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OBJECTIVES: The relationship intimacy model of psychosocial adjustment to illness indicates that a patient's willingness to communicate about their illness, as perceived by the spouse, is a strong predictor of spouse relational and psychological well-being. Inspired by the relationship intimacy model, the current study examined the psychological adjustment of spouses of individuals with dual-sensory loss (DSL), a disability where interpersonal communication is of particular concern. METHOD: Surveys were sent to all known individuals and their partners who were 50 years of age or older and were enrolled in services for acquired DSL in Denmark. A total of 65 spouses met the inclusion criteria of which 45 (69%) returned a partner survey. RESULTS: Results showed a significant association between couples' sensory loss-related communication, relationship satisfaction, perceived support and psychological well-being. Perceived support significantly mediated the association between couples' sensory loss communication and spouse psychological well-being. CONCLUSION: The current study's findings provide support for a relationship-focused perspective of spousal psychological adjustment in the context of DSL. Further, couples' sensory loss-related communication is presented as a potential intervention target to enhance spouse perceived support and psychological well-being.

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OBJECTIVES: Previous research has shown that marital communication is key to couples' successful illness adjustment. However, little is known about couples' experiences of health conditions characterised by communication difficulties such as acquired hearing, vision, and dual-sensory loss. The aim of this review was to identify the effect of sensory loss, and associated communication difficulties, on couples' relational and psychosocial adjustment. METHOD: A systematic search was conducted to identify studies investigating the social, psychological, and relational impact of sensory loss on couples. RESULTS: Twenty-four articles met the criteria for inclusion in the review. Significant heterogeneity in the measurements and design of the quantitative studies prevented statistical data synthesis. All but two studies reported some effect of sensory loss on couples' psychosocial or relational wellbeing. Higher levels of marital satisfaction were found to buffer against adverse psychological outcomes. Results of quantitative and qualitative studies were synthesised to form an integrative model illustrating the associations between sensory loss and couples' relational and psychosocial wellbeing. CONCLUSIONS: Although this review reports an association between sensory loss and couples' relational and psychosocial wellbeing, the results should be viewed with caution given that relatively few studies on couples' experiences of acquired sensory loss exist, and many have methodological limitations.

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The primary objective of this paper is to examine and inform the mental health and psychosocial support standards of the 2011 edition of the Sphere Project's Humanitarian Charter and Minimum Standards in Humanitarian Response. This is done through a qualitative analysis of internal evaluation documents, reflecting four long-term humanitarian psychosocial programmes in different countries in post-tsunami Asia. The analysis yielded three overall conclusions. First, the Sphere standards on mental health and psychosocial support generally are highly relevant to long-term psychosocial interventions after disasters such as the Indian Ocean tsunami of 26 December 2004, and their application in such settings may improve the quality of the response. Second, some of the standards in the current Sphere handbook may lack sufficient guidance to ensure the quality of humanitarian response required. Third, the long-term intervention approach poses specific challenges to programming, a problem that could be addressed by including additional guidance in the publication.

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BACKGROUND: Women with breast cancer experience different symptoms related to surgical or adjuvant therapy. Previous findings and theoretical models of mind-body interactions suggest that psychological wellbeing, i.e. levels of distress, influence the subjective evaluation of symptoms, which influences or determines functioning. The eight-week mindfulness-based stress reduction (MBSR) program significantly reduced anxiety and depression in breast cancer patients in a randomized controlled trial (NCT00990977). In this study we tested the effect of MBSR on the burden of breast cancer related somatic symptoms, distress, mindfulness and spiritual wellbeing and evaluated possible effect modification by adjuvant therapy and baseline levels of, distress, mindfulness and spiritual wellbeing. MATERIAL AND METHODS: A population-based sample of 336 women Danish women operated for breast cancer stages I-III were randomized to MBSR or usual care and were followed up for somatic symptoms, distress, mindfulness skills and spiritual wellbeing post-intervention and after six and 12 months. Effect was tested by general linear regression models post-intervention, and after six and 12 months follow-up and by mixed effects models for repeated measures of continuous outcomes. Effect size (Cohen's d) was calculated to explore clinical significance of effects among intervention group. Finally, modification of effect of MBSR on burden of somatic symptoms after 12 months' follow-up by adjuvant therapy and baseline levels of, distress, mindfulness and spiritual wellbeing were estimated. RESULTS: General linear regression showed a significant effect of MBSR on the burden of somatic symptoms post-intervention and after 6 months' follow-up. After 12 months' follow-up, no significant effect of MBSR on the burden of somatic symptoms was found in mixed effect models. A statistically significant effect of MBSR on distress was found at all time-points and in the mixed effect models. Significant effects on mindfulness were seen after six and 12 months and no significant effect was observed for spiritual wellbeing. No significant modification of MBSR effect on somatic symptom burden was identified. CONCLUSION: This first report from a randomized clinical trial on the long-term effect of MBSR finds an effect on somatic symptom burden related to breast cancer after six but not 12 months follow-up providing support for MBSR in this patient group.

