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  • 1. Blom, Eva Henje
    et al.
    Olsson, Erik M. G.
    Serlachius, Eva
    Ericson, Mats
    Swedish National Defence College.
    Ingvar, Martin
    Heart rate variability is related to self-reported physical activity in a healthy adolescent population2009In: European Journal of Applied Physiology, ISSN 1439-6319, E-ISSN 1439-6327, Vol. 106, no 6, 877-883 p.Article in journal (Refereed)
    Abstract [en]

    This study investigated whether there is a relationship between heart rate variability (HRV) versus lifestyle and risk factors for cardiovascular disease in a population of healthy adolescents. HRV is as an index of tonic autonomic activity and in adults HRV is related to lifestyle and risk factors for cardiovascular disease, but it is not known if this is the case in adolescents. HRV was registered for 4 min in sitting position in 99 healthy adolescents (age range 15 years 11 months-17 years 7 months) and repeated after 6 months. On both occasions there were significant correlations (P < 0.05) between physical activity and HRV, with respective r values: high frequency (HF) 0.26, 0.30; low frequency power (LF) 0.35, 0.29 and the standard deviation of inter-beat intervals (SDNN) 0.28, 0.37. There was no significant interaction between first and second measurements. In contrast, there were no correlations to sleeping patterns, eating habits and smoking. Risk factors for cardiovascular disease [body mass index (BMI = weight (kg)/length in m(2)), systolic blood pressure and p-glucose] did not show any repeatable significant correlations to HRV. Multiple regression models showed that physical activity was a predictor for HF, LF and SDNN in both measurements. In conclusion HF, LF and SDNN were reproducible after 6 months and were related to physical activity on both occasions.

  • 2. Boström, I.
    et al.
    Hall-Lord, M-L.
    Larsson, Gerry
    The Centre for Public Health Research, The County Council of Värmland.
    Wilde, B.
    Nursing theory based changes of work organisation in an ICU: Effects on quality of care1992In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 8, no 1, 10-16 p.Article in journal (Refereed)
  • 3. Boström, I
    et al.
    Hall-Lord, M-L
    Larsson, Gerry
    Swedish National Defence College, Department of Security, Strategy and Leadership (ISSL), Ledarskapscentrum.
    Wilde, Bodil
    Organisationsförändring vid IVA baserad på omvårdnadsteori: Effekter på vårdkvalitet1992Report (Other academic)
  • 4.
    Börjesson, Marcus
    et al.
    Swedish National Defence College, Department of Security, Strategy and Leadership (ISSL), Ledarskapscentrum.
    Enander, Ann
    Swedish National Defence College, Department of Security, Strategy and Leadership (ISSL), Ledarskapscentrum.
    Perceptions and sociodemographic factors influencing vaccination uptake and precautionarybehaviours in response to the A/H1N1 influenza in Sweden2014In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 42, 215-222 p.Article in journal (Refereed)
    Abstract [en]

    Aims: In response to the 2009 outbreak of A/H1N1 influenza, Swedish authorities decided on a programme for universal vaccination. Over 60% of the population received at least one dose of vaccine. This study examines demographic factors and perceptions related to the decision whether or not to become vaccinated. Methods: A combined web/postal survey was conducted (n = 1587, response rate 53%) in late spring 2010. Questions reported here concerned perceptions, precautionary behaviours and vaccination decision. Results: Main reasons for becoming vaccinated were concerns about spreading the disease to relatives or in the community and confidence in the good effect of vaccination. Vaccination rates were higher among women, those with young children or belonging to a risk group. Main reasons for abstaining were belief that the flu was not a serious threat, low risk of spreading the disease, concern about side-effects and perceived uncertainties in information. Three profiles representing different patterns of thought and beliefs were identified by cluster analysis, respectively labelled as a vulnerable, a trusting and a sceptical group. Vaccination rates and precautionary behaviours were demonstrated to differ between these groups. Conclusions: Perceptions relating to the 2009 pandemic are likely to influence uptake of vaccination in the future. Authorities need to be aware of different patterns of beliefs and attitudes among the public, and that these may vary in different phases. Communication of risk needs to be dynamic and prepared to engage with the public before, during and even for some time after the acute risk period.

  • 5.
    Deverell, Edward
    et al.
    Swedish National Defence College, Department of Security and Strategic Studies (ISS), CRISMART (National Center for Crisis Management Research and Training).
    Örtenwall, Per
    Almgren, Ola
    Bombattentatet i köpcentrumet i Finland 20022005Book (Other academic)
  • 6.
    Deverell, Edward
    et al.
    Swedish National Defence College, Department of Security, Strategy and Leadership (ISSL), CRISMART (National Center for Crisis Management Research and Training).
    Örtenwall, Per
    Almgren, Ola
    Riddez, Louis
    KAMEDO Report No. 87: Bomb Attack in Finnish Shopping Center, 20022007In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 22, no 1, 86-88 p.Article in journal (Refereed)
  • 7. Elander Lindberg, N.
    et al.
    Lindberg, E.
    Larsson, Gerry
    University of Karlstad.
    Experiences of psychotherapy in amalgam illness1994In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 52, 219-228 p.Article in journal (Refereed)
  • 8.
    Ericsson, Johnny
    Swedish National Defence College.
    Vita praeponitur: Livet främst2006Independent thesis Basic level (professional degree), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    The purpose of this essay is to investigate if the medical function in the Air Defence Battalion is enough.

     The question to be answered in this essay is as follows: When, considering deployment geometry, medical time-demands and evacuation capacity does the medical function become a limiting factor for the AD Battalion?

     A descriptive method is used in this essay. Material has been gathered and analysed to show the limitations of the battalion considering the medical function. A study has also been made. The material and the study are used as a base in the discussion and from the discussion and the results from the analysis, conclusions are drawn.

    One of these conclusions is that: It is not probable that all units in the Air Defence Battalion will receive proper medical attention within the time-span established in the guiding medical documents.

