Post-migration stressors, mental health and well-being in resettled refugees from Syria: Do individuals' coping strategies matter?

BACKGROUND

The evidence is mixed as to whether individuals' coping strategies may mitigate the adverse mental health effects of post-displacement stressors in refugee populations, with some indications that the buffering effects of coping strategies are context dependent. The present study examined if problem-solving and acceptance coping strategies were effect modifiers between post-migration stressors and mental health in adult refugees from Syria resettled in Sweden.

METHODS

Study aims were investigated using cross-sectional survey data from a nationwide, randomly sampled group of adult refugees from Syria granted permanent residency in Sweden between 2011 and 2013 (Nsample = 4000, nrespondents = 1215, response rate 30.4%). Post-migration stressors examined included: financial strain, social strain, host-country competency strain and discrimination. Two mental health outcomes were used: anxiety/depression, measured with the Hopkins Symptom Checklist-25; and well-being, measured with the WHO-5 Well-being Index. Both outcomes were modelled continuously. Coping strategies were measured using the BRIEF Cope scale. Interactions between coping strategies and post-migration stressors were tested in fully adjusted linear regression models using Wald test for interaction, corrected for multiple testing using the Benjamini-Hochberg procedure.

RESULTS

Both problem-solving and acceptance coping strategies buffered the adverse association between financial strain and symptoms of anxiety/depression, and problem-solving coping strategies buffered the adverse association between host-country competency strain and anxiety/depression.

CONCLUSIONS

The study suggests that individuals' coping strategies may to some degree buffer the adverse mental health effects of financial strain and host-country competency strain experienced by refugees in the resettlement phase. Although this pattern was only found in regard to anxiety/depression and not subjective well-being, the findings show that individual-level coping skills among refugees may contribute to adaptation in the face of post-settlement adversities. Notwithstanding the importance of attending to refugees' psychosocial conditions, refugees residing in refugee camps and newly resettled refugees might benefit from interventions aiming at enhancing individual coping resources and skills. The potential effect of increased controllability and decreased conflict-proximity also warrants further exploration in future studies.

Cross-Cultural Adaptation and Psychometric Properties of the Swahili Version of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-BR45 among Breast Cancer Patients in Tanzania

Breast cancer is the most frequent cancer in women in Africa and contributes to premature death and poor quality of life. This study aimed to determine the validity, reliability, and psychometric properties of the Swahili version of EORTC QLQ-BR45 among women with breast cancer in Tanzania. A cross-sectional study design with non-probability convenience sampling was employed. Data were collected in two tertiary hospitals and one national cancer institute; 414 participants completed the EORTC-QLQ-C-30 and EORTC-QLQ-BR45. The reliability of QLQ-BR45 was measured using Cronbach's alpha and McDonald's Omega coefficients. The factor structure of EORTC QLQ-BR45 was assessed using confirmatory factor analysis. The internal consistencies for the five dimensions were all above 0.7 indicating satisfaction, except for systemic therapy side effects with a marginal value of 0.594 and significant correlations between the dimensions of QLQ-C30 and BR45. The final model fit well to the data, with the comparative fit index = 0.953, Tucker-Lewis index = 0.947, root mean square error of approximation = 0.041 (90% CI: 0.035, 0.046), and standardized root mean square residual = 0.072. In conclusion, the QLQ BR45 Swahili version displayed good reliability, validity, and psychometric properties and can be used in Swahili-speaking Sub-Saharan countries.

Physical activity, post-traumatic stress disorder, and exposure to torture among asylum seekers in Sweden: a cross-sectional study

BACKGROUND

Forced migrant populations have high rates of trauma-related ill health, including post-traumatic stress disorder (PTSD). Physical activity (PA) is well-established as an effective stress reliever, while insufficient PA is associated with adverse effects on both mental and physical health. The aim of this study was to examine the prevalence of different levels of PA and its association with PTSD symptom severity, controlled for exposure to torture, among asylum seekers in Sweden.

METHODS

A cross-sectional survey study, with data from 455 asylum seekers, originating from Afghanistan, Eritrea, Iraq, Somalia, and Syria, residing at large housing facilities across Sweden. Level of PA was assessed by the Exercise Vital Sign and categorized as; Inactive, Insufficient PA, and Sufficient PA. Prevalence estimates for proportions of different levels of PA were calculated. Analysis of variance were conducted to determine the association between levels of PA and PTSD symptom severity, measured by the Harvard Trauma Questionnaire. Multivariable logistic regression analysis was performed to determine the contribution of PA on PTSD beyond sex, age, and exposure to torture.

RESULTS

About half of the participants (53.3, 95% CI: 48.6-58.1) met the recommendations for Sufficient PA. One third of the participants (33.3, 95% CI: 28.7-37.8) were insufficiently engaged in PA, and 13.4% (95% CI: 10.1-16.7) were inactive. There was a significant difference in PTSD symptom severity between groups of asylum seekers with different levels of PA (F(2, 316) = 23.15, p < .001). When controlling for sex, age, and exposure to torture, Sufficient PA was found to be associated with less PTSD symptom severity compared to both Insufficient PA (B = 0.297, SE = 0.086, p < .001) and Inactive (B = 0.789, SE = 0.104, p < .001).

CONCLUSIONS

Insufficient PA was common among the asylum seekers and our findings suggest that more PA is highly associated with lower PTSD symptom severity. An increased focus on assessment and promotion of PA is justified and discussed as particularly pertinent considering the much extended time of asylum-seeking processes. The results support previous evidence of PA as a potentially important factor in the context of PTSD and forced migrants' health.

Coping in Limbo? The Moderating Role of Coping Strategies in the Relationship between Post-Migration Stress and Well-Being during the Asylum-Seeking Process

Asylum seekers are faced with high levels of post-migratory stress due to uncertainty and uncontrollability of the application process, resulting in higher levels of mental health problems. Little is known about the coping strategies utilized by asylum seekers in this context. Structural equation modeling and the stepwise modeling approach were utilized on cross-sectional data from a cohort of asylum seekers in Sweden (N = 455) to examine whether adaptive coping in the form of problem-focused and cognitive-based coping would buffer the impact of post-migratory stressors by moderating the relationship between the stressors and well-being. Fit indices showed good to excellent fit of the final model that regressed well-being on selected post-migratory stressors and coping (CFI = 0.964, RMSEA = 0.043 (90% CI = 0.035-0.051), SRMR = 0.044). Well-being was negatively and significantly regressed on both perceived discrimination (B = -0.42, SE = 0.11, p < 0.001) and distressing family conflicts (B = -0.16, SE = 0.07, p = 0.037), and positively and significantly regressed on cognitive restructuring (B = 0.71, SE = 0.33, p = 0.030). There was, however, no evidence that coping strategies modified the adverse associations between the two post-migratory stressors and well-being. Interventions and policies should prioritize improving contextual factors inherent in the asylum-seeking process in order to reduce stress and enable coping.