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OBJECTIVE: To analyze whether qualitative themes in breast cancer patients' self-presentations predicted symptoms of psychological distress and depression in order to improve the consultation process. METHODS: Ninety-seven breast cancer patients gave unstructured, 10-min self-presentations at their first consultation in a clinical registered trial (CRT identifier: NCT00990977). Self-presentations were categorized thematically and the most prevalent themes investigated as predictors for scores on the symptom check-list 90-revised (SCL-90-R) and the center for epidemiological studies depression scale (CES-D). RESULTS: Among the qualitative themes, only the percentage of words spent on talking about 'Acceptance-based psychological coping' was related to symptoms. In regression models controlling for age, education and time since diagnosis, a stronger focus on acceptance-based coping predicted less psychological distress and depression, respectively. A cross-validation including only the first few minutes of speech per patient confirmed these results and supported their practical utility in health consultations. CONCLUSION: Patients' focus on acceptance-based coping significantly predicted decreased psychological distress and depression, respectively. No other qualitative themes predicted symptoms. Doctor-patient studies may benefit from combined qualitative-quantitative methods. PRACTICE IMPLICATIONS: While quantitative symptom assessment is important for a consultation, health care providers may improve their understanding of patients by attending to patients' presentations of acceptance-based psychological coping.

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BACKGROUND: Discussion regarding the necessity to identify patients with both the need and motivation for psychosocial intervention is ongoing. Evidence for an effect of mindfulness-based interventions among cancer patients is based on few studies with no systematic enrollment. METHODS: We used Danish population-based registries and clinical databases to determine differences in demographics, breast cancer and co-morbidity among 1208 women eligible for a randomized controlled trial (www.clinicaltrials.gov identifier: NCT00990977) of mindfulness-based stress reduction MBSR. RESULTS: Participants (N = 336) were found to be younger (p < 0.001) and have a less recent diagnosis at invitation than decliners (N = 872; p < 0.001). After adjustment for age and time since diagnosis at invitation, a statistically significant difference was also found between the two groups in use of psychologist sessions (p < 0.05), whereas neither breast cancer variables nor co-morbidity was significantly different. Self-reported data obtained by use of validated psychometric scales from 169 decliners and 336 women who agreed to enroll in the trial showed statistically significant differences in level of education, distress, anxiety, depression, well being and symptom burden. No differences were observed with regard to marital status, children living at home, affiliation to the work market, psychiatric caseness or any lifestyle measure. CONCLUSION: Our findings indicate that participants are younger, have a less recent diagnosis and have a higher level of education than those who refuse. This should be taken into account in designing and evaluating trials of psychosocial interventions and in planning mindfulness-based interventions.