  • 9. Hall-Lord, M-L.
    et al.
    Larsson, Gerry
    The Centre for Public Health Research, The County Council of Värmland, Sweden.
    Boström, I.
    Elderly patients' experiences of pain and distress in intensive care: A grounded theory study1994In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 10, no 2, 133-141 p.Article in journal (Refereed)
    Abstract [en]

    The aim of the present study was to develop a theoretical understanding of elderly patients' experiences of pain and distress in intensive care, using a grounded theory approach. 18 patients, 7 women and 11 men, were interviewed and observed in an intensive care unit (ICU). Their average age was 76.5, varying from 70–85. A model was generated from data, according to which elderly patients' experiences of pain and distress in intensive care can be described as four interrelated aspects: a sensory, an intellectual, an emotional, and an existential dimension. 16 categories form the four dimensions. The categories, in turn, are grounded in a number of interview and observational data. The sensory dimension is formed by the categories physical pain, physical discomfort, fatigue, and breathing problems, and the intellectual dimension by the categories not knowing, difficulty in expressing oneself/not being understood and confused perception of reality. The categories in the emotional dimension are worry, fear, resignation, bitterness, anger/irritation and dependency. Finally, the existential dimension is formed by the categories despair, threat to life and death acceptance. The categories within the four dimensions may be separate, but often they interact and influence each other in various ways. The model is discussed in relation to existing models and definitions of pain, where the intellectual and existential dimensions in particular have not been emphasized in a similar way.

  • 10. Hall-Lord, M-L.
    et al.
    Larsson, Gerry
    Swedish National Defence College, Ledarskapsinstitutionen.
    Steen, B.
    Chronic pain and distress among elderly in the community: Comparison of patients' experiences and enrolled nurses' assessments1999In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 7, no 1, 45-54 p.Article in journal (Refereed)
    Abstract [en]

    AIM: This study compared elderly patients' reported experiences of pain and distress with enrolled nurses' assessments and related potential differences to patient and enrolled nurse characteristics.

    BACKGROUND: Many elderly suffer from chronic pain but few studies have focused on this group of patients.

    METHODS: Data were collected through personal interviews with 38 patients and questionnaires completed by 38 enrolled nurses.

    FINDINGS: Enrolled nurses underestimated patients' experiences of physical pain, physical discomfort, breathing problems, resignation, and dependency. Pain and distress were overestimated by enrolled nurses who had lower scores on three of the five personality scales used. In contrast, enrolled nurses who had higher scores on these personality scales tended to underestimate the patients' pain and distress.

    CONCLUSIONS: There is a need to develop staff training programmes in order to optimize the care for elderly patients with chronic pain in the community.

  • 11. Hall-Lord, M-L.
    et al.
    Larsson, Gerry
    Swedish National Defence College, Ledarskapsinstitutionen.
    Steen, B.
    Chronic pain and distress in older people: A cluster analysis1999In: International Journal of Nursing Practice, ISSN 1322-7114, E-ISSN 1440-172X, Vol. 5, no 2, 78-85 p.Article in journal (Refereed)
    Abstract [en]

    Chronic pain represents a major health problem among older people. The aims of the present study were to: (i) identify various profiles of pain and distress experiences among older patients; and (ii) compare whether background variables, sense of coherence, functional ability and experiences of interventions aimed at reducing pain and distress varied among the patient profiles. Interviews were carried out with 42 older patients. A cluster analysis yielded three clusters, each representing a different profile of patients. Case illustrations are provided for each profile. There were no differences between the clusters, regarding intensity and duration of pain. One profile, with subjects of advanced age, showed a decreased functional ability and favourable scores in most of the categories of pain and distress. Another profile of patients showed favourable mean scores in all categories. The third cluster of patients showed unfavourable scores in most categories of pain and distress. There appears to be a need to treat the three groups of patients in different ways in the caring situation.

  • 12. Hall-Lord, M-L.
    et al.
    Larsson, Gerry
    Department of Geriatric Medicine, Göteborg University.
    Steen, B.
    Pain and distress among elderly intensive care unit patients: Comparison of patients' experiences and nurses' assessments1998In: Heart & Lung, ISSN 0147-9563, E-ISSN 1527-3288, Vol. 27, no 2, 123-132 p.Article in journal (Refereed)
  • 13. Hall-Lord, M-L.
    et al.
    Steen, B.
    Larsson, Gerry
    Swedish National Defence College, Ledarskapsinstitutionen.
    Postoperative experiences of pain and distress in the elderly patients: An explorative study1999In: Aging Clinical and Experimental Research, ISSN 1594-0667, E-ISSN 1720-8319, Vol. 11, 73-82 p.Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to explore postoperative experiences of pain and distress in elderly patients, as well as interventions aimed at reducing these conditions, on three occasions. The study group was composed of 100 patients who had undergone elective surgery in two orthopedic and two general surgical units. Of the 50 patients in the orthopedic units, 26 had undergone hip arthroplasty and 24 knee arthroplasty: of the 50 patients in the general surgical units, 23 had had breast cancer surgery, and 27 abdominal surgery. The patients were interviewed, using a structured interview format, on three occasions; at the ward on the first and second day after surgery, and by telephone about ten days after discharge from hospital. Within both the sensory and the emotional dimensions, logistic regression analyses showed that the dependent variables of pain and distress were significantly related above all to type of surgery and sense of coherence (SOC). In a cluster analysis, three meaningful clusters of patients were obtained. The patients in the different profiles showed variations in their experiences of pain and distress. The 12 patients with the least favorable scores had weaker SOC than the patients in the other profiles. It is concluded that type of surgery and psychological factors influenced patients' experiences of pain and distress after undergoing surgery. These experiences should be reduced by identifying risk patients, and improving assistance and support in the nursing ward, and also when patients have returned home.

