Health-related quality of life in school children: validation of instrument, child self assessment, parent-proxy assessment and school nursing documentation of health check-ups

The aims of this study were to validate an international Health-Related Quality of Life (HRQL) instrument, to describe child self and parent-proxy assessed HRQL at child age 10 to 12 and to compare child self assessments with parent-proxy assessments and school nursing documentation. The study is part of the Schools on the Move –research project. In phase one, a cross-cultural translation and validation process was performed to develop a Finnish version of Pediatric Quality of Life Inventory™ 4.0 (PedsQL™ 4.0). The process included a two-way translation, cognitive interviews (children n=7, parents n=5) and a survey (children n=1097, parents n=999). In phase two, baseline and follow-up surveys (children n=986, parents n=710) were conducted to describe and compare the child self and parent-proxy assessed HRQL in school children between the ages 10 and 12. Phase three included two separate data, school nurse documented patient records (children n=270) and a survey (children n=986). The relation between child self assessed HRQL and school nursing documentation was evaluated. Validity and reliability of the Finnish version of PedsQL™ 4.0 was good (Child Self Report α=0.91, Parent-Proxy Report α=0.88). Children reported lower HRQL scores at the emotional (mean 76/80) than the physical (mean 85/89) health domains and significantly lower scores at the age of 10 than 12 (dMean=4, p=<0.001). Agreement between child self and parent-proxy assessment was fragile (r=0,4, p=<0.001) but increased as the child grew from age 10 to 12 years. At health check-ups, school nurses documented frequently children’s physical health, such as growth (97%) and posture (98/99%) but seldom emotional issues, such as mood (2/7%). The PedsQLTM 4.0 is a valid instrument to assess HRQL in Finnish school children although future research is recommended. Children’s emotional wellbeing needs future attention. HRQL scores increase during ages between childhood and adolescence. Concordance between child self and parent-proxy assessed HRQL is low. School nursing documentation, related to child health check-ups, is not in line with child self assessed HRQL and emotional issues need more attention.

How (not) to interview children : interviews with young children in sexual abuse investigations in Finland

