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Background Informal care is vital to many people with severe mental illness under normal circumstances. Little is known about how extraordinary circumstances affect relatives with a family member with mental illness. This study investigated the consequences of the first COVID-19 lockdown in Norway from the perspective of relatives of persons with psychotic- and/or bipolar disorders: What were the challenges and for whom? Method Relatives were invited to complete an online survey shortly after the first lockdown was initiated. Both quantitative and qualitative data were collected concerning experiences of relatives’ own and their affected family members’ health and situation. Two hundred and seventy-nine relatives completed the survey, mostly mothers and partners. Results One-third of the relatives reported considerable deterioration in their family members’ mental health, and a substantial minority worried about severe self-harm or suicide. Main themes in the qualitative analyses were “Isolation and its effects on mental health”, “Worrying about the pandemic and its consequences”, “Increased symptomatology” and “Suicide”. Being a relative during the lockdown put heavy strain on the relatives’ own health, in particular disturbance of sleep, concentration, and the ability to take care of others in the family. Relatives of family members with psychotic bipolar disorder, not currently in treatment, or living with their family experienced the situation especially challenging. Conclusions Many relatives found the first lockdown hard for their family. Efforts to integrate relatives’ perspectives in health care and contingency plans under normal circumstances could potentially alleviate some of the extra burden experienced by families during extraordinary circumstances.

Background A worldwide pandemic of a new and unknown virus is characterised by scientific uncertainty. However, despite this uncertainty, health authorities must still communicate complex health risk information to the public. The mental models approach to risk communication describes how people perceive and make decisions about complex risks, with the aim of identifying decision-relevant information that can be incorporated into risk communication interventions. This study explored how people use mental models to make sense of scientific information and apply it to their lives and behaviour in the context of COVID-19. Methods This qualitative study enrolled 15 male and female participants of different ages, with different levels of education and occupational backgrounds and from different geographical regions of Norway. The participants were interviewed individually, and the interview data were subjected to thematic analysis. The interview data were compared to a expert model of COVID-19 health risk communication based on online information from the Norwegian Institute of Public Health. Materials in the interview data not represented by expert model codes were coded inductively. The participants’ perceptions of and behaviours related to health risk information were analysed across three themes: virus transmission, risk mitigation and consequences of COVID-19. Results The results indicate that people placed different meanings on the medical and scientific words used by experts to explain the pandemic (e.g., virus transmission and the reproduction number). While some people wanted to understand why certain behaviour and activities were considered high risk, others preferred simple, clear messages explaining what to do and how to protect themselves. Similarly, information about health consequences produced panic in some interviewees and awareness in others. Conclusion There is no one-size-fits-all approach to public health risk communication. Empowering people with decision-relevant information necessitates targeted and balanced risk communication.

BackgroundSince the early 2000s, Healthy Life Centres have been established in Norway to promote physical and mental health. Yet to date, little is known about the efficacy of Healthy Life Centres in promoting health behaviour change and maintenance or the factors that underlie these processes. Accordingly, the aim of the current study was to examine the factors that participants in a Healthy Life Centre perceive as relevant for the initiation and maintenance of lifestyle changes toward more physical activity and consumption of a healthier diet.MethodParticipants were purposely recruited from among adherers in a 12-month multi-method research project at a Healthy Life Centre. Individual, semi-structured interviews were conducted with 8 women and 6 men who were between the ages of 20 and 61 years old. Data were analysed using Systematic Text Condensation.ResultsThree main themes were derived from this analysis. The first theme focused on the motives behind initiation and maintenance of lifestyle changes along with the importance of a relationally supportive environment to promote perceived competence in pursuing a healthy lifestyle. The second theme focused on strategies for coping with the challenges and potential pitfalls that were associated with various unpleasant experiences and life events. The third theme focused on several specific skills that were helpful to the initiation and maintenance of lifestyle changes.ConclusionThe current study enhanced an understanding of the initiation and maintenance of lifestyle changes, although these processes were not disentangled in participants’ experiences. In line with self-determination theory, the results suggested that lifestyle change is more likely to be initiated and maintained when goals are not only achievable but also regulated with autonomous motivation and of intrinsic value. Conversely, lifestyle change is difficult to maintain when motives are external to the self. Further, cognitive and behavioural skills were valuable and necessary in coping with unpleasant emotions. Finally, the critical function of self-regulation skills for making realistic plans and prioritizations in order to balance healthy lifestyle behaviours with the routines of “daily life” while monitoring outcomes was readily apparent. Healthy Life Centres can contribute to these processes in meaningful ways.