Disability pension and mortality in individuals with specific somatic and mental disorders: examining differences between refugees and Swedish-born individuals

Background

More than half a million refugees have arrived to Sweden during the last decade. The aim was to investigate differences between refugees and Swedish-born individuals regarding different specific somatic and mental disorders, and subsequent disability pension and mortality.

Methods

All refugees (n=239 742) and Swedish-born individuals (n=4 133 898), aged 19–60 years, resident in Sweden on 31st of December in 2009 were included in this population-based prospective cohort study. Data from six nationwide Swedish registers were linked by the unique anonymised identification number. HRs with 95% CIs were computed for disability pension and mortality 2010–2013 by Cox regression models.

Results

Compared with their Swedish-born counterparts with mental or somatic diagnoses, refugees with these diagnoses had a higher risk of subsequent disability pension and a lower risk of mortality. Highest estimates for disability pension were seen for refugees with neoplasm (HR: 1.72; 95% CI: 1.56 to 1.91), musculoskeletal disorders (HR: 1.57; 95% CI: 1.47 to 1.67), diseases of the circulatory system (HR: 1.33; 95% CI: 1.22 to 1.45), depressive disorders (HR: 1.31; 95% CI: 1.21 to 1.41) and diabetes mellitus (HR: 1.30; 95% CI: 1.15 to 1.47). The risk of mortality was lowest for refugees with regard to bipolar disorders (HR: 0.37; 95% CI: 0.16 to 0.82), post-traumatic stress disorder (HR: 0.37; 95% CI: 0.25 to 0.54) and least pronounced in regard to neoplasm (HR: 0.69; 95% CI: 0.61 to 0.77) compared with Swedish-born with similar disorders.

Conclusion

Refugees have a generally higher risk of disability pension compared with Swedish-born with specific somatic and mental disorders. Despite this, refugees with all specific disorders have lower risk estimates of mortality, probably due to a healthy selection. The higher risk of disability pension might therefore be due to other causes besides poor health.

Adaptation of Coping Effectiveness Training for Patients With Heart Failure and Patient-Reported Experience of the Intervention

Although patients with chronic heart failure (CHF) often experience psychological distress, psychosocial aspects are not an integral part of their treatment and care. The aim is to describe the adaptation of Coping Effectiveness Training for patients with CHF and the participants’ reported experiences. The intervention workbook and manual were translated into Swedish and adapted for patients with CHF. Patient-reported experience from 33 of 35 participants, that had completed the psychosocial intervention, was measured with an evaluation form consisting of closed and open-ended questions. Most participants thought they benefited from the intervention, were pleased with the structure and did not want to add anything to the program. The benefits experienced were learning how to cope with the illness and meeting other people to share and discuss experiences. There was a variation concerning the group process of how much direction should be given during the discussions. Overall, unique data from patient-reported experience measure showed that the participants were satisfied with the psychosocial intervention, applied for the first time to patients with CHF.

Mental health in adult refugees from Syria resettled in Norway between 2015 and 2017: a nationwide, questionnaire-based, cross-sectional prevalence study

BACKGROUND

The number of forcibly displaced people globally has never been higher, with refugees from Syria constituting the largest displaced population worldwide. Many studies have documented elevated levels of mental health problems in refugee populations, though prevalence estimates of common mental disorders vary considerably between studies, explained both by methodological and contextual factors.

OBJECTIVE

Using questionnaire-based screening checklists to approximate the prevalence of and investigate risk factors for post-traumatic stress disorder (PTSD), anxiety and depression among adult refugees from Syria resettled in Norway and to compare estimates with a sister-study in Sweden.

METHOD

Cross-sectional survey of a randomly selected sample from the National Population Register in Norway of adult refugees from Syria who were granted residency rights in Norway between 2015 and 2017 (N_sample = 9,990; n_respondents = 902). Above-threshold scores on the Harvard Trauma Questionnaire (HTQ) and Hopkins Symptoms Checklist (HSCL-25) defined caseness for PTSD (HTQ>2.06); anxiety (HSCL_anxitey>1.75); and depression (HSCL_depression>1.80).

RESULTS

Weighted, checklist-positive prevalence estimates for PTSD, anxiety and depression were 29.7% (25.4%-34.4%), 30.1% (25.7%-34.9%), and 45.2% (40.6%-49.8%), respectively. Cumulative exposure to potentially traumatic experiences before or during flight was a clear risk factor for all outcomes, and female gender was a risk factor for anxiety and depression, though only in adjusted analyses. The choice of HTQ cut-off to define PTSD caseness (2.5 vs. 2.06) had a notable effect on prevalence estimates.

CONCLUSION

In line with prior evidence, the present study suggests adult refugees from Syria resettled in Norway have higher rates of anxiety and depression and markedly higher rates of PTSD compared to general, non-refugee populations, and that this is clearly linked to past traumatic experiences. Prevalence estimates were highly consistent with estimates from the sister-study in Sweden, which used almost identical methodology. Findings underline the importance of screening for and intervening on mental health problems in newly arrived refugees.

Children at risk: A nation-wide, cross-sectional study examining post-traumatic stress symptoms in refugee minors from Syria, Iraq and Afghanistan resettled in Sweden between 2014 and 2018

Background

The objective of the present study was to assess nation-wide, representative prevalence estimates for symptom-defined posttraumatic stress disorder (PTSD) within populations of refugee minors from Afghanistan, Syria and Iraq resettled in Sweden.

Methods

A nation-wide, cross-sectional, questionnaire study with a stratified sample of refugee minors, aged 16–18 years, from Afghanistan, Iraq and Syria, resettled in Sweden between 2014 and 2018 (N = 5071) was conducted. The response rate was 22.3%, leaving n = 1129 refugee minors (boys 53.1% / girls 46.9%) in the final sample. Symptom-defined prevalences of PTSD were measured using CRIES-8 with ≥17 as cut-off. Data were analyzed using frequency distributions, and strata-specific PTSD prevalences with 95% confidence intervals (95% CIs), were estimated. The association between migratory status on arrival (unaccompanied vs. accompanied) and PTSD was estimated using crude and adjusted odds ratios (OR) utilizing logistic regression analyses with 95% CIs.

Results

Overall, the weighted PTSD prevalence was 42% (95% CI 38.9–45.1), with minors from Afghanistan presenting the highest prevalence (56.9, 95% CI 51.5–62.2), compared to minors from Iraq (36.8, 95% CI 28.9–45.4) and Syria (33.4, 95% CI 29.4–37.6). Unaccompanied minors from Afghanistan had higher odds of PTSD compared to accompanied minors from Afghanistan (OR = 1.92, 95% CI 1.08–3.40). Gender differences were non-significant.