  • 14. Johansson, I.
    et al.
    Athlin, E.
    Frykholm, L
    Boliner, H.
    Larsson, Gerry
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Urinary tract infections among patients with hip fracture: A study within a nursin quality improvement project2002In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 11, 651-656 p.Article in journal (Refereed)
  • 15. Johansson, I.
    et al.
    Hamrin, E.
    Larsson, Gerry
    Centre for Public Health Research, The County Council of Värmland, Sweden.
    Evaluation of the prognostic value of the Health Assessment Form among patients clinically ready for discharge1994In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 2, no 2, 77-85 p.Article in journal (Refereed)
    Abstract [en]

    The aim of the study was to identify patterns of physical, psychological, and social conditions that may be of prognostic value when it comes to assessing continued care of patients clinically ready for discharge; a related aim was to evaluate instruments used for this identification, especially a Swedish version of the health assessment form. The sample consisted of 53 consecutive patients (mean age 82.8 years, SD = 6.6 years) All patients came from their own homes and were admitted to surgical and orthopaedic departments. Interviews were carried out on the day the patients were assessed as medically ready for discharge, and a second time 1 month later. The health assessment form measured the persons' social and environmental situation, health history, and functional health status, and another instrument measured the persons' sense of coherence. Few significant differences in functional health status were noted between persons who could return to their homes (n =25) and persons who were referred to institutions after discharge (n = 17). However, the persons being referred to institutions showed less favourable scores within the areas of mood, sense of coherence, and worries about their home accommodation situation. When another sub-group was included (patients who died between the interview occasions; n = 8), significant differences were also noted in the health functions breathing, digestion, elimination, and body movement. Sense of coherence had a significant prognostic value for the continued care after discharge irrespective of whether the deceased patients were included or not.

  • 16. Johansson, I.
    et al.
    Hamrin, E.
    Larsson, Gerry
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Psychometric testing of the NEECHAM Confusion Scale among patients with hip fracture2002In: Research in Nursing & Health, ISSN 0160-6891, E-ISSN 1098-240X, Vol. 25, no 3, 203-211 p.Article in journal (Refereed)
    Abstract [en]

    The main aim of this study was to assess the reliability and validity of a Swedish translation of the NEECHAM Confusion Scale among 73 patients having surgery for hip fractures. Cronbach's alpha before and 7 days after surgery were .73 and .82, respectively. Principal-component analyses yielded three factors explaining 69% of the variance of the variables preoperatively and 73.6% of the variance 7 days postoperatively. Four months after discharge vital function, factor II in the NEECHAM scale, significantly predicted the total score on the Ferrans and Powers Quality of Life Index. Items reflecting information processing, behavior, and urinary continence, factor I, also predicted functional capacity, using the Standardized Practical Equipment test, a tool measuring instrumental daily activity. The scale seems to be a reliable and valid instrument for evaluating acute confusional state among patients with hip fracture.

  • 17. Johansson, I.
    et al.
    Larsson, Gerry
    The Centre for Public Health Research, The County Council of Värmland, Sweden.
    Hamrin, E.
    Decentralized nursing organization in a surgical department: Effects on work satisfaction and quality of care1994In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 3, 169-175 p.Article in journal (Refereed)
  • 18. Johansson, I.
    et al.
    Wilde, B.
    Athlin, E.
    Larsson, Gerry
    Swedish National Defence College, Ledarskapsinstitutionen.
    DySSSy i Värmland: Exempel på kvalitetssäkringsarbete vid centralsjukhuset i Karlstad1994In: Kvalitetssäkring inom omvårdnad: Olika perspektiv / [ed] G. Udén, Lund: Studentlitteratur, 1994, 69-76 p.Chapter in book (Refereed)
  • 19. Klässbo, M.
    et al.
    Harms-Ringdahl, K.
    Larsson, Gerry
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Examination of passive ROM and capsular patterns in the hip2003In: Physiotherapy Research International, ISSN 1358-2267, E-ISSN 1471-2865, Vol. 8, no 1, 1-12 p.Article in journal (Refereed)
    Abstract [en]

    Background and Purpose

    The present study was conducted to examine passive hip range of motion (PROM) for patients with hip dysfunction, including pain, with or without hip osteoarthritis, to arrange and describe PROM patterns and to count the number of hips presenting Cyriax's and Kaltenborn's capsular patterns.

    Method

    The study is theory-testing, observational, cross-sectional and descriptive. One hundred and sixty-eight patients (mean age 61.7 years, range 36–90 years), 50 with no hip osteoarthritis, 77 with unilateral hip osteoarthritis and 41 with bilateral osteoarthritis, based on radiological reports, were consecutively recruited by physicians in primary health care and orthopaedic settings. One examiner tested PROM bilaterally, by use of a goniometer and a standardized protocol. PROM limitations were calculated by comparing norms from the symptom-free hips (n = 100) in the study, from Kaltenborn and, in patients with unilateral hip osteoarthritis (n = 77), from the non-osteoarthritis hip. The limitations were arranged by size in PROM patterns. The patterns and the numbers of hips with patterns corresponding to Cyriax's and Kaltenborn's capsular patterns were counted.

    Results

    Between 68 and 138 PROM patterns were identified by use of different PROM norms for defining limitations. Few osteoarthritis hips showed Cyriax's capsular pattern and none Kaltenborn's capsular pattern.

    Conclusions

    The concept of capsular pattern for the hip should be re-examined. No support was found in the present study for its existence. It is impossible to anticipate radiological evidence of hip osteoarthritis from the multitude of PROM patterns. Every patient should be regarded as unique.

  • 20. Klässbo, M.
    et al.
    Larsson, Gerry
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Harms-Ringdahl, K.
    Promising outcome of a Hip School for patients with hip dysfunktion2003In: Arthritis Care and Research, ISSN 0893-7524, E-ISSN 1529-0123, Vol. 49, no 3, 321-327 p.Article in journal (Refereed)
    Abstract [en]

    Objective

    To evaluate, in an exploratory study, a hip school led by physical therapists for patients with hip dysfunction including pain.

    Methods

    Physicians in primary care and orthopedic units consecutively recruited patients by residential area to a treatment group (T group; n = 77) and a control group (C group; n = 68), mean age 61.8 years, 59 men, 86 women. Ninety-nine of the 145 subjects had radiologic hip osteoarthritis. Outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Nottingham Health Profile (NHP).

