To Örebro University

BACKGROUND: Living in residential aged care (RAC) facilities can have a passivating effect on older adults. Reablement is an approach to increase activity and participation in daily life. However, research on reablement in RAC facilities remains limited, making further research necessary.

AIMS/OBJECTIVES: This study aimed to investigate the feasibility of an 8-week reablement programme, Reablement in Residential Aged Care (Re-RAC), prior to a planned randomized controlled trial (RCT).

MATERIAL AND METHODS: Re-RAC aligns with the Swedish RAC context and international reablement principles. Qualitative and quantitative data on occupational performance, physical activity, psychological well-being, quality of life, adherence, and residents' and staff experiences were collected at an RAC facility in Sweden. Descriptive statistics and content analysis were used.

RESULTS: Six residents and 12 staff participated in the intervention. The methodology and intervention procedures were feasible overall. Participants requested more regular occupational therapy support, and staff requested support to motivate participants.

CONCLUSIONS: This study demonstrates that Re-RAC was a feasible and well-accepted intervention in a Swedish RAC facility, although some areas for improvement were identified. Maintaining motivation was highlighted, and extended support will be incorporated.

SIGNIFICANCE: This study provides practical guidance for reablement in RAC facilities, emphasizing resident motivation and staff engagement.

BACKGROUND: Living in residential aged care (RAC) facilities can be passivating and negatively impact residents' well-being and quality of life. With a growing global population of older adults and an increasing number residing in RAC facilities, it is crucial to address these concerns. Person-centered reablement, which enhances activity and participation through tailored, multidisciplinary strategies, has shown promising results in home settings. However, its implementation in RAC facilities, especially in Sweden, requires further evaluation. This research project will examine whether the reablement intervention in RAC (Re-RAC) impacts activity performance and satisfaction, participation, quality of life, and well-being, in older adults living in RAC facilities. Additionally, the project will evaluate the health-economic effects of the intervention and explore potential associations with the outcomes. A further aim is to describe the experiences of both the participating older adults and RAC facility staff involved in Re-RAC.

METHODS: This is a multi-center prospective pragmatic randomized controlled trial has two parallel groups comparing the Re-RAC intervention with usual care. A total of 86 participants are planned to be enrolled. The 8-week intervention will be evaluated using quantitative, qualitative, and health-economic methods. Data will be collected at baseline and after the intervention. Health-economic data will also be gathered 3 months before and after intervention. Primary outcomes are activity performance and satisfaction with performance captured using the Canadian Occupational Performance Measure; secondary outcomes, i.e., health-related quality of life, psychological well-being, and physical activity levels will also be evaluated. Experiences of participants and staff will be captured through individual and focus-group interviews. Cost-effectiveness will be estimated by calculating the cost per quality-adjusted life year gained. Quantitative data will be analyzed using descriptive and comparative statistics; qualitative data will be analyzed using thematic analysis and focus-group methodology.

DISCUSSION: This study evaluates the Re-RAC intervention for older adults in RAC through a real-world pragmatic trial, examining activity performance, satisfaction, quality of life, well-being, and health outcomes for older adults in RAC facilities. The study also explores participant and staff experiences and evaluates cost-effectiveness. The results will offer valuable insights informing the future implementation and assessment of reablement interventions in RAC settings.

TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT06793501 . Registered on 20 January 2025.

Aim and hypothesis To explore the agreement between parentand child reported measures of somaticdistress, gastrointestinal symptoms, mentalhealth and self-rated health, in girls 9-13years old with functional abdominal pain.

Methods Secondary analysis of data from aprospective randomized controlled trialcalled the Just in TIME study (1, 2), on girlsaged 9–13 years with FunctionalAbdominal Pain Disorders (FAPDs). Weanalyzed data from instruments that bothgirls and their legal guardians answeredseparately, at study start: Childrenssomatization inventory - gastrointestinaldistress (CSSI-GI) and somatic distress(CSSI-nonGI), Self-rated health (SRH), andMental Health Symptoms (MHS).

