DOI Listing
July 2015

Are there high-risk groups among physicians that are more vulnerable to on-call work?

Am J Emerg Med 2015 May 28;33(5):614-9. Epub 2015 Jan 28.

National Institute for Health and Welfare, Helsinki, Finland.

Background: Work done in the emergency departments is one stressful aspect of physicians' work. Numerous previous studies have highlighted the stressfulness of on-call work and especially of night on call. In addition, previous studies suggest that there may be individual differences in adjusting to changes in circadian rhythms and on-call work.

Objective: The objective of this study was to examine whether physicians' on-call work is associated with perceived work-related stress factors and job resources and whether there are groups that are more vulnerable to on-call work according to sex, age, and specialization status.

Methods: This was a cross-sectional questionnaire study among 3230 Finnish physicians (61.5% women). The analyses were conducted using analyses of covariance adjusted for sex, age, specialization status, and employment sector.

Results: Physicians with on-call duties had more time pressure and stress related to team work and patient information systems compared with those who did not have on-call duties. In addition, they had less job control opportunities and experienced organization as less fair and team climate as worse. Older physicians and specialists seemed to be especially vulnerable to on-call work regarding stress factors, whereas younger and specialist trainees seemed vulnerable to on-call work regarding job resources.

Conclusions: Focusing on team issues and resources is important for younger physicians and trainees having on-call duties, whereas for older and specialists, attention should be focused on actual work load and time pressure.
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http://dx.doi.org/10.1016/j.ajem.2015.01.034DOI Listing
May 2015

Job demands and job strain as risk factors for employee wellbeing in elderly care: an instrumental-variables analysis.

Eur J Public Health 2015 Feb 8;25(1):103-8. Epub 2014 Aug 8.

1 National Institute for Health and Welfare, Helsinki, Finland.

Background: The association between psychosocial work environment and employee wellbeing has repeatedly been shown. However, as environmental evaluations have typically been self-reported, the observed associations may be attributable to reporting bias.

Methods: Applying instrumental-variable regression, we used staffing level (the ratio of staff to residents) as an unconfounded instrument for self-reported job demands and job strain to predict various indicators of wellbeing (perceived stress, psychological distress and sleeping problems) among 1525 registered nurses, practical nurses and nursing assistants working in elderly care wards.

Results: In ordinary regression, higher self-reported job demands and job strain were associated with increased risk of perceived stress, psychological distress and sleeping problems. The effect estimates for the associations of these psychosocial factors with perceived stress and psychological distress were greater, but less precisely estimated, in an instrumental-variables analysis which took into account only the variation in self-reported job demands and job strain that was explained by staffing level. No association between psychosocial factors and sleeping problems was observed with the instrumental-variable analysis.

Conclusions: These results support a causal interpretation of high self-reported job demands and job strain being risk factors for employee wellbeing.
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http://dx.doi.org/10.1093/eurpub/cku115DOI Listing
February 2015

Inflows of foreign-born physicians and their access to employment and work experiences in health care in Finland: qualitative and quantitative study.

Hum Resour Health 2014 Aug 7;12:41. Epub 2014 Aug 7.

National Institute for Health and Welfare (THL), Service System Research Unit, Mannerheimintie 103 b, P,O, Box 30, FI-00271 Helsinki, Finland.

Background: In many developed countries, including Finland, health care authorities customarily consider the international mobility of physicians as a means for addressing the shortage of general practitioners (GPs). This study i) examined, based on register information, the numbers of foreign-born physicians migrating to Finland and their employment sector, ii) examined, based on qualitative interviews, the foreign-born GPs' experiences of accessing employment and work in primary care in Finland, and iii) compared experiences based on a survey of the psychosocial work environment among foreign-born physicians working in different health sectors (primary care, hospitals and private sectors).

Methods: Three different data sets were used: registers, theme interviews among foreign-born GPs (n = 12), and a survey for all (n = 1,292; response rate 42%) foreign-born physicians living in Finland. Methods used in the analyses were qualitative content analysis, analysis of covariance, and logistic regression analysis.