    Results

    After hip school (6 months) the T group showed greater reduction on the subscales of pain and activity limitations (WOMAC) than the C group. The subscales sleep disturbances, pain, and physical mobility (NHP) showed improvement for the T group compared with at start. The results for the T group persisted after an additional 6 months.

    Conclusion

    A hip school may reduce pain and activity limitations and improve health-related quality of life for patients with hip dysfunction including pain.

  • 21.
    Larsson, Gerry
    Centrum för folkhälsoforskning, Högskolan i Karlstad.
    Health inequalities in Europe1991In: WHO, Challenges for health promotion: Prevention of noncommunicable diseases, Toronto, Canada: World Health Organization , 1991Chapter in book (Refereed)
  • 22.
    Larsson, Gerry
    Centrum för folkhälsoforskning, Högskolan i Karlstad.
    Preventing health problems among the elderly1992In: Health policy development for disadvantaged groups / [ed] Per-Gunnar Svensson & Bengt Starrin, Oslo: Scandinavian University Press , 1992, 59-76 p.Chapter in book (Refereed)
  • 23.
    Larsson, Gerry
    Swedish National Defence College, Department of Leadership and Management (ILM).
    "Situation awareness": En kritisk granskning utifrån ett stressteoretiskt perspektiv2003Report (Other academic)
  • 24.
    Larsson, Gerry
    Swedish National Defence College, Ledarskapsinstitutionen.
    Understanding psychological debriefings: A grounded theory approach2000In: Qualitative research methods in the service of health / [ed] B. Fridlund & C. Hildingh, Lund: Studentlitteratur, 2000, 148-163 p.Chapter in book (Refereed)
  • 25.
    Larsson, Gerry
    et al.
    Centre for Public Health Research, The County Council of Värmland, Karlstad, Sweden.
    Berg, V.
    Linen in the hospital bed: Effects on patients' well-being1991In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 16, no 8, 1004-1008 p.Article in journal (Refereed)
    Abstract [en]

    The aim of the study was to determine if using linen in hospital beds affects patients' well-being An experimental group consisting of 52 patients (mean age 64 4 years) at a medical ward used linen in the bottom sheet, the protective sheet, the pillow-case and the patient gown for 4 weeks A control group consisting of 40 patients (mean age 67 5 years) at the same ward was observed for 4 weeks using the conventional material (cotton, cotton/polyester) Marginal positive effects on patients' well-being were noted when linen was used It was discussed that the relative importance of the bed material to patients' well-being may be low, compared to medical treatment, nursing, etc Given the high cost of linen, about 15 times more than the conventional material, it was suggested that the health care system should refrain from large-scale use of linen in hospital beds

  • 26.
    Larsson, Gerry
    et al.
    The Centre for Public Health Research, The County Council of Värmland, Sweden.
    Hall-Lord, M-L.
    Personality development in nursing education: A Swedish study1993In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 7, no 2, 79-83 p.Article in journal (Refereed)
    Abstract [en]

    The aim of the study was to explore personality development during nursing education. The sample consisted of 122 Swedish nursing students. Ninety-three per cent of the students were female and the mean age at the beginning of the nursing education (which lasts for two years) was 27.6 years. Personality inventories were administered at the beginning and end of the education. The post-education assessment rendered several statistically significant differences of means. Compared with the pre-education assessment, the nursing students reported a more positive profession-oriented self-perception at the end of the education, a stronger ideal, real, and mirror identity, a reduced trait anxiety, stronger needs for achievement, exhibition, autonomy, dominance, and nurturance, and a weaker abasement need. The practical significance of the results was discussed.

  • 27.
    Larsson, Gerry
    et al.
    The Centre for Public Health Research, The County Council of Varmland, Sweden.
    Johansson, I.
    Hamrin, E.
    Sense of coherence among elderly somatic patients: Predictive power regarding future needs of care1995In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 3, no 6, 307-311 p.Article in journal (Refereed)
    Abstract [en]

    The main aim was to study the predictive power of sense of coherence regarding future needs of care among elderly patients evaluated as medically ready for discharge from somatic emergency care. A secondary aim was to study the consistency of sense of coherence over time among patients with this kind of experience. The sample consisted of 53 Swedish patients (mean age 82.8 years, SD = 6.6 years) who had completed their medical treatment at surgical or orthopaedic departments. The predominant diagnosis was lower limb fractures. Sense of coherence was assessed twice, on the day the patient was evaluated as medically ready for discharge and 1 month later. On the second assessment occasion, 28 patients had returned to their homes, 17 were staying at institutions, and eight had died. Patients who returned to their homes reported the strongest sense of coherence while still in hospital. Patients who were staying at institutions scored lowest on the overall sense of coherence scale and on the comprehensibility subscale. Patients who died before the second measurement occasion scored lowest on the meaningfulness subscale. A correlation of 0.51 was noted between the two assessments of sense of coherence, indicating a moderate temporal consistency

  • 28.
    Larsson, Gerry
    et al.
    The Centre for Public Health Research, The County Council of Värmland, Sweden.
    Nordström, L.
    Ljunggren, G.
    Nyberg, A.
    Resare, B.
    Schedewin, G.
    Wahlgren, M.
    The Grossarth-Maticek and Eysenck personality types, health-related behaviour, and indicators of transitory ill-health1995In: European Journal of Personality, ISSN 0890-2070, E-ISSN 1099-0984, Vol. 9, no 2, 75-87 p.Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to scrutinize the relationship between personality type as described by Grossarth-Maticek and Eysenck, health-related behaviours, and indicators of transitory ill health in a community sample. The sample consisted of all per sons aged 40 years (45 men and 35 women) in a Swedish municipality who agreed to take part in a health examination at the primary health care centre of the municipality. The Short Interpersonal Reactions Inventory (Grossarth-Maticek and Eysenck, 1990) was used to measure personality type. Self-report data were obtained regarding seven health-related behaviours. Health was assessed in three ways; self-report (paper and pencil), self-report (interview response to physician), and measures of 36 biological variables including immune system indicators. The allocation of persons to the different personality types proved problematic using the established methods. By combining the types, according to Eysenck's personality model, and performing a cluster analysis on this combination, a ‘healthy’ and a ‘stressed’ profile were identified within both the male and the female group of subjects. Persons in the healthy personality cluster showed more favourable scores on the health-related behaviour indices and on the self-report health scales than the persons in the stressed cluster. They also tended to score lower than those in the stressed cluster on most of the biological markers known to increase during acute stress. The possibility that this implies a higher level of strain for the persons in the stressed cluster on various bodily systems is discussed.