The present thesis had two main objectives: The first was to assess how child sexual abuse (CSA) interviews in Finland are conducted through analysing the interviewing techniques applied and the language used by the interviewers, as well as to suggest ways to improve interviews if they were found to have deficiencies. The second main aim was to contribute to the growing research corpus concerning CSA interviews, in particular, by addressing how interviewers follow up information provided by the child, by analysing whether child health care professionals would use childadapted language, and by studying the kind of modifications in the verbal behaviour of interviewers and children that were associated with a) repeated interviews, b) a support person’s presence at the interview, and c) the use of anatomically detailed dolls. Two complementary samples of CSA interviews were analysed. The first one was composed of child interviews with 3-12-year-old children (N = 27) that had been considered problematic by lawyers or other involved professionals (Studies I and IV). The second sample consisted of unselected interviews (N = 43) with children aged 3 to 8 years conducted in a number of hospitals in different parts of the country (Studies II and III). Study I: The verbal interaction between interviewer and child was analysed in a sample of interviews that had been considered to be problematic by involved professionals. Results showed that interviewers used inappropriate questioning techniques, relying on option-posing, specific suggestive and unspecific suggestive questions to a significant extent, these comprising around 50% of all interviewer utterances. The proportion of invitations, which the research community recommends interviewers to rely on, was strikingly low. Invitations and directive utterances were associated with an increase in informative responses by the child in terms of response type, number of new details reported, as well as length of response. The opposite was true for option-posing and suggestive utterances. Longer questions by the interviewer (in number of words) often rendered no reply from the child, whereas shorter questions were followed by descriptive answers. Even after the child had provided an informative answer, interviewers failed to follow up the information in an adequate way and instead continued to rely on focused and leading questions. Study II: Due to the possible bias of the sample analysed in Study I, the most important analyses were rerun with the unselected sample and reported separately. Results were quite similar between the two studies, indicating that the problems observed in Study I, with interviewers relying on option-posing and suggestive questions to a significant extent, are likely to be general and not specific for those interviews. Even if suggestive questions were slightly less and invitations slightly more common in this sample than in the previous study, almost half of the interviewer questions were still optionposing or suggestive, and also in this sample, interviewers failed to follow up information by the child in a facilitating manner. Differentiating between judicial and contextual details showed that while facilitators, invitations, and directive utterances elicited more contextual than judicial details, the opposite was true for specific suggestive utterances. These results might be explained by the reluctance of children to describe sexual details related to the abuse events. Alternatively, they may also be due to children describing incorrect sexual details as a result of suggestive interviewing techniques. Study III: This study examined features of the language used by the interviewers. Interviewer utterances included multiple questions, long statements, complicated grammar and concepts, as well as unclear references to persons and situations. More than a fifth of the interviewer utterances were coded as belonging to at least one of these categories. The results suggest that even professionals who are experienced in interacting with children may have difficulties in using a child-sensitive language, adding to the pool of studies showing similar problems to occur in legal hearings with children conducted by lawyers. As children rarely comment on, or even recognise, their lack of comprehension, the use of a language that is too complex can have detrimental consequences for the outcomes of investigative interviews. Interviewers used different approaches to introduce the topic of abuse. While 15% of the children spontaneously addressed the topic of abuse, probably indicating that they felt confident with the interviewer and the situation, in almost 50% of the cases, the interviewer introduced the topic of abuse in a way that can be considered leading. Interviews were characterised by a lack of structure, apparent in frequent rapid switches of topic by the interviewer. This manner was associated with a decrease in the number of new details provided by the children. Study IV: This study analysed possible changes in the interview dynamics associated with repeated interviewing, the presence of a support person (related to the child), and the use of anatomically detailed (AD) dolls. Repeated interviewing, in combination with suggestive questions, has previously been found to seriously contaminate children’s accounts. In the present material, interviewers used significantly more suggestive utterances in the repeated condition, thus endangering the reliability of the children’s reports. Few studies have investigated the effects of a support person’s presence at the interview. The results of the present study showed that interviewers talked more and children provided less information when a support person was present. Supporting some earlier findings regarding the use of AD dolls, the present results showed that using AD dolls was associated with longer interviewer utterances and shorter, less responsive, and less detailed child responses. Interviewers used up to five times more unspecific suggestive utterances when dolls were used, for instance through repeatedly asking the child to show “what really happened” with the dolls. Conclusion: The results indicate that CSA interviews in Finland are not conducted in a manner that follows best practice as defined by the research community and as stated in a number of guidelines. When comparing these questioning strategies with the recommendations, which have been predominant in the field for more than ten years now, it can be concluded that the interviews analysed were conducted in a manner that undermines the possibility to elicit an uncontaminated and accurate narrative from the children. A particularly worrying finding was the fact that interviewers did not follow up relevant information by the children in an adequate way. A number of clinical implications can be drawn from the results, particularly concerning the need for improvement in the quality of CSA interviews. There is convincing research regarding how to improve CSA interviews, notably through training forensic child interviewers to use a structured interviewing protocol, and providing them with continuous supervision and feedback. Allocating appropriate resources to improve the quality of forensic child interviews is a matter of protecting the rights of all persons involved in CSA investigations, in particular those of the children.

Individual dietary counselling during and after pregnancy: Impact on diet and body weight

In Finland, maternity and child health clinics play a key role in promoting health in young families. Currently, obesity causes the greatest challenges to clinics. In obese pregnant women, an increased risk for metabolic diseases exist which can affect both the mother and child. The purpose of this thesis was to explore the role of dietary counselling: in Finnish health clinics; in the regulation of dietary intake; and in affecting the body weight of women. The main aim was to test the effect of dietary counselling and probiotic intervention on dietary intake and maternal body weight during and after pregnancy. In addition to dietary counselling, the effect of other factors, such as eating behaviour on dietary intake and body weight control after pregnancy was assessed. Another aim was also to evaluate dietary counselling practices by nurses (n = 327) in Finnish health clinics assessed by a questionnaire. At the beginning of the pregnancy, women (n = 256) enrolled in a dietary intervention study, were randomised into three groups. One group received dietary counselling with probiotics, one had counselling with placebo and the third group was the control group. The control group consisted of women whom did not receive counselling and took placebo. Probiotics and placebo supplements were used until the end of exclusive breastfeeding or six months after pregnancy. Women were followed from early pregnancy up to four years after pregnancy. Follow-up visits took place three times during pregnancy, at one and six months, and one, two and four years after pregnancy. Dietary counselling, provided by a nutritionist, aimed to influence the quality of dietary fat intake. Dietary counselling is important to provide in clinics, as determined by the nurses, and these nurses expressed a want to improve their own nutritional knowledge through education. The nurses had varying knowledge of current dietary recommendations. Dietary counselling for women during and after pregnancy resulted in beneficial changes in dietary intake up to one year after pregnancy and body weight and waist circumference up to four years after pregnancy. Probiotics had a beneficial effect together with dietary counselling on waist circumference until one year after pregnancy, but not throughout the long term, four years after pregnancy. Other factors, such as eating behaviour, associated with dietary intake and body weight control after pregnancy. Specifically, dietary recommendations are reached amongst women whom had high cognitive restraint in their eating behaviour and did not demonstrate uncontrolled eating. Overweight women more frequently emotionally ate compared to normal weight women and women with central adiposity related more frequently to having an uncontrolled eating behaviour than women with normal waist circumference. In addition, being overweight prior to pregnancy and excessive weight gain during pregnancy associated with increased body weight retention after pregnancy. This study showed that individual dietary counselling is useful in influencing dietary intake which adheres to dietary recommendations and this counselling influences, favourably, body weight after pregnancy. Especially, women with the risk for weight retention, such as women who have emotional and uncontrolled eating behaviours, who were overweight prior to pregnancy or those who had excessive weight gain during pregnancy, may benefit from individual dietary counselling. This study underscores the need to develop dietary counselling practices for pregnant women and their follow-up after pregnancy in Finnish health clinics. These practices include increasing the efficacy of the counselling such as collaboration with families, having knowledgable health professionals and having sufficient resources.