Results: The number of foreign-born physicians has increased dramatically in Finland since the year 2000. In 2000, a total of 980 foreign-born physicians held a Finnish licence and lived in Finland, accounting for less than 4% of the total number of practising physicians. In 2009, their proportion of all physicians was 8%, and a total of 1,750 foreign-born practising physicians held a Finnish licence and lived in Finland. Non-EU/EEA physicians experienced the difficult licensing process as the main obstacle to accessing work as a physician. Most licensed foreign-born physicians worked in specialist care. Half of the foreign-born GPs could be classified as having an 'active' job profile (high job demands and high levels of job control combined) according to Karasek's demand-control model. In qualitative interviews, work in the Finnish primary health centres was described as multifaceted and challenging, but also stressful.

Conclusions: Primary care may not be able in the long run to attract a sufficient number of foreign-born GPs to alleviate Finland's GP shortage, although speeding up the licensing process may bring in more foreign-born physicians to work, at least temporarily, in primary care. For physicians to be retained as active GPs there needs to be improvement in the psychosocial work environment within primary care.
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http://dx.doi.org/10.1186/1478-4491-12-41DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139137PMC
August 2014

Employment, psychosocial work environment and well-being among migrant and native physicians in Finnish health care.

Eur J Public Health 2014 Jun 19;24(3):445-51. Epub 2014 Mar 19.

National Institute for Welfare and Health, Helsinki, Finland.

Background: Although international migration of physicians is increasing, research information on their adjustment to working in a new country is scarce. This study examined the differences in employment, perceptions of psychosocial work environment and well-being between migrant and native physicians in Finland.

Methods: A cross-sectional survey was sent to a random sample of physicians in Finland (N = 7000) and additionally to all foreign-born physicians licensed to practice in Finland (N = 1292). The final response rates were 56% (n = 3646) among native Finns and 43% (n = 553) among foreign-born physicians.

Results: Migrant physicians worked more often in primary care and on-call services and less often in leadership positions than native Finns. They more often experienced lack of professional support and lower work-related well-being compared with native Finns. Those migrant physicians who had lived for a shorter time in Finland perceived less stress related to electronic patient records systems and higher organizational justice compared with native physicians or those foreign physicians who had migrated earlier.

Conclusions: Foreign-born physicians are more often employed in the primary care sector, where there are most difficulties in recruiting from the native workforce in Finland. Attention should be paid to enhancing equitable career opportunities and well-being among foreign-born physicians working in Finnish health care. Although migrant physicians are relatively well adjusted to Finnish health care in terms of perceptions of psychosocial work environment, their lower well-being calls for attention.
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http://dx.doi.org/10.1093/eurpub/cku021DOI Listing
June 2014

Is working in culturally diverse working environment associated with physicians' work-related well-being? A cross-sectional survey study among Finnish physicians.

Health Policy 2014 Aug 14;117(2):187-94. Epub 2014 Feb 14.

National Institute for Health and Welfare, P.O. Box 30, FI-00271 Helsinki, Finland. Electronic address:

International mobility of health care professionals is increasing, though little is known about how working in a culturally diverse team affects the native physicians' psychosocial work environment. We examined Finnish physicians' perceptions of work-related wellbeing according to whether they had foreign-born colleagues (FBCs) in their work unit. We also examined whether work-related resources moderate the potential association between work-related wellbeing and working alongside FBCs. A cross-sectional survey was conducted for a random sample of physicians in Finland in 2010 (3826 respondents, response rate 55%). Analyses were restricted to native Finnish physicians working in public health care. The results were analyzed by ANCOVA. In unadjusted analyses, having FBCs was related to poor team climate (p<0.001) and poor job satisfaction (p=0.001). Those physicians who reported high procedural justice and high job control perceived also higher job satisfaction even if they had many FBCs in the work unit (p=0.007 for interaction between FBCs and procedural justice and p<0.001 for interaction between FBCs and job control). These associations were robust to adjustments for age, sex, health care sector, specialization, on-call duty, employment contract, full-time employment and leadership position. The results indicate that culturally diverse work units face challenges related to team climate and job satisfaction. The results also show that leadership plays an important role in culturally diverse work units. The potential challenges of culturally diverse teams for native physicians may be reduced by fair decision-making and by increasing physicians' job control.
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http://dx.doi.org/10.1016/j.healthpol.2014.02.006DOI Listing
August 2014

Work-related stress, job resources, and well-being among psychiatrists and other medical specialists in Finland.