  • 29.
    Larsson, Gerry
    et al.
    Swedish National Defence College, FOA 55, Beteendevetenskapliga institutionen.
    Setterlind, S.
    Steffner-Starrin, L.
    Avslappningsträning inom hälso- och sjukvård: teoretisk orientering och praktisk handledning1985Book (Other academic)
  • 30.
    Larsson, Gerry
    et al.
    Centrum för folkhälsoforskning, Högskolan i Karlstad.
    Starrin, B.
    Patient-nurse interactions: relationships between person characteristics, empathy, content of communication, and patients' emotional reactions1990In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 4, no 3, 129-135 p.Article in journal (Refereed)
    Abstract [en]

    Relationships between antecedent person variables (sex and age), empathic understanding, content of communication, and patients' emotional reactions were studied in 3200 patient-assistant nurse dyadic interactions. The sample consisted of 32 psychiatric patients (20 males and 12 females, mean age: 61 years) and eight female assistant nurses at a nursing-home in Sweden. Four assistant nurses were younger (25 years old or less) and four were older (45 years old or more). All interactions were regular morning meetings at which the patient's activity plans for the day were discussed. These meetings were held in each patient's private room, and lasted for about 15 min. High empathic understanding on part of the helper covaried with more communication of "everyday character" and communication dealing with "personal and emotional qualities", with less communication dealing with "facts and practical issues", and with a more cheerful emotional state among the patients during the encounters. Male patients were more cheerful during encounters with younger assistant nurses while female patients were more cheerful when interacting with older assistant nurses. Helpers with higher scores on empathic understanding seemed to have a higher awareness of relational history.

  • 31.
    Larsson, Gerry
    et al.
    Centrum för folkhälsoforskning, Högskolan i Karlstad.
    Starrin, B.
    Wilde, B.
    Contributions of stress theory to the understanding of helping1991In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 5, no 2, 79-85 p.Article in journal (Refereed)
    Abstract [en]

    The paper is theoretical, patient centred, and focuses on the two following questions: (1) In what way might a stress theoretical approach further our understanding of how helping can affect somatic and psychological processes in patients, and (2) in what way might stress theory offer action oriented guidelines for those who offer help ? A stress model is outlined involving relationships between a patient's cognitive appraisal of a given care situation, his or her coping efforts, and emotional and physiological reactions. Several conditions, related to the patient and to the care giving situation, which might influence the patient's appraisal process are discussed. Possible short- and long-term effects of helping in the somatic and psychological domains are presented. Two examples of common care situations are analysed to show how stress theory may offer helpers an action oriented tool. The concept of participatory caring, implying not only patient involvement but actual power sharing between patients and health professionals, is discussed.

  • 32.
    Larsson, Gerry
    et al.
    Centre for Public Health Research, The County Council of Värmland, Sweden.
    Starrin, Bengt
    Centre for Public Health Research, The County Council of Värmland, Sweden.
    Relaxation training as an integral part of caring activities for cancer patients: Effects on well-being1992In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 6, no 3, 179-185 p.Article in journal (Refereed)
    Abstract [en]

    The purposes of this study were twofold. The first was to investigate if relaxation training conducted by nurses as an integral part of their caring activities affected breast cancer patients' experiences of radiotherapy sessions as well as their general wellbeing. Second was to evaluate a pedagogical model for large scale application of relaxation training as an integral part of caring. The sample consisted of 64 consecutive outpatients with breast cancer at a Swedish oncology clinic, receiving their first radiotherapy treatment course following surgery. Every second patient was assigned to an experimental group (n= 32, mean age: 59.5 years) and every other second patient was assigned to a control group (n= 32, mean age: 60.0 years). The programme resulted in the following general effects: fewer perceived daily hassles and a more cheeful overall mood state. The following treatment situation specific effects were noted: programme participants appraised the treatment sessions as successively more benign-positive and less threatening. They also reported more perceived muscular tensions during treatment sessions. Most goals concerning the routinization of the pedagogical model were reached.

  • 33.
    Larsson, Gerry
    et al.
    Centre for Public Health Research, Värmland County Council, Sweden.
    Wilde, B.
    Daughters helping their elderly mothers: Impact of early attachment, daughter's trait anxiety, and helping interaction characteristics1994In: International Journal of Social Welfare, ISSN 1369-6866, E-ISSN 1468-2397, Vol. 3, no 3, 167-172 p.Article in journal (Refereed)
    Abstract [en]

    The aim of the study was to explore the relationships between early attachment between mother and daughter, the adult daughter's general anxiety level, and characteristics of the helping interaction between the adult daughter and her elderly mother on the one hand and the quality of this help on the other. One sample consisted of 46 Swedish women (mean age: 55 years) who acted as informal caregivers for their elderly mothers. A second sample consisted of 106 Swedish female nursing students (mean age: 27 years). The participants rated the quality of the practical, physical and psychosocial help they gave their elderly mothers (imagined helping activities in a predefined situation among the nursing students). Subjects also rated their mother's degree of caring and overprotection in childhood, their own trait anxiety, and various characteristics of their helping interactions. A high degree of motherly caring and a low degree of motherly overprotection in childhood covaried with a lower level of trait anxiety in the adult daughters. These conditions, in turn, covaried with mutual friendliness during the helping interactions. All these conditions covaried with high-quality psychosocial support. The quality of practical help and physical caring covaried with friendliness during the helping interactions only.

