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Stress and perceived health among primary care visitors in two corners of Europe: Scandinavia and Greece
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Primary Care Center, Primary Health Care Center Vikbolandet.
Thriasson Gen Hosp Elefsina, Greece.
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0003-4224-1032
Linköping University, Department of Biomedical and Clinical Sciences, Division of Clinical Chemistry. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Chemistry.ORCID iD: 0000-0003-0756-7723
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2020 (English)In: International Journal of Health Geographics, E-ISSN 1476-072X, Vol. 19, no 1, article id 55Article in journal (Refereed) Published
Abstract [en]

Background The global financial crisis emerging in 2008 struck Greece especially hard, whereas Scandinavian countries were less affected. This has created a unique opportunity to study the long-term effect of community stress on populations. Increasing frequencies of mental health issues and poorer perceived health among the Greek population have been reported. The physiological marker of long-term stress, cortisol in hair, is applied in this study together with measures of perceived health and stress, depression and anxiety. Our aim was to study self-reported and physiological stress, perceived health, including mental health, in the general population of Greece compared to Scandinavia, in order to assess long-term effects of the economic crisis on these parameters. Methods A cross-sectional comparative study of adult (18-65 years) Primary Health Care visitors from semi-rural areas in Greece (n = 84) and Scandinavia (n = 140). Data collection was performed in 2012, and encompassed a questionnaire with a variety of health and stress indicators as well as hair samples for analyzes of cortisol levels. Results The Greek sample reported significantly poorer overall health (p < 0.0001) than the Scandinavians and a significantly higher perceived stress (p < 0.0001). The Greeks were also less hopeful of the future (p < 0.0001), and to a larger extent fulfilled the HAD criteria for depression (p < 0.0001) and anxiety (p = 0.002). The strongest predictors explaining ill health in logistic regressions were being Greek (p = 0.001) and feeling hopeless about the future p = 0.001, OR = 6.00 (CI 2.10-14.88). Strong predictors in logistic regressions for high perceived stress were anxiety: high (p < 0.0001) and medium (p = 0.0001), as well as medium depression (p = 0.02). Conclusions Greek adult Primary Health Care visitors perceived their health more negatively than the Scandinavians, including a higher presence of depression, anxiety, and a lower hope for the future. The Greeks also reported higher perceived stress, but this was not reflected in higher cortisol levels. The findings presented here, identify possible adverse long-term effects of the economic crisis in the examined Greek population that are not seen in the Scandinavian cohort. These differences may also be interpreted against the background of socio-cultural differences in the northern and south-eastern corners of Europe.

Place, publisher, year, edition, pages
BMC , 2020. Vol. 19, no 1, article id 55
Keywords [en]
Stress; Cortisol; Depression; Anxiety; Perceived health; Economic crisis; Scandinavia; Greece
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-172196DOI: 10.1186/s12942-020-00248-8ISI: 000597296400003PubMedID: 33276781OAI: oai:DiVA.org:liu-172196DiVA, id: diva2:1512939
Note

Funding Agencies|Linkoping University Library

Available from: 2020-12-28 Created: 2020-12-28 Last updated: 2024-05-03
In thesis
1. Stress and mental health in populations of societies exposed to extraordinary circumstances: with focus on perceived and biological stress, perceived health, psychosocial factors, and sense of coherence
Open this publication in new window or tab >>Stress and mental health in populations of societies exposed to extraordinary circumstances: with focus on perceived and biological stress, perceived health, psychosocial factors, and sense of coherence
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

As our societies have grown larger, and communications have become global and fast-paced, our bodies and minds have been subjected to a mental stress different from the "fight or flight" situations we have adapted to through evolution. Furthermore, mental health issues are now seen to be on the rise all over the world. Globalisation has enabled social crises of different origins, e.g. financial or biological, to influence nations worldwide and spread faster than ever before. This thesis aims to investigate how populations are affected in regard to stress and mental health by the extraordinary circumstances of the global financial crisis of 2008 and the COVID-19 pandemic of 2020-2023.

The first two studies in this thesis focus on the effects of the financial crisis on young adults (Paper I) and adults in working ages (Paper II). Greece was severely affected by the global financial crisis of 2008 and went into a decade long recession, whereas Scandinavian countries were less affected. University students were recruited from the psychology and medicine programs in Athens, Greece and Linköping, Sweden. Primary care visitors were recruited consecutively at primary health care centres (PHCC) in Greece, Sweden, and Norway. Data was collected in connection to recruitment. All participants filled out the same short questionnaire and gave hair samples that were analysed for cortisol concentrations (HCC) as a biological measure of stress.