Psychiatr Serv 2014 Jun;65(6):796-801

Objectives: Previous studies suggest that psychiatrists may be more stressed than other medical specialists and mental health professionals. This study examined differences in stress factors, job resources, psychological distress, and job satisfaction between psychiatrists and other medical specialists. In addition, the study examined whether stress factors or job resources accounted for possible differences between the groups in psychological distress or job satisfaction.

Methods: In 2010, the authors obtained cross-sectional, Web-based survey data from a random sample of 2,776 Finnish physicians, including 1,647 women (59%), ranging in age from 25 to 69 years old. Comparisons between the two groups used analyses of covariance adjusted for gender, age, and employment sector.

Results: Psychiatrists were less satisfied with their jobs, felt more stressed about patients, and experienced more psychological distress compared with other medical specialists. However, psychiatrists had more opportunities to control their jobs and better team climate compared with other medical specialists. High psychological distress among psychiatrists was partly accounted for by high patient-related stress. The differences in psychological distress and job satisfaction between the two groups were not accounted for by work-family conflicts or optimism.

Conclusions: It is important to try to alleviate the high levels of patient-related stress among psychiatrists and to further increase their job resources. Doing so may enhance the attractiveness of psychiatry as a specialty choice.
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http://dx.doi.org/10.1176/appi.ps.201300200DOI Listing
June 2014

Do nurses who work in a fair organization sleep and perform better and why? Testing potential psychosocial mediators of organizational justice.

J Occup Health Psychol 2013 Oct;18(4):481-91

Service System Department, National Institute for Health and Welfare.

We examined whether organizational justice is associated with sleep quality and performance in a population-based sample of 1,729 Finnish registered nurses working full time. In addition, we tested psychological mechanisms mediating the potential association. The results of multivariate linear regression analyses showed higher organizational justice to be associated with fewer sleeping problems (β values range from -.20 to -.11) and higher self-reported performance (β values range from .05 to .35). Furthermore, psychological distress (related to the psychological stress model) and job involvement (related to the psychosocial resource model) mediated the association between organizational justice and sleep. Sleeping problems partly mediated the association between organizational justice and performance. Psychological distress explained 51% to 83% and job involvement explained 10% to 15% of the total effects of justice variables on sleeping problems. The findings provide support for the psychological stress model and offer practical implications for reducing nurses' sleeping problems.
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http://dx.doi.org/10.1037/a0033990DOI Listing
October 2013

Quality of life and costs of levonorgestrel-releasing intrauterine system or hysterectomy in the treatment of menorrhagia: a 10-year randomized controlled trial.

Am J Obstet Gynecol 2013 Dec 30;209(6):535.e1-535.e14. Epub 2013 Aug 30.

Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Helsinki, Finland. Electronic address:

Objective: Menorrhagia is a common problem impairing the quality of life (QOL) of many women. Both levonorgestrel-releasing intrauterine system (LNG-IUS) and hysterectomy are effective treatment modalities but no long-term comparative studies of QOL and costs exist. The objective of this study was to compare QOL and costs of LNG-IUS or hysterectomy in the treatment of menorrhagia during 10-year follow-up.

Study Design: A total of 236 women, aged 35-49 years, referred for menorrhagia to 5 university hospitals in Finland were randomly assigned to treatment with LNG-IUS (n = 119) or hysterectomy (n = 117) and were monitored for 10 years. The main outcome measures were health-related QOL (HRQOL), psychosocial well-being, and cost-effectiveness.

Results: A total of 221 (94%) women were followed for 10 years. Although 55 (46%) women assigned to the LNG-IUS subsequently underwent hysterectomy, the overall costs in the LNG-IUS group ($3423) were substantially lower than in the hysterectomy group ($4937). Overall, levels of HRQOL and psychosocial well-being improved during first 5 years but diminished between 5 years and 10 years and the improved HRQOL returned close to the baseline level. There were no significant differences between LNG-IUS and hysterectomy groups.