Conclusions

High prevalences of symptom-defined PTSD among refugee minors in general and in unaccompanied minors from Afghanistan in particular, were revealed. Findings calls for continued efforts to support this especially vulnerable group.

Exploring Social and Financial Hardship, Mental Health Problems and the Role of Social Support in Asylum Seekers Using Structural Equation Modelling

Asylum seekers are exposed to a range of social and financial difficulties suggested to adversely impact mental health. Uprooted social networks and living conditions during the asylum seeking process potentially predispose this population to low access to social support. The aim of this study was to examine the relationship between social and financial hardship and mental health problems, and assess the potential mediating role of social support among asylum seekers. Cross sectional survey data from a cohort of asylum seekers in Sweden (N = 455) were subjected to structural equation modelling for examining hypothesized pathways between social and financial hardship, common mental health problems (CMHPs) and social support. Fit indices showed adequate to excellent fit of the examined models with CMHPs as the outcome (all CFI ≥ 0.951, RMSEA < 0.05, SRMR < 0.056). CMHPs were positively regressed on social and financial hardship (B = 0.786, S = 0.102, p < 0.001) and negatively regressed on social support (B = -0.103, SE = 0.032, p = 0.001). Social support mediated the association between social and financial hardship and CMHPs (effect estimate = 0.075, 95% CI = 0.032-0.136). The results point to the importance of social and living conditions of asylum seekers and indicate that social support is both socially patterned and may act as a mitigating resource to inform interventions and policies.

Translation, culture adaption and psychometric testing of the MISSCARE Survey-Swedish version

AIM

To translate the MISSCARE Survey into Swedish and establish its validity and reliability by evaluating its psychometric properties.

BACKGROUND

Missed nursing care is defined as any aspect of required nursing care that is omitted or delayed. The consequence of missed nursing care is a threat to patient safety. The MISSCARE Survey is an American instrument measuring missed nursing care activities (part A) and its reasons (part B).

METHODS

The translation was accomplished according to World Health Organization guidelines, focusing on a culture adaptation. Acceptability, construct validity, test-retest reliability and internal consistency were analysed. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) was used as reporting checklist.

RESULTS

The translation and culture adaptation needed several revisions. A total of 126 nurses answered the test and retest which showed acceptability of missing data. The factor analysis revealed a lack of fit to data for the original factorial structure in part B, while further analysis provided results suggesting a modification based on omitting six items. The internal consistency for part B and its subscales showed good results.

CONCLUSIONS

The MISSCARE Survey-Swedish version is a reliable and valid instrument, with good psychometric properties.

RELEVANCE TO CLINICAL PRACTICE

More reliable language versions of the instrument enable national and international comparisons that could be valuable for nursing managers and/or directors of nursing who are responsible for quality of care and patient safety in the strategic care planning process.

Teachers' Personal and Collective Work-Identity Predicts Exhaustion and Work Motivation: Mediating Roles of Psychological Job Demands and Resources

The aim of this study was to investigate the mediating roles of teachers' psychological job demands and resources regarding personal and collective work-identity, respectively, and exhaustion and self-determined work motivation, respectively. A total of 2,905 members of a Swedish teacher's trade union received an online questionnaire by e-mail; 768 individuals answered the questionnaire and so participated in this study. The data were obtained by self-reported measures (e.g., emotional and cognitive components of work-identity, psychological job demands and resources, exhaustion and work motivation) and analyzed by mediation regression analyses. The results showed that teachers' psychological job demands (prosocial extra-role performance) mediated relationships between cognitive personal work-identity and emotional collective work-identity, respectively, and exhaustion. Teachers' psychological job resources (educational inspiration) mediated relationships between emotional personal work-identity and cognitive collective work-identity, respectively, and self-determined work motivation. Thus, teachers might be disadvantaged by stronger personal work-related thinking and collective work-related feeling when related to exhaustion, to some extent accounted for by psychological job demands, and they might find advantage in stronger personal work-related feeling and collective work-related thinking when related to work motivation, to some extent accounted for by psychological job resources.

Cohort profile: Resettlement in Uprooted Groups Explored (REFUGE)-a longitudinal study of mental health and integration in adult refugees from Syria resettled in Norway between 2015 and 2017

PURPOSE

In the field of forced migration and mental health research, longitudinal studies with large sample sizes and rigorous methodology are lacking. Therefore, the Resettlement in Uprooted Groups Explored (REFUGE)-study was initiated in order to enhance current knowledge on mental health, quality of life and integration among adult refugees from Syria resettled in Norway. The main aims of the study are to investigate risk and protective factors for mental ill health in a longitudinal perspective; to trace mental health trajectories and investigate important modifiers of these trajectories and to explore the association between mental health and integration in the years following resettlement. The aims will be pursued by combining data from a longitudinal, three-wave questionnaire survey with data from population-based registries on education; work participation and sick-leave; healthcare utilisation and drug prescription. The goal is to incorporate the data in an internationally shared database, the REFUGE-database, where collaborating researchers may access and use data from the study as well as deposit data from similar studies.

PARTICIPANTS

Adult (≥18 years), Syrian citizens who arrived in Norway as quota refugees, asylum seekers or through Norway's family reunion programme between 1 January 2015 and 31 December 2017. Of the initial 9990 sampled individuals for the first wave of the study (REFUGE-I), 8752 were reached by post or telephone and 902 responded (response rate=10.3%).

FINDINGS TO DATE

None published.

FUTURE PLANS

The REFUGE-cohort study will conduct two additional data collections (2020 and 2021). Furthermore, questionnaire data will be linked to population-based registries after all three waves of data collection have been completed. Registry data will be obtained for time-periods both prior to and after the survey data collection points. Finally, pending ethics approval, we will begin the process of merging the Norwegian REFUGE-cohort with existing datasets in Sweden, establishing the extended REFUGE-database.

TRIAL REGISTRATION NUMBER

ClincalTrials.gov Registry (NCT03742128).

Asylum-seekers' psychosocial situation: A diathesis for post-migratory stress and mental health disorders?

OBJECTIVE

While flight experiences of refugees and asylum-seekers might differ profoundly, previous research has, to a large degree, not differentiated between these forcibly displaced groups. Furthermore, research has mainly focused on post-migratory stress measured after resettlement. The aim of this study was therefore to chart mental health disorders and the associations between mental health and early post-migratory stress among asylum-seekers.

METHOD

Using a cross sectional survey design, data collection was conducted from 2016 to 2018, in three large asylum-seekers' housing facilities located in Sweden.