Background School non-completion and early work disability is a great public health challenge in Norway, as in most western countries. This study aims to investigate how medically based disability pension (DP) among young adults varies geographically and how municipal socioeconomic conditions interact with non-completion of secondary education in determining DP risk. Methods The study includes a nationally representative sample of 30% of all Norwegians (N = 350,699) aged 21–40 in 2010 from Statistic Norway’s population registries. Multilevel models incorporating factors at the individual, neighbourhood and municipal levels were applied to estimate the neighbourhood and municipality general contextual effects in DP receipt, and detect possible differences in the impact of municipal socioeconomic conditions on DP risk between completers and non-completers of secondary education. Results A pattern of spatial clustering at the neighbourhood (ICC = 0.124) and municipality (ICC = 0.021) levels are clearly evident, indicating that the underlying causes of DP receipt have a systematic neighbourhood and municipality variation in Norway. Non-completion of secondary education is strongly correlated with DP receipt among those younger than 40. Socioeconomic characteristics of the municipality are also significantly correlated with DP risk, but these associations are conditioned by the completion of secondary education. Living in a socioeconomically advantageous municipality (i.e. high income, high education levels and low unemployment and social security payment rates) is associated with a higher risk of DP, but only among those who do not complete their secondary education. Although the proportion of DPs was equal in rural and urban areas, it is evident that young people living in urban settings are more at risk of early DP than their counterparts living in rural parts of the country when controlling for other risk factors. Conclusion The association between school non-completion and DP risk varies between municipalities and local socioeconomic environments. The interplay between personal characteristics and the local community is important in DP risk among young adults, implying that preventive measures should be directed not only at the individual level, but also include the educational system and the local community. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/)

Background: Lifestyle intervention may reduce the development of type 2 diabetes among high-risk individuals. The aim of this study was to explore how older adults perceived their own lifestyle and being at increased risk for type 2 diabetes while they participated in a lifestyle intervention programme. Methods: A nested qualitative study was performed with 26 participants (mean age 68 years) in the VEND-RISK Study. Participants had previously participated in the HUNT3 Study and the HUNT DE-PLAN Study, where their risk for developing type 2 diabetes (FIND-RISC ≥ 15) had been identified. The data were analysed using systematic text condensation. Results: Two main themes were identified. The first theme was having resources available for an active lifestyle, which included having a family and being part of a social network, having a positive attitude toward life, and maintaining established habits from childhood to the present. The second theme was being at increased risk for type 2 diabetes, which included varied reactions to the information on increased risk, how lifestyle intervention raised awareness about risk behaviour, and health-related worries and ambitions as type 2 diabetes prevention. Conclusions: Assessing a participant’s resources could improve the outcomes of lifestyle intervention programmes. Both family history and risk perception could be used in preventive strategies to enhance changes in lifestyle. © 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Background The positive association between parental socioeconomic position (PSEP) and health among adolescents may be partly explained by dietary behaviour. We investigated the associations between fruit intake, vegetable intake, energy-dense food intake, the Healthy Nutrition Score for Kids and Youth (HuSKY) and parental education in a nationwide, cluster-randomized sample of adolescents in Germany. Methods The German Health Interview and Examination Survey for Children and Adolescents 2003–2006 (KiGGS) included 17,641 individuals aged 0–17 years and their parents. Complete information on relevant variables was available for 6359 individuals in the 11–17 age group. The associations between nutrition indicators and parental education were analysed separately for boys and girls, using multivariate logistic regression analysis. Odds ratios (ORs) adjusted for age, region, income, occupation, physical activity and weight status related variables, were calculated for the associations between parental education and nutrition indicators. Results After full adjustment, higher parental education level was associated with lower energy-dense food intake – with an OR of 1.3 (95 % CI 1.0–1.7) for boys with secondary educated parents and 1.8 (1.4–2.3) for boys with tertiary educated parents compared to boys with primary educated parents; the corresponding ORs for girls were 1.2 (0.9–1.5) and 1.6 (1.2–2.2). Higher parental education was associated with higher fruit intake – with an OR of 1.3 (1.0–1.7) for boys with secondary educated parents and 2.0 (1.5–2.7) for boys with tertiary educated parents compared to boys with primary educated parents; the corresponding ORs for girls were 1.0 (0.8–1.4) and 1.5 (1.0–2.1). Among boys and girls with tertiary educated parents compared to those with primary educated parents an OR of 1.3 (CI boys: 1.0–1.7, CI girls: 1.0–1.6) was observed for high vegetable intake. Among boys with tertiary educated parents compared to boys with primary educated parents an OR of 1.6 (1.2–2.2) was observed for a high HuSKY; the corresponding OR for girls was 1.5 (1.1–1.9). Conclusions A high PSEP is associated with consumption of less energy-dense food, more fruits and vegetables and more favourable overall dietary behaviour. Preferably school-based interventions are needed to promote healthy dietary behaviour among German adolescents and a special effort is needed to reach adolescents from low-PSEP families. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1830-2) contains supplementary material, which is available to authorized users.