Results Data from 121 girls (mean age 10.6 years)were analyzed, including 74 with FAPD and47 with Irritated Bowel Syndrom. For CSSI-GIthe girls reported a mean score of 6.98 (SD4.39) and the guardians 7.27 (4.31) with anintraclass correlation (ICC) of 0.84 (p<0.001).Corresponding numbers for CSSI-nonGI were8.75 (6.51) and 6.79 (5.05), ICC 0.75(p<0.001). The weighted Cohen’s kappa was0.32 (p<0.001) for SRH and for the MHS itemsthe kappa varied from 0.20 to 0.52, allsignificant.

Discussion The findings reveal good agreement forgastrointestinal and general somaticsymptoms but lower agreement whenreporting mental and general health.

Importance Understanding parent-child agreement in self-reported health measures enhances insight intohow symptoms are perceived across informants and contexts. It also informs when and forwhom a child’s self-report may be considered sufficient in clinical or research settings.

BACKGROUND AND OBJECTIVE: Mapping algorithms can be used for estimating quality-adjusted life years (QALYs) when studies apply non-preference-based instruments. In this study, we estimate a regression-based algorithm for mapping between the World Health Organization Disability Assessment Schedule (WHODAS 2.0) and the preference-based instrument SF-6D to obtain preference estimates usable in health economic evaluations. This was done separately for the working and non-working populations, as WHODAS 2.0 discriminates between these groups when estimating scores.

METHODS: Using a dataset including 2258 participants from the general Swedish population, we estimated the statistical relationship between SF-6D and WHODAS 2.0. We applied three regression methods, i.e., ordinary least squares (OLS), generalized linear models (GLM), and Tobit, in mapping onto SF-6D from WHODAS 2.0 at the overall-score and domain levels. Root mean squared error (RMSE) and mean absolute error (MAE) were used for validation of the models; R2 was used to assess model fit.

RESULTS: The best-performing models for both the working and non-working populations were GLM models with RMSE ranging from 0.084 to 0.088, MAE ranging from 0.068 to 0.071, and R2 ranging from 0.503 to 0.608. When mapping from the WHODAS 2.0 overall score, the preferred model also included sex for both the working and non-working populations. When mapping from the WHODAS 2.0 domain level, the preferred model for the working population included the domains mobility, household activities, work/study activities, and sex. For the non-working population, the domain-level model included the domains mobility, household activities, participation, and education.

CONCLUSIONS: It is possible to apply the derived mapping algorithms for health economic evaluations in studies using WHODAS 2.0. As conceptual overlap is incomplete, we recommend using the domain-based algorithms over the overall score. Different algorithms must be applied depending on whether the population is working or non-working, due to the characteristics of WHODAS 2.0.

Background: Core symptoms in attention deficit hyperactivity disorder (ADHD) are inattention, impulsivity and hyperactivity. Many individuals with this disorder also have a sedentary lifestyle, co-morbid mental illness such as depressive and anxiety disorders, and reduced quality of life. People with ADHD often have impaired executive function, which among other things may include difficulty in time management and structuring of everyday life. Pharmacological treatment is often the first-line option, but non-pharmacological treatment is also available and is used in clinical settings. In children and adolescents with ADHD, physical exercise is used as a non-pharmacological treatment. However, the evidence for the effectiveness of exercise in adults is sparse.

Objective: To implement the START intervention (START = Stöd i Aktivitet, Rörelse och Träning [Support in activity, movement and exercise]) consisting of a 12-week, structured mixed exercise programme with or without a cognitive intervention, in adults with ADHD, and study whether it has an effect on core symptoms of ADHD as well as physical, cognitive, mental and everyday functioning compared with usual treatment. A secondary aim is to investigate the participants' experiences of the intervention and its possible benefits, and to evaluate the cost-effectiveness of START compared with usual treatment.

Methods: This is a randomized controlled trial planned to be conducted in 120 adults with ADHD, aged 18-65. The intervention will be given as an add-on to standard care. Participants will be randomized to three groups. Group 1 will be given a physiotherapist-led mixed exercise programme for 12 weeks. Group 2 will receive the same intervention as group 1 with the addition of occupational therapist-led cognitive skills training. Group 3 will be the control group who will receive standard care only. The primary outcome will be reduction of ADHD symptoms measured using the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS-v1.1), Clinical Global Impression-Severity scale (CGI-S) and CGI-Improvement scale (CGI-I). The effect will be measured within 1 week after the end of the intervention and 6 and 12 months later.