RESULTS

In total 455 asylum-seekers from Afghanistan, Eritrea, Iraq, Somalia and Syria responded to the questionnaire. The most prevalent type of mental health disorder was depression (67.9%) followed by posttraumatic stress disorder (PTSD) (60.7%), and anxiety (59.3%). More men than women reported mental health disorders particularly with regard to anxiety and PTSD, and respondents with the lowest level of education (≤9 years) reported the highest levels of mental health problems. Associations between mental health disorders and post-migratory stress revealed that three post-migratory stressors were consistently the strongest indicators of mental health disorders.

CONCLUSIONS

Compared to previous research within populations of refugees who have received formal refugee status or resident permits, the prevalences of mental health disorders reported in the present study were substantially larger and the associations between post-migratory stressors and mental health disorders appears to be substantially stronger for asylum-seekers. This might suggest that the asylum-seekers' psychosocial situation becomes a diathesis or predisposition that interacts with early post-migratory stressors, in turn having detrimental effects on mental health.

The refugee post-migration stress scale (RPMS) - development and validation among refugees from Syria recently resettled in Sweden

Background

Despite the growing recognition of the impact of post-resettlement factors on the mental health of refugees, a clear definition of the concept of post-migration stress, as well as an updated, valid instrument for assessing the construct, are still lacking. The aim of the current study was to develop and validate the Refugee Post-Migration Stress Scale (RPMS), a concise, multi-dimensional instrument for assessing post-migration stress among refugees.

Results

Based on a review of previous research and observations from a refugee trauma clinic, a preliminary 24-item instrument was developed, covering seven hypothesized domains of post-migration stress: perceived discrimination, lack of host country specific competences, material and economic strain, loss of home country, family and home country concerns, social strain, and family conflicts.

In the context of a population-based survey of mental health among refugees from Syria recently resettled in Sweden (n = 1215), the factorial structure of the RPMS was investigated. Confirmatory Factor Analysis revealed slightly insufficient fit for the initial theorized multi-domain model. Exploratory Factor Analysis in four iterations resulted in the omission of three items and an adequate fit of a 7-factor model, corresponding to the seven hypothesized domains of post-migration stress. To assess concurrent validity, correlational analyses with measures of anxiety, depression, post-traumatic stress disorder (PTSD), and mental wellbeing were carried out. All domains of post-migration stress showed significant correlations with anxiety, depression, and PTSD scores, and significant negative correlations with mental wellbeing scores.

Conclusions

The newly developed RPMS appears to be a valid instrument for assessing refugee post-migration stress. Our findings that post-migration stress primarily relating to social and economic factors seems to be associated with mental ill health among refugees is in line with previous research.

The role of refugee status and mental disorders regarding subsequent labour market marginalisation: a register study from Sweden

PURPOSE

This study aimed to assess the role of refugee status and specific mental disorders regarding subsequent labour market marginalisation.

METHODS

Prospective cohort study of all refugees (n = 216,930) and Swedish-borns (n = 3,841,788), aged 19-60 years, and resident in Sweden in 2009. Hazard ratios (HRs) with 95% Confidence Intervals (CIs)  for long-term unemployment (> 180 days) and disability pension (DP) were calculated with Cox regression analyses.

RESULTS

Mental disorders were more prevalent in refugees compared to Swedish-born individuals, with greatest differences seen for post-traumatic stress disorder (PTSD; refugees 1.3%; Swedish-born individuals 0.1%). Regarding long-term unemployment, refugees without a mental disorder had an adjusted HR (aHR) of 2.68 (95% CI 2.65-2.71) compared to Swedish-born individuals without mental disorders, which was above the aHR of refugees (aHR 2.33, 95% CI 2.29-2.38) and Swedish-born individuals (aHR 1.44, 95% CI 1.43-1.45) with mental disorders. Regarding DP, compared to Swedish-born individuals without mental disorders, the aHRs were 1.44 (95% CI 1.34-1.54) for refugees without, but 6.11 (95% CI 5.84-6.39) for refugees with mental disorders. Swedish-born individuals with mental disorder had an aHR of 3.96 (95% CI 3.85-4.07). With regard to specific disorders, the aHRs for refugees, as compared to Swedish-born individuals without mental disorders, were markedly increased for all disorders (e.g. PTSD: long-term unemployment aHR: 2.03 (95% CI 1.89-2.18); DP 7.07 (95% CI 6.42-7.78).

CONCLUSION

Mental disorders are more prevalent in refugees than in Swedish-born individuals but do not appear to increase their risk of long-term unemployment. Refugee status and mental disorders strongly contribute to the risk of DP, indicating that factors beyond medical considerations contribute to their granting of DP.

Prevalence and predictors of low future expectations among Syrian refugees resettled in Sweden

Background

Future Expectation is important for motivation and wellbeing, however drastic life events such as in refugee situations may result in low expectations. This study aims to investigate the prevalence and determinants of low future expectations among Syrian refugees resettled in Sweden.

Methods

A random sample of 1215 Syrian refugees resettled in Sweden responded to questionnaire. Weighted analyses and adjusted relative risks were conducted to determine the prevalences and predictors of low future expectations. Synergy index was calculated for low social support and depression in relation to low expectations.

Results

The prevalences of low future expectations for labour market, social and economic intergration were 10.9%, 13.4% and 14.1% respectively. Longer stay in Sweden, being older, low social support and depression were associated with low future expectations. The simultaneous presence of depression and low social support had a synergistic effect on low social expectation.

Discussions

Understanding and addressing factors related to low future expectations among refugees may be useful for facilitating their labour market, social and economic integration.

Family conflict mediates the relationship between past violence and wellbeing among female refugees

Background

Past exposure to violence has been suggested to have a lasting effect on subjective well being (SWB). Similarly, family conflict is another known predictor of SWB. Research shows that refugee women exposed to gender based violence (GBV) before resettlement may also face post-resettlement family conflicts due to socio-cultural factors, changes in social network and migration-based shifting gender roles. This study examines the role of family conflict as a likely mediator between past exposure to violence and SWB among Syrian refugee women in Sweden.

Methods

A total of 452 women out of a random sample of 1215 Syrian refugee women in Sweden responded to a questionnaire survey in Arabic. Variables include Past violence i.e. exposure to any of torture, physical or sexual violence preflight or during flight before arriving Sweden; Post-resettlement distressing family conflicts i.e. feeling disrespected or unimportant in the family or distressing conflicts; SWB was measured by WHO-5 wellbeing index. Maximum likelihood estimation with Robust standard errors and bias corrected bootstrapped 95% confidence intervals for all estimates.

Results

Total effect of past violence on SWB was significant (Estimate = -6.63; CI= -12.73 - -0.46). Similarly, family conflicts were associated with decreased SWB (Estimate = -3.80; CI= -5.17 - -2.40), and past violence exposure increased family conflicts (Estimate = 0.57; 0.13 - 1.08). The total effect of violence exposure on decreased SWB was decomposed into a direct and an indirect effect (mediated via family conflicts). The indirect effect via family conflicts was significant (M= -2.19; C1= -4.30 - 0.59), while decomposing rendered the direct effect non-significant (Estimate= -4.44, CI= -10.51 - 1.52).