  • 34.
    Larsson, Gerry
    et al.
    Swedish National Defence College, Ledarskapsinstitutionen.
    Wilde, B.
    Kvalitetssäkring och organisationsutveckling: Några teoretiska reflektioner1994In: Kvalitetssäkring inom omvårdnad: Olika perspektiv, Lund: Studentlitteratur, 1994, 113-129 p.Chapter in book (Refereed)
  • 35.
    Larsson, Gerry
    et al.
    Swedish National Defence College, Ledarskapsinstitutionen.
    Wilde, B.
    Är patienten nöjd?1995In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 92, 1587-1590 p.Article in journal (Refereed)
  • 36.
    Larsson, Gerry
    et al.
    Swedish National Defence College, Ledarskapsinstitutionen.
    Wilde, B.
    Johansson, I.
    Äldrevårdens svaga länkar: Praktiska lösningar på psykologiska och organisatoriska problem1996Book (Other academic)
  • 37.
    Larsson, Gerry
    et al.
    Karlstads universitet.
    Wilde, B.
    Starrin, B.
    Patients' views on quality of care: Theory-based assessment1996In: QUIS5: Advancing service quality: A global perspective / [ed] B. Edvardsson, S.W Brown, R. Jonston & E.E. Scheving, New York: St John's University , 1996, 164-168 p.Chapter in book (Other academic)
  • 38.
    Larsson, Gerry
    et al.
    Swedish National Defence College, Ledarskapsinstitutionen.
    Wilde Larsson, B.
    Quality of care: Relationships between the perceptions of elderly home care users and their caregivers1998In: International Journal of Social Welfare, ISSN 1369-6866, E-ISSN 1468-2397, Vol. 7, no 3, 252-258 p.Article in journal (Refereed)
    Abstract [en]

    The aim was to study the relationship between elderly home care users', and their caregivers', perceptions of the quality of care. The sample consisted of 151 matched elderly home care user-caregiver pairs in a Swedish municipality. The elderly home care users were interviewed and their caregivers filled in questionnaires using an established, theory-based instrument. Results showed that the elderly home care users evaluated most care components more favourably than their caregivers. On ratings of the various care components' subjective importance to the caretaker, the caregivers consistently scored higher than the elderly home care users. Within the subset of elderly home care users who received help at least twice a day, there were greater similarities between caregivers and caretakers. The results are related to comparable research and discussed in terms of caregivers' needs to legitimize their professional identity and actions.

  • 39.
    Larsson, Gerry
    et al.
    Swedish National Defence College, Ledarskapsinstitutionen.
    Wilde Larsson, B.
    Munck, I.
    Refinement of the questionnaire 'quality of care from the patient's perspective' using structural equation modelling1998In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 12, no 2, 111-118 p.Article in journal (Refereed)
    Abstract [en]

    In 1994, the questionnaire 'Quality of Care from the Patient's Perspective' (QPP) was developed using a conventional factor analytical approach (Wilde et al. 1994). The items and conceptual framework of this questionnaire were derived from a theoretical model, which, in turn, was developed from qualitative patient interviews, using a grounded theory method of analysis (Wilde et al. 1993). The aims of this study were to develop further the dimensionality of the QPP using structural equation modelling combined with advances in factor analysis modelling, and to refine the instrument. This comparatively new methodology extracts more information out of questionnaire data and is considered to be superior to traditional scaling methods. The sample consisted of 611 somatic inpatients from four departments at a Swedish hospital. Data collected with the QPP were explored with the new tool tracing the dimensions postulated in the theoretical model underlying the QPP. A nested factor model was developed fulfilling statistical criteria for adjustment between model and data. The model consists of a general factor and 16 subordinate factors. Most of the original QPP scales were reproduced with the new statistical technique. However, some content changes were made which appear to bring the QPP scales closer to patients' meaning representations of the area. Some changes were also made to the response format, changes which appear to strengthen the psychometric properties of the instrument. The refined QPP will hopefully contribute to a more differentiated picture of quality of care when applied in the field. All scales, items, and response formats of the revised QPP are presented in an appendix.

  • 40.
    Larsson, Gerry
    et al.
    Swedish Defence University, Department of Security, Strategy and Leadership (ISSL), Ledarskapscentrum.
    Wilde Larsson, Bodil
    Karlstads universitet.
    Vårdkvalitet och patienttillfredsställelse: Sanningen bor i patientens öga2012In: Kvalitetsarbete för bättre och säkrare vård / [ed] Nordström G., Wilde Larsson, B., Lund: Studentlitteratur, 2012, 69-88 p.Chapter in book (Refereed)
  • 41.
    Larsson, Gerry
    et al.
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Wilde-Larsson, B.
    Quality improvement measures based on patient data: Some psychometric issues2003In: International Journal of Nursing Practice, ISSN 1322-7114, E-ISSN 1440-172X, Vol. 9, no 5, 294-299 p.Article in journal (Refereed)
    Abstract [en]

    Existing methods for handling patients’ opinions as a basis for quality improvement measures tend to be too sophisticated for practical nursing and/or weak psychometrically. An Index of Measures was developed by combining patients’ perceptions of actual care conditions with the subjective importance they ascribed to these conditions. Data from Swedish somatic inpatients (n = 4002) indicated that this index gave added value compared to patients’ ratings of actual care conditions only. Interpretation of the Index of Measures focused on the proportion of patients who receive the value ‘deficiency.’ This value is obtained if a given patient has a subjective importance rating on a given item which is higher than the mean subjective importance score for the whole patient group on that item, as well as a perceived reality rating on the item in question which is lower than the mean perceived reality rating for the whole group on that item. Guidelines are suggested on when improvement actions are necessary and when they are not necessary.