Discussion: Data collection began in March 2021. The final 12-month follow-up is anticipated to be completed by autumn 2024.

Trial registration: ClinicalTrials.gov (Identifier: NCT05049239). Registered on 20 September 2021 (last verified: May 2021).

BACKGROUND: Functional abdominal pain disorders (FAPDs) affect children worldwide, being more prevalent among girls. The individual and societal burdens of the disease are substantial, and evidence-based interventions are needed. Non-pharmacological treatments have generally produced promising results, with dance and yoga specifically having potential as an effective treatment option. Beside efficacy, the cost-effectiveness of interventions is important when prioritizing and allocating public resources.

OBJECTIVE: This study evaluated the cost-effectiveness of an 8-month dance and yoga intervention for girls with functional abdominal pain or irritable bowel syndrome, based on a randomized control trial called 'Just in TIME'.

METHODS: The intervention, performed in Sweden, was studied using a decision analysis tool, i.e., a decision tree within the trial followed by a Markov model with a time horizon of 10 years. The base case considered healthcare costs as well as productivity losses, measuring the effects in gained quality-adjusted life-years (QALYs) and presenting an incremental cost-effectiveness ratio (ICER).

RESULTS: The base case results show that the intervention, compared with current practice, was the dominant strategy from both the 12-month and long-term perspectives. The sensitivity analyses indicated that the long-term, but not the short-term, findings were robust for different assumptions and changes in parameter estimates, resulting in ICERs similar to those of the base case scenario.

CONCLUSIONS: Offering dance and yoga to young girls with FAPDs generates small QALY gains and monetary savings compared with standard healthcare and is likely cost-effective. These findings make a valuable contribution to an area where evidence-based and cost-effective treatment interventions are needed.

CLINICAL TRIALS REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT02920268; Name: Just in TIME-Intervention With Dance and Yoga for Girls With Recurrent Abdominal Pain.

Adolescent depression is linked to adult ill-health and functional impairment, but recent research suggests that individual/contextual factors might account for this association. This study aimed to test whether the clinical heterogeneity of adolescent depression is related to marginalization from the labor market across early to middle adulthood. Data were drawn from the Uppsala Longitudinal Adolescent Depression Study, a community-based cohort initially assessed with structured clinical interviews at age 16-17. The cohort (n = 321 depressed; n = 218 nondepressed) was followed up after 2+ decades through linkage to nationwide population-based registries. Outcomes included consecutive annual data on unemployment, work disability, social welfare recipiency, and a composite marginalization measure, spanning from age 21 to 40. Longitudinal associations were examined using logistic regression analysis in a generalized estimating equations modeling framework. Subsequent depressive episodes and educational attainment in early adulthood were explored as potential pathways. The results showed that adolescent depression was associated with adult marginalization outcomes, but the strength of association varied across depressed subgroups. Adolescents with persistent depressive disorder had higher odds of all outcomes, including the composite marginalization measure (adjusted OR = 2.0, 95% CI = 1.4-2.7, p < 0.001), and this was partially (31%) mediated by subsequent depressive episodes in early adulthood. Exploratory moderation analysis revealed that entry into tertiary education mitigated the association with later marginalization, but only for adolescents with episodic major depression. In conclusion, the risk for future labor market marginalization is elevated among depressed adolescents, particularly those presenting with persistent depressive disorder. Targeted interventions seem crucial to mitigate the long-lasting impact of early-onset depression.

Background: Functional abdominal pain disorders (FAPDs) affect children, especially girls, all over the world. The evidence for existing treatments is mixed, and effective accessible treatments are needed. Dance, a rhythmic cardio-respiratory activity, combined with yoga, which enhances relaxation and focus, may provide physiological and psychological benefits that could help to ease pain.

Objectives: The aim with this study was to evaluate the effects of a dance and yoga intervention on maximum abdominal pain in 9- to 13-year- old girls with FAPDs.