Conclusions

Post-resettlement distressing family conflicts mediate the effect of prior exposure to violence on reduced SWB among refugee women.

Key messages

Past violence exposure reduces refugee women’s SWB via aggravated family conflicts implying the need for family targeted interventions to improve SWB of female refugees previously exposed to violence. Strategies to improve subjective wellbeing among female refugees should include screening for and addressing all forms of previous and ongoing GBV.

Identifying subgroups of refugees from Syria resettled in Sweden based on multiple trauma exposures: A latent class analysis of trauma history and mental health outcomes

OBJECTIVE

Many refugees have been subjected to pre-migratory trauma. Evidence is needed to address the heterogeneity within refugee populations in regard to patterns of multiple trauma exposures. This study identified subgroups within a refugee population displaying different profiles of multiple trauma exposures and assessed sociodemographic predictors and differences in mental health symptom severity across these classes.

METHODS

Study population consisted of 1215 refugees from Syria resettled in Sweden. Latent class analysis 3-step method for modelling predictors and outcomes and a class-specific weighted multigroup approach were used to identify classes of refugees using self-reported data on violent and non-violent trauma exposures, sociodemographic variables and symptom severity scores for depression, anxiety and PTSD.

RESULTS

Three classes were identified: class 1 'multiple violent and non-violent trauma' (39.3%, n = 546); class 2 'witnessing violence and multiple non-violent trauma' (40.8%, n = 569); and class 3 'low multiple non-violent trauma' (20.1%, n = 281). Trauma exposure and gender significantly predicted class membership. Male gender and highest severity of mental ill health defined class 1. Female gender predicted higher mental ill health within classes 1 and 2. Across all three classes living with a partner was associated with lower severity of mental ill health regardless of trauma exposure classes.

CONCLUSIONS

There are distinct patterns within refugee populations concerning exposure to multiple trauma. Violence is a primary marker for higher likelihood of multiple trauma exposures and severity of mental health. Gender predisposes individuals to trauma exposure and its outcomes differentially.

Social support attenuates the link between torture exposure and post-traumatic stress disorder among male and female Syrian refugees in Sweden

BACKGROUND

The aim of this study is threefold: (i) to establish the psychometric properties and gender invariance of ENRICHD Social Support Inventory (ESSI), which was used for the first time in the present study in the population of Syrian refugees resettled in Sweden; (ii) to assess whether gender moderates the associations between social support, exposure to torture and PTSD; (iii) to assess whether social support mediates the association between exposure to torture and PTSD, and whether this mediation is in turn moderated by gender.

METHODS

Data from a cross-sectional and population-based study of a random sample of Syrian refugees (n = 1215) resettled in Sweden 2011-2013 was analyzed within a Structural Equation Modeling (SEM) framework.

RESULTS

Our results indicate adequate fit and gender invariance for a unidimensional model of ESSI. Exposure to torture was associated with lower social support (B = -0.22, p < 0.01) and with higher odds ratio (OR) for PTSD (OR 2.52, 95% Confidence interval (CI) 1.83-3.40). Furthermore, higher social support was associated with less likelihood for PTSD (B = -0.56, p < 0.001). Social support partially mediated the effect of torture exposure on PTSD (OR 1.13, 95% bias corrected bootstrap CI 1.06-1.26). Gender did not moderate this pattern.

CONCLUSION

The results indicate that social support attenuates the link between torture exposure and PTSD, and may function as a protective factor for PTSD among both torture-exposed refugee men and women.

Inability to act was associated with an extended delay prior to care-seeking, in patients with an acute myocardial infarction

BACKGROUND

The out-of-hospital mortality in patients with acute myocardial infarction remains unchanged in contrast to a decrease in inhospital mortality. Interventions aiming to shorten patient delay have been largely unsuccessful. A deeper understanding is apparently needed on patients' appraisal prior to care-seeking.

AIM

To investigate whether appraisal processes influence patient delay, and if the questionnaire 'Patients' appraisal, emotions and action tendencies preceding care seeking in acute myocardial infarction' (PA-AMI) could discriminate between patients with prolonged care-seeking and those with a short delay.

METHODS

A cross-sectional study including 326 acute myocardial infarction patients filling out the validated questionnaire PA-AMI. The impact of subscales on delay was analysed by projection to latent structures regression. Discrimination opportunities between patients with short and long delays were analysed by projection to latent structures discriminant analysis.

RESULTS

The subscales 'perceived inability to act' and 'symptom appraisal' had a major impact on patient delay (P<0.0001). 'Perceived inability to act' had its main influence in patients with a delay exceeding 12 hours, and 'symptom appraisal' had its main influence in patients with a delay shorter than one hour.

CONCLUSION

Appraisal processes influence patient delay. Acute myocardial infarction patients with a prolonged delay were, besides a low perceived symptom severity and urgency to seek medical care, characterised by a perceived loss of control and ability to act. Therefore, future interventions aimed at decreasing delay should pay attention to appraisal processes, and perceived inability to act may be a sign of a health threat and therefore a signal to seek medical care.

Labour market marginalisation among refugees from different countries of birth: a prospective cohort study on refugees to Sweden

BACKGROUND

The aim was to elucidate if the risk of labour market marginalisation (LMM), measured as long-term unemployment, long-term sickness absence, disability pension and a combined measure of these three measures, differed between refugees and non-refugee migrants with different regions of birth compared with native Swedes.

METHODS

All non-pensioned individuals aged 19-60 years who were resident in Sweden on 31 December 2009 were included (n=4 441 813, whereof 216 930 refugees). HRs with 95% CIs were computed by Cox regression models with competing risks and time-dependent covariates with a follow-up period of 2010-2013.

RESULTS

Refugees had in general a doubled risk (HR: 2.0, 95% CI 1.9 to 2.0) and non-refugee migrants had 70% increased risk (HR: 1.7, 95% CI 1.7 to 1.7) of the combined measure of LMM compared with native Swedes. Refugees from Somalia (HR: 2.7, 95% CI 2.6 to 2.8) and Syria (HR: 2.5, 95% CI 2.5 to 2.6) had especially high risk estimates of LMM, mostly due to high risk estimates of long-term unemployment (HR: 3.4, 95% CI 3.3 to 3.5 and HR: 3.2, 95% CI 3.1 to 3.2). African (HR: 0.7, 95% CI 0.6 to 0.7) and Asian (HR: 1.0, 95% CI 1.0 to 1.1) refugees had relatively low risk estimates of long-term sickness absence compared with other refugee groups. Refugees from Europe had the highest risk estimates of disability pension (HR: 1.9, 95% CI 1.8 to 2.0) compared with native Swedes.