Papers III and IV are based on the Healthy OLD-study and investigate mental health, stress, and coping in older adults (70-80 years) during the COVID-19 pandemic. This age group was particularly vulnerable to the virus and therefore subjected to protective restrictions like social isolation. Participants were randomly recruited from five PHCC in south-east Sweden. Data was collected during one visit at the participant’s own PHCC and consisted of a comprehensive questionnaire, biometrics, and samples of blood, hair, and saliva. In Paper III only the questionnaire was used, and in Paper IV both the questionnaire and hair samples (analysed for HCC) were used.

In Papers I and II the Greek participants reported a significantly higher occurrence of self-reported stress, anxiety, and depressive symptoms than their Swedish/Scandinavian peers. They also experienced more serious life events, and less hope for the future. In Paper I, cortisol levels were significantly lower for the Greek participants than the Swedish, which could indicate a fatigued Hypothalamic-Pituitary-Adrenal (HPA) axis due to longterm stress exposure, and/or genetic differences, and/or cultural differences. However, there was no significant difference in cortisol values between adults in working ages for Greeks and Scandinavians in Paper II, although significantly poorer overall health was reported in the Greek population compared to the Scandinavian population in Paper II. The strongest predictors explaining self-reported poor health were being Greek and feeling hopeless about the future. The strongest predictors for high perceived stress were moderate and high anxiety, and moderate depression.

In Paper III social distancing was the factor most participants found had affected them the most during the COVID-19 pandemic. The participants who stated they had suffered a decline in mental health due to the COVID-19 pandemic reported more anxiety, depression, and stress than the participants who stated they had not been affected mentally. Risk factors for experiencing deteriorating mental health due to the pandemic were found to be a negative change in social life, experiencing a bad family situation, a change in physical activity, anxiety, and being a woman.

In Paper IV, a low sense of coherence was significantly associated with anxiety, self-reported poor financial status, little belief in the future, and perceived negative mental effect from the COVID-19 pandemic. Anxiety was found to be a possible mediator between being mentally affected and sense of coherence. No association was found between sense of coherence and hair cortisol levels in this study. In general, women reported poorer mental health and quality of life than men, but there was no significant difference in hair cortisol levels.

To conclude, the findings of this thesis show a high occurrence of stress, anxiety, and depression in adults living in societies exposed to financial crisis or the COVID-19 pandemic. Symptoms of anxiety and depression were shown to be predictors of high levels of perceived stress in young adults. Anxiety was especially prominent in older adults during the pandemic and is suggested to be a mediator in the association between sense of coherence (SoC) and participants who reported a decline in mental health due to the pandemic. A multitude of psychosocial factors were strongly correlated with SoC, respectively those mentally affected by the pandemic. Young Greek adults presented with lower HCC than their Swedish peers, which could be caused by fatigue of the HPA axis due to long-term stress exposure.

The aim of this thesis does not have a direct clinical application, but the high occurrence of mental health issues, especially anxiety, found among adults living in societies exposed to extreme events emphasizes the importance of actively asking a patient how he/she is affected by a difficult life event, not least older women.

Abstract [sv]

I och med att våra samhällen har blivit allt större och vår kommunikation allt snabbare och mer global, så utsätts våra kroppar och sinnen för en mental stress som skiljer sig från de "fight and flight" situationer som vi evolutionärt är anpassade till. Dessutom ökar mental ohälsa över hela världen. Globaliseringen har möjliggjort att sociala kriser av olika slag, t.ex. finansiella eller biologiska, påverkar länder över hela världen och sprids fortare än någonsin tidigare. Den här avhandlingen har till syfte att undersöka hur befolkningen påverkas avseende stress och mental hälsa i samhällen som exponeras för svåra händelser, mer specifikt den globala finansiella krisen 2008 och COVID-19 pandemin 2020–2023.

De två första studierna i den här avhandlingen fokuserar på effekterna av finansiell kris på unga vuxna (Studie I) och vuxna i arbetsför ålder (Studie II). Grekland drabbades särskilt hårt av den globala finansiella krisen 2008 och gick in i en recession som varade ett decennium, medan skandinaviska länder blev mindre drabbade. Universitetsstudenter rekryterades från psykolog- och läkarprogrammen i Aten, Grekland, och Linköping, Sverige. Vårdcentralsbesökare rekryterades konsekutivt vid vårdcentraler i Grekland, Sverige och Norge. Data samlades in i samband med rekryteringen. Alla deltagare fyllde i samma korta enkät och gav ett hårprov, vilket analyserades för kortisolkoncentrationer (HCC) som ett biologiskt mått på stress.