Background:\ud The use of electronic media has been found to be a risk factor for higher BMI and for being overweight. Physical activity has been found to be associated with lower BMI and lower risk for being overweight. Little is known about whether the associations between physical activity and electronic media use are additive or interactive in predicting BMI and risk for overweight among adolescents.\ud \ud Methods:\ud The data used in this study stem from the 2009/2010 survey of “Health Behaviour in School-aged Children (HBSC) study: A WHO Cross-National Survey. The sample consisted of 107184 13 and 15 year students from 30 different countries. Multilevel regression models were used to produce the presented estimates.\ud \ud Results:\ud Overall, 18% of boys and 11% of girls were classified as overweight. EM use was found to be associated with increased BMI z-scores and odds for overweight among both boys and girls who did not comply with physical activity guidelines. Among physically active adolescents, EM was found to be significantly associated with BMI or odds for overweight among girls, but not among boys.\ud \ud Conclusion:\ud While the usage of EM appear to be inconsequential for BMI and the risk of overweight among physically active boys, we find evidence indicating that EM use is associated with BMI and risk for overweight among girls, including those who report complying with MVPA guidelines.

Background The assessment of real-life, community-based interventions to tackle obesity is an important step in the development of effective policies. Especially multi-level interventions have a high likely effectiveness and potential reach in counteracting the obesity epidemic. Although much can be learned from these initiatives, performing an evaluation of such interventions is challenging. The aim of the current article is to provide a descriptive overview of the data collection process and general results of an assessment of ongoing multi-level obesity prevention community interventions for adults in Europe, and the lessons learned from this effort. Methods The data collection was divided into two main phases: a) finding the ongoing obesity prevention interventions by contacting key informants in each of the European Union countries and the European Economic Area, and searching existing databases; and b) collecting detailed information (including the reach, effectiveness, adoption, implementation and maintenance (RE-AIM)) of the selected interventions using questionnaires for informants in each of the interventions. Results A total of 78 interventions from 24 European countries were included in the final sample. The number of identified interventions varied greatly per country. The interventions covered various implementation levels (national, regional or local) and determinants (physical, sociocultural, economic, political), mostly addressing both nutrition and physical activity behaviours. Conclusions We found that many multi-level obesity prevention interventions among adults are currently active in Europe, although we found relatively few in Southern and Eastern Europe. Identifying interventions and obtaining detailed information proved to be a difficult, time consuming and painstaking process. We discuss some of the reasons why this might be the case and present recommendations based on our experiences. We suggest that future research uses a step-wise approach, keeping participant burden to a minimum. The use of personalised and tailored strategies is recommended, led by researchers who exercise flexibility, tact and patience during the data collection process. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1563-2) contains supplementary material, which is available to authorized users.

