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Hälsopromotion i skolan. Utvärdering av DISA - ett program för att förebygga depressiva symtom hos ungdomar.

Garmy, Pernilla LU (2016) In Lund University, Faculty of Medicine Doctoral Dissertation Series 2016:12.
Abstract (Swedish)
Popular Abstract in Swedish

Bakgrund

Hälsopromotion i skolan förespråkas för att främja välmående och förebygga depressiva symtom hos ungdomar, men insatsernas effektivitet och kostnadseffektivitet behöver utvärderas löpande. Depressiva symtom klassas av WHO som den största sjukdomsbördan hos unga människor och skapar såväl stort lidande för den enskilda och de anhöriga, som höga samhällskostnader.

Elevhälsan ska prioritera åtgärder som främjar elevers psykiska hälsa. Program som fokuserar på livskunskap finns idag som en integrerad del i många skolors ordinarie verksamhet. En växande medvetenhet om ökande psykisk ohälsa bland ungdomar, och i synnerhet bland flickor, under slutet av 1990-talet gjorde att... (More)
Popular Abstract in Swedish

Bakgrund

Hälsopromotion i skolan förespråkas för att främja välmående och förebygga depressiva symtom hos ungdomar, men insatsernas effektivitet och kostnadseffektivitet behöver utvärderas löpande. Depressiva symtom klassas av WHO som den största sjukdomsbördan hos unga människor och skapar såväl stort lidande för den enskilda och de anhöriga, som höga samhällskostnader.

Elevhälsan ska prioritera åtgärder som främjar elevers psykiska hälsa. Program som fokuserar på livskunskap finns idag som en integrerad del i många skolors ordinarie verksamhet. En växande medvetenhet om ökande psykisk ohälsa bland ungdomar, och i synnerhet bland flickor, under slutet av 1990-talet gjorde att landstinget i Stockholms län gav sin folkhälsoenhet i uppdrag att möta detta behov. Programmet Coping With Stress Course (CWS) från USA modifierades och anpassades för svenska förhållanden, och fick namnet DISA. Programmet syftar till att förebygga stress och depressiva symtom hos ungdomar och baseras på tekniker hämtade från kognitiv beteendeterapi (KBT). DISA erbjuds i många högstadieskolor i Sverige som ett frivilligt eller obligatoriskt program med strukturerade gruppträffar, en gång i veckan under tio veckor. Ledare för DISA är i oftast elevhälsans personal som skolkuratorer och skolsköterskor, eller pedagoger på skolan, och de har gått en tredagars utbildning i metoden. Programmet erbjöds ursprungligen till flickor och även i dag är det flest flickor som går det, men på flera skolor erbjuds nu DISA även för pojkar.

Forskning om CWS har visserligen visat goda resultat, och det finns även viss forskning om DISA som stärker detta. Men DISA har också kraftigt kritiserats för sitt patogena fokus och risk för stigmatisering när det enbart erbjuds till flickor.



Syfte

Dessa motsägelsefulla resultat av styrkor och svagheter med programmet motiverar en vidare undersökning av tillämpningen av DISA. Syftet med denna avhandling är att utvärdera DISA:s effektivitet avseende att minska depressiva symtom och förbättra självskattad hälsa hos ungdomar, undersöka vilka erfarenheter ungdomar och ledare har av DISA, samt belysa programmets kostnadseffektivitet.



Metod

I denna avhandling har elever besvarat enkäter innan start av DISA, samt ett år efteråt. Elever som inte deltagit i DISA utgjorde kontrollgrupp och besvarade enkäter med samma intervall. Totalt har över 900 elever deltagit i studien. Jag har även intervjuat drygt 20 DISA-ledare och knappt 90 ungdomar i fokusgrupper.



Resultat och slutsatser

Resultatet från denna avhandling tyder på att DISA förebygger depressiva symtom och stärker ungdomars självskattade hälsa, samt att kostnaden är låg i förhållande till dess effekt. Dessa analyser indikerar att DISA kan anses vara kostnadseffektivt. Slutsatsen grundar sig på data från svenska högstadieskolor.