Conclusion: Both LNG-IUS and hysterectomy improved HRQOL. The improvement was most striking during the first 5 years. Although many women eventually had hysterectomy, LNG-IUS remained cost-effective.
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http://dx.doi.org/10.1016/j.ajog.2013.08.041DOI Listing
December 2013

Psychosocial stress factors and intention to leave job: differences between foreign-born and Finnish-born general practitioners.

Scand J Public Health 2013 Jun 18;41(4):405-11. Epub 2013 Mar 18.

National Institute for Health and Welfare (THL), Service System Research Unit, Helsinki, Finland.

Aims: Physicians' high dropout rate is a significant problem in primary care in many countries. One solution to this issue is to recruit internationally mobile physicians. This study explores the role of psychosocial factors in explaining intention to leave among GPs including potential differences between foreign-born and Finnish GPs.

Methods: A cross-sectional questionnaire was sent to randomly-selected Finnish physicians (n = 7000) and all foreign-born physicians (n = 1297) living in Finland in the year 2010. The questionnaire was returned by 4333 physicians, of whom 832 were GPs. Of those 176 were foreign-born GPs.

Results: Intention to leave was more common among foreign-born GPs (59%) than among Finnish GPs (52%). High job demands were associated with higher intention to leave from primary care both in foreign-born (OR 1.90) and Finnish GPs (OR 2.20). This association remained among foreign-born GPs after adjusted the model for the country of origin or the reason for migration (OR 1.80, 1.82). Lack of job control, patient-related stress, and stresses related to teamwork were associated with higher intention to leave only among Finnish GPs (ORs 0.45, 1.75 and 1.99).

Conclusions: There may be cultural differences in the psychosocial factors that enhance or prevent job involvement among physicians. Thus, novel thinking is needed in organizational development of GP work in order to better understand foreign-born physicians' specific needs in a target country. This study also suggests that lightening workload could help to attract more GPs, both foreign-born and Finnish, to primary care.
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http://dx.doi.org/10.1177/1403494813477248DOI Listing
June 2013

Job demands and musculoskeletal symptoms among female geriatric nurses: the moderating role of psychosocial resources.

J Occup Health Psychol 2013 Apr 4;18(2):211-9. Epub 2013 Mar 4.

Service System Department, National Institute for Health and Welfare, Helsinki, Finland.

The present study examined whether job resources (job control, social support, and distributive justice) moderate the associations of high job demands induced by physical and mental workload with musculoskeletal symptoms among geriatric nurses. The data were drawn in Finland from 975 female nurses working in 152 geriatric units who responded to a survey questionnaire. Information on the objective workload in terms of resident characteristics and structural factors was also collected at the unit level. After adjusting for the objective workload, multilevel logistic regression analyses showed that self-reported physical workload was associated with higher risk of musculoskeletal symptoms (OR = 1.93, 95 % CI [1.38, 2.72]) among nurses with low social support. In addition, mental workload was associated with higher risk of musculoskeletal symptoms (OR = 1.72, 95% CI [1.12, 2.62]) for those with low distributive justice. The results suggest that social support and fair reward systems may help to buffer against the detrimental effects of heavy job demands on nurses' musculoskeletal symptoms.
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http://dx.doi.org/10.1037/a0031801DOI Listing
April 2013

Psychosocial factors in GP work: the effects of taking a GP position or leaving GP work.

Eur J Public Health 2013 Jun 28;23(3):361-6. Epub 2012 Aug 28.

National Institute for Health and Welfare, Helsinki, Finland.

Background: We examined the effects of leaving public sector general practitioner (GP) work and of taking a GP position on changes in work-related psychosocial factors, such as time pressure, patient-related stress, distress and work interference with family. In addition, we examined whether changes in time pressure and patient-related stress mediated the association of employment change with changes of distress and work interference with family.

Methods: Participants were 1705 Finnish physicians (60% women) who responded to surveys in 2006 and 2010. Analyses of covariance were conducted to examine the effect of employment change to outcome changes adjusted for gender, age and response format. Mediational effects were tested following the procedures outlined by Baron and Kenny.

