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Frequencies in reported psychosomatic illnesses have increased in Sweden among children, adolescents, and young adults. Little is known about demographic differences in self-reported psychosomatic complaints, such as between urban and rural areas, and whether surveys launched on the Internet could be a useful method in sampling such data.
This study examines the connection between psychosomatic illnesses and demographics in Swedish children and youth. The feasibility of using the Internet to gather large amounts of data regarding psychosomatic complaints in this group is another major objective of this study.
A cross-sectional study using 7 validated questions about psychosomatic health, were launched in a controlled way onto a recognized Swedish Internet community site, which targeted users 10 to 24 years of age. The subjects were able to answer the items while they were logged in to their personal domain. The results were analyzed cross-geographically within Sweden.
In total, we received 100,000 to 130,000 individual answers per question. Subjects of both sexes generally reported significantly higher levels of self-reported psychosomatic complaints in major city areas as compared with minor city/rural areas, even though the differences between the areas were small. For example, 12.00% (4472/37,265) of females in minor regions reported always feeling tense, compared with 13.80% (3156/22,873) of females in major regions (
In subjects aged 10 to 24 years, higher levels of psychosomatic complaints appear to correlate with living in major city areas in comparison with minor city/rural areas. Surveys launched on the Internet could be a useful method in sampling data regarding psychosomatic health for this age group.
Children, adolescents, and young adults in Sweden frequently report mental health issues [
The development from chronic stress to psychosomatic symptoms and eventually disease depends on multiple factors, such as genetic vulnerability [
In addition, the surrounding environment has an impact on disease development [
In a previous Internet-based study, we have shown that stress and psychosomatic health complaints are common in children, adolescents, and young adults. Older teenage females (16-18 years of age) had the highest levels of complaints, and both sexes reported a slightly worse self-perceived general health status in 2010 than in 2007 [
The purpose of the present study was to examine self-reported psychosomatic complaints among children and adolescents, to unravel potential differences with regard to these complaints depending on sociodemographic factors and residential environment in Sweden. Our hypothesis is that psychosomatic complaints are more prevalent among the young in urban areas and more frequent in females
The use of Internet has the benefit of providing a high number of respondents in all categories concerning age, sex, and geographical region. We recruited 130,000 study participants by convenience sampling through the website LunarStorm. LunarStorm's website was one of the first social Web communities to be established in Sweden. At the time of our sampling (2005), LunarStorm was the largest Internet community in Sweden. It had 1.3 million active members and approximately 360,000 unique visitors per day who spent approximately 40 minutes per visit on the site (TNS Gallup/Red Measure, Nielsen/Net Ratings). Among 15- to 20-year olds in Sweden by that time, 83% were LunarStorm members, and 25 of 30 pupils in every secondary school class were connected (Lunarworks AB/SCB). Of members, 53% were females.
To assess psychosomatic complaints among the participants we used the well-established Psychosomatic Problems Scale (PBS) [
Our data were collected by launching the questions on 7 consecutive days in the spring of 2005. We posted 1 question per day rather than presenting the complete questionnaire on a single occasion because the Web community administrator had the experience that using long composite questionnaires substantially decreased the participation rate. However, it is therefore not possible to directly compare the results of this study with results from studies using the original composite measure. Each participant could log into their own ‘LunarStorm corner' and voluntarily choose to complete the questions in private and in their own time on the community site. These privacy and time aspects may contribute to more reliable replies [
While the use of computerized psychological assessment has increased with time, there are a limited number of validation analyses regarding Internet-based surveys among young people. However, most research to date seems to conclude that results from Internet-based recruitment corresponds well to results from more traditional administration means. In a recent study, a brief Web-based screening questionnaire for common mental disorders was validated with follow-up phone interviews, using a Diagnostic and Statistical Manual of Mental Disorders–based interview manual as a gold standard [
Members saw the question after login, and only 1 answer per login was permitted and counted. Each answer was registered as unique; hence, it was not possible repeat login and reply more than once. We focused on young people aged 10 to 24 years. The age groups were differentiated as follows: 10 to 12 years (children), 13 to 16 years (adolescents), and 17 to 24 years (young adults). The percentage of LunarStorm members in these different age groups, ranged between 20% and 88%, with the highest values (>80%) being adolescents between 13 and 16 years of age.
Based on individual Internet protocol adresses, we made a geographical categorization of the subjects into 3 major city regions (Stockholm, Göteborg, and Malmö) and 18 minor cities and regions with lower population density in Sweden (Blekinge, Dalarna, Gotland, Gävleborg, Halland, Jämtland, Jönköping, Kalmar, Kronoberg, Norrbotten, Södermanland, Uppsala, Värmland, Västerbotten, Västernorrland, Västmanland, Örebro, and Östergötland). This sample was then dichotomized into ‘major city regions’ and ‘minor city/rural regions.’
The LunarStorm site did not provide data on socioeconomic background. Therefore, we added demographic data separately via Statistics Sweden, from the Swedish Living Conditions Surveys [
Each of the possible responses to each of the 7 questions in the Likert format was assigned a number: ‘no, never=1’; ‘no, seldom=2’; ‘yes, sometimes=3’; ‘yes, often=4’ and ‘yes, always=5’. Respondents answering, “don’t know” were excluded from the analysis. The response frequency was calculated and independent samples
Ethical approval was obtained from the chairman of the review board. According to the ethical guidelines of the ethics board in Gothenburg, Sweden, posting questionnaires on the Internet does not require formal ethical approval from a committee. However, we choose to discuss these issues thoroughly with the chairman and received full approval.
Females answered the questions more frequently, and also reported significantly higher frequencies of psychosomatic complaints than males on all 7 questions (
The percentage of ”Yes, always” responses to different psychosomatic complaints for 10- to 24-year-old females and males from major and minor regions of Sweden.
For all 7 questions, females from the small city/rural areas presented with better self-perceived health as compared with those from the major city areas (
Sex differences regarding self-reported psychosomatic complaints.
Question/alternative | Yes, always, % | Yes, often, % | Yes, some-times, % | No, seldom, % | No, never, % | Number of responders | Overall |
||
Major regions | |||||||||
Females | 10.80 | 16.10 | 46.20 | 19.50 | 7.40 | 24,846 | |||
Males | 12.10 | 6.20 | 31.90 | 27.90 | 22.00 | 16,408 | <.001 | ||
Minor regions | |||||||||
Females | 9.50 | 16.10 | 46.10 | 20.60 | 7.60 | 41,661 | |||
Males | 11.30 | 6.00 | 31.50 | 28.30 | 23.00 | 28,198 | <.001 | ||
Major regions | |||||||||
Females | 13.80 | 21.90 | 44.50 | 14.00 | 5.80 | 22,873 | |||
Males | 16.40 | 10.90 | 41.70 | 17.80 | 13.20 | 17,386 | <.001 | ||
Minor regions | |||||||||
Females | 12.00 | 21.10 | 45.40 | 15.50 | 6.10 | 37,265 | |||
Males | 15.60 | 9.80 | 41.30 | 18.70 | 14.60 | 29,801 | <.001 | ||
Major regions | |||||||||
Females | 8.40 | 9.40 | 41.20 | 22.80 | 18.10 | 22,770 | |||
Males | 10.00 | 5.00 | 28.70 | 23.40 | 33.00 | 15,785 | <.001 | ||
Minor regions | |||||||||
Females | 7.40 | 8.90 | 41.50 | 23.60 | 18.60 | 36,860 | |||
Males | 10.00 | 4.70 | 28.20 | 24.10 | 33.00 | 26,919 | <.001 | ||
Major regions | |||||||||
Females | 12.30 | 27.00 | 47.70 | 9.90 | 3.10 | 31,056 | |||
Males | 11.30 | 11.20 | 43.40 | 21.60 | 12.50 | 19,817 | <.001 | ||
Minor regions | |||||||||
Females | 11.10 | 27.00 | 48.30 | 10.60 | 3.10 | 50,511 | |||
Males | 11.20 | 11.50 | 42.90 | 22.30 | 12.20 | 33,409 | <.001 | ||
Major regions | |||||||||
Females | 15.50 | 21.90 | 47.60 | 10.50 | 4.60 | 27,883 | |||
Males | 17.30 | 14.60 | 44.40 | 14.70 | 9.00 | 20,114 | <.001 | ||
Minor regions | |||||||||
Females | 14.30 | 21.90 | 48.70 | 10.70 | 4.40 | 46,293 | |||
Males | 17.30 | 14.60 | 44.60 | 14.70 | 8.80 | 33,792 | <.001 | ||
Major regions | |||||||||
Females | 12.10 | 13.10 | 44.10 | 21.80 | 8.80 | 29,488 | |||
Males | 14.90 | 9.30 | 35.40 | 24.20 | 16.10 | 20,621 | <.001 | ||
Minor regions | |||||||||
Females | 11.20 | 12.70 | 44.40 | 22.60 | 9.20 | 48,583 | |||
Males | 14.30 | 8.90 | 35.70 | 24.60 | 16.60 | 34,999 | <.001 | ||
Major regions | |||||||||
Females | 12.80 | 18.60 | 48.90 | 18.50 | 5.30 | 26,494 | |||
Males | 12.80 | 8.70 | 38.60 | 27.30 | 12.60 | 17,899 | <.001 | ||
Minor regions | |||||||||
Females | 11.60 | 18.30 | 45.20 | 19.60 | 5.20 | 43,164 | |||
Males | 11.50 | 8.10 | 38.70 | 28.90 | 12.90 | 30,808 | <.001 |
Percentage demographic distribution of responders across Sweden, answering 7 items of self- reported psychosomatic complaints on the web in May 2005.
Question/alternative | Yes, always |
Yes, often |
Yes, sometimes % | No, seldom |
No, never % | Number of responders | Overall |
Interpretation | |
Females, major regions | 10.80 | 16.10 | 46.20 | 19.50 | 7.40 | 24,846 | |||
Females, minor regions | 9.50 | 16.10 | 46.10 | 20.60 | 7.60 | 41,661 | <.001 | Females in minor |
|
Males, major regions | 12.10 | 6.20 | 31.90 | 27.90 | 22.00 | 16,408 | |||
Males, minor regions | 11.30 | 6.00 | 31.50 | 28.30 | 23.00 | 28,198 | <.001 | Males in minor regions fewer complaints | |
Females, major regions | 13.80 | 21.90 | 44.50 | 14.00 | 5.80 | 22,873 | |||
Females, minor regions | 12.00 | 21.10 | 45.40 | 15.50 | 6.10 | 37,265 | <.001 | Females in minor |
|
Males, major regions | 16.40 | 10.90 | 41.70 | 17.80 | 13.20 | 17,386 | |||
Males, minor regions | 15.60 | 9.80 | 41.30 | 18.70 | 14.60 | 29,801 | <.001 | Males in minor regions fewer complaints | |
Females, major regions | 8.40 | 9.40 | 41.20 | 22.80 | 18.10 | 22,770 | |||
Females, minor regions | 7.40 | 8.90 | 41.50 | 23.60 | 18.60 | 36,860 | <.001 | Females in minor |
|
Males, major regions | 10.00 | 5.00 | 28.70 | 23.40 | 33.00 | 15,785 | |||
Males, minor regions | 10.00 | 4.70 | 28.20 | 24.10 | 33.00 | 26,919 | .41 | No difference | |
Females, major regions | 12.30 | 27.00 | 47.70 | 9.90 | 3.10 | 31,056 | |||
Females, minor regions | 11.10 | 27.00 | 48.30 | 10.60 | 3.10 | 50,511 | <.001 | Females in minor |
|
Males, major regions | 11.30 | 11.20 | 43.40 | 21.60 | 12.50 | 19,817 | |||
Males, minor regions | 11.20 | 11.50 | 42.90 | 22.30 | 12.20 | 33,409 | .74 | No difference | |
Females, major regions | 15.50 | 21.90 | 47.60 | 10.50 | 4.60 | 27,883 | |||
Females, minor regions | 14.30 | 21.90 | 48.70 | 10.70 | 4.40 | 46,293 | .006 | Females in minor |
|
Males, major regions | 17.30 | 14.60 | 44.40 | 14.70 | 9.00 | 20,114 | |||
Males, minor regions | 17.30 | 14.60 | 44.60 | 14.70 | 8.80 | 33,792 | 0.61 | No difference | |
Females, major regions | 12.10 | 13.10 | 44.10 | 21.80 | 8.80 | 29,488 | |||
Females, minor regions | 11.20 | 12.70 | 44.40 | 22.60 | 9.20 | 48,583 | <.001 | Females in minor |
|
Males, major regions | 14.90 | 9.30 | 35.40 | 24.20 | 16.10 | 20,621 | |||
Males, minor regions | 14.30 | 8.90 | 35.70 | 24.60 | 16.60 | 34,999 | .006 | Males in minor regions fewer complaints | |
Females, major regions | 12.80 | 18.60 | 48.90 | 18.50 | 5.30 | 26,494 | |||
Females, minor regions | 11.60 | 18.30 | 45.20 | 19.60 | 5.20 | 43,164 | <.001 | Females in minor |
|
Males, major regions | 12.80 | 8.70 | 38.60 | 27.30 | 12.60 | 17,899 | |||
Males, minor regions | 11.50 | 8.10 | 38.70 | 28.90 | 12.90 | 30,808 | <.001 | Males in minor regions fewer complaints |
In the separate data sampling performed via Statistics Sweden [
When analyzing household income data (
Demographic distribution of population with zero income.
% 0 income | All age groups | 20-24 years | 25-29 years | 30-34 years | 35-39 years | 40-44 years | 45-49 years |
5.70 (0.87) | 10.20 |
6.43 |
4.49 (1.17) | 3.84 |
3.74 |
3.48 |
|
4.13 |
7.79 |
4.63 |
2.61 (0.56) | 2.07 |
2.10 |
1.91 |
|
.005 | .031 | .006 | Not significant | <.001 | <.001 | <.001 |
The major finding of this study was that psychosomatic complaints were reported to a significantly higher degree in females from the major city areas as compared with the minor city/rural areas. This pattern also prevailed for males, although there was no statistically significant difference regarding the following items: difficulty in concentrating, low appetite, and felt low (
The higher levels of complaints in females compared with males in both area categories support and extend the results from earlier studies [
These results are in line with a study by Samanta et al [
Several other factors are known to increase the risk for psychosomatic complaints among children and adolescents, such as housing, school system, neighborhood context, and other environmental issues [
We speculate that these large socioeconomic differences in the urban areas may contribute to the ratings of higher degrees of psychosomatic complaints in our subjects living in these areas. These complementary data may have provided a partial explanation for the regional differences in self-reported psychosomatic health found in the current study. Our approach did not allow matching on an individual level for the 2 different datasets (the data collected from the website and the data from Statistics Sweden), but merely provides a spatial correlation for the major and the minor areas. However, it provides a general picture of the geographical distribution of socioeconomic issues in Sweden and how these, at least partly, overlap with the general picture of the distribution of psychosomatic complaints in respective areas.
We are unable to draw any conclusion about the causality between city living and the potentially increased risk for psychosomatic complaints from this cross-sectional study. One hypothesis is that differences in exposure to nature and green areas for recreation may account for some of the variance. Numerous studies show that access to green spaces has been associated with health benefits at both individual and neighbourhood levels [
A common stressor in adults is having a low perceived degree of control over ones day to day life: it is plausible that living in an urban environment with plenty of potentially challenging outer structures, such as living in dense areas, commuting and fighting for resources on highly competitive social arenas could be stress factors also accounting for this variability in young people. Social stress and lack of control [
Because the data were gathered in collaboration with the LunarStorm site that did not provide information regarding specific age, socioeconomic background, ethnicity, family background, living conditions, or general wellness the analytical base of the study is limited, with restricted control for confounding variables. Some accountancy for this was taken by the additional dataset from Statistics Sweden displaying sociodemographic patterns of the populations on a regional spatial level.
The PBS was originally analyzed when all items were answered at the same time, and the good psychometric properties cannot automatically be supposed to also be valid in this sample, where each item was answered on a separate day. We did omit 1 item: ‘felt giddy.’ This was due to low reply frequencies, which means that the scale presented was incomplete.
Another limitation is that approximately 350,000 people logged in on a given day, raising the possibility of selection bias. Due to the fact that the subjects were anonymous, we could not investigate selection effects. However, a recent study using the Internet for health-related topics was independent of gender, age, and diagnosis in a group of patients with psychosomatic disorders [
Because studies on Internet-based assessment are a relatively recent phenomenon, the validity of the data gathered in this manner is uncertain and worth further exploration. In our study, the spatial resolution is low and areas with some of the highest variability in socioeconomic factors were merged together by the LunarStorm site administrator and classified as “major city area.” Because perceived stress and ill health have a strong association with socioeconomic status, the merging of areas might have attenuated our findings. A higher spatial resolution might have shown more pronounced differences between areas, also because within city areas there are large socioeconomic and neighborhood differences [
One of the strengths of the present study is that the subject could log into her/his own LunarStorm corner privately and at a suitable time, and voluntarily chose to participate. While representing a convenience sample, this raises the probability of sincere replies.
Another advantage is the 100,000 to 130,000 of subjects of various ages who responded. The received responses from 100,000 to 130,000 individuals per day, represents on average 36% of the entire population of members logging in daily (n=360,000). This volume of responders would be difficult to reach in such a short time space by other ways of communication. Furthermore, such administrative factors as data transcription, the risk of excluded values and ‘odd’ answers, and the concern that other people might read the answers can be overcome by computer- and Internet-based surveys.
Young people in Sweden have a generally high prevalence of self-reported psychosomatic complaints, and these seem to be more common in major city areas as compared with minor city/rural areas. As urbanization progresses globally this might be of importance as a risk factor hampering the wellbeing of children and adolescents. The current study provides valuable information on the importance of regional differences and the potential benefit of living closer to nature, which should be taken into account when planning for healthier living environments. The study inspires to identifying urban environmental features that promote health as well as finding interventions to raise subjective and collective psychological resilience of, especially young, city dwellers. In addition, it motivates further studies exploring the causality and mechanistic explanations for environmentally as well as socioeconomically related links to psychosomatic health.
psychosomatic problems scale
We would like to thank Thomas Karlsson for statistical help. This study was funded by Sahlgrenska Hospital, Olle Engkvist Foundation, Kempe-Carlgrenska Foundation, and the Public Health Committee of West Sweden.
The study was jointly designed by WO and PF. All authors were responsible for the data analyses. PF and WO were responsible for data acquisition. All authors jointly interpreted findings. KLF drafted the paper outline. All authors contributed to successive drafts. All authors approved the final manuscript.
None declared.