Background In many low-income countries, children are at high risk of iodine deficiency disorders, including brain damage. In the early 1990s, Tanzania, a country that previously suffered from moderate to severe iodine deficiency, adopted universal salt iodation (USI) as an intervention strategy, but its impact remained unknown. Methods We report on the first national survey in mainland Tanzania, conducted in 2004 to assess the extent to which iodated salt was used and its apparent impact on the total goitre prevalence (TGP) and urinary iodine concentrations (UIC) among the schoolchildren after USI was initiated. In 2004, a cross-sectional goitre survey was conducted; covering 140,758 schoolchildren aged 6 - 18 years were graded for goitre according to new WHO goitre classification system. Comparisons were made with district surveys conducted throughout most of the country during the 1980s and 90s. 131,941 salt samples from households were tested for iodine using rapid field test kits. UIC was determined spectrophotometrically using the ammonium persulfate digestion method in 4523 sub-sampled children. Results 83.6% (95% CI: 83.4 - 83.8) of salt samples tested positive for iodine. Whereas the TGP was about 25% on average in the earlier surveys, it was 6.9% (95%CI: 6.8-7.0) in 2004. The TGP for the younger children, 6-9 years old, was 4.2% (95%CI: 4.0-4.4), n = 41,965. In the 27 goitre-endemic districts, TGP decreased from 61% (1980s) to 12.3% (2004). The median UIC was 204 (95% CF: 192-215) μg/L. Only 25% of children had UIC Conclusion Our study demonstrates a marked improvement in iodine nutrition in Tanzania, twelve years after the initiation of salt iodation programme. The challenge in sustaining IDD elimination in Tanzania is now two-fold: to better reach the areas with low coverage of iodated salt, and to reduce iodine intake in areas where it is excessive. Particular attention is needed in improving quality control at production level and perhaps the national salt iodation regulations may need to be reviewed.

Background Malaria and malnutrition are the major causes of morbidity and mortality in under-five children in developing countries such as Ethiopia. Malnutrition is the associated cause for about half of the deaths that occur among under-five children in developing countries. However, the relationship between malnutrition and malaria is controversial still, and it has also not been well documented in Ethiopia. The aim of this study was to assess whether malnutrition is associated with malaria among under-five children. Methods A case–control study was conducted in Adami Tulu District of East Shewa Zone in Oromia Regional State, Ethiopia. Cases were all under-five children who are diagnosed with malaria at health posts and health centres. The diagnosis was made using either rapid diagnostic tests or microscopy. Controls were apparently healthy under-five children recruited from the community where cases resided. The selection of the controls was based on World Health Organization (WHO) cluster sampling method. A total of 428 children were included. Mothers/caretakers of under-five children were interviewed using pre-tested structured questionnaire prepared for this purpose. The nutritional status of the children was assessed using an anthropometric method and analyzed using WHO Anthro software. A multivariate logistic analysis model was used to determine predictors of malaria. Results Four hundred twenty eight under-five children comprising 107 cases and 321 controls were included in this study. Prevalence of wasting was higher among cases (17.8 %) than the controls (9.3 %). Similarly, the prevalence of stunting was 50.5 % and 45.2 % among cases and controls, respectively. Severe wasting [Adjusted Odds Ratio (AOR) =2.9, 95 % CI (1.14, 7.61)] and caretakers who had no education [AOR = 3, 95 % CI (1.27, 7.10)] were independently associated with malarial attack among under-five children. Conclusion Children who were severely wasted and had uneducated caretakers had higher odds of malarial attack. Therefore, special attention should be given for severely wasted children in the prevention and control of malaria. publishedVersion

Background Multi-state models, as an extension of traditional models in survival analysis, have proved to be a flexible framework for analysing the transitions between various states of sickness absence and work over time. In this paper we study a cohort of work rehabilitation participants and analyse their subsequent sickness absence using Norwegian registry data on sickness benefits. Our aim is to study how detailed individual covariate information from questionnaires explain differences in sickness absence and work, and to use methods from causal inference to assess the effect of interventions to reduce sickness absence. Examples of the latter are to evaluate the use of partial versus full time sick leave and to estimate the effect of a cooperation agreement on a more inclusive working life. Methods Covariate adjusted transition intensities are estimated using Cox proportional hazards and Aalen additive hazards models, while the effect of interventions are assessed using methods of inverse probability weighting and G-computation. Results Results from covariate adjusted analyses show great differences in sickness absence and work for patients with assumed high risk and low risk covariate characteristics, for example based on age, type of work, income, health score and type of diagnosis. Causal analyses show small effects of partial versus full time sick leave and a positive effect of having a cooperation agreement, with about 5 percent points higher probability of returning to work. Conclusions Detailed covariate information is important for explaining transitions between different states of sickness absence and work, also for patient specific cohorts. Methods for causal inference can provide the needed tools for going from covariate specific estimates to population average effects in multi-state models, and identify causal parameters with a straightforward interpretation based on interventions. publishedVersion