  • 42.
    Larsson, Gerry
    et al.
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Wilde-Larsson, Bodil
    Fakulteten för samhälls- och livsvetenskaper, Karlstad universitet .
    Quality of care and patient satisfaction: A new theoretical and methodological approach2010In: International Journal of Health Care Quality Assurance, ISSN 0952-6862, E-ISSN 1758-6542, Vol. 23, no 2, 228-247 p.Article in journal (Refereed)
  • 43.
    Lassarp, Vanessa
    Swedish National Defence College.
    Tränad för strid i urbaniserad terräng: Fysiska egenskaper som krävs i strid i bebyggelse2009Independent thesis Basic level (professional degree), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    This paper´s objective was to identify what physical abilities today’s soldiers must have when operating in urban areas and how to reach these physical abilities. The purpose is to make the reader start reflecting about his or her role of being in charge of the conscripts physical training.

    Based on a descriptive method I have gathered information through a literature search, reading and described it, then drawing conclusions and referred to the literature. Finally identified the main points of these physical abilities.

    My main literary source was Lars Michalsik & Jens Bangsbo, Aerob och anaerob träning and Försvarsmaktens reglemente Militära operationer i urbaniserad terräng. I have also conducted interviews with people with special knowledge and experience in the subject.

    Results indicate that the main focus of physical training must be on running short distances up to 400 meters with combat gear and personal weapon, maximal strength in ties and endurance strength in the back and stomach and relative strength in upper body. My conclusions are that by changing today’s requirements for the conscripts can lead towards a better focus in physical training and a better result in the end with soldiers that have the right strength to succeed in FIBUA, Fighting in Built-Up Areas.

  • 44. Lindberg, E.
    et al.
    Elander Lindberg, N.
    Theorell, T.
    Larsson, Gerry
    National Institute for Psychosocial Factors and Health, Stockholm, Sweden.
    Psychotherapy in rheumatoid arthritis: A parallel-process study of psychic state and course of rheumatic disease1996In: Zeitschrift für Rheumatologie, ISSN 0301-6382, Vol. 55, no 1, 28-39 p.Article in journal (Refereed)
    Abstract [en]

    In this study, well-known psychosomatic (psychoneuroimmunological) connections have been used for therapeutic purposes. Fifteen patients with rheumatoid arthritis (RA) were treated with analytical insight therapy for 60-90 min weekly during 10 months to 4.5 years (median 3.3 years). Six patients showed great and largely continuous improvement, both psychic and physical, throughout the period of psychotherapy and often for a long time thereafter. In another five cases, improvements in psychic state and the joint disease took place over a period of 1-2 years. Later, when the emotional channels to childhood traumata were opened, these five patients relapsed and the course of their disease became more variable. In four cases, the connections between psychic state and the course of the joint disease were more varied throughout the period of psychotherapy. In the studied group the correlation between psychic state and course of rheumatic disease was highly significant. The probability of the outcome of the study being due to chance alone is considered very small, especially taking into account the fact that RA is a chronic progressive disease.

  • 45. Lindberg, G.
    et al.
    Larsson, Gerry
    Centre for Public Health Research, Karlstad, Sweden.
    Setterlind, S.
    Råstam, L.
    Serum lipids and mood in working men and women in Sweden1994In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 48, 360-363 p.Article in journal (Refereed)
    Abstract [en]

    STUDY OBJECTIVE--To explore the link between serum cholesterol and suicide by investigating the relation between serum lipids and depressive symptoms. DESIGN--This was a cross sectional study of the relation between serum cholesterol, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, and triglycerides on the one hand and depressive symptoms as expressed in a questionnaire on the other. SETTING--An organisational development programme in industry with assistance from occupational health care. PARTICIPANTS--A total of 644 male and 261 female employees (mainly white-collar workers) participated. MAIN RESULTS--Total cholesterol and LDL cholesterol values were lower in those men who, sometimes, often, or very often, had experienced low mood or glumness during the past month compared with those who had not. Serum triglyceride concentrations did not differ between the groups. In women, however, the serum triglyceride value, but not the total cholesterol or LDL cholesterol, was lower in those who reported low mood, depression, or anxiety during the past six months. CONCLUSIONS--Decreasing appetite as a consequence of depression in men would probably lead to both decreasing cholesterol and triglyceride concentrations. Thus, these data indicate the presence of some other explanation for the relation between the level of LDL cholesterol and depressive symptoms in men.

  • 46.
    Nilsson, Josefine
    Swedish National Defence College.
    Veteransoldatutredningen: en granskning av dess förslag till förbättring i frågan om psykisk ohälsa2009Independent thesis Basic level (professional degree), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    14 juni 2007 beslutade regeringen att tillkalla en särskild utredare med uppdrag att utforma förslag till en svensk veteranpolitik, som skulle innefatta ansvaret för personalen före, under och efter internationella militära insatser. Utredningen, som tog namnet Veteransoldatutredningen, lämnade i oktober 2008 sitt slutbetänkande. Syftet med denna uppsats var att kritiskt granska utredningens förslag till förbättring i frågan om psykologisk ohälsa, stressprevention, inför insats och med utgångspunkt i litteraturen försöka förutsäga om förslaget skulle komma att ge effekt

     Metodvalen i denna uppsats har utgjorts av kvalitativ textanalys samt deskription. Tyngdpunkten i essän ligger i att definiera stressreaktioner samt åtgärder för stressprevention. Därefter följer analysen för att kunna se om det finns en förankring i aktuell forskning, och mot slutet granskas om förslagen kommer att ge effekt.

    I uppsatsen söktes svar på följande frågeställningar:

    -          Finns det en förankring i förslagen från Veteransoldatutredningen i aktuell forskning med inriktning på preventiva åtgärder?

    -          Är det rimligt att anta att med stöd av aktuell forskning att förslagen kan förebygga psykisk ohälsa efter internationell insats?

    De viktigaste slutsatserna som har dragits från denna studie är:

    Förslagen från veteransoldatutredningen finns till del förankrade i aktuell litteratur. De förslag som väntas kunna förebygga psykisk ohälsa efter internationell insats är som följer.

    -          En förbättrad och mer effektiv rekrytering genom större personlig kontakt medger en noggrannare rekrytering som gör att man får rätt människor, på rätt plats med godkända vitsord samt psykisk lämplighet och detta minskar i sin tur risken för stressreaktioner.