Results: Employment change was significantly associated with all the outcomes. Leaving public sector GP work was associated with substantially decreased time pressure, patient-related stress, distress and work interference with family. In contrast, taking a position as a public sector GP was associated with an increase in these factors. Mediation tests suggested that the associations of employment change with distress change and work interference with family change were partially explained by the changes in time pressure and patient-related stress.

Conclusions: Our results showed that leaving public sector GP work is associated with favourable outcomes, whereas taking a GP position in the public sector is associated with adverse effects. Primary health-care organizations should pay more attention to the working conditions of their GPs, in particular, to time pressure and patient-related stress.
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http://dx.doi.org/10.1093/eurpub/cks112DOI Listing
June 2013

The Beck Depression Inventory and General Health Questionnaire as measures of depression in the general population: a validation study using the Composite International Diagnostic Interview as the gold standard.

Psychiatry Res 2012 May 23;197(1-2):163-71. Epub 2012 Feb 23.

National Institute for Health and Welfare, Helsinki, Finland.

The Beck Depression Inventory (BDI) and the General Health Questionnaire (GHQ) are commonly used in population studies as measures of depression. We examined in a population sample the validity of four scales for depressive symptoms, the GHQ-12, the 21- and 13-item versions of the BDI, and a new 6-item version of the BDI developed for this study. A total of 5561 participants in the "Health 2000" survey (30-79 years) completed the four scales and were assessed with the Composite International Diagnostic Interview (CIDI), which was used as the validation criterion. We selected items for the BDI-6 through an exploratory factor analysis for the BDI-21. The accuracy of the scales, including the BDI-6, was satisfactory (c-statistics 0.88-0.92 for depression within the past 2 weeks and 0.80-0.83 within the past 12 months) and slightly better for men (0.92-0.96 and 0.85-0.87) than for women (0.86-0.88 and 0.78-0.79). Higher scores in all the scales were associated with more severe depression and more recent depressive episodes. This study suggests that various versions of the BDI and the GHQ-12 are useful in detecting depressive disorders in the general population. Even the 6-item version of the BDI showed acceptable criterion validity, although replication in an independent dataset is needed to confirm its validity.
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http://dx.doi.org/10.1016/j.psychres.2011.09.008DOI Listing
May 2012

Physical activity and change in quality of life during menopause--an 8-year follow-up study.

Health Qual Life Outcomes 2012 Jan 23;10. Epub 2012 Jan 23.

School of Health Sciences, University of Tampere, Tampere, Finland.

Background And Objectives: The aim of this study was to study the role of menopausal status and physical activity on quality of life.

Methods: A total of 1,165 Finnish women aged 45-64 years from a national representative population-based study were followed up for 8 years. Study participants completed the Health 2000 study questionnaire and follow-up questionnaire in 2008. Ordinal logistic regression analysis was used to measure the effect of menopausal status on global quality of life (QoL). Other variables included in the analyses were age, education, change of physical activity as assessed with metabolic equivalents, change of weight and hormone therapy (HRT) use.

Results: Peri- and postmenopausal women increased their physical activity (28% and 27%) during the eight-year follow up period slightly more often than premenopausal (18%) women (p = 0.070). Menopausal status was not significantly correlated with change of QoL. QoL of the most highly educated women was more likely to improve than among the less educated (eb = 1.28, 95%CI 1.08 to 1.51 p = 0.002). Women whose physical activity increased or remained stable had greater chances for improved QoL than women whose physical activity decreased (eb = 1.49, 95%CI 1.23 p < 0.001 to 1.80, eb = 1.46, 95%CI 1.24 to 1.73 p < 0.001 respectively). Women whose weight remained stable during follow-up also improved their QoL compared to women who gained weight (eb = 1.26, 95%CI 1.07 to 1.50 p > 0.01). Women who had never used HRT had 1.26 greater odds for improved QoL (95%CI 1.02 to 1.56 p = < 0.05).

Conclusion: Improvement of global QoL is correlated with stable or increased physical activity, stable weight and high education, but not with change in menopausal status.
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http://dx.doi.org/10.1186/1477-7525-10-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311608PMC
January 2012
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