CONCLUSION

Refugees had in general a higher risk of all measures of LMM compared with native Swedes. There were, however, large differences in risk estimates of LMM between subgroups of refugees and with regard to type of LMM. Actions addressing differences between subgroups of refugees is therefore crucial in order to ensure that refugees can obtain as well as retain a position on the labour market.

Trauma-afflicted refugees' experiences of participating in physical activity and exercise treatment: a qualitative study based on focus group discussions

Background: Refugees with prolonged and repeated experiences of trauma, often in combination with post-migration living difficulties, are subjected to severe levels of stress and stress-related ill health, including post-traumatic stress disorder (PTSD). Physical activity (PA) is well-established as an effective stress reliever. However, the effect of PA and exercise has received scarce attention in the context of PTSD, and particularly in the field of refugees' health. Objective: The objective of this study was to explore the experience of participation in PA and exercise as part of the treatment for trauma-afflicted refugees. Method: An explorative qualitative research design was used. Six focus group discussions were conducted with 33 female and male participants that had experience of group-based PA and exercise treatment. The gathered data was analysed by qualitative content analysis. Results: The analysis resulted in one over-arching theme reflecting the participants overall experience of PA and exercise as a process of building resilience. Participants experienced improvements in both physical and mental health domains. Increased self-awareness and self-confidence were seen as additional important benefits, and the interruption of daily stressors provided a sense of relief and recovery. The treatment group settings were experienced as becoming a vehicle for overcoming social fear and isolation, which also carried an empowering and strength-building impact over to participants' family life and social relationships. Treatment characteristics were experienced as highly supportive and often referred to as the basis of other positive experiences and perceived health benefits. Conclusions: The result of this study outlines a detailed account of trauma-afflicted refugees' experiences and preferences of PA and exercise-based treatment from a broad range of perspectives. These findings provide a starting point for future research in this field and indicate a particular need for both research and intervention development to include the real-life impact of participating in such treatments.

Trajectories of work disability and unemployment among young adults with common mental disorders

BACKGROUND

Labour-market marginalisation (LMM) and common mental disorders (CMDs) are serious societal problems. The aims were to describe trajectories of LMM (both work disability and unemployment) among young adults with and without CMDs, and to elucidate the characteristics associated with these trajectories.

METHODS

The study was based on Swedish registers and consisted of all individuals 19-30 years with an incident diagnosis of a CMD in year 2007 (n = 7245), and a matched comparison group of individuals without mental disorders during the years 2004-07 (n = 7245). Group-based trajectory models were used to describe patterns of LMM both before, and after the incident diagnosis of a CMD. Multinomial logistic regressions investigated the associations between sociodemographic and medical covariates and the identified trajectories.

RESULTS

Twenty-six percent (n = 1859) of young adults with CMDs followed trajectories of increasing or constant high levels of work disability, and 32 % (n = 2302) followed trajectories of increasing or constant high unemployment. In the comparison group, just 9 % (n = 665) followed increasing or constant high levels of work disability and 21 % (n = 1528) followed trajectories of increasing or constant high levels of unemployment. A lower share of young adults with CMDs followed trajectories of constant low levels of work disability (n = 4546, 63%) or unemployment (n = 2745, 38%), compared to the level of constant low work disability (n = 6158, 85%) and unemployment (n = 3385, 50%) in the comparison group. Remaining trajectories were fluctuating or decreasing. Around 50% of young adults with CMDs had persistent levels of LMM at the end of follow-up. The multinomial logistic regression revealed that educational level and comorbid mental disorders discriminated trajectories of work disability, while educational level, living area and age determined differences in trajectories of unemployment (R2difference = 0.02-0.05, p < 0.001).

CONCLUSIONS

A large share, nearly 50%, of young adults with CMDs, substantially higher than in the comparison group of individuals without mental disorders, display increasing or high persistent levels of either work disability or unemployment throughout the follow-up period. Low educational level, comorbidity with other mental disorders and living in rural areas were factors that increased the probability for LMM.

Predicting general mental health and exhaustion: the role of emotion and cognition components of personal and collective work-identity

The aim of this study was to investigate relationships between emotion and cognition components of personal and collective work-identity and self-reported general mental health and exhaustion, in Swedish teachers (N = 768). In line with our predictions, we showed that the emotion component of personal work-identity and the cognition component of collective work-identity associated positively with general mental health and negatively with exhaustion. The reverse result was found, however, for the cognition component of personal work-identity and emotion component of collective work-identity. In general, all this indicates that person-work bonding might, to some degree, account for general mental health and exhaustion in employees. In particular, the findings suggest that general mental health and exhaustion may vary symmetrically across the: (1) Type of person-work bonding (personal vs. collective work-identity); and (2) Type of psychological component (emotion vs. cognition) involved in personal- and collective work-identity.

Prevalence of mental ill health, traumas and postmigration stress among refugees from Syria resettled in Sweden after 2011: a population-based survey

OBJECTIVES

To estimate the prevalence of and associations between anxiety, depression, post-traumatic stress disorder (PTSD), low subjective well-being (SWB), potential traumas and postmigration stress among refugees from Syria resettled in Sweden.

DESIGN

A cross-sectional and population-based questionnaire study based on a known and complete sample frame. The survey included multiple measures of mental ill health and factors of particular relevance for refugees. Weighted analyses were conducted to calculate representative prevalence rates and associations. Associations were investigated through a series of logistic regression analyses. All analyses were supplemented with robust 95% CIs.

SETTING

Sweden.

PARTICIPANTS

A random sample of 1215 individuals (response rate 30.4%) from Syria aged 18-64 years that were granted residency in Sweden on grounds of asylum between 2011 and 2013.

MAIN OUTCOME MEASURES

Anxiety, depression, PTSD and low SWB were assessed through Hopkins Symptom Checklist, Harvard Trauma Questionnaire and WHO-5 Well-being Index, using established cut-offs.

RESULTS

A majority of the participants met the criteria for at least one of the studied types of mental ill health, and the comorbidity was high. Depression was the most the common type with 40.2% (95% CI 36.9% to 43.3%), followed by low SWB with 37.7% (95% CI 34.8% to 40.1%), anxiety with 31.8% (95% CI 29.2% to 34.7%) and PTSD with 29.9% (95% CI 27.2% to 32.6%). Refugee-related potentially traumatic events (PTEs) experienced before or during migration was common as was substantial levels of postmigration stress. Most types of refugee-related PTEs, especially being exposed to interpersonal violence, and postmigration stress were associated with increased risks for anxiety, depression, low SWB and PTSD.