Dental Health in Primary Teeth after Prevention of Mother-Child Transmission of Mutans Streptococci. A Historical Cohort Study on Restorative Visits and Maternal Prevention Costs

Mutansstreptokokkitartunnan ehkäisemisen pitkäaikaisvaikutukset maitohampaiden terveyteen. Kohorttitutkimus korjaavan hoidon määrästä ja kariesehkäisyn kustannuksista. Tutkimuksen tarkoituksena oli selvittää varhaisen mutansstreptokokki (MS)-kolonisaation ehkäisyn pitkäaikaisvaikutuksia korkean kariesriskin omaavien lasten maitohampaistossa sekä tarkastella MS-tartunnan estämisen kustannuksia. Tiedot lasten hampaiden terveydestä ja hammashoitotoimenpiteistä syntymästä 10-vuotiaaksi sekä äiteihin kohdistuneen kariesehkäisyn kustannuksista kerättiin Ylivieskan terveyskeskuksen asiakirjoista. Tutkimuksessa oli mukana yhteensä 507 lasta, heistä 148 oli osallistunut aikaisempaan Ylivieskan äiti-lapsitutkimukseen, jossa verrattiin äitien käyttämän ksylitolipurukumin ja äidille tehtyjen fluori- tai klooriheksidiinilakkausten vaikutusta pikkulasten hampaiden terveyteen. Maitohammaskariesta esiintyi 10-vuotiaaksi asti merkitsevästi vähemmän lapsilla, jotka eivät olleet saaneet MS-tartuntaa alle 2-vuotiaana, heidän maitohampaansa säilyivät 3,4 vuotta kauemmin täysin ehjinä (p<0.001) ja he tarvitsivat vähemmän maitohampaiden korjaavaa hoitoa (p=0.005) kuin lapset, joiden hampaisto oli kolonisoitunut MS-bakteerilla jo 2-vuotiaana. Koska ksylitoliryhmän lasten MS-kolonisaatio oli vähäisintä, heidän maitohampaissaan oli vähemmän kariesta ja korjaavan hoidon tarvetta kuin kahden muun korkeariskisen ryhmän lapsilla. Äitien käyttämän ksylitolipurukumin kustannukset olivat yhteensä 116 euroa ja lapsen maitohampaiden säilyminen täysin ehjinä vuoden pidempään maksoi 37 euroa. Kun MS-tartunta oli saatu estettyä, korkean kariesriskin omaavien lasten hampaiden terveys oli samalla tasolla kuin keskimäärin koko ikäkohortilla. Lapsen maitohampaat säilyvät terveinä pidempään ja korjaavan hoidon tarve vähenee, kun MS-kolonisaatio alle 2-vuotiaana saadaan estettyä. Lapsen MS-kolonisaatio vähenee merkitsevästi, kun äiti käyttää ksylitolipurukumia lapsen ollessa 0-2 vuoden ikäinen, siten pikkulapsen äidin säännöllinen ksylitolipurukumin käyttö saattaa olla julkisen tereydenhuollon kannalta tarkoituksenmukainenterveyttä edistävä menetelmä.