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UNLABELLED: Approximately 30% of cancer patients suffer from psychological distress, and psychotherapy has been shown to be effective in alleviating it. Based on the 'Behavioral Model of Health Service Use', we investigated equity in the use of publicly subsidized psychotherapy in a cohort of Danish cancer patients. We present descriptive data on patients' use of psychotherapy and examine characteristics of those who used this service. MATERIAL AND METHODS: The study population comprised 3646 participants in the prospective Diet, Cancer and Health cohort, diagnosed with a first cancer between 2003 and 2009, aged 56-80 years. Data on cancer diagnosis, psychotherapy use and comorbid conditions were obtained from registers, whereas data on demographics, social support and health status were obtained from questionnaires. Cox proportional hazards regression was used to identify factors related to use, which were subsequently evaluated with regard to equity. RESULTS: Subsidized psychotherapy was used by 2.3% of the cancer patients. Longer education (> 10 years compared to < 8) was associated with greater likelihood of initiating psychotherapy [hazard ratio (HR), 1.97; 95% confidence interval (CI), 1.06-3.65], as was previous psychotherapy use compared to no previous use (2.86; 1.32-6.20). Patients with partners who did not reliably provide emotional support were significantly more likely to use psychotherapy than those without a partner (2.36; 1.05-5.30), a difference not found for those with partners who did provide support. Further, a higher SF-36 mental component score (0.96; 0.94-0.98, per point increase), and older age were associated with less use (65-69 years: 0.43; 0.21-0.89, 70-74 years: 0.17, 0.07-0.41; > 74 years: 0.07, 0.01-0.57, compared to < 60 years). CONCLUSIONS: The results allow several possible interpretations. We found that mental health plays a role for accessing subsidized psychotherapy, suggesting that use of psychotherapy is predicted by need and thus characterized by equity. However, education and previous psychotherapy use also play a role, suggesting elements of inequity.

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INTRODUCTION: As the incidence of and survival from breast cancer continue to raise, interventions to reduce anxiety and depression before, during and after treatment are needed. Previous studies have reported positive effects of a structured 8-week group mindfulness-based stress reduction program (MBSR) among patients with cancer and other conditions. PURPOSE: To test the effect of such a programme on anxiety and depression among women with breast cancer in a population-based randomised controlled study. METHODS: A total of 336 women who had been operated on for breast cancer (stage I-III) were randomised to usual care or MBSR+usual care. Questionnaires including the Symptom Checklist-90r anxiety and depression subscales and the Center for Epidemiological Studies-Depression scale were administered before randomisation and immediately, 6 and 12 months after the intervention. RESULTS: Intention-to-treat analyses showed differences between groups in levels of anxiety (p=0.0002) and depression (SCL-90r, p<0.0001; CES-D, p=0.0367) after 12 months. Graphical comparisons of participants with higher levels of anxiety and depression at baseline showed a significantly greater decrease in the intervention group throughout follow-up and no differences among least affected participants. Medium-to-large effects were found for all outcomes in the intervention group in analyses of change scores after 12 months' follow-up. CONCLUSION: The 8-week group based MBSR intervention had clinically meaningful, statistically significant effects on depression and anxiety after 12 months' follow-up, and medium-to-large effect sizes. Our findings support the dissemination of MBSR among women with breast cancer. (Clintrials.gov No.: NCT00990977).

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OBJECTIVE: To evaluate the impact of Advanced Life Support in Obstetrics (ALSO) training on staff performance and the incidences of post-partum hemorrhage (PPH) at a regional hospital in Tanzania. DESIGN: Prospective intervention study. SETTING: A regional, referral hospital. POPULATION: A total of 510 women delivered before and 505 after the intervention. METHODS: All high- and mid-level providers involved in childbirth at the hospital attended a two-day ALSO provider course. Staff management was observed and post-partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training. MAIN OUTCOME MEASURES: PPH (blood loss ≥500ml), severe PPH (blood loss ≥1000ml) and staff performance to prevent, detect and manage PPH. RESULTS: The incidence of PPH was significantly reduced from 32.9 to 18.2%[RR 0.55 (95%CI: 0.44-0.69)], severe PPH from 9.2 to 4.3%[RR 0.47 (95%CI: 0.29-0.77)]. The active management of the third stage of labor was also significantly improved. There was a significant decrease in episiotomies. By visual estimation, staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training. A significantly higher proportion of women with PPH had continuous uterine massage, oxytocin infusion and bimanual compression of the uterus after the training. CONCLUSIONS: A two-day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short-term effects.