Kritiken mot DISA är framför allt att programmet har ett patogent och negativt fokus. Rekommendationen här är att öka dess hälsofrämjande fokus och att satsa på att stärka ungdomarnas förmågor i stället för att lägga avsevärd tid på att identifiera negativa tankar. Dessa hälsofrämjande komponenter finns redan i programmet, men kan behöva lyftas fram mer.

Annan kritik gällde att DISA i vissa fall var en obligatorisk kurs bara för flickor, men det resultatet är inte entydigt. I flera skolor fungerar det med en kurs enbart för flickor, och på andra skolor och i vissa DISA-grupper framkom missnöje mot detta. Organiserandet av DISA behöver diskuteras vidare. (Less)
Abstract
Background: DISA (Depressive Symptoms In Swedish Adolescents) is a cognitive behavioral intervention aimed at preventing stress and depressive symptoms in adolescents. It is frequently used in Swedish schools for students aged 13-15

years. DISA is commonly offered to females, but at some schools, the intervention is also offered to males. In this study, the

application of the intervention for both females and males is evaluated.

Aim: The overarching aim of this thesis was to explore the experience, significance, and effectiveness of the school-based

intervention DISA. The specific aims were to investigate the effectiveness of depressive symptoms and self-reporting health,

and costs and... (More)
Background: DISA (Depressive Symptoms In Swedish Adolescents) is a cognitive behavioral intervention aimed at preventing stress and depressive symptoms in adolescents. It is frequently used in Swedish schools for students aged 13-15

years. DISA is commonly offered to females, but at some schools, the intervention is also offered to males. In this study, the

application of the intervention for both females and males is evaluated.

Aim: The overarching aim of this thesis was to explore the experience, significance, and effectiveness of the school-based

intervention DISA. The specific aims were to investigate the effectiveness of depressive symptoms and self-reporting health,

and costs and cost-effectiveness as well as to elucidate the experiences of adolescents and tutors.

Methods: The effectiveness of DISA was investigated using method triangulation. The thesis is based on two quantitative

and two qualitative studies. The quantitative studies were quasi-experimental trials with an intervention group (I, IV), and

a control group (IV), with follow-up measurements obtained at 3 and 12 months after baseline. The qualitative studies were

based on focus group interviews with adolescents (II) and tutors (III). The school-based cognitive behavioral prevention

program DISA was presented by school health staff and teachers once per week for ten weeks. Students in grade 8 (median

age: 14) participated in the intervention in study I (n=62, 52% females) and study IV (n=462, 79% females), and 486

students (46% females) were allocated to the control group (study IV). Focus group interviews were conducted with 89

adolescents (II) and 22 tutors (III). The interviews were analyzed with qualitative content analysis.

Findings: The intervention group decreased their self-reported depressive symptoms and improved their self-rated health

more than the control group (p<0.05) at the 12-month follow-up. The majority of the adolescents rated the cognitive

behavioral program as a positive experience, and the attendance rate was high. The incremental cost-effectiveness ratio was

approximately USD 6,300 per quality-adjusted life year (QALY). The focus group interviews with the adolescents revealed

that the students found that they developed intrapersonal strategies through DISA, such as directed thinking, improved

self-confidence, stress management, and positive activities. They also gained an increased interpersonal awareness regarding

trusting the group and considering others. However, structural constraints of the DISA program, such as negative framing

and an emphasis on performance, were also noted. The focus group interviews with the tutors identified an overall theme

of striking a balance between strictly following the manual and meeting student needs.