    -          Utökad och bättre information till allmänheten från den politiska ledningen och från Försvarsmakten om missioner minskar förhoppningsvis samhällets opposition genom att öka förståelsen för Försvarsmakten och dess uppgifter. Detta nedbringar i sin tur den kumulativa stress i soldatens vardag p g a externa stressorer från samhälle och media.

    -          Ytterligare utbildning i mänskliga rättigheter och krigets lagar bidrar till att skapa trygghet i vad soldater får - och inte får - göra. Genom dylik utbildning kan frustrationen, som uppstår då soldaterna inte vet hur de skall hantera specifika situationer, minskas. 

  • 47. Persson, L.
    et al.
    Larsson, Gerry
    Swedish National Defence College, Ledarskapsinstitutionen.
    The other side of the coin - Subjective living conditions: Concepts and measurement1998In: Methods for studying living conditions for persons with disabilities / [ed] E. Hjelmqvist & L Kebbon, Stockholm: Swedish Council for Social Research , 1998, 52-63 p.Chapter in book (Refereed)
  • 48.
    Romanowska, Julia
    et al.
    Karolinska Institutet.
    Larsson, Gerry
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Eriksson, Maria
    Stockholms universitet.
    Wikström, Britt-Maj
    Karolinska Institutet.
    Theorell, Töres
    Karolinska institutet.
    Health effects on leaders and co-workers of an art-based leadership development program2011In: Psychotherapy and Psychosomatics, ISSN 0033-3190, E-ISSN 1423-0348, Vol. 80, no 2, 78-87 p.Article in journal (Refereed)
    Abstract [en]

    Background:There are very few evaluations of the effectiveness of leadership development programs. The purpose of the study was to examine whether an art-based leadership program may have a more beneficial effect than a conventional one on leaders' and their corresponding subordinates' mental and biological stress. Methods: Participating leaders were randomized to 2 year-long leadership programs, 1 art-based and 1 conventional, with follow-up of the leaders and their subordinates at 12 and 18 months. The art-based program built on an experimental theatre form, a collage of literary text and music, followed by writing and discussions focused on existential and ethical problems. Results: After 18 months a pattern was clearly visible with advantage for the art-based group. In the art group (leaders and their subordinates together as well as for subordinates only) compared to the conventional group, there was a significant improvement of mental health, covert coping and performance-based self-esteem as well as significantly less winter/fall deterioration in the serum concentration of the regenerative/anabolic hormone dehydroepiandrosterone-sulfate. Conclusions: Our findings indicate a more beneficial long-term health effect of the art-based intervention compared to a conventional approach. Positive results for both standardized questionnaires and biological parameters strengthened the findings. The study provides a rationale for further evaluation of the effectiveness of this alternative educational approach.

  • 49. Räty, L.
    et al.
    Larsson, Gerry
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Söderfeldt, B.
    Wilde Larsson, B.
    Psychosocial aspects of helath in adolescence: The influence of gender self-concept2005In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 36, no 6, 530.e21-530.e28 p.Article in journal (Refereed)
    Abstract [en]

    Purpose

    The aim of this study was to describe age and gender differences in psychosocial aspects of health in adolescents. A further aim was to explore if self-rated behavior problems varied with the adolescents’ general self-concept and sense of coherence.

    Methods

    Questionnaires on self-rated psychosocial aspects of health were answered by 282 (n = 282/390) randomly selected adolescents, aged 13–22 years (M 17.9/18.0). The instruments used were “I think I am (ITIA),” “Youth Self Report (YSR),” “Sense of coherence (SOC),” and “Family APGAR.” Differences between males and females (cross-individual grouping) were analyzed using nonparametric tests. A cluster analysis was performed using a three-cluster solution to identify and describe profiles (person-centered grouping).

    Results

    Compared with males, adolescent females scored less favorably on self-esteem (ITIA) (p = .028), reported more behavior problems (YSR) (p = .000), and showed a lower sense of coherence (SOC) (p = .003). The differences were most evident in the age group 15–17 years. The three clusters significantly differed from each other regarding how high proportions of problems the adolescents of each profile reported.

    Conclusions

    Compared with male adolescents, adolescent females experienced a poorer psychosocial health in somatic, depressive, and internalizing areas. The result indicated that psychological factors had a major impact on the proportions of problems that the adolescents reported.

  • 50. Räty, L.
    et al.
    Söderfält, B. A.
    Larsson, Gerry
    Swedish National Defence College, Department of Leadership and Management (ILM).
    Wilde-Larsson, B.
    The relationship between illness severity, sociodemographic factors, general self-perception and illness-specific attitude in Swedish young people with epilepsy2004In: Seizure, ISSN 1059-1311, E-ISSN 1532-2688, Vol. 13, no 6, 375-382 p.Article in journal (Refereed)
    Abstract [en]

    Purpose: The aim of this study was to describe the relationship between the epilepsy condition (illness severity), sociodemographic factors, general self-concept, and illness-specific attitude in adolescents with uncomplicated epilepsy. Methods: Adolescents, aged 13–22, fulfilling criteria registered in four Swedish hospitals, answered questionnaires (n=149). The instruments “I think I am” and “Sense of coherence” measured the patients’ general self-concept. The “Child Attitude Toward Illness Scale” measured illness-specific attitude. A summary score (index) calculated from seizure frequency, seizure type, and antiepileptic drug (AED) with side effects measured “Illness Severity”. Results: Illness severity was significantly related to the participants’ general self-concept, as well as to their attitude toward their condition; i.e. higher illness severity scores were correlated with lower sense of coherence (SOC), poorer self-esteem, and a more negative attitude towards the epilepsy condition. Females had more severe illness according to the Illness Severity Index, with almost 80% found in the moderate and high severity groups as compared to 63% of males in the moderate/high severity groups. Conclusions: It was concluded that the severity of the epilepsy condition was related to the adolescents’ general self-concept and illness-specific attitude, but further research is needed to understand the causality of the relationship. The brief assessment of illness severity, constructed and used in this study should be addressed and developed further.

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