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The aim of this field study was to analyze the main dynamics and conflicts in attending and providing good quality delivery care in a local Tanzanian rural setting. The women and their relatives did not see the problems of pregnancy and birth in isolation but in relation to multiple other problems they were facing in the context of poverty. Local health professionals were aware of the poor quality of care at health facilities but were still blaming the community. The study describes the difficulties within the conceptual framework of the widely used "three delays model" to disentangle different perspectives and to identify a feasible strategy of action to improve access to timely and effective emergency obstetric care. There seems to be a need for a supplementary analytic model that more clearly has the health system as the central agent responsible for improving maternal health. A modified "actantial model is suggested for that purpose.

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BACKGROUND: People with a major mental disorder are at increased risk of committing crimes, especially violent crimes, compared with the general population. Sub-groups have been identified based on age of onset of anti-social or violent behaviour. Mentally disordered offenders with early onset anti-social behaviour tend to have a lifelong pattern of it, but in a clinical setting, are they easily identifiable as a distinct sub-group? AIMS: Our main aim was to establish whether distinct groups of early and later onset offenders can be identified from the standard clinical record of men with schizophrenia spectrum disorders selected for hospital treatment after conviction for a serious crime, and to test the hypothesis that even in such a clinically selected group, early onset offending would be associated with subsequent persistent and versatile offending. METHODS: A retrospective case file review of all 83 men with a schizophrenia spectrum disorder in a complete 2-year discharge cohort from one specialist secure forensic hospital unit (2001-2002). RESULTS: A sub-group of patients with early onset anti-social behaviour was confirmed. Prior to this specialist hospitalisation, this group had sustained significantly more criminal convictions and were more criminally versatile than their late onset peers. CONCLUSIONS: The recognition of clinically meaningful sub-groups among hospitalised offender patients seems straightforward, and may be useful in the development of more specifically focused intervention and in making sense of more longer-term outcomes.

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OBJECTIVE: To evaluate the management of prolonged labor and neonatal care before and after Advanced Life Support in Obstetrics (ALSO) training. METHODS: Staff involved in childbirth at Kagera Regional Hospital, Tanzania, attended a 2-day ALSO provider course. In this prospective intervention study conducted between July and November 2008, the management and outcomes of 558 deliveries before and 550 after the training were observed. RESULTS: There was no significant difference in the rate of cesarean deliveries owing to prolonged labor, and vacuum delivery was not practiced after the intervention. During prolonged labor, action was delayed for more than 3 hours in half of the cases. The stillbirth rate, Apgar scores, and frequency of neonatal resuscitation did not change significantly. After the intervention, there was a significant increase in newborns given to their mothers within 10 minutes, from 5.6% to 71.5% (RR 12.71; 95% CI, 9.04-17.88). There was a significant decrease from 6 to 0 neonatal deaths before discharge among those born with an Apgar score after 1 minute of 4 or more (P=0.03). CONCLUSION: ALSO training had no effect on the management of prolonged labor. Early contact between newborn and mother was more frequently practiced after ALSO training and the immediate neonatal mortality decreased.

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OBJECTIVE: (i) To identify clinical causes of maternal deaths at a regional hospital in Tanzania and through confidential enquiry (CE) assess major substandard care and make a comparison to the findings of the internal maternal deaths audits (MDAs); (ii) to describe hospital staff reflections on causes of substandard care. METHODS: A CE into maternal deaths was conducted based on information available from written sources supplemented with participatory observations and interviews with staff. The compiled information was summarized and presented anonymously for external expert review to assess for major substandard care. Hospital based maternal deaths between 2006 and 2008 (35 months) were included. Of 68 registered maternal deaths sufficient information for reviewing was retrieved for 62 cases (91%). As a supplement, in-depth interviews with staff about the underlying causes of substandard care were performed. RESULTS: The causes of death were infection (40%), abortion (25%), eclampsia (13%), post-partum haemorrhage (12%), obstructed labour (6%) and others (4%). The median time available for hospital staff to manage the fatal complication was 47 h. The CE identified major substandard care in 46 (74%) of the 62 cases reviewed. During the same time period MDA identified substandard care in 18 cases. Staff perceived poor organization of work and lack of training as important causes for substandard care. Local MDA was considered useful although time-consuming and sometimes threatening, and staff dedication to the process was questioned. CONCLUSION: Quality assurance of emergency obstetric care might be strengthened by supplementing internal MDA with external CE.