Methods: This study was a prospective randomised controlled trial with 121 participants recruited from outpatient clinics as well as the general public. The intervention group participated in dance and yoga twice weekly for 8 months; controls received standard care. Abdominal pain, as scored on the Faces Pain Scale–Revised, was recorded in a pain diary. A linear mixed model was used to estimate the outcomes and effect sizes.

Results: Dance and yoga were superior to standard healthcare alone, with a medium to high between-group effect size and significantly greater pain reduction (b = −1.29, p = 0.002) at the end of the intervention.

Conclusions: An intervention using dance and yoga is likely a feasible and beneficial complementary treatment to standard health care for 9- to 13-year-old girls with FAPDs.

Significance:  FAPDs affect children, especially girls, all over the world. The negative consequences such as absence from school, high consumption of medical care and depression pose a considerable burden on children and their families and effective treatments are needed. This is the first study examining a combined dance/yoga intervention for young girls with FAPDs and the result showed a reduction of abdominal pain. These findings contribute with new evidence in the field of managing FAPDs in a vulnerable target group. 

Emotional problems and pain symptoms among children and adolescents are a global public health challenge that imposes a great burden on the individuals affected and on society. Because resources are limited, allocation and prioritization are needed. Health economic analysis can constitute a foundation for such decisions.

The overall aim of this thesis is to estimate long-term outcomes associated with adolescent depression and to evaluate interventions for emotional problems and pain symptoms in childhood and adolescence from a health economic perspective. The thesis is based on four papers: paper I is a longitudinal cohort study of 539 participants, showing that adolescent depression is associated with reduced earnings in adulthood, papers II, III, and IV are based on two randomized controlled trials of interventions. In paper II, a dance intervention for 112 adolescent females with internalizing symptoms were evaluated. A cost–utility analysis was performed, indicating that the intervention was costeffective given a willingness-to-pay threshold of USD 50,000 with an incremental cost-effectiveness ratio of USD 3830/quality-adjusted life year. Papers III and IV evaluated a dance and yoga intervention for 121 girls, 9–13 years old, with functional abdominal pain disorders. Paper III showed that the intervention group decreased their abdominal pain more than did the control group. In paper IV, the cost–utility analysis of the trial indicated a negative incremental cost-effectiveness ratio, investigated from a societal perspective, over both one and ten years.

In conclusion, this thesis identifies a need for preventive as well as treatment interventions for emotional problems in adolescence, to decrease the prevalence of emotional problems and mitigate negative outcomes. Dance or dance and yoga combined can be effective and cost-effective early treatment interventions for emotional problems and pain symptoms among females in childhood and adolescence. These findings may assist decision-makers in resource allocation within this area

PURPOSE: Depression at all ages is recognized as a global public health concern, but less is known about the welfare burden following early-life depression. This study aimed to (1) estimate the magnitude of associations between depression in adolescence and social transfer payments in adulthood; and (2) address the impact of major comorbid psychopathology on these associations.

METHODS: This is a longitudinal cohort study of 539 participants assessed at age 16-17 using structured diagnostic interviews. An ongoing 25-year follow-up linked the cohort (n = 321 depressed; n = 218 nondepressed) to nationwide population-based registries. Outcomes included consecutive annual data on social transfer payments due to unemployment, work disability, and public assistance, spanning from age 18 to 40. Parameter estimations used the generalized estimating equations approach.

RESULTS: Adolescent depression was associated with all forms of social transfer payments. The estimated overall payment per person and year was 938 USD (95% CI 551-1326) over and above the amount received by nondepressed controls. Persistent depressive disorder was associated with higher recipiency across all outcomes, whereas the pattern of findings was less clear for subthreshold and episodic major depression. Moreover, depressed adolescents presenting with comorbid anxiety and disruptive behavior disorders evidenced particularly high recipiency, exceeding the nondepressed controls with an estimated 1753 USD (95% CI 887-2620).

CONCLUSION: Adolescent depression is associated with considerable public expenditures across early-to-middle adulthood, especially for those exposed to chronic/persistent depression and psychiatric comorbidities. This finding suggests that the clinical heterogeneity of early-life depression needs to be considered from a longer-term societal perspective.