Studie III och IV baseras på Healthy-OLD-studien och undersöker mental hälsa, stress och coping hos äldre (70–80 år) under COVID-19-pandemin. Denna åldersgrupp var särskilt sårbar för viruset, varför förebyggande restriktioner, som social isolering, i synnerhet riktades mot de äldre. Deltagare rekryterades randomiserat från fem vårdcentraler i sydöstra Sverige. Data insamlades vid ett besök på deltagarnas egna vårdcentraler och utgjordes av en omfattande enkät, biometriska värden, blodprov, hår och saliv. I Studie III användes endast enkäten och i Studie IV användes både enkäten och hår (vilket analyserades för HCC).

I Studie I och II hade de grekiska deltagarna en signifikant högre förekomst av självrapporterad stress, ångest och depressiva symtom än motsvarande svenska/skandinaviska deltagare. De upplevde också fler svåra livshändelser och lägre framtidstro. I Studie I var kortisolnivåerna signifikant lägre hos de grekiska deltagarna än de svenska, vilket skulle kunna indikera en uttröttad Hypotalamus-Hypofys-Binjure (HPA)-axel p.g.a. långvarig stressexponering, och/eller genetiska skillnader, och/eller kulturella skillnader. Emellertid fanns ingen signifikant skillnad i kortisolnivåer mellan grekiska och svenska deltagare i arbetsför ålder i Studie II, men signifikant sämre allmän hälsa rapporterades i den grekiska populationen jämfört med den skandinaviska populationen i Studie II. De starkaste prediktiva faktorerna som förklarar självrapporterad dålig allmän hälsa var grekisk härkomst och låg framtidstro. Motsvarande faktorer för hög upplevd stress var måttlig till hög ångest och måttlig depression.

I Studie III var social distansering den faktor som deltagarna upplevde hade påverkat dem mest under COVID-19-pandemin. De deltagare som uppgav att deras mentala hälsa hade försämrats av COVID-19-pandemin rapporterade mer ångest, depression och stress än de deltagare som uppgav att deras mentala hälsa inte hade påverkats. Riskfaktorer för att uppleva en försämrad mental hälsa pga pandemin befanns vara en försämring av det sociala livet, en upplevd dålig familjesituation, en förändring i graden av fysisk aktivitet, ångest och att vara kvinna.

I Studie IV befanns låg känsla av sammanhang (KASAM) vara signifikant associerad till ångest, självrapporterad dålig ekonomisk situation, låg framtidstro och upplevd försämring av den mentala hälsan pga COVID-19- pandemin. Ångest befanns vara en möjlig mediator mellan de mentalt påverkade och KASAM. Ingen association hittades mellan KASAM och HCC i denna studie. Generellt rapporterade kvinnor sämre mental hälsa och lägre livskvalitet än män, men där fanns ingen signifikant skillnad i HCC.

Sammanfattningsvis visar fynden i denna avhandling på en hög förekomst av stress, ångest och depression hos vuxna som lever i samhällen exponerade för finansiell kris eller COVID-19-pandemin. Symtom på ångest och depression befanns vara prediktiva för hög upplevd stress hos unga vuxna. Ångest var särskilt framträdande hos äldre under pandemin och är en möjlig mediator för associationen mellan KASAM och upplevd försämring av mental hälsa pga pandemin. En mångfald av psykosociala faktorer var starkt korrelerade till KASAM respektive upplevelsen av försämrad mental hälsa pga pandemin. Unga grekiska vuxna hade lägre HCC än svenska unga vuxna, vilket kan ha orsakats av uttröttad HPA axel pga långvarig stress.

Syftet med denna avhandling har inte en direkt klinisk koppling, men fyndet av den höga förekomsten av mental ohälsa, särskilt ångest, hos vuxna som lever i samhällen exponerade för svåra händelser betonar vikten av att aktivt fråga patienten hur hen påverkas av en svår livshändelse, inte minst äldre kvinnor.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2024. p. 64
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1910
Keywords
Stress, Mental health, Cortisol in hair, Financial crisis, COVID-19 pandemic, Young adults, Adults in working ages, Older adults, Sense of Coherence
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-203201 (URN)10.3384/9789180756037 (DOI)9789180756020 (ISBN)9789180756037 (ISBN)
Public defence
2024-06-05, Fornborgen, Vrinnevisjukhuset, Norrköping, 13:00 (Swedish)
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Supervisors
Available from: 2024-05-03 Created: 2024-05-03 Last updated: 2024-06-10Bibliographically approved

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