Conclusions: The DISA program appears to be a feasible, cost-effective school-based cognitive behavioral program with

high levels of student adherence and satisfaction, as well as positive mental health benefits. However, a desire for a more

health-promoting approach was expressed. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Skärsäter, Ingela, Högskolan i Halmstad
organization
publishing date
type
Thesis
publication status
published
subject
keywords
Adolescents, Depressive Symptoms, School-Based Program, Prevention, Cognitive Behavior Program, Health Education, Mental Health, Evaluation
categories
Higher Education
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
volume
2016:12
pages
93 pages
publisher
Institutionen för kliniska vetenskaper, Malmö
defense location
SSSH-salen (Hörsal 1), HSC, Baravägen 3 i Lund
defense date
2016-02-12 13:00
ISSN
1652-8220
ISBN
978-91-7619-238-2
language
English
LU publication?
yes
id
7ec883bd-2e1b-4899-9c49-92eed472cc71 (old id 8539870)
date added to LUP
2016-01-27 08:06:57
date last changed
2016-09-19 08:44:51
@phdthesis{7ec883bd-2e1b-4899-9c49-92eed472cc71,
  abstract     = {Background: DISA (Depressive Symptoms In Swedish Adolescents) is a cognitive behavioral intervention aimed at preventing stress and depressive symptoms in adolescents. It is frequently used in Swedish schools for students aged 13-15<br/><br>
years. DISA is commonly offered to females, but at some schools, the intervention is also offered to males. In this study, the<br/><br>
application of the intervention for both females and males is evaluated.<br/><br>
Aim: The overarching aim of this thesis was to explore the experience, significance, and effectiveness of the school-based<br/><br>
intervention DISA. The specific aims were to investigate the effectiveness of depressive symptoms and self-reporting health,<br/><br>
and costs and cost-effectiveness as well as to elucidate the experiences of adolescents and tutors.<br/><br>
Methods: The effectiveness of DISA was investigated using method triangulation. The thesis is based on two quantitative<br/><br>
and two qualitative studies. The quantitative studies were quasi-experimental trials with an intervention group (I, IV), and<br/><br>
a control group (IV), with follow-up measurements obtained at 3 and 12 months after baseline. The qualitative studies were<br/><br>
based on focus group interviews with adolescents (II) and tutors (III). The school-based cognitive behavioral prevention<br/><br>
program DISA was presented by school health staff and teachers once per week for ten weeks. Students in grade 8 (median<br/><br>
age: 14) participated in the intervention in study I (n=62, 52% females) and study IV (n=462, 79% females), and 486<br/><br>
students (46% females) were allocated to the control group (study IV). Focus group interviews were conducted with 89<br/><br>
adolescents (II) and 22 tutors (III). The interviews were analyzed with qualitative content analysis.<br/><br>
Findings: The intervention group decreased their self-reported depressive symptoms and improved their self-rated health<br/><br>
more than the control group (p&lt;0.05) at the 12-month follow-up. The majority of the adolescents rated the cognitive<br/><br>
behavioral program as a positive experience, and the attendance rate was high. The incremental cost-effectiveness ratio was<br/><br>
approximately USD 6,300 per quality-adjusted life year (QALY). The focus group interviews with the adolescents revealed<br/><br>
that the students found that they developed intrapersonal strategies through DISA, such as directed thinking, improved<br/><br>
self-confidence, stress management, and positive activities. They also gained an increased interpersonal awareness regarding<br/><br>
trusting the group and considering others. However, structural constraints of the DISA program, such as negative framing<br/><br>
and an emphasis on performance, were also noted. The focus group interviews with the tutors identified an overall theme<br/><br>
of striking a balance between strictly following the manual and meeting student needs.<br/><br>
Conclusions: The DISA program appears to be a feasible, cost-effective school-based cognitive behavioral program with<br/><br>
high levels of student adherence and satisfaction, as well as positive mental health benefits. However, a desire for a more<br/><br>
health-promoting approach was expressed.},
  author       = {Garmy, Pernilla},
  isbn         = {978-91-7619-238-2},
  issn         = {1652-8220},
  keyword      = {Adolescents,Depressive Symptoms,School-Based Program,Prevention,Cognitive Behavior Program,Health Education,Mental Health,Evaluation},
  language     = {eng},
  pages        = {93},
  publisher    = {Institutionen för kliniska vetenskaper, Malmö},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral Dissertation Series},
  title        = {Hälsopromotion i skolan. Utvärdering av DISA - ett program för att förebygga depressiva symtom hos ungdomar.},
  volume       = {2016:12},
  year         = {2016},
}