CONCLUSIONS

Mental ill health, in terms of anxiety, depression, low SWB and PTSD, are highly elevated and comorbid among refugees from Syria. Increased attention from multiple societal sectors to adequately support Syrian refugees' mental health needs, promoting recovery and reducing postmigration stress are needed.

Labour-market marginalisation after mental disorders among young natives and immigrants living in Sweden

Background

The aim was to investigate the associations between mental disorders and three different measures of labour-market marginalisation, and differences between native Swedes and immigrants.

Methods

The study comprised 1,753,544 individuals, aged 20–35 years, and resident in Sweden 2004. They were followed 2005–2011 with regard to disability pension, sickness absence (≥90 days) and unemployment (≥180 days). Immigrants were born in Western countries (Nordic countries, EU, Europe outside EU or North-America/Oceania), or in non-Western countries (Africa, Asia or South-America). Mental disorders were grouped into seven subgroups based on a record of in- or specialised outpatient health care 2001–2004. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed by Cox regression models with both fixed and time-dependent covariates and competing risks. We also performed stratified analyses with regard to labour-market attachment.

Results

Individuals with mental disorders had a seven times higher risk of disability pension, a two times higher risk of sickness absence, and a 20% higher risk of unemployment than individuals without mental disorders. Individuals with personality disorders and schizophrenia/non-affective psychoses had highest risk estimates for having disability pension and long-term sickness absence, while the risk estimates of long-term unemployment were similar among all subgroups of mental disorders. Among persons with mental disorders, native Swedes had higher risk estimates for disability pension (HR:6.6; 95%CI:6.4–6.8) than Western immigrants (4.8; 4.4–5.2) and non-Western immigrants (4.8; 4.4–5.1), slightly higher risk estimates for sickness absence (2.1;2.1–2.2) than Western (1.9;1.8–2.1), and non-Western (1.9;1.7–2.0) immigrants but lower risk estimates for unemployment (1.4;1.3–1.4) than Western (1.8;1.7–1.9) and non-Western immigrants (2.0;1.9–2.1). There were similar risk estimates among sub-regions within both Western and non-Western countries. Stratification by labour-market attachment showed that the risk estimates for immigrants were lower the more distant individuals were from gainful employment.

Conclusions

Mental disorders were associated with all three measures of labour-market marginalisation, strongest with subsequent disability pension. Native Swedes had higher risk estimates for both disability pension and sickness absence, but lower risk estimates for unemployment than immigrants. Previous labour-market attachment explained a great part of the association between immigrant status and subsequent labour-market marginalisation.

Discriminant validity of the 12-item version of the general health questionnaire in a Swedish case-control study

BACKGROUND

The 12-item version of the General Health Questionnaire (GHQ-12) is widely used as a proxy for Affective Disorders in public health surveys, although the cut-off points for distress vary considerably between studies. The agreement between the GHQ-12 score and having a clinical disorder in the study population is usually unknown.

AIMS

This study aimed to assess the criterion validity and to determine the sensitivity and specificity of the GHQ-12 in the Swedish population.

METHODS

This study used 556 patient cases surveyed in specialized psychiatric care outpatient age- and sex-matched with 556 controls from the Stockholm Health Survey. Criterion validity for two scoring methods of GHQ-12 was tested using Receiver Operating Characteristics (ROC) analyses with Area Under the Curve (AUC) as a measure of agreement. Reference standard was (1) specialized psychiatric care and (2) current depression, anxiety or adjustment disorder.

RESULTS

Both the Likert and Standard GHQ-12 scoring method discriminated excellently between individuals using specialized psychiatric services and healthy controls (Likert index AUC = 0.86, GHQ index AUC = 0.83), and between individuals with current disorder from healthy controls (Likert index AUC = 0.90, GHQ index AUC = 0.88). The best cut-off point for the GHQ index was ≥4 (sensitivity = 81.7 and specificity = 85.4), and for the Likert index ≥14 (sensitivity = 85.5 and specificity = 83.2).

CONCLUSIONS

The GHQ-12 has excellent discriminant validity and is well suited as a non-specific measure of affective disorders in public mental health surveys.

Refugee trauma measurement: a review of existing checklists

Abstract

Studies have shown that a high proportion of refugees have been subjected to potentially traumatic experiences (PTEs). PTEs, including torture, are powerful predictors of mental ill health. This paper reports a review of refugee trauma history self-report measures used in population studies.

Methods

A review of existing instruments and checklists, up to September 2015, was performed.

Results

The types of measures for refugee trauma history vary from semi-structured interviews and medical records to extensive multi-item trauma-checklists. The Harvard Trauma Questionnaire (HTQ) was the most commonly used instrument for measuring trauma history among refugee populations. Few checklists included PTEs during the flight.

Conclusion

Trauma history checklists are often used as a tool to control for background variables when studying refugees’ mental health and have mostly been developed in clinical or semi-clinical settings. There is a need for acceptable, reliable and valid brief checklists for measuring trauma in refugees, for the purpose of performing larger scale population studies.

Trajectories of Anxiety Among Women with Breast Cancer: A Proxy for Adjustment from Acute to Transitional Survivorship

Anxiety is one of the main components of distress among women with breast cancer (BC), particularly in the early stages of the disease. Changes in anxiety over time may reflect the process of adjustment or lack thereof. The process of adjustment in the traverse of acute to transitional stages of survivorship warrants further examination. To examine the trajectory of anxiety and the specific patterns that may indicate a lack of adjustment within 2 years following BC surgery, survey data from a 2-year prospective cohort study of 725 women with BC were analyzed by Mixture Growth Modelling and logistic regression and Analysis of Variance. A piece-wise growth curve displayed the best fit to the data, indicating a significant decrease in anxiety in the first year, followed by a slower rate of change during the second year. Four classes of trajectories were identified: High Stable, High Decrease, Mild Decrease, and Low Decrease. Of these, High Stable anxiety showed the most substantive indications of lack of adjustment. This subgroup was predominantly characterized by sociodemographic variables such as financial difficulties. Our results support an emphasis on the transitional nature of the stage that follows the end of primary active treatment and imply a need for supportive follow up care for those who display lack of adjustment at this stage.

Evaluation of a Coping Effectiveness Training intervention in patients with chronic heart failure - a randomized controlled trial

BACKGROUND

Impaired emotional well-being has detrimental effects on health outcomes in patients with chronic heart failure (CHF).

AIMS

To evaluate a nurse-led Coping Effectiveness Training (CET) group intervention for patients with CHF. It was hypothesized that CET would increase emotional well-being (primary outcome) and health-related quality (HRQoL) of life and improve clinical outcomes. Furthermore, changes in appraisal and coping as mediators of the intervention effect were examined.

METHODS

Participants were randomized to either control group (n=51) receiving standard health care or CET intervention group (n=52). Self-assessments of positive affect, negative affect, depression, anxiety, HRQoL, illness perception, coping strategies and social support were performed pre- and post-intervention and after six weeks, six months and 12 months. Time to death and hospitalizations were measured during the entire follow-up (median 35 months, interquartile range 11 months).

RESULTS

No significant improvements for emotional well-being and HRQoL in the intervention group compared with the control group were found. After excluding patients with clinical anxiety and depression at baseline the intervention group had significantly lower negative affect (p = 0.022). There were no significant differences regarding cardiovascular events between the groups. The intervention group had greater sense of control over their illness in the short-term (p = 0.036).

CONCLUSION

CET intervention was found to increase sense of control over the illness in the short term. Psychosocial support programmes, like CET, for patients with CHF is currently lacking evidence for implementing in clinical practice. However, the results provide a basis for future studies with a modified CET intervention design and increased study size.

Prevalence of torture and other warrelated traumatic events in forced migrants: A systematic review

AIM

To describe and appraise the research literature reporting prevalence of torture and/or war-related potentially traumatic experiences (PTEs) in adult forced migrants living in high-income countries.

METHODS

A search for peer-reviewed articles in English was conducted in PubMed, Web of Science, PILOTS, key journals, and reference lists. Studies based on clinical samples and samples where less than half of participants were forced migrants were excluded. Data was extracted and a methodological quality appraisal was performed.

RESULTS

A total of 3,470 titles and abstracts were retrieved and screened. Of these, 198 were retrieved in full-text. Forty-one articles fulfilled inclusion criteria and the total number of study participants was 12,020 (median 170). A majority focused on specific ethnic groups or nationalities, Southeast Asian, Middle Eastern and Balkan being the most frequent. Reported prevalence rates of torture ranged between one and 76 % (median 27 %). Almost all participants across all studies had experienced some kind of war-related PTE.

CONCLUSIONS

Reported prevalence rates of torture and war-related PTEs vary between groups of forced migrants. Trauma history was often studied as a background variable in relation to mental health. The heterogeneity of data, as well as the methodological challenges in reaching forced migrants and defining and measuring traumatic experiences, prevent generalisation concerning trauma history across groups.

Assessment of Coping Strategies and Their Associations With Health Related Quality of Life in Patients With Chronic Heart Failure: the Brief COPE Restructured

Background

Individuals with chronic heart failure (CHF) need to cope with both the physical limitations and the psychological impacts of the disease. Since some coping strategies are beneficial and others are linked to increased mortality and worse health-related quality of life (HRQoL), it is important to have a reliable and valid instrument to detect different coping styles. Brief COPE, a self-reporting questionnaire, has been previously used in the context of CHF. There is, however, currently a lack of consensus about the theoretical or empirical foundations for grouping the multiple coping strategies assessed by Brief COPE into higher order categories of coping. The main purpose of this study was to examine the structure of Brief COPE, founded on the higher order grouping of its subscales in order to establish an assessment model supported by theoretical considerations. Furthermore, the associations between these higher order categories of coping and HRQoL were examined to establish the predictive validity of the selected model in the context of CHF.

Method

One hundred eighty-three patients diagnosed with CHF were recruited at a heart failure outpatient clinic or at a cardiac ward. Self-reported questionnaires were filled in to measure coping strategies and HRQoL. Confirmatory factor analyses were performed to investigate different hierarchical structures of Brief COPE found in the literature to assess coping strategies in patients with CHF. Regression analyses explored associations of aggregated coping strategies with HRQoL.

Results

A four factorial structure of Brief COPE displayed the most adequate psychometric properties, consisting of problem focused coping, avoidant coping, socially supported coping and emotion focused coping. Avoidant coping was associated with worse HRQoL in CHF.

Conclusions

This study provides support for a four-factor model of coping strategies in patients with CHF. This could facilitate assessment of coping both in clinical and research settings.

Consistency of breast and arm symptoms during the first two years after breast cancer surgery

PURPOSE/OBJECTIVES

To examine the severity and development of breast and arm symptoms separately during the two years following breast cancer surgery, and to examine whether previously defined predictors of arm symptoms are associated with breast symptoms.

DESIGN

Prospective cohort study with two-year follow-up.

SETTING

Three institutions in the Stockholm, Sweden, region.

SAMPLE

645 women, aged 20-63 years, enrolled within 12 weeks of surgery for primary breast cancer.

METHODS

Baseline register and questionnaire data with five follow-ups were submitted to descriptive, inferential, and logistic regression analysis.

MAIN RESEARCH VARIABLES

Severity of breast and arm symptoms measured by the European Organisation for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire.

FINDINGS

Most participants had undergone breast-conserving 
surgery and sentinel lymph node dissection, and were scheduled for postoperative radiation therapy. Overall mean levels of breast and arm symptoms were low, but with large individual variations. At all six time points, the mean levels of breast symptoms were significantly higher than those of arm symptoms. Overall, the mean level of both types of symptoms decreased during follow-up. A body mass index (BMI) of 25 or greater and breast symptoms at eight months were associated with having breast symptoms at two years. Arm symptoms at baseline and at eight months, and radiation therapy and a BMI of 25 or greater were associated with having arm symptoms at two years.

CONCLUSIONS

Breast symptoms show different patterns of change and are not associated with the same factors as arm symptoms.

IMPLICATIONS FOR NURSING

For nurses monitoring women treated for breast cancer, the results of this study provide knowledge regarding the importance of early symptom identification and long-term symptoms after treatment.

Stress as a Trigger for Relapses in IBD: A Case-Crossover Study

Background

It is important to identify factors that influence the risk of relapses in inflammatory bowel disease. Few studies have been conducted and with limited methodology. This prospective case-crossover study, aims to examine whether perceived stress has a short-term acute effect, namely whether it acts as a trigger, on the risk of relapse in inflammatory bowel disease.

Methods

Sixty patients with inflammatory bowel disease and in remission were included. The case-crossover design was employed, which is an epidemiological design developed to study triggers for acute events and diseases. To collect information regarding symptoms and potential trigger factors, such as perceived stress, a structured diary was constructed. The participants were instructed to fill in the diary daily during six months. Fifty patients completed the study.

Results

The analysis showed an effect for high level of perceived stress. Being exposed to “quite a lot” of stress, yield an increase in risk for relapse during the forthcoming day (OR = 4.8, 95% CI 1.09 - 21.10). No statistically increased risk for lower levels of perceived stress was found, although elevated effect estimates were found for “some” stress.

Conclusion

This study supports earlier findings regarding perceived stress as an important factor in triggering relapses in IBD. However, this is the first case-crossover study performed to explore the trigger risk of stress in this population. Further investigations with larger patient samples are needed to confirm the findings.