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INTRODUCTION: There is solid documentation for the positive relationship between spirituality and health, but few examples of how this link may be used in projects of rehabilitation after war, civil conflicts and natural disasters. One such example is the Danida funded Tibetan Torture Program in India. This study aims to provide evidence of the Tibetan torture survivors' degree of traumatisation and their use of spirituality to overcome their difficult situation. MATERIAL AND METHODS: The study consists of an assessment and a rehabilitation part. A total of 102 Tibetan torture survivors were interviewed about their coping mechanisms in overcoming trauma. In all, 36 of these survivors were receiving counselling and both the clients and their 16 professionals were interviewed after the treatment with open-ended questions about what was helpful and not helpful. RESULTS: The torture survivors had symptoms of severe traumatisation (Hopkin's Symptom Checklist), but probably not as extensive as torture survivors from other cultures. CONCLUSION: The Tibetan torture survivors use Tibetan Buddhism as an important coping mechanism. Most clients expressed satisfaction with counselling, but criticised the crudeness of our methods.

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BACKGROUND. Although psychosocial interventions have been found to be beneficial for cancer patients, the role of the patients' perceptions of illness in these interventions remains unclear. We examined illness perceptions and psychological adjustment (distress and QoL) among women who had survived breast cancer and attended a psychosocial rehabilitation course. MATERIAL AND METHODS. From an ongoing longitudinal study, we used data from two sub-studies with a total of 177 survivors (145 from the descriptive study and 32 from the randomised trial). The survivors from the descriptive study and the half of the randomised survivors attended a 1-week rehabilitation course, whereas the other half of the randomised survivors only received standard care (no intervention). All survivors filled out a questionnaire 2.5 weeks before and one and six months after the course. RESULTS AND DISCUSSION. No differences in the change of illness perceptions and the level of psychological adjustment were observed between the three groups of survivors between baseline and one and six months of follow-up. Baseline analyses showed that illness perceptions were associated with distress and QoL. This study indicates that illness perceptions are associated with adjustment; however, illness perceptions did not change after participation in a one-week multi-component rehabilitation course.

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Our study falls in line with the numerous studies providing a critique of the use of western diagnostic instruments for assessing trauma in a cross-cultural context. Our purpose has been to give evidence for the Tibetan torture survivors' degree of traumatisation and for their use of spirituality to overcome their difficult situation. In addition we wanted to question the use of our western methods in an Asian context. 102 tortured refugees attended a formalised needs assessment including neuropsychological and psychological measures of Post Traumatic Stress Disorder (PTSD) and the Hopkins Symptom Checklist 25 (HSCL-25). Even though significant correlations between the amount of the measures of organized violence and neuropsychological and psychological distress were found in our data, the division of the material into different subgroups according to e.g. religious and non-religious groups did not have an influence on the level of distress. After the assessment study, eight Tibetan lamas were interviewed about their views on our methods and results. They questioned the validity of our western rating scales and explained that our results might be influenced by the Tibetan culture, which among other things can be characterized as having a view and articulation of suffering much more complex than the units of our study's rating scales.

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Discovery of genetic variants of the HFE gene has made it possible to screen for hereditary hemochromatosis. However, genetic screening raises ethical, legal, social, and psychological questions, which need to be addressed. To assess the psychological impact on individuals undergoing genetic screening for hereditary hemochromatosis and to determine the effects of providing different levels of information to the participants. Male residents, aged 30-50 years (n = 10,993) were invited to a genetic screening for hereditary hemochromatosis. Carriers of the gene variants H63D, S65C, and C282Y were offered additional biochemical screening using serum ferritin and transferrin saturation. Psychological factors were evaluated through questionnaires before and after genetic and biochemical screening. According to genotype, participants were divided into three groups with different risks profiles for having/developing clinical hemochromatosis (at-risk, uncertain risk, no risk). Before completion of the questionnaires, 929 participants received only genetic information and 366 received both genetic and biochemical information. At-risk participants receiving only genetic information generally displayed negative reactions to the test result, whereas participants receiving both genetic and biochemical information were more satisfied and had fewer negative psychological reactions to the test result. Genetic screening is more readily accepted by subjects when genetic information is supported by biochemical measurements, especially in participants with a risk